Psychotherapy including CBT and other counselling - benefits and harms

I have done much less therapy than the writer, but her decription of her experiences with CBT being harmful was very much like mine.
I imagine the article was commissioned at the behest of advertisers such as health and disability insurance companies and therapy companies.

 

That link takes you through to a Guardian article about the NICE ME/CFS Guideline (at the time, the draft version).

 

Mollon really seems to be having an internal struggle. He seems to love Freud and the idea of psychoanalysis but is acknowledging, with the help of some great quotes, that psychoanalysis has considerable risks and problems.

Despite my initial impression (edit - he has a couple of technical issues), I found much in this that was relevant and/or interesting:


First slide: 'Research indicates psychotherapy is often not very effective in alleviating people's problems and can sometimes leave people in a worse state.
but : 'The original and simple mode of therapy developed by Freud has become perverted in a variety of ways'

Bad experiences
'An NHS patient with severe regional pain syndrome (which is a terrible degenerative condition triggered by an injury) will soon be better if she has CBT. Absurd.'

'A patient is told that CBT will cure her anxiety - when it does not, she experiences even more panic.'

'A patient is referred for psychotherapy because of 'unexplained medical symptoms' - that catch-all phrase that is commonly used, and it's usually used with an implication that the person making that diagnosis thinks the problems are somehow of a psychological nature. But in reality that person has a serious disease, such as Lyme disease or Ehlers-Danlos Syndrome, hypermobility, both of which can give rise to a whole range, multiple physical or psychological issues.'

The case of Osheroff 10 mins
(somewhat surprisingly, the quote is from a book by E. Shorter. Oddly, because the case seems to favour medical intervention over talking therapy and Shorter has been a strong advocate for psychosomatic medicine.)
A doctor experiencing psychosis spent 7 months undergoing talk therapy, during which he lost his practice and his marriage, and was subsequently cured in a second institution with psychotropic medicine. He sued the first institution.

Dangers of emotional arousal 13 mins
'Interventions that risk increasing a person's feeling of being stigmatised or in which they are blamed for not meeting intervention targets, have been held to increase helplessness and self-blame, and so undermine a sense of self-efficacy.' There's an academic paper referenced for that quote, which might come in useful.

Hazards of CBT 14.45 mins
'CBT shifts responsibility onto the individual for engagement and conduct of the techniques. A recipient of this may feel guilty if the treatment does not result in the expected improvements, without realising that there are many other factors that may affect response.'

Dangers of psychodynamic therapy. 16.00 mins
'A potential consequence of externalising attributions of current difficulties to the behaviour of others (particularly parents) is estrangement and passive adoption of the victim role.' (I think this is a real danger where people are told that their ME/CFS symptoms are a result of childhood trauma.)

ADHD 21.30
'ADHD as a model of avoiding reality'. Mollon's description of ADHD ('Unrestrained narcissism' and 'pursuit of pleasure') struck me as very judgemental.

Freud - and outline of psychoanalysis 24.00
I thought the next slide on Freud's views of what the psychonanalyst should be doing was actually a better example of narcissism - the assumption that the psychoanalyst knew best. It's quite a freudian juxtaposition, I thought. Freud is quoted as 'Our knowledge is to make up for his ignorance and to give back his ego mastery over the lost provinces of his mental life. This pact constitutes the psychoanalytic situation '. Mollon approves, saying it is very good and sensible.

(but) Psychotherapy is sometimes not very effective 25.00
Quotes 'The Great Psychotherapy Debate' Bruce Wampold
Some percentages given on outcomes e.g. 15-24% of adolescents leave therapy in a worse state than when they started.

'Much hyped NHS IAPT Programme' (Parry et al) Only 6% of people referred to the programme recovered. This figure isn't publicised.'
(Could be worth tracking that paper down if we don't have it already.)

The most consistent finding in psychotherapy research is that there is very little difference between different sorts of therapies. The difference is between therapists.

Psychotherapists' Blind spot 28.00
90% of psychotherapists think that their outcomes are better than average.
Lambert did some research asking therapists to identify patients deteriorating under psychotherapy and likely to leave therapy worse off, and concluded 'psychodynamic therapists are usually over-confident in their clinical judgement'. Only one of 40 therapists, a trainee, was able to identify one such person, even though the researchers identified 40 such people out of 350. (Could be interesting to review that research.)

Doing what we do 29.30
Psychoanalyst Arnold Goldberg 'The analysis of failure', about psychoanalysis
'We do what we do and explain both success and failure on the basis of the theoretical approach that is most congenial to us.'

Addiction to psychoanalytical beliefs 30.00
Heinz Kohut's book of 1981 'How does analysis cure?'
'in the largest number of instances, a future analyst's training commits him ... to a particular set of theoretical beliefs. With very few exceptions ... the analyst does not stray from these beliefs, which he comes to make his own. Rather, he defends them loyally, displaying hostility and contempt toward those who do not share them. ... I do not believe that groups whose members display such deep and unswerving loyalty to specific sets of theories are encountered with such frequency in other sciences.'

Taking a break, and I'm only half way through. Thanks @Haveyoutriedyoga, there's a lot in that presentation.

 

Goals that are not legitimate 37.00
Include:

• offering formulas for illusory happiness
• persuading the client to adopt the therapist's world view, values or life strategies
• the therapist as the "one who knows" - the analyst is not in possession of special insights or knowledge concerning the secrets of life

(think CBT and the emphasis on producing management plans with goals)

A book of a German woman's account of undergoing psychotherapy 42.30
von Drigalski - Flowers on Granite
"Doubting the analyst would mean questioning the whole analysis, one's entire personal commitment, the point of the expense of time, emotion and money ... To doubt the analyst and all institutions his authority is based on requires self-confidence, something that I for one very soon lost."
"The fact that he had been so annoyed with me was my fault ... I was a difficult, complicated, sly person ... robbing him ... of power and potency. He was the recognised analyst and I was the hard case."
"He insisted on his own interpretation"
"Readers who wrote to me from all over convinced me that deterioration in psychoanalysis is teh rule rather than the exception"

"All things considered, having both been in therapy and dispensed it for many years, I would now take the position that the climate created by psychoanalysis destroys human relations, and that by and large, psychoanalytic treatment does more harm than good."
(Mollon struggles with this - after all he's given his life to this practice.)


Some of the ways analysis can become perverted 44.00
'Making hurtful interpretations; aggressively imposing a theory on a patient' (Mollon doesn't seem to have noticed he was making hurtful interpretations of the behaviour of people with ADHD just before.)

'Placing emphasis upon the patient's psychopathology - including pathologising aspects that are actually common in the population' (we've seen this again and again in ME/CFS - the suggestion that being sad and worried when your life comes to a screaming halt is depression and anxiety, and the depression and anxiety is somehow causing the illness.)

'Subtly denigrating or dismissing the patient's own insights and perspectives.'


Transmission 44.40

• "The analyst adheres to a 'strong' theory - rigidly held, all-encompassing
• The patients own preceptions, beliefs and emotions are constantly invalidated
• The patient may leave
• If the patient does not leave, the patient may identify with the aggressor, learn the theory and impose it on self and others
• May result in a perverse and cultish variant"

(think BPS, LP, ...)

Alienating impacts of diagnostic labels ( e.g. functional illnesses) 45.00
Diagnosis has commercial implications. The worse the diagnosis, the more money the institution earns. But the person identifies with the diagnosis.


How to fail as a therapist 47.30
Schwartz and Flowers - 50 ways to lose or damage your patients

• presuming to know too much
• ignoring science
• failing to provide an appropriate therapy for the client's condition

Ways of minimising risk of harm 58.00
Ask 'if something were stopping you from getting better, what would you guess it might be? What comes to mind?'
'Convey that it is the client's deeper mind that knows what needs to be addressed.'
(I think it can just as as easily be a way to cause harm if the person's illness has a physical cause. How is the patient supposed to work out what might make them better if the doctor can't? I think it's a recipe for giving all sorts of wrong ideas credence. Probably though the approach is helpful with addiction or harmful patterns of behaviour.)

I have to give Mollon credit - he has reflected on the topic of how psychotherapy can harm pretty comprehensively. It takes some courage and intelligence to look critically at your beliefs, and he seems to have spent time doing that.