Selling Bad Therapy to Trauma Victims

[Cheshire]

by Jonathan Shedler Ph.D.

Some very interesting remarks about psychotherapy RCTs (many relevant to CFS trials). But I worry some people would agree with this, say evaluation is impossible (main argument of psychoanalysts in France for eg.) and take the opportunity to sell even worst treatments...

This is a tricky question, really.

Patients received one of the “highly recommended” forms of CBT (prolonged exposure therapy) or a control treatment.

Here is what the study found.

• Nearly 40 percent of those who started CBT dropped out of treatment. They voted with their feet about its usefulness.
• 60 percent of the patients still had PTSD when the study ended.
• All patients were clinically depressed at the start of treatment and remained clinically depressed after treatment.
• At six-month follow-up, patients who received CBT were no better than those who received the control treatment.
• Nineteen serious “adverse events” occurred over the course of the study, including suicide attempts and psychiatric hospitalizations.
• The authors soberly noted that the patients “may need more treatment than the relatively small number of sessions typically provided in a clinical trial.”
• I did not choose this study as an example because it is a poor study. I chose it because it is arguably the best.

https://www.psychologytoday.com/blo...ded/201711/selling-bad-therapy-trauma-victims

 

[Jonathan Edwards]

by Jonathan Shedler Ph.D.

Some very interesting remarks about psychotherapy RCTs (many relevant to CFS trials). But I worry some people would agree with this, say evaluation is impossible (main argument of psychoanalysts in France for eg.) and take the opportunity to sell even worst treatments...

This is a tricky question, really.
https://www.psychologytoday.com/blo...ded/201711/selling-bad-therapy-trauma-victims

This is in fact just nonsense. He does not even identify the crucial difference between controlled trials and blinded controlled trials. He says that most science does not use randomised controlled trials but it does. CERN looking for the Higgs particle had to use a randomised controlled method, or at least an unselected controlled method. He is talking rubbish. His argument about flossing works because dentists say so is the worst of all arguments. It would be perfectly possible to do a randomised controlled trial of flossing - probably best to do a dose response study with people flossing either every day or once a week or twice a week.

Even Simon Wessely and Peter White can do better then this chap!!

 

[TiredSam]

A rag-bag of well-dodgy arguments.

Copernicus, Galileo, Darwin, Einstein, Niels Bohr, Marie Curie, Stephen Hawking. What do they have in common? None of them ever conducted an RCT.

Psychotherapy isn't physics. It isn't even science. This guy thinks the observations of psychotherapists should be equated with the work of Einstein and Hawking? In his dreams. I'm afraid Freud didn't quite make the grade:

http://www.asianage.com/life/more-features/300917/sigmund-freud-and-the-nobel-prize-trauma.html

 

[Cheshire]

This is in fact just nonsense. He does not even identify the crucial difference between controlled trials and blinded controlled trials. He says that most science does not use randomised controlled trials but it does. CERN looking for the Higgs particle had to use a randomised controlled method, or at least an unselected controlled method. He is talking rubbish. His argument about flossing works because dentists say so is the worst of all arguments. It would be perfectly possible to do a randomised controlled trial of flossing - probably best to do a dose response study with people flossing either every day or once a week or twice a week.

Even Simon Wessely and Peter White can do better then this chap!!

I was a bit uncomfortable with some of his arguments, and you're completely right about his critics of RCTs in general. In fact it's not RCTs per se, but the way they are taylored for CBT to give results (lenght of treaments etc...), but in general, critics of CBT in psychiatry come from even worst theorists...

I"m really wondering what good psychiatry looks like (I guess a good psychiatrist is empathetic and listens to his patients, especially about medication side effects, but that's not enough...)

 

[Hoopoe]

I"m really wondering what good psychiatry looks like (I guess a good psychiatrist is empathetic and listens to his patients, especially about medication side effects, but that's not enough...)

I'm guessing a good psychiatrist firmly stands with the patient, is well aware of the diagnostic uncertainty present in this area, and is pragmatic when it comes to treatment. So basically the opposite of White, Sharpe, etc.

 

[Jonathan Edwards]

I"m really wondering what good psychiatry looks like (I guess a good psychiatrist is empathetic and listens to his patients, especially about medication side effects, but that's not enough...)

Good psychiatry is awesome and I have had the privilege to come across it. It is humble, pragmatic and knowledgeable and does not give up when things do not work out but carries on until a human solution has been found. It has pretty much nothing to do with psychotherapy of any sort.

 

[Woolie]

I read the article, and was pretty taken aback by the clear agenda shining through - which is that we just "know" therapy works, we don't care what RCTs show. RCTs fail to demonstrate its "true" effectiveness, because they don't provide enough sessions or the therapists they engage are just not good enough at it.

Its bit like saying that studies have failed to provide evidence of the existence of psychic abilities only because you can't test it under controlled conditions. Its still "real".

An awfully biased account written by someone with a huge personal and professional investment in psychotherapy who's not going to be dissuaded by a few negative RCT's.

Spend enough time/money on us, he argues, and eventually, you will benefit. Trust me, I'm a psychologist.

 

[Alvin]

I don't have the energy to pick apart the multiple pieces of nonsense in that article so i'll just say its a perfect example of why the facepalm emoji is so necessary

 

[Trish]

I agree with everyone here that the article is unscientific junk.

So RCT trials are done on short courses of poor quality therapy and shows they don't work. So far so good. It's surely a good thing to show that a few sessions of CBT by poorly trained therapists doesn't help patients suffering serious trauma.

It is also probably reasonable to point out that such trials say nothing about the effectiveness or otherwise of long courses of more intensive therapy by more experienced practitioners.

But it is not OK to say that therefore clinical trials are the problem, and that we 'know' that 'good' therapy works, using all sorts of ridiculous and irrelevant arguments about other areas of science.

 

[Woolie]

So RCT trials are done on short courses of poor quality therapy and shows they don't work. So far so good. It's surely a good thing to show that a few sessions of CBT by poorly trained therapists doesn't help patients suffering serious trauma.

We don't really know if they were bad at their job though, do we? The only thing we know for sure is the the writer thinks the dose of therapy give was insufficient.

He mentions that 75% of patients feel better after 40 sessions. But that must take about a year. Surely, by then, a lot of people will be feeling better anyway - especially if they were being treated for a recent trauma.

 

[Alvin]

We don't really know if they were bad at their job though, do we? The only thing we know for sure is the the writer thinks the dose of therapy give was insufficient.

He mentions that 75% of patients feel better after 40 sessions. But that must take about a year. Surely, by then, a lot of people will be feeling better anyway - especially if they were being treated for a recent trauma.

It basically seems to come down to science is failing our ideology so disregard it
Funny that it never comes down to science is not backing us up, why is that, lets find out why and improve our processes.