The Elephant on the Couch: Side-Effects of Psychotherapy (Berk & Parker, 2009)

I haven't looked at the main article yet. But if they're saying the biggest problem with CBT is that some patients don't have the smarts to fully engage with it, then that's more the mouse on the couch, not the elephant.

The elephant on the couch is the assumption that negative thoughts and behaviours drive negative feelings. And changing the first two will fix the last. Why anyone would accept this assumption completely unquestioningly is beyond me. It would seem much more likely that the feelings drive the thoughts and behaviours.
 
The real problem looks to me to be in the first sentence - the assumption that there is something called a 'cognitive schema' that 'causes...' or that there are 'cognitive assumptions'. It is time psychologists admitted that nobody knows what these terms mean.

But I guess the full article is about CBT in general and the need for therapists to realise that they can do as much harm as good - which cannot be bad.
 
Jonathan Edwards said:
But I guess the full article is about CBT in general and the need for therapists to realise that they can do as much harm as good - which cannot be bad.
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I'm not so sure - if the message is, 'Your patients may be so stupid that they can't implement your brilliant therapy,' then I think it could just reinforce a positive sense of 'the therapist is always right', which is the big problem from the get-go.

Woolie said:
It would seem much more likely that the feelings drive the thoughts and behaviours.
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I find each quite plausible - does the technology exist yet to yield an answer to the question of which way round it is?
 
I've skim read through the whole article. It seemed to me to be quite a usefully thoughtful article, suggesting many ways in which therapy has been shown to be worse than useless, causing more harm than good, and some reasons why this may happen.

Probably the sort of thing that should be stuck in front of students training to be therapists, and practising therapists, to remind them that they are not gods, and their idea of a wise course for their patients may be counterproductive.
 
How do we know that the CBT therapist doesn't need CBT themselves to decide which behaviours are "right or wrong" and then if they do receive CBT how do we know that the therapist delivering it to them doesn't need it and if that therapist is receiving it how do we know that the person delivering it to them doesn't need it, and then if they are receiving it..........

And then when we get to the Wizard behind the curtain how do we know that they are not a complete bullshitter and who oversees their logic?
 
Why is the adverse side of the ledger neglected?

If these exemplars of omission and commission are accepted as potential cost risks to psychotherapy, why do we neglect this side of the ledger? First, it may be that we assume that the caveat emptor principle holds – that if a patient is referred to a psychotherapist who is clearly ineffective, exploitative or insensitive, they would choose not to return, thus preventing exposure to any distinct adverse event. For those who chose to stay, however, two processes may occur that, because they are neither overt nor clearly causal, may not be appreciated as generating adverse events. First, the ‘boiling frog’ principle, in which we adjust to stressors if they occur incrementally or slowly, and become accepting. Thus, when omission and commission concerns are less evident, blatant or immediate, a patient may continue with the psychotherapy despite a progressive smouldering enmeshment process that, because it unfolds slowly or subtly, builds to the boiling frog analogy. Examples include an unstructured meandering psychotherapy that fails to address the patient's problems, or the therapist subtly prioritizing their own needs. Worse, the patient may be unaware of the exploitation and, as one consequence of the confused agendas, even enjoy it. As Beddoe observed: ‘Within days Max's visits became the most anticipated event in my day’ [4].

A second contribution is that, while there is usually a clear-cut causal process in establishing a drug side-effect, it is less easy to argue any temporal causal link associated with psychotherapy. For example, if a depressed patient is commenced on an antidepressant drug, and they report immediate sedation and weight gain, the drug is the a priori causal agent. For a depressed patient receiving ineffective or inappropriate psychotherapy, negative consequences lack the immediacy of a distinctive drug side-effect. Even if the patient feels some discomfort about the psychotherapeutic approach and/or the psychotherapist themselves, there is a risk that such concerns will be rationalized (e.g. ‘I'm aware that therapy will take a long time’; ‘I'm not so sure about my therapist, but maybe that's my fault’) rather than being linked to something lacking or inappropriate in therapy.
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I think it boils down to the fact that patients are inevitably vulnerable, and doctors frequently in a position of having to play god, with all the power that comes with that. A sound moral compass, strong sense of responsibility, competence, etc, are crucial. Patients genuinely needing CBT will be vulnerable by definition.
 
Sasha said:
I find each quite plausible - does the technology exist yet to yield an answer to the question of which way round it is?
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I agree that thoughts can contribute to certain mild states of distress. Worry about finances. Lack of confidence in your appearance. But even in these examples, I suspect there's still a mood element driving it all beneath the surface.

I suspect its a natural human illusion to imagine that our thoughts are running the show. Most of the time its our emotions and core drives and our learned responses. The idea that we think over options, then act according to the output of our thinking, is unlikely to be true. More likely we use the thoughts to rationalise our drives, emotions and propensities.

Not saying people can't think rationally. But its an add-on, its not what supports the core of our behavior.

And people with serious psychological problems don't get there by having "the wrong thoughts". This is definitely the tail wagging the dog. Depression, anxiety and such are at their core emotional distress, and it is harmful to make a person feel they got that way by having negative thoughts. And that they need to fix their attitude if they want to get better.

Actually, when you start to think on it, this is exactly the same kind of harm that PwMEs experience when we're told we can get better by replacing our bad thoughts with good ones.
 
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Woolie said:
I agree that thoughts can contribute to certain mild states of distress. Worry about finances. Lack of confidence in your appearance. But even in these examples, I suspect there's still a mood element driving it all beneath the surface.

I suspect its a natural human illusion to imagine that our thoughts are running the show. Most of the time its our emotions and core drives and our learned responses. The idea that we think over options, then act according to the output of our thinking, is unlikely to be true. More likely we use the thoughts to rationalise our drives, emotions and propensities.

Not saying people can't think rationally. But its an add-on, its not what supports the core of our behavior.

And people with serious psychological problems don't get there by having "the wrong thoughts". This is definitely the tail wagging the dog. Depression, anxiety and such are at their core emotional distress, and it is harmful to make a person feel they got that way by having negative thoughts. And that they need to fix their attitude if they want to get better.

Actually, when you start to think on it, this is exactly the same kind of harm that PwMEs experience when we're told we can get better by replacing our bad thoughts with good ones.
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Where is the 'Double Like' button?
 
Woolie said:
I agree that thoughts can contribute to certain mild states of distress [..]

And people with serious psychological problems don't get there by having "the wrong thoughts". This is definitely the tail wagging the dog. Depression, anxiety and such are at their core emotional distress, and it is harmful to make a person feel they got that way by having negative thoughts.
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Bereavement, for instance, can cause serious depression - and since that's an external event, it can only be one's cognitive/psychological reaction to it that causes the depression. It's not that people got there by having 'wrong thoughts' - but surely they did get there by having thoughts?

Once the damage is done and the person is in serious depression, their thinking seems so utterly irrational and bizarre that it does look to me like something driven by a biological process and not by 'wrong thoughts'. But whether adjusting your thoughts when depressed could help as a treatment is surely an empirical matter (and I'm not talking about the sort of shit trials that typically get done in psychiatry).

I may be arguing against an empirical case that has already been well-made but I'm not up on that literature. :)

Actually, when you start to think on it, this is exactly the same kind of harm that PwMEs experience when we're told we can get better by replacing our bad thoughts with good ones.
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We know we didn't get ME by 'bad thoughts' because we know ME isn't a psychological illness. A large chunk of us don't have depression or any sign of deluded thinking. But when an illness has peculiar thinking as one of its key symptoms, I think it's understandable to look at that thinking and see if attempting to alter it can affect the illness. What's not understandable is to persist in that model if it's wrong.

But is it wrong? Is there research evidence that bears on this question?
 
Sasha said:
Bereavement, for instance, can cause serious depression - and since that's an external event, it can only be one's cognitive/psychological reaction to it that causes the depression. It's not that people got there by having 'wrong thoughts' - but surely they did get there by having thoughts?
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But "cognitive/psychological reaction" covers a lot of ground. I'm arguing the reaction in cases like grief is primarily emotional, not cognitive.

I don't think its necessary to add in a layer of self-reflection, or negative thought patterns, to understand grief. We humans form deep attachments and can come to depend on special people for warmth, love, support security. It is a major loss when someone close dies, our world is turned upside down. And its not just us but all social species, who go into retreat for long periods in the face of such loss. You don't need to assume the person is thinking catastophically or anything.
Sasha said:
We know we didn't get ME by 'bad thoughts' because we know ME isn't a psychological illness. A large chunk of us don't have depression or any sign of deluded thinking. But when an illness has peculiar thinking as one of its key symptoms, I think it's understandable to look at that thinking and see if attempting to alter it can affect the illness. What's not understandable is to persist in that model if it's wrong.
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Yes, its fine to consider that. My concerns is that it is not "considered", it is assumed. Unquestioningly.
Sasha said:
But is it wrong? Is there research evidence that bears on this question?
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No, there isn't. No-one's interested in testing this view. Everyone's interested in supporting the model that aligns with CBT and other form of psychotherapy.
 
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Woolie said:
But "cognitive/psychological reaction" covers a lot of ground. I'm arguing the reaction in cases like grief is primarily emotional, not cognitive.

I don't think its necessary to add in a layer of self-reflection, or negative thought patterns, to understand grief.
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Nor do I, and I think we agree on this - I'm just saying that the trigger is cognitive (if you don't know someone has died, there's no trigger for the grief). But whether grief is susceptible to a cognitive intervention is a different matter. If a cognitive event can trigger grief, perhaps another cognitive event can help heal it. Or perhaps not.

Yes, its fine to consider that. My concerns is that it is not "considered", it is assumed. Unquestioningly.

No, there isn't. No-one's interested in testing this view. everyone's interested in supporting the model that aligns with CBT and other form of psychotherapy.
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I think then that there needs to be an empirical testing of the model - properly done, and by people not invested in the CBT model. I think they have a plausible model, and I think that what you're saying is also plausible. I think we have to be careful of making strong claims on either side.
 
I've now read to the end of the article. It was really good. Some nice examples of possible harms in psychotherapy:
  • Psychotherapy with troubled and vulnerable psychiatric patients, which involves powerful suggestion based on a unsubstantiated models of the persons' key difficulties. e.g. In Anna O, Breuer may have "unwittingly encouraged and amplified Anna's dissociations, reified her ego fragments, and then explained Anna's symptoms with the pseudo-memories and confabulations recovered from Anna while she was hypnotized".
  • Therapies that are highly confrontational, where patients are chastised for not meeting targets (e.g,m some substance abuse therapies. Or "high-risk treatment processes such as confrontation, criticism and highly emotive techniques, because they can exacerbate primary symptoms, or initiate new symptoms such as increased anxiety or anger"
  • Therapies that focus on past events, rather than current issues, "may promote an externalized locus of control...". For example, if the patient is encouraged to attribute their problems to the behaviour of others, and as parents. The consequences can be "estrangement, disengagement and passive adoption of the victim role".
  • .... although many patients are unlikely to take up or continue with a treatment that lacks credibility, individuals with psychological distress are often so perturbed by their condition that their judgment about such matters can be compromised. If in doubt, they may continue with the therapy, due to the belief that the credibility or benefits of the therapy will emerge over time, or that there's something wrong with them, or because they are unaware of alternative strategies
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This one was interesting, as it touches on what happens when sick people are sent for therapy to treat their "symptoms":
  • Some patients describe analytic psychotherapy as providing a ‘heads you lose, tails you lose’ model. If you abandon protective defence mechanisms and declare frailties, you are exposed; if you deny, you demonstrate resistance. Both analytic and cognitive therapies provide cogent explanations for an individual's distress. Individuals with personality disorders who have rigid and extreme schemas frequently struggle to compare their perceptions with those of the expert, and are forced to accept or reject these without the capacity for them to be integrated. The resulting dissonance between inner experience and the imposed perspective can risk bewilderment and further instability
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I don't know how many different kinds of psychotherapy there are. But what has been described in the various posts and links on this thread doesn't match my experience of treatment that was referred to as psychotherapy.

It began in the late 1970s. I was a teenager. I was severely depressed (for good reasons). I was referred to a psychiatrist, seen once and promptly dismissed as not being in need of his help. He suggested that I might benefit from seeing a psychotherapist, and somehow (I can't remember the details now) this was arranged.

So, I ended up seeing a woman whose idea of how to treat me appeared to have been modelled on stereotypes of how Freud is supposed to have treated his patients. The only difference is that I sat in a chair facing her, I didn't lie on a couch with the therapist out of sight. And I spent the next few months with her mostly just sitting there and barely saying a word, while I struggled to find things to say without repeating myself. When she did speak she spent her time telling me that all my problems were my own fault and I should take responsibility for being depressed. What can I say about it? It was an absolute disaster, served no purpose whatsoever, didn't make me any better, or any less depressed, or any mentally stronger. And I saw this woman fairly regularly for about 18 months, then wrote to her and said I was discharging myself and wouldn't see her again. All I remember after that was that she was absolutely furious. What a waste of time and NHS resources it was.
 
How awful, @Arnie Pye! Its amazing just how long we put up with this sort of shit, isn't it? Because we're told they know their stuff, and we're taught to be agreeable and cooperative patients.

I saw a psychiatrist when I first got ill in my 20s, mainly because I wanted support and at that time only psychiatry was covered by our national medical scheme. Similar to your experience, he just sat there taking what appeared to be copious notes (who really knows), which he never seemed to use or refer to ever again. At least he wasn't outright harmful, like your woman appeared to be. But like you, I kept going back for quite a while despite no apparent benefit, and when I finally said I wouldn't be returning, he was desperate to convince me to keep on (something about how he hadn't seen a case of CFS before, as if somehow it was all about him).

He also diagnosed me with depression (gave me prozac), which I now realise was incorrect. I was upset and in grief for my lost health and just needed some support and understanding.
 
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