Aaron Beck & Cognitive Therapy
October 9, 2009 6:05 PM Subscribe
“The psychoanalytic mystique was overwhelming. It was a little bit like the evangelical movement.” How Aaron Beck and Cognitive Behavioral Therapy helped increase empiricism in psychotherapy.
Yeah, one of the most interesting things here for me -- who thinks of Beck as a hardcore anti-analyst -- is this:
"Psychoanalysis is comparable to an authoritarian type of religion where people have absolute control of the faith and there is no place for dissent. Everything is predetermined. The more contact I had with the psychoanalytic establishment, the more distasteful it became to me. If there was an emotional component in my rejecting psychoanalysis, it is that I do not like to be wrong. I did not want to be wrong by rejecting it totally and I do feel that I learned a number of important things from psychoanalysis which other schools were not aware of. Transference is one of these things, and I do deal with transference in my work..."
and so on.
I think lots of Beck's followers, though, find nothing of value in psychoanalysis -- except the baseline fact, now pretty well empirically validated, that having regular conversations with somebody who's paying attention is good for you. Even if they're paid to pay attention. (Especially if they're paid to pay attention, Freud would have said.)
posted by escabeche at 6:30 PM on October 9, 2009 [1 favorite]
"Psychoanalysis is comparable to an authoritarian type of religion where people have absolute control of the faith and there is no place for dissent. Everything is predetermined. The more contact I had with the psychoanalytic establishment, the more distasteful it became to me. If there was an emotional component in my rejecting psychoanalysis, it is that I do not like to be wrong. I did not want to be wrong by rejecting it totally and I do feel that I learned a number of important things from psychoanalysis which other schools were not aware of. Transference is one of these things, and I do deal with transference in my work..."
and so on.
I think lots of Beck's followers, though, find nothing of value in psychoanalysis -- except the baseline fact, now pretty well empirically validated, that having regular conversations with somebody who's paying attention is good for you. Even if they're paid to pay attention. (Especially if they're paid to pay attention, Freud would have said.)
posted by escabeche at 6:30 PM on October 9, 2009 [1 favorite]
I've personally encountered the CBT acronym in at least two rather orthogonal interpretations, only one of which is what this post refers to. Both have improved my mood. Maybe it's something about those three letters?
posted by treepour at 6:43 PM on October 9, 2009 [7 favorites]
posted by treepour at 6:43 PM on October 9, 2009 [7 favorites]
While I have no firsthand experience with CBT, I am a big fan of its concepts and have tried to implement them in my own life with varying degrees of success. I think it has a lot to offer.
posted by Mike Buechel at 6:47 PM on October 9, 2009
posted by Mike Buechel at 6:47 PM on October 9, 2009
Any more s&m puns you dorks and I'll come to your house with rigging equipment.
posted by Non Prosequitur at 6:51 PM on October 9, 2009
posted by Non Prosequitur at 6:51 PM on October 9, 2009
Yes, as one of my friends says, "CBT is helpful, but not deep."
I think most people in CBT would say "There's no evidence that it's helpful to be deep." And Freud would say "The point is to be deep, and if it's helpful that's just an agreeable side effect." Which I guess is to say they agree.
posted by escabeche at 6:56 PM on October 9, 2009 [5 favorites]
I think most people in CBT would say "There's no evidence that it's helpful to be deep." And Freud would say "The point is to be deep, and if it's helpful that's just an agreeable side effect." Which I guess is to say they agree.
posted by escabeche at 6:56 PM on October 9, 2009 [5 favorites]
Another thread about Glenn Beck? Huh? Wrong Beck? Well, yeah, he did a good version of "Everybody's Gotta Learn Sometime", but I wouldn't call it 'Cognitive Therapy'...
posted by evilmidnightbomberwhatbombsatmidnight at 6:59 PM on October 9, 2009
posted by evilmidnightbomberwhatbombsatmidnight at 6:59 PM on October 9, 2009
the powerful American Psychoanalytic Institute rejected his membership application on the grounds that his mere desire to conduct scientific studies signaled that he’d been improperly analyzed. (The decision still has the capacity to make him angry: “It was just the height of stupidity . . . total thought control.”)
Amazing. And there are still a large number of Psychoanalytic Institutes and non-empirically based psychoanalysts in the world. There are probably still lots of witch doctors in the world too.
I think sometimes it can be useful to have someone with an air of mystical wisdom listen to your problems. I just don't think such people should be paid a lot of money.
posted by eye of newt at 7:24 PM on October 9, 2009 [3 favorites]
Amazing. And there are still a large number of Psychoanalytic Institutes and non-empirically based psychoanalysts in the world. There are probably still lots of witch doctors in the world too.
I think sometimes it can be useful to have someone with an air of mystical wisdom listen to your problems. I just don't think such people should be paid a lot of money.
posted by eye of newt at 7:24 PM on October 9, 2009 [3 favorites]
Parallel and similar to CBT would be behaviorism (see: B.F Skinner). My father, barely post-WWII, was an early adopter of this therapeutic mode, and was the only one in his class not to undergo psychoanalysis. (He was a child psychiatrist, working with a clientele perhaps best suited to the behaviorist model.)
Although psychologists have embraced a lot of modalities over the years, there was really only a brief window of time between the Freudian era and the pharmaceutical era when other practices were tolerated in the psychiatric world. My father was of a scientific bent, and did not believe that studies validated the efficacy of psychoanalysis.
On a personal note, he was a wonderful father but a bit remote...at one point my mother said maybe be might have benefited from some psychoanalysis.
posted by kozad at 7:50 PM on October 9, 2009 [2 favorites]
Although psychologists have embraced a lot of modalities over the years, there was really only a brief window of time between the Freudian era and the pharmaceutical era when other practices were tolerated in the psychiatric world. My father was of a scientific bent, and did not believe that studies validated the efficacy of psychoanalysis.
On a personal note, he was a wonderful father but a bit remote...at one point my mother said maybe be might have benefited from some psychoanalysis.
posted by kozad at 7:50 PM on October 9, 2009 [2 favorites]
Starting in my teens, I've been through a bunch of different talk therapies for major depression: Freudian analysis, eclecticism, CBT, CBASP (a sub-field based on CBT, but focused on individual events rather than overarching thoughts) and hypnosis. I enjoyed the Freudian analysis the most, but it was the CBASP that actually led to a result.
Which was a pity, really, because Freudian analysis is so much more romantic.
posted by subbes at 9:06 PM on October 9, 2009 [1 favorite]
Which was a pity, really, because Freudian analysis is so much more romantic.
posted by subbes at 9:06 PM on October 9, 2009 [1 favorite]
My extremely fallible memory tells me I read this in either _Against Depression_ by Peter Kramer or in one of his blog posts on Psychology Today's site:
In the late 60s and early 70s it was becoming clear to everyone in psychiatry, except extreme partisans of partcular forms of therapy, that just about all forms of talk therapy were approximately equally effective. What was not known is how effective any of them were vis-a-vis other forms of treatment, such as drugs, ECT, etc.
A series of studies were done to test this effectiveness. For consistency they picked one form of talk therapy, one which was very easy to replicate -- you followed simple rules as to how to respond to your client and what habits to try to inculcate in him or her. Couldn't be something that required deep and difficult training or particular personal qualities on the part of the therapist, that would introduce too many variables into the experiment. You needed, in short, a fairly boring and simple therapy.
Cognitive-behavioral therapy fit the bill! So a series of studies was done comparing CBT to various other treaments, where CBT was supposed to be a convenient exemplar of talk therapy in general.
These experiments showed that talk therapy did fairly well in comparison to other forms of treatment.
The next thing to do would have been to compare different forms of talk therapy to each other, to see if differences could be found in their relative effectiveness, now that talk therapy had been experimentally validated as effective.
Guess what! It was the 70s. Rough time for mental health care. Funding for mental health issues dried the hell up.
Through this historical accident, CBT became "the only form of psychotherapy which is experimentally validated as clinically effective in an extensive series of studies." It became the psychotherapy of choice because of these credentials. Its theories of mind and emotion gained prestige.
(enter rant mode!)
Everything became a matter of thinking wrong! You've got mental health issues? Don't worry if you were raped repeatedly as a child. Don't worry if schizophrenia or bipolar disorder have run in your family for generations. Don't worry if you watched your buddies ripped to shreds on the battlefield. That's not your real problem. Your real problem is that you haven't learned to think properly about these things! If you feel bad, you're thinking wrong, because all feelings come from thoughts, and hurtful feelings come from irrational thoughts.
(end rant mode)
posted by edheil at 9:14 PM on October 9, 2009 [10 favorites]
In the late 60s and early 70s it was becoming clear to everyone in psychiatry, except extreme partisans of partcular forms of therapy, that just about all forms of talk therapy were approximately equally effective. What was not known is how effective any of them were vis-a-vis other forms of treatment, such as drugs, ECT, etc.
A series of studies were done to test this effectiveness. For consistency they picked one form of talk therapy, one which was very easy to replicate -- you followed simple rules as to how to respond to your client and what habits to try to inculcate in him or her. Couldn't be something that required deep and difficult training or particular personal qualities on the part of the therapist, that would introduce too many variables into the experiment. You needed, in short, a fairly boring and simple therapy.
Cognitive-behavioral therapy fit the bill! So a series of studies was done comparing CBT to various other treaments, where CBT was supposed to be a convenient exemplar of talk therapy in general.
These experiments showed that talk therapy did fairly well in comparison to other forms of treatment.
The next thing to do would have been to compare different forms of talk therapy to each other, to see if differences could be found in their relative effectiveness, now that talk therapy had been experimentally validated as effective.
Guess what! It was the 70s. Rough time for mental health care. Funding for mental health issues dried the hell up.
Through this historical accident, CBT became "the only form of psychotherapy which is experimentally validated as clinically effective in an extensive series of studies." It became the psychotherapy of choice because of these credentials. Its theories of mind and emotion gained prestige.
(enter rant mode!)
Everything became a matter of thinking wrong! You've got mental health issues? Don't worry if you were raped repeatedly as a child. Don't worry if schizophrenia or bipolar disorder have run in your family for generations. Don't worry if you watched your buddies ripped to shreds on the battlefield. That's not your real problem. Your real problem is that you haven't learned to think properly about these things! If you feel bad, you're thinking wrong, because all feelings come from thoughts, and hurtful feelings come from irrational thoughts.
(end rant mode)
posted by edheil at 9:14 PM on October 9, 2009 [10 favorites]
A recent Newsweek editorial specifically addresses the conflict between empircal and non-empirical forms of psychology. Personally, I think there is room for a variety of therapies out there. And sometimes it is about "getting better" and sometimes getting better isn't the point -- maybe sometimes the point is simply to have a safe neutral place to process what is going on in your life.
posted by Deathalicious at 9:49 PM on October 9, 2009
posted by Deathalicious at 9:49 PM on October 9, 2009
From my experience edheil's rant is right on the money. The idea that you can just think the right way and all your problems will evaporate is flawed. The biggest benefit from the CBT group I was in, was talking to people in a similar situation and talking about living with those problems.
I tend to treat working on my depression as a full time job so I took the ideas behind CBT and tried to apply them everywhere I could. I hit wall after wall of marginal usefulness.
posted by Submiqent at 10:11 PM on October 9, 2009 [1 favorite]
I tend to treat working on my depression as a full time job so I took the ideas behind CBT and tried to apply them everywhere I could. I hit wall after wall of marginal usefulness.
posted by Submiqent at 10:11 PM on October 9, 2009 [1 favorite]
Everything became a matter of thinking wrong! You've got mental health issues? Don't worry if you were raped repeatedly as a child. Don't worry if schizophrenia or bipolar disorder have run in your family for generations. Don't worry if you watched your buddies ripped to shreds on the battlefield. That's not your real problem. Your real problem is that you haven't learned to think properly about these things! If you feel bad, you're thinking wrong, because all feelings come from thoughts, and hurtful feelings come from irrational thoughts.
This rant could be applied equally to every other form of talk therapy out there.
posted by afu at 10:36 PM on October 9, 2009
This rant could be applied equally to every other form of talk therapy out there.
posted by afu at 10:36 PM on October 9, 2009
Not to be difficult, but edhell's rant is a stupid cartoon of CBT. Maybe there are stupid, cartoonish CBT therapists who practice this way -- how could there not be? But the idea of CBT isn't:
That's not your real problem. Your real problem is that you haven't learned to think properly about these things! If you feel bad, you're thinking wrong, because all feelings come from thoughts, and hurtful feelings come from irrational thoughts.
or
Don't worry if you were raped repeatedly as a child.
You can tell these aren't the real ideas behind CBT, because these ideas are stupid, and the people who founded CBT weren't.
A better paraphrase would be something like
"Your feelings, like everyone's feelings, are immensely complicated and arise from some combination of your life experience, your genes, your neurochemistry, your thoughts, your behaviors, and so on. The first two are impossible to change. The third, psychopharmacology knows something about how to change. The fourth and fifth are the ones talk therapy is good at changing, so we concentrate on developing techniques for changing them in ways that make you feel better."
posted by escabeche at 11:00 PM on October 9, 2009 [3 favorites]
That's not your real problem. Your real problem is that you haven't learned to think properly about these things! If you feel bad, you're thinking wrong, because all feelings come from thoughts, and hurtful feelings come from irrational thoughts.
or
Don't worry if you were raped repeatedly as a child.
You can tell these aren't the real ideas behind CBT, because these ideas are stupid, and the people who founded CBT weren't.
A better paraphrase would be something like
"Your feelings, like everyone's feelings, are immensely complicated and arise from some combination of your life experience, your genes, your neurochemistry, your thoughts, your behaviors, and so on. The first two are impossible to change. The third, psychopharmacology knows something about how to change. The fourth and fifth are the ones talk therapy is good at changing, so we concentrate on developing techniques for changing them in ways that make you feel better."
posted by escabeche at 11:00 PM on October 9, 2009 [3 favorites]
CBT fits in very nicely in a Western, Cartesian paradigm of healing. Isolate thoughts, behaviors, emotions, etc into their meaningful (or not meaningful, whatever) components and then increase or decrease them accordingly. Measure what is observable, don't pay attention to what isn't observable because that's not convenient, and therefore could not be important.
I'm not against whatever works for people. . . CBT is a lot less threatening because you don't have to face things that are uncomfortable-- but when you start to realize the role that the uncomfortable (which can be a euphemistic term here) in how it runs your life, well, then CBT homework assignments start to look kind of limiting.
What is encouraging is that efficacy studies of Psychodynamic/Psychoanalytic therapeutic interventions (even, wait for it. . . empirical ones!) are very positive, and particularly in the long term. CBT, not as much. But, if you went to therapy looking for a band-aid (as opposed to a foundational change) and got your band-aid, well, I'm glad that worked out for you.
posted by No New Diamonds Please at 11:47 PM on October 9, 2009 [7 favorites]
I'm not against whatever works for people. . . CBT is a lot less threatening because you don't have to face things that are uncomfortable-- but when you start to realize the role that the uncomfortable (which can be a euphemistic term here) in how it runs your life, well, then CBT homework assignments start to look kind of limiting.
What is encouraging is that efficacy studies of Psychodynamic/Psychoanalytic therapeutic interventions (even, wait for it. . . empirical ones!) are very positive, and particularly in the long term. CBT, not as much. But, if you went to therapy looking for a band-aid (as opposed to a foundational change) and got your band-aid, well, I'm glad that worked out for you.
posted by No New Diamonds Please at 11:47 PM on October 9, 2009 [7 favorites]
I think there's a wall plaque like that:
"God, Give us the grace to accept with serenity
the things that cannot be changed, Courage
to change the things which should be changed,
And the wisdom to distinguish the one from the other."
You can change your thoughts and behaviors, so why not make the effort?
posted by Jimmy Havok at 12:02 AM on October 10, 2009 [1 favorite]
"God, Give us the grace to accept with serenity
the things that cannot be changed, Courage
to change the things which should be changed,
And the wisdom to distinguish the one from the other."
You can change your thoughts and behaviors, so why not make the effort?
posted by Jimmy Havok at 12:02 AM on October 10, 2009 [1 favorite]
don't pay attention to what isn't observable because that's not convenient
Yeah, being unable to observe something makes paying attention to it very inconvenient. Like a blind man doesn't pay attention to his color coordination because it's not convenient.
posted by Jimmy Havok at 12:06 AM on October 10, 2009 [4 favorites]
Yeah, being unable to observe something makes paying attention to it very inconvenient. Like a blind man doesn't pay attention to his color coordination because it's not convenient.
posted by Jimmy Havok at 12:06 AM on October 10, 2009 [4 favorites]
I can't speak for other disorders but I can vouch for this type of therapy in the treatment of gambling addiction. I struggled for 30 years with a serious gambling addiction. Very rarely would a day go by without me having a bet on the horses, trots, dogs, buying a lottery ticket, playing the one-arm bandits, going to footie clubs to play the pokies and casinos to play cards (illegal initially [hard] and then legal [easy] - fuck you very much Star City), even visiting bingo halls fer' chrissakes. I hit 'rock bottom', alienated friends and family and was in all sorts of financial trouble many times. I tried willpower, attended GA, went to the Wesley Mission and read as much as I could on the subject to inform myself and try and understand why I did what I did. I outed myself, thinking that then I would stop because it's so shameful and everyone would know what I'm doing. All of it came to naught.
About 5 years ago I read a newspaper article about Fadi Anjoul and the work he was doing at Sydney University – Counselling Problem Gamblers [pdf]. I had a 6 month course of treatment and it turned my life around and possibly saved it (suicide is never far away in your thoughts when you are in desperate straits).
It isn't a cure, I had a small bust a couple of years ago (a couple of all-niters on the pokies when other stuff in my life was proving difficult to handle) and it scared the hell out of me so I went for a top-up at St. Vincents (they also employ the CBT model) and that fixed me up quicksmart. This is an important point, you need refreshers — I don't know if that's true of other therapies.
It won't be for everyone. If you are not a list keeper, not into self-discovery and don't dig Socratic questioning, it might not appeal. I embraced it because it employed science (how the odds are stacked against you) and behavioural modification (recognising that you react in this way, because…).
If you have family or friends who are struggling as I was, I would recommend that you encourage them to try this type of counselling.
Thank you, Aaron Beck.
posted by tellurian at 1:37 AM on October 10, 2009 [8 favorites]
About 5 years ago I read a newspaper article about Fadi Anjoul and the work he was doing at Sydney University – Counselling Problem Gamblers [pdf]. I had a 6 month course of treatment and it turned my life around and possibly saved it (suicide is never far away in your thoughts when you are in desperate straits).
It isn't a cure, I had a small bust a couple of years ago (a couple of all-niters on the pokies when other stuff in my life was proving difficult to handle) and it scared the hell out of me so I went for a top-up at St. Vincents (they also employ the CBT model) and that fixed me up quicksmart. This is an important point, you need refreshers — I don't know if that's true of other therapies.
It won't be for everyone. If you are not a list keeper, not into self-discovery and don't dig Socratic questioning, it might not appeal. I embraced it because it employed science (how the odds are stacked against you) and behavioural modification (recognising that you react in this way, because…).
If you have family or friends who are struggling as I was, I would recommend that you encourage them to try this type of counselling.
Thank you, Aaron Beck.
posted by tellurian at 1:37 AM on October 10, 2009 [8 favorites]
if you went to therapy looking for a band-aid (as opposed to a foundational change) and got your band-aid, well, I'm glad that worked out for you.
So what you're saying is that if CBT worked for someone, it's because they didn't really have serious problems? WTF? Or is it that CBT doesn't give a real solution, just a fake one?
What exactly are you basing this opinion on?
posted by harriet vane at 3:45 AM on October 10, 2009
So what you're saying is that if CBT worked for someone, it's because they didn't really have serious problems? WTF? Or is it that CBT doesn't give a real solution, just a fake one?
What exactly are you basing this opinion on?
posted by harriet vane at 3:45 AM on October 10, 2009
Well, it's pretty clear : psychoanalysis considers that symptoms have meanings. If you want to look for these meanings, psychoanalysis is a praxis that allows you to do so. If you do not want to, psychoanalysis doesn't tell you that you should. Nothing could be more different from an evangelical movement.
posted by nicolin at 4:01 AM on October 10, 2009
posted by nicolin at 4:01 AM on October 10, 2009
Just a few things, for what it's worth.
1. When you listen to tapes of Beck using CBT he really is doing something much more psychoanalytic than CBT.
2. Most CBT practitioners these days acknowledge that the baby has been thrown out of the bathwater and analytic ideas are essential to working with patients with personality disorders. Otherwise a terrible mess can ensue due to CBT therapists dismissing the idea that 'something' might be going on in the room between patient and therapist beyond a mechanistic apprehension of their cognitions. This relational perspective has been adopted throughout psychotherapy and nobody, apart form hardcore NYC Freudians, would still hold onto a "me doctor, you patient" attitude. Additionally, Schema Focused Therapy, a hardcore version of CBT is really analytic work (from the Object Relations School) in disguise.
3. There's quite a significant evidence base that has been developed and continues to be developed for transference based therapies (i.e. psychodynamic, psychoanalytic, Mentalisation-based Therapy) e.g. JAMA 2008 . The problem is that proponents of CBT are much more up for 'bigging' up their therapy compared to most analytic/dynamic therapists. Also... government / HMOs love the idea that 16 sessions of a manualised therapy that can be delivered cheaply online (how demoralising that a PC can replace a therapist) or by a member of nursing staff (also much more cost effective) will "cure" depression, anxiety and longstanding personality difficulties. They do not love the idea that, especially in the case of personality disorder, that managing these problems take time, patience, skill and therefore cost more.
4. I should add, as a disclaimer of sorts, that I'm training as a psychoanalytic psychotherapist but also practise cognitive-analytic therapy, group-analytic therapy, systems theoretical groups and MBT. They are all useful but it is horses for courses. CBT is ace - but it's not a panacea.
Now if I can just get down from my high horse and get back to writing up my analytic reports.......oh! and I'll have somehting to talk to with my analyst on monday now. Schweet!
posted by you're only jung once at 4:33 AM on October 10, 2009 [8 favorites]
1. When you listen to tapes of Beck using CBT he really is doing something much more psychoanalytic than CBT.
2. Most CBT practitioners these days acknowledge that the baby has been thrown out of the bathwater and analytic ideas are essential to working with patients with personality disorders. Otherwise a terrible mess can ensue due to CBT therapists dismissing the idea that 'something' might be going on in the room between patient and therapist beyond a mechanistic apprehension of their cognitions. This relational perspective has been adopted throughout psychotherapy and nobody, apart form hardcore NYC Freudians, would still hold onto a "me doctor, you patient" attitude. Additionally, Schema Focused Therapy, a hardcore version of CBT is really analytic work (from the Object Relations School) in disguise.
3. There's quite a significant evidence base that has been developed and continues to be developed for transference based therapies (i.e. psychodynamic, psychoanalytic, Mentalisation-based Therapy) e.g. JAMA 2008 . The problem is that proponents of CBT are much more up for 'bigging' up their therapy compared to most analytic/dynamic therapists. Also... government / HMOs love the idea that 16 sessions of a manualised therapy that can be delivered cheaply online (how demoralising that a PC can replace a therapist) or by a member of nursing staff (also much more cost effective) will "cure" depression, anxiety and longstanding personality difficulties. They do not love the idea that, especially in the case of personality disorder, that managing these problems take time, patience, skill and therefore cost more.
4. I should add, as a disclaimer of sorts, that I'm training as a psychoanalytic psychotherapist but also practise cognitive-analytic therapy, group-analytic therapy, systems theoretical groups and MBT. They are all useful but it is horses for courses. CBT is ace - but it's not a panacea.
Now if I can just get down from my high horse and get back to writing up my analytic reports.......oh! and I'll have somehting to talk to with my analyst on monday now. Schweet!
posted by you're only jung once at 4:33 AM on October 10, 2009 [8 favorites]
Not to be missed. I have seen studies that suggest statistically that CBT has a better success rate than just about all other forms of therapy.
posted by Postroad at 5:17 AM on October 10, 2009
posted by Postroad at 5:17 AM on October 10, 2009
From the article: “Most psychotherapists, consciously or unconsciously, are doing a lot of the things that Beck pushed”
Aside from the throw-away concept that people aren't necessarily conscious of what they do, one established in the culture by psychoanalysis, this is absolutely true. CBT is just a packaging of a subset of techniques that have always been used. (This is also pointed out here
Deborah Tannen pointed out in The Argument Culture how these issues are always framed as a fight between two opposing sides. The straw man of the psychoanalysis of the 50s and 60s, which, incidentally, bore as much relationship to the way Freud worked as Christianity does to the teachings of Christ, isn't hard to debunk.
From my prospective, the most significant advance in talk therapy comes from the distinction, first enunciated by Kohut between the experience-near theories, which focuses on patients' actual felt experiences, versus experience-distant theories, which frame things in abstract reified language (e.g. in the original article, Beck's telling his patient that her anxiety was the result of repressed sexual impulses.)
Beck shouldn't have been so surprised when his patient responded with, “Actually, I was afraid I was boring you,” because, as a trained analyst, he should have known that the key issues always manifest in the analytic relationship. Science finds it difficult to deal with things like relationships because they resist measurement. If CBT was really conducted as claimed, more as psycho-education than human interaction, it could be administered by a computer. Unfortunately for the measurers of the world, talk psychotherapy is largely influenced by the personality of the practitioner and (even worse for the measurers) how it is or is not compatible with that of the patient.
Some books that give a non-straw-man account of psychoanalysis are Unformulated Experience and Ritual and Spontaneity.
posted by Obscure Reference at 5:35 AM on October 10, 2009 [4 favorites]
Aside from the throw-away concept that people aren't necessarily conscious of what they do, one established in the culture by psychoanalysis, this is absolutely true. CBT is just a packaging of a subset of techniques that have always been used. (This is also pointed out here
Deborah Tannen pointed out in The Argument Culture how these issues are always framed as a fight between two opposing sides. The straw man of the psychoanalysis of the 50s and 60s, which, incidentally, bore as much relationship to the way Freud worked as Christianity does to the teachings of Christ, isn't hard to debunk.
From my prospective, the most significant advance in talk therapy comes from the distinction, first enunciated by Kohut between the experience-near theories, which focuses on patients' actual felt experiences, versus experience-distant theories, which frame things in abstract reified language (e.g. in the original article, Beck's telling his patient that her anxiety was the result of repressed sexual impulses.)
Beck shouldn't have been so surprised when his patient responded with, “Actually, I was afraid I was boring you,” because, as a trained analyst, he should have known that the key issues always manifest in the analytic relationship. Science finds it difficult to deal with things like relationships because they resist measurement. If CBT was really conducted as claimed, more as psycho-education than human interaction, it could be administered by a computer. Unfortunately for the measurers of the world, talk psychotherapy is largely influenced by the personality of the practitioner and (even worse for the measurers) how it is or is not compatible with that of the patient.
Some books that give a non-straw-man account of psychoanalysis are Unformulated Experience and Ritual and Spontaneity.
posted by Obscure Reference at 5:35 AM on October 10, 2009 [4 favorites]
Obscure Reference nails it. But the problems with researching non-manualised therapies, including psychoanalytic and psychodynamic ones don't just end with practitioner variables. They also include -
1. Length of study required (you're not going to resolve anyone's life long personality difficulties in 16 sessions; it can take years.) - this has cost implications.
2. Inter-treater reliability (as Obscure Reference points out)
3. Therapists often practise as their supervisor does so you need to randomise by supervisor. Big, unwield, hard to do, expensive.
4. Cost is obviously a problem, as above. Big multi-centre studies require lots of case and resources. Not a lot of drug companies (who do a lot of study funding) want to stump up cash for a trial that doesn't involve drugs. Some studies now do trials of therapy plus/minus SSRIs to get round this.
5. What outcome variables do you look at? Global personality change? BDI? HADS? Readmission rates to hospital? Rates of parasuicide? Rates of criminal recidivism? (note the last 3 are probably the best as give a good indication of social function)
6. How do you assess what is leading to the change? Is it the regularity and consistency of appointments that helps or is it the wicked-clever interpretation that was made. As an aside to this there's a study, which I can't now find irritatingly, which asked patients and therapists what made the difference. Therapists say "clever interpretations" - patients say "moments of affective understanding".
These are some of the reasons why psychodynamic/analytic therapies don't have as large an evidence-base as cognitive based therapies. But, to paraphrase Freud, size isn't everything. It's just how you feel about the size of it.
posted by you're only jung once at 6:11 AM on October 10, 2009 [1 favorite]
1. Length of study required (you're not going to resolve anyone's life long personality difficulties in 16 sessions; it can take years.) - this has cost implications.
2. Inter-treater reliability (as Obscure Reference points out)
3. Therapists often practise as their supervisor does so you need to randomise by supervisor. Big, unwield, hard to do, expensive.
4. Cost is obviously a problem, as above. Big multi-centre studies require lots of case and resources. Not a lot of drug companies (who do a lot of study funding) want to stump up cash for a trial that doesn't involve drugs. Some studies now do trials of therapy plus/minus SSRIs to get round this.
5. What outcome variables do you look at? Global personality change? BDI? HADS? Readmission rates to hospital? Rates of parasuicide? Rates of criminal recidivism? (note the last 3 are probably the best as give a good indication of social function)
6. How do you assess what is leading to the change? Is it the regularity and consistency of appointments that helps or is it the wicked-clever interpretation that was made. As an aside to this there's a study, which I can't now find irritatingly, which asked patients and therapists what made the difference. Therapists say "clever interpretations" - patients say "moments of affective understanding".
These are some of the reasons why psychodynamic/analytic therapies don't have as large an evidence-base as cognitive based therapies. But, to paraphrase Freud, size isn't everything. It's just how you feel about the size of it.
posted by you're only jung once at 6:11 AM on October 10, 2009 [1 favorite]
What is encouraging is that efficacy studies of Psychodynamic/Psychoanalytic therapeutic interventions (even, wait for it. . . empirical ones!) are very positive, and particularly in the long term. CBT, not as much.
Sources for this extraordinary claim, please.
A big part of the problem with this discussion, leading to bizarre interpretations of CBT such as edheil's above, is based on the imputation of a moral position to CBT that good CBT practitioners don't in fact hold. To focus on the way experiences are interpreted in thought, rather than the experiences themselves, is not to imply that the "blame" for suffering lies with the interpreter/thinker, instead of the people who caused the experience. It is not to address the thorny question of blame at all.
"Irrational thinking" has a precise meaning and does not mean "stupid or blameworthy thinking."
Of course part of the cause of this is the horrible cheapened distortion of CBT in many self-help books.
posted by game warden to the events rhino at 7:58 AM on October 10, 2009
Sources for this extraordinary claim, please.
A big part of the problem with this discussion, leading to bizarre interpretations of CBT such as edheil's above, is based on the imputation of a moral position to CBT that good CBT practitioners don't in fact hold. To focus on the way experiences are interpreted in thought, rather than the experiences themselves, is not to imply that the "blame" for suffering lies with the interpreter/thinker, instead of the people who caused the experience. It is not to address the thorny question of blame at all.
"Irrational thinking" has a precise meaning and does not mean "stupid or blameworthy thinking."
Of course part of the cause of this is the horrible cheapened distortion of CBT in many self-help books.
posted by game warden to the events rhino at 7:58 AM on October 10, 2009
Sources for this extraordinary claim, please.
Here's one. I ran across recently.
posted by Obscure Reference at 8:31 AM on October 10, 2009
Here's one. I ran across recently.
posted by Obscure Reference at 8:31 AM on October 10, 2009
Here's the journal article that is referenced by the news article Obscure Reference links to.
Conclusions Psychological intervention for post-partum depression improves maternal mood (EPDS) in the short term. However, this benefit is not superior to spontaneous remission in the long term.
Neuroskeptic on the same article.
The claim that psychoanalytic intervention is effective "especially in the long term" is not supported by the evidence.
Science!
posted by logicpunk at 9:42 AM on October 10, 2009 [1 favorite]
Conclusions Psychological intervention for post-partum depression improves maternal mood (EPDS) in the short term. However, this benefit is not superior to spontaneous remission in the long term.
Neuroskeptic on the same article.
The claim that psychoanalytic intervention is effective "especially in the long term" is not supported by the evidence.
Science!
posted by logicpunk at 9:42 AM on October 10, 2009 [1 favorite]
All forms of talk therapy--CBT and psychoanalysis--are very effective for people having mental health issues and seeking mental health treatment. The effect size is about 0.80, which is quite robust, and certainly exceeds the effect size of most psychiatric medications. CBT certainly works for some people some of the time, as does psychoanalysis.
The mistake of partisans on both sides is in assuming that specific factors account for this effectiveness. CBT proponents want to argue that it's empirically validated because it is easy to study the specific interventions that CBT therapists make. Psychoanalysts want to claim that the benefits of analysis are deeper, and too ineffable to pin down. The problem is easily solved by studying outcome instead of process. Outcome studies not only conclusively demonstrate that psychotherapy is very effective, they also demonstrate that the factors common to all therapies, specifically relationship with a therapist, hope for improvement, and a plan for change, are the curative factors. There is almost no evidence that specific interventions have specific effects. Indeed, Bruce Wampold has argued that the evidence against specific factors being constitutive of cure is strong enough that this is the current null hypothesis that all psychotherapy research needs to assume.
I think the partisans in this debate are tiresome, don't know the research, and probably care less about people getting better than they do about their therapy of choice. I don't think that Aaron Beck was like that.
posted by OmieWise at 9:46 AM on October 10, 2009 [2 favorites]
The mistake of partisans on both sides is in assuming that specific factors account for this effectiveness. CBT proponents want to argue that it's empirically validated because it is easy to study the specific interventions that CBT therapists make. Psychoanalysts want to claim that the benefits of analysis are deeper, and too ineffable to pin down. The problem is easily solved by studying outcome instead of process. Outcome studies not only conclusively demonstrate that psychotherapy is very effective, they also demonstrate that the factors common to all therapies, specifically relationship with a therapist, hope for improvement, and a plan for change, are the curative factors. There is almost no evidence that specific interventions have specific effects. Indeed, Bruce Wampold has argued that the evidence against specific factors being constitutive of cure is strong enough that this is the current null hypothesis that all psychotherapy research needs to assume.
I think the partisans in this debate are tiresome, don't know the research, and probably care less about people getting better than they do about their therapy of choice. I don't think that Aaron Beck was like that.
posted by OmieWise at 9:46 AM on October 10, 2009 [2 favorites]
After reading this thread I'm more confused, anxious, and depressed than ever! Wow, it felt great getting that off my chest. Thanks for listening.
posted by Greg_Ace at 9:57 AM on October 10, 2009 [1 favorite]
posted by Greg_Ace at 9:57 AM on October 10, 2009 [1 favorite]
What is encouraging is that efficacy studies of Psychodynamic/Psychoanalytic therapeutic interventions (even, wait for it. . . empirical ones!) are very positive, and particularly in the long term. CBT, not as much. But, if you went to therapy looking for a band-aid (as opposed to a foundational change) and got your band-aid, well, I'm glad that worked out for you.
There are very few such studies. CBT is far more documented with studies--they demanded results-oriented work.
Both have a lot going for them and it is unfortunate that some people reject them out of anger or fear.
posted by Ironmouth at 10:06 AM on October 10, 2009
There are very few such studies. CBT is far more documented with studies--they demanded results-oriented work.
Both have a lot going for them and it is unfortunate that some people reject them out of anger or fear.
posted by Ironmouth at 10:06 AM on October 10, 2009
Right, absolutely — the far more important point than anything else here is OmieWise's one. A skilled and committed therapist, who also clicks with you personally, is vastly more important in terms of outcome than what school of therapy that therapist subscribes to.
But if we are going to have that much less important debate, about the degree to which the efficacy of CBT versus the psychoanalytic has been empirically supported, arguing in favor of psychoanalysis, on an empirical basis, is really a non-starter. Of course, many psychoanalytic writers and thinkers through history would probably reject the idea that empirical outcome studies are relevant to what they do. Which is fine — I wouldn't demand that poets provide empirical proof that they make people happier, either, and I'm still glad we have them. Their perspective enriches us. The difference is only relevant if my goal is to get happier, relatively lastingly and relatively quickly, in which case there isn't really a contest, on the evidence.
posted by game warden to the events rhino at 10:10 AM on October 10, 2009
But if we are going to have that much less important debate, about the degree to which the efficacy of CBT versus the psychoanalytic has been empirically supported, arguing in favor of psychoanalysis, on an empirical basis, is really a non-starter. Of course, many psychoanalytic writers and thinkers through history would probably reject the idea that empirical outcome studies are relevant to what they do. Which is fine — I wouldn't demand that poets provide empirical proof that they make people happier, either, and I'm still glad we have them. Their perspective enriches us. The difference is only relevant if my goal is to get happier, relatively lastingly and relatively quickly, in which case there isn't really a contest, on the evidence.
posted by game warden to the events rhino at 10:10 AM on October 10, 2009
Okay okay.
With respect to GWTOER's remarks, as alluded to in my second comment, the effect size between therapies is minimal, as shown in this relatively large study . This is not in keeping with the way that psychodynamic and CBT are often presented including by GWTOER, i.e. CBT is amazing and Psychoanalysis is just "poetry". Well, on reflection psychoanalytic work might be poetic in terms of it not being manualised - sorry, I'm being facetious now. On an unrelated note, is facetious the only word in English which has all the vowels in order, or should I put that on the green?
To return to the actual topic, there are therapist vs therapy studies that often show results demonstrating that it is the former that is more predictive of outcome (whatever the hell that really means) rather than the latter.
As a final, Jerry-Springer-esque, thought; while looking up some ideas for this comment I found this interesting study, which looks at how what learning style you have is associated with what therapy you choose to practise. The result that CBT therapists have more of a "think and do" propensity compared to the "feel and watch" psychodynamic therapists may explain why the latter push out the research and get the plaudits/funding.
On reflection, "feel[ing] and watch[ing]" probably does nothing for analysts' reputations....
posted by you're only jung once at 10:47 AM on October 10, 2009
With respect to GWTOER's remarks, as alluded to in my second comment, the effect size between therapies is minimal, as shown in this relatively large study . This is not in keeping with the way that psychodynamic and CBT are often presented including by GWTOER, i.e. CBT is amazing and Psychoanalysis is just "poetry". Well, on reflection psychoanalytic work might be poetic in terms of it not being manualised - sorry, I'm being facetious now. On an unrelated note, is facetious the only word in English which has all the vowels in order, or should I put that on the green?
To return to the actual topic, there are therapist vs therapy studies that often show results demonstrating that it is the former that is more predictive of outcome (whatever the hell that really means) rather than the latter.
As a final, Jerry-Springer-esque, thought; while looking up some ideas for this comment I found this interesting study, which looks at how what learning style you have is associated with what therapy you choose to practise. The result that CBT therapists have more of a "think and do" propensity compared to the "feel and watch" psychodynamic therapists may explain why the latter push out the research and get the plaudits/funding.
On reflection, "feel[ing] and watch[ing]" probably does nothing for analysts' reputations....
posted by you're only jung once at 10:47 AM on October 10, 2009
Psychoanalysis is just "poetry"
There's no "just" about it. It depends what your goal is. I think it's actually a very narrow view of the psychoanalytic tradition to imply that its entire raison d'etre would be destroyed by evidence that it's just not a very good technique for making sad people happier fairly efficiently. I do indeed think that it is not a very good technique for this. But perhaps the other contributions it makes are greater; perhaps there's something politically problematic about the idea of making sad people into happy little cogs in society; etc etc etc.
posted by game warden to the events rhino at 10:59 AM on October 10, 2009
There's no "just" about it. It depends what your goal is. I think it's actually a very narrow view of the psychoanalytic tradition to imply that its entire raison d'etre would be destroyed by evidence that it's just not a very good technique for making sad people happier fairly efficiently. I do indeed think that it is not a very good technique for this. But perhaps the other contributions it makes are greater; perhaps there's something politically problematic about the idea of making sad people into happy little cogs in society; etc etc etc.
posted by game warden to the events rhino at 10:59 AM on October 10, 2009
These are some of the reasons why psychodynamic/analytic therapies don't have as large an evidence-base as cognitive based therapies. But, to paraphrase Freud, size isn't everything. It's just how you feel about the size of it.
So the process is ill-defined, the outcomes are ill-defined, yet we know it works? How, pray tell?
posted by Mental Wimp at 11:11 AM on October 10, 2009
So the process is ill-defined, the outcomes are ill-defined, yet we know it works? How, pray tell?
posted by Mental Wimp at 11:11 AM on October 10, 2009
To be clear. the evidence I've provided from two high-imapact journals state it is as effective (and if you're being pedantic as per the JAMA study, efficacious) as CBT. Which is also not a "very good" technique for making people "happier". Even the big man, Dr S Freud, said it was [only. my words] "his aim to use analysis to turn abject misery into ordinary unhappiness".
posted by you're only jung once at 11:14 AM on October 10, 2009
posted by you're only jung once at 11:14 AM on October 10, 2009
urg. high-impact. not high-imapact.
.....embarassed pause.....
So how about those Astros?
posted by you're only jung once at 11:15 AM on October 10, 2009
.....embarassed pause.....
So how about those Astros?
posted by you're only jung once at 11:15 AM on October 10, 2009
To be clear. the evidence I've provided from two high-imapact journals state it is as effective (and if you're being pedantic as per the JAMA study, efficacious) as CBT. Which is also not a "very good" technique for making people "happier". Even the big man, Dr S Freud, said it was [only. my words] "his aim to use analysis to turn abject misery into ordinary unhappiness".
Hmm, your use of quotation marks implies that you think you are providing evidence to contradict my comments. (Apologies if I'm mistaken about that.) But a) I completely agree that differences between schools of therapy are unimportant compared to differences between therapists, as I said upthread, and b) I completely agree that Freud and others did not see psychoanalysis as a route to happiness.
I repeat, though, that if your goal is to alleviate unhappiness in relatively short order and in a relatively lasting way, and if you are trying to make a choice between CBT and psychoanalysis, then the overwhelming body of empirical evidence suggests that you should choose CBT. But that it won't be hugely important which you choose.
posted by game warden to the events rhino at 12:08 PM on October 10, 2009 [1 favorite]
Hmm, your use of quotation marks implies that you think you are providing evidence to contradict my comments. (Apologies if I'm mistaken about that.) But a) I completely agree that differences between schools of therapy are unimportant compared to differences between therapists, as I said upthread, and b) I completely agree that Freud and others did not see psychoanalysis as a route to happiness.
I repeat, though, that if your goal is to alleviate unhappiness in relatively short order and in a relatively lasting way, and if you are trying to make a choice between CBT and psychoanalysis, then the overwhelming body of empirical evidence suggests that you should choose CBT. But that it won't be hugely important which you choose.
posted by game warden to the events rhino at 12:08 PM on October 10, 2009 [1 favorite]
Also... government / HMOs love the idea that 16 sessions of a manualised therapy that can be delivered cheaply online (how demoralising that a PC can replace a therapist) or by a member of nursing staff (also much more cost effective) will "cure" depression, anxiety and longstanding personality difficulties. They do not love the idea that, especially in the case of personality disorder, that managing these problems take time, patience, skill and therefore cost more. "
And psychoanalysts love the idea that therapy needs to last for years, and to be slow, expensive and costly. Nobody's unbiased here.
posted by game warden to the events rhino at 12:12 PM on October 10, 2009 [1 favorite]
And psychoanalysts love the idea that therapy needs to last for years, and to be slow, expensive and costly. Nobody's unbiased here.
posted by game warden to the events rhino at 12:12 PM on October 10, 2009 [1 favorite]
yes folks, expensive AND costly.
posted by game warden to the events rhino at 12:12 PM on October 10, 2009
posted by game warden to the events rhino at 12:12 PM on October 10, 2009
Kathrineg, sorry if I appeared that way but I'm not dismissive of other treatments such as CBT. Their cost-effectiveness is a massive selling point and why I think it definitely has a place within the psychiatrists' armamentarium, particularly in a rationed health service such as the NHS. 16 sessions of CBT (ie 6 months in practice) has been proven to be as effective as pretty much anything for mild-mod depression and anxiety disorders - though I would temper this by saying that it has a synergistic effect with SSRIs.
I'd also like to say that I'm drawing a distinction between psychodynamic therapy, which my links referred to and not psychoanalysis. The latter's 3-5 times a week on a couch and in the UK you almost always have to pay for that yourself. The former is how analytic ideas are put into practice with patients with personality, relationship, neurotic and depressive difficulties, once weekly, face-to-face for usually no more than 1-2 years. This can and is provided for free by the good old NHS. I don't thnk it's fair to either CBT or psychoanalysis to compare them together unless its for examining how well they can treat longstanding personality problems over the long-term.
Sorry if I've been a snark. I feel embattled. My 360 just got the Rings of Death today. I'm assuming it projectively identified with my feelings of anger and resentment at Bill Gates.
posted by you're only jung once at 12:25 PM on October 10, 2009
I'd also like to say that I'm drawing a distinction between psychodynamic therapy, which my links referred to and not psychoanalysis. The latter's 3-5 times a week on a couch and in the UK you almost always have to pay for that yourself. The former is how analytic ideas are put into practice with patients with personality, relationship, neurotic and depressive difficulties, once weekly, face-to-face for usually no more than 1-2 years. This can and is provided for free by the good old NHS. I don't thnk it's fair to either CBT or psychoanalysis to compare them together unless its for examining how well they can treat longstanding personality problems over the long-term.
Sorry if I've been a snark. I feel embattled. My 360 just got the Rings of Death today. I'm assuming it projectively identified with my feelings of anger and resentment at Bill Gates.
posted by you're only jung once at 12:25 PM on October 10, 2009
Cheers. I've been in therapy 4 times a week for 4 and a half years. Clearly, I've still got a touch of the old narcissistic vulnerability to work on but from a purely n of 1, anecdotal view point I think it's been one of the most important experiences I've had. But Game Warden's right.. it is both expensive and costly and not just in terms of money.
A happy medium between CBT and psychodynamic can be found in Cognitive Analytic therapy. 16 sessions, face-face, structured and it takes into account the transference and counter-transference. Both of the lattter being fundamental to analytic principles. I've found it good to use with all kinds of difficulties.
posted by you're only jung once at 12:46 PM on October 10, 2009 [2 favorites]
A happy medium between CBT and psychodynamic can be found in Cognitive Analytic therapy. 16 sessions, face-face, structured and it takes into account the transference and counter-transference. Both of the lattter being fundamental to analytic principles. I've found it good to use with all kinds of difficulties.
posted by you're only jung once at 12:46 PM on October 10, 2009 [2 favorites]
The pomo among you might also enjoy reading this deconstruction of the evidence-based model.
I also think psychotherapists tend to charge too much (CBT & analysts both) but I attribute that to the medical model (not to say that medical doctors don't also charge too much.)
I'm assuming [my 360] projectively identified with my feelings of anger and resentment at Bill Gates.
Hardware is not subject to projective identification and won't be until it can pass the Turing test.
Lastly, "abstemious" also has the vowels in order and there are a few others, I seem to recall, though not what they are.
posted by Obscure Reference at 2:26 PM on October 10, 2009
I also think psychotherapists tend to charge too much (CBT & analysts both) but I attribute that to the medical model (not to say that medical doctors don't also charge too much.)
I'm assuming [my 360] projectively identified with my feelings of anger and resentment at Bill Gates.
Hardware is not subject to projective identification and won't be until it can pass the Turing test.
Lastly, "abstemious" also has the vowels in order and there are a few others, I seem to recall, though not what they are.
posted by Obscure Reference at 2:26 PM on October 10, 2009
He lived a abstemious lifestyle, yet now his face seemed caesious. Then he brightened: "Isn't y considered a vowel?" he asked facetiously.
posted by eye of newt at 2:45 PM on October 10, 2009 [3 favorites]
posted by eye of newt at 2:45 PM on October 10, 2009 [3 favorites]
Empirical evidence has arguably borne out out many of Freud's ideas. In addition, psychodynamic and psychoanalytic therapies have been successfully tested on disorders like depression, bulimia, substance abuse, and borderline personality disorder. There's some evidence that longer-term psychodynamic therapies work well and better than shorter-term therapies. And in at least one case (borderline personality disorder), the available evidence seems to indicate that psychodynamic therapy might be superior to a state-of-the-art behavioral therapy like dialectical behavior therapy.
posted by Malad at 7:09 PM on October 10, 2009 [1 favorite]
posted by Malad at 7:09 PM on October 10, 2009 [1 favorite]
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