Is Cognitive Behavioral Therapy the Gold Standard for Psychotherapy?

[Liv aka Mrs Sowester]

Like @Squeezy I find anti-depressants very helpful to mediate the reactive depression I've developed after 7+ years of this illness.
I take mirtazapine now because I was thinking frequently about how nice it would be to be able to end my life, because it's boring, tiring and painful. The ME ennui is entirely different from the depression I suffered in my teens which was mentally crushing and paralysing. In the 80s people didn't believe teenagers could get depressed, I wish I'd been offered anti-depressants then.

I think in this debate people aren't differentiating enough between CBT delivered for overcoming negative emotional patterns (which can actually be effective, especially in relationships) and CBT delivered for ME, which is clearly pants and dangerous.

I had a therapist who used some CBT to help me in a family dynamic, it helped me see that the problem was with the family member's sense of self and not a reflection on me, now their antics don't hurt me. It was brilliant, life changing stuff.

I see upthread people discussing alcohol and marijuana in the context of self medication; alcohol is a depressant and interferes with sleep quality, I like a drink (a little too much) and have to be strict to keep myself in check. I've known too many booze casualties to be entirely comfortable with it.
And weed does make people anxious and encourages negative thought patterns, no two ways about it. In my opinion it is much safer to get a prescription from the doctor than to get stoned. I've known too many weed casualties to be entirely comfortable with that either!

 

[adreno]

I think the original question was, if CBT is (or should be) the gold standard for psychotherapy. And to that the answer must be "no". That doesn't mean that CBT is never helpful, however.

 

[TiredSam]

But the BEST help in managing my childhood memories of parental emotional abuse was your much-derided CBT.

I'm not sure that accusing those who hold a different opinion to yours of "damning, cavalierly belittling and deriding" is helpful, in fact it's probably a rule breach, so can you just stick to the facts or your personal experience without inflaming the discussion?

It's great if CBT helped you, I'm sure CBT is helpful for a number of things. In fact if I had any sense I'd get myself along to a therapist to sort out my arachnophobia, which it's supposed to be very effective for.

I have never suffered from depression or had to be treated for it, so I can't speak to that.

But I do have ME. And being told that what I need is a treatment which may be effective for dealing with trauma, childhood emotional abuse, phobias or depression annoys me greatly. I do not want my illness to be wrongly categorised just so that "they" (the government, the medical profession, health insurance companies, DWP, certain territory-grabbing psychologists of the BPS variety) can say they have an effective treatment for it, because ME sufferers being forced to go along with their fiction, sometimes to the detriment of their health and under threat of sanctions, is an appalling situation that has gone on for too long. It has also delayed the search for real treatments for ME.

Because of this, ME sufferers have an interest investigating whether CBT / anti-depressants are all they're cracked up to be. Discussing things like that is what this forum is for. Your experience and opinion are a valuable part of the discussion.

If you can speak like this, then you have DEFINITELY never been depressed.

Questioning another member's diagnosis is also sailing pretty close to the wind rule-wise.

 

[Inara]

I don't joke about this, i say the same thing (with experience). Marijuana is safer and less addictive then SSRI and its variants. Alcohol is safer as well though can be addictive.

I meant "cynical joke"
I totally agree, and if asked I'd recommend Marijuana, too, and after that alcohol in limits. I'd highly advice against psychopharmaceuticals.

Also our "official" understanding of psychology is practically still in its infancy (with a few notable exceptions, there are some experts who have real wisdom, but it needs to get into the textbooks).

My impression is psychology is split. There was a branch in the past ("field psychology") which fascinated me along with cognitive and behavioral psychology: Why do humans act in a certain way and in which conext? Is there a set of behaviors which is common in every human, independent/dependent from cultural context? And so on...
Then there's the other part: In the second half of the 20th century psychology thought it would be nice to be a nature science, and they discovered statistics to be a suited tool, without properly understanding statistics. This is the branch I critisize.

Most people equal soul with psyche, which is psychologically incorrect. Due to psychology, the psyche is an own entity. What exactly I cannot tell, I didn't find a unique definition.

I think the problem of psychology is that it wants to "play" being a scientist using objective measures. But in my opinion, they're failing.

Then there is Psychiatry. I'll call it modern inquisition.

But the BEST help in managing my childhood memories of parental emotional abuse was your much-derided CBT.

I think that people who want it should find someone to talk to. A place where you are valued and accepted, no matter what are your beliefs and problems. This can be a friend, a family member, a coach, a "therapist", whatever. A place where you can talk about your feelings and problems and find a way to solve them - if you want to.

I am sure there exist therapists that can provide that.

I know that psychotherapists call that life counseling, and they say they're not available for life counseling but for treatment of a psychological illness.

I also know there are tons of therapists who lack empathy and love and who work by the numbers. CBT comes with a manual. This really sounds like empathy, patience, love and humanstic.

I'd say you were lucky to come across an empathetic person who accompanied you.

 

[Inara]

I disagree, he takes the position that chemicals for depression are a crutch and depression is caused by hopelessness (of various causes). As i mentioned there is a lot of money involved in denying this viewpoint and we all know what alternative facts gets us (even if we don't want to face it and deny it instead).

My problem is that calling a natural reaction to certain situations, e.g. hopelessness in case of extreme poverty and finding not one possibility of solving it, which happens millions of times, or hopelessness in case of people who have two jobs, work 16h daily, but who don't have enough money to survive, calling that "an illness", that is despicable. Or to call a physical illness "psychological" (translation from history: simulant), that is despicable. Then forcing you into questionable "treatments" if you can't do that anymore to make you function again. To call you therapy resistent and to blame YOU if treatment fails, that is inhuman. In case of antidepressants it may happen you loose all your feelings for good - which is great with respect to functioning.

Do you know the movie "Equilibrium"?

Most needed solutions, e.g. to "depression", cannot be realized due to well-known forced boundary conditions, e.g. being productive at any cost. For instance, strict lifestyle changes would be needed who are highly linked with money. Nobody will provide that.

Psychiatry stood and stands for getting disposed of "the unproductive" and "unwelcomed".

 

[Inara]

Have any of you suffered from Major Depression, suicidal feelings, suicide attempts, or anxiety?

I won't say which one of those listed, but yes, I did. I had a natural reaction to a situation I felt to be existentially threatening.

I had beloved people who were at my side, who helped me by supporting me and loving me, who were just there to listen and to find solutions - while psychiatrists and psychotherapists mistreated me abominably. I needed them for sick leave, but after each visit my feelings of despair grew; they were just cold. Don't tell me I saw the wrong ones - I met a lot of them, telling me "the next will be better!" And after a time I UNDERSTOOD. Never again I will believe to be "psychologically ill".

 

[alex3619]

The issue in this thread is not whether CBT might work in individual cases, but whether or not any claim to it being gold standard is warranted. To me the answer is no.

There are layers of issues here. This includes issues around both scientific research and evidence based medicine.

First, a diagnosis of depression is unstable. Its an artificial construct. Depression is a symptom of a wide variety of issues. It can be extreme, and lead to suicide. Its not trivial. However we lack a proper diagnostic test. There are many scientists and doctors working to solve this. Until that happens the category depression is actually a category mistake.

On top of this is psychiatric pharma research. Its not clear they use objective outcomes a lot, though I have not investigated this. However they do have double blinding, and placebo controls, which means studies can indeed meet gold standard requirements. Gold standard does not make a study correct, it just eliminates many of the common biases, though not all. The study can still be wrong or misleading. This is why the fine details of a study are so important.

In the case of antidepressants some studies have shown there are major responders, and minor responders, and non responders. They sell the product without knowing which a patient will be. Their claims are often based on average responses, without mentioning how many are only getting the placebo effect. This is not likely to be only found in psychopharmacology though. Most treatments have this risk. Even antibiotics. However when you cannot even be sure what is wrong with someone, and diagnose only on a single symptom (depression, fatigue or pain) then the chance of getting it right is greatly decreased. This is a problem for people who are depressed because of nutritional deficiencies or pathogens.

Psychopsychiatric research can never be gold standard. That means the bias and error rate is likely to be higher overall. By never, I mean NEVER. That means claims to efficacy and certainty are doubtful. Some will do well, some wont, and some might get worse. Because of the issues in measuring problems its very hard to say how effective these things are.

To compound this there are two broad types of CBT. The first is classical type CBT, though recently I became aware of another variant used in phobias. These are management tools. In the case of asthma, schizophrenia, CFS and ME, much more extensive claims have been made. The asthma and schizophrenia claims were debunked. The CFS and ME claims are ludicrous, and based on poor scientific methodology.

Evidence based medicine requires a bunch of things for a study to be gold standard. First it has to be methodologically sound. Then it requires double blinding. It also requires a placebo control. There are some other things too, but these are where psychopsychiatry including CBT fail.

This does not mean that these therapies do not work. This means they cannot prove they work to a scientific standard. In other words they cannot be said to be scientifically justified.

 

[large donner]

The issue in this thread is not whether CBT might work in individual cases, but whether or not any claim to it being gold standard is warranted. To me the answer is no.

I think this is a key issue in "EBM". The gold standard is often the best scoring bullshit on a subjective, data withheld, conflict of interest "study".

On top of that its often the case, especially in psychiatry/psychology, that the "illness" is badly defined or never even existed in the first place to warrant being medicalised.

That often happens when definitions become so stretched that they become meaningless and cross over into everyday feelings behaviours and situations.

Then we are left with:

"The Gold standard (a bias subjective) is the "treatment" for the "illness" (a made up poorly defined or normal behavioural state).

Very scientific.

 

[Jonathan Edwards]

There was a thing on the radio today about robot CBT being really good. But the psychotherapist made sure to say that it was not intended to replace psychotherapists. And it was too early to compare something as unproven as a robot with a (fully proven) psychotherapist.

I am very happy to believe that people can get great benefit from sessions that happen to be called 'CBT' in the diary. However, having talked to Sion Wessely (who should know) it seems fairly certain that most people delivering CBT have to idea what CBT is and maybe nobody knows what it is. (And of course CBT for ME isn't CBT anyway.) It is just that some people are good at helping other people by talking to them in a way that suits them - and being a psychotherapist may not be a very good qualification for that.

 

[Inara]

Evidence based medicine requires a bunch of things for a study to be gold standard. First it has to be methodologically sound. Then it requires double blinding. It also requires a placebo control. There are some other things too, but these are where psychopsychiatry including CBT fail.

Agreed.
Honestly, I wouldn't say a scientific paper is gold standard, even if it fulfilled all the criteria, not without having controled it in detail. And maybe even then I would be careful of using the term "gold standard". Science is an "approximation process to reality" in small steps.

(I say this after having experienced myself how (physical) data can be made to look "prettier". Even some maths papers are not protected against errors. But that shouldn't surprise. Humans aren't perfect.)

But that's what you also said.

"Gold standard" contains a certain amount of subjective judgement, no?

 

[Inara]

having talked to Sion Wessely (who should know) it seems fairly certain that most people delivering CBT have to idea what CBT is and maybe nobody knows what it is. (And of course CBT for ME isn't CBT anyway.) It is just that some people are good at helping other people by talking to them in a way that suits them - and being a psychotherapist may not be a very good qualification for that.

Maybe you have said it elsewhere - and I know, strictly, it doesn't belong here maybe - but what did Wessely say about CBT?

Is it

It is just that some people are good at helping other people by talking to them in a way that suits them

or is that your understanding of CBT? Sorry I don't understand right away.

 

[Jonathan Edwards]

Maybe you have said it elsewhere - and I know, strictly, it doesn't belong here maybe - but what did Wessely say about CBT?

Is it



or is that your understanding of CBT? Sorry I don't understand right away.

Sorry, my post was ambiguous. The bit about people being good at helping others was me.

Dr Wessely said he was worried that after the brilliant PACE trial lots of people would get 'CBT' but from people who were 'not properly trained' so it wouldn't be any good. What he did not explain is how without any trials of different techniques anyone could know what proper training would involve.

 

[Squeezy]

@Skippa I apologise for any inflammatory remarks that overstepped the line.

The views of some other members on this thread are clearly highly charged against CBT because they live in the UK where it has been hijacked disgracefully by the NHS as a weapon of coercion against ME sufferers.

I do NOT live in the UK, so I have mercifully been spared this horror, where I currently live, CBT is implemented properly. Israel is streets ahead in psychological treatment. You wouldn't believe the psychiatric wards here. Fantastic. I'll miss the standards of healthcare terribly when I come home to England in a couple of years.

I was riled up by statements such as,
"... ignoring reality and treating it with CBT is like putting a band aid on a gushing wound, it won't work.

"You don't deal with emotions by ignoring them or recategorizing them."

"In the past you had labour camps, now there's CBT."

Oh, and the 30% efficacy for antidepressants, which I'm sure is wrong.

@TiredSam I apologise for offending you by expressing myself with charged language. I should have taken a few minutes and calmed down.

I feel like you all use technical language to back your bias, and stand in judgement on things - true CBT and antidepressants - that you do not have real experience of. And in your case, @Alvin you confirmed I was correct.

It is EASY to malign treatments that you do not need. I think you should be careful of bias in your discussions.

I will leave you all to vent spleen about the dreadful UK version of a fantastic psychological treatment method that has been twisted and bastardised. I'm clearly not in a position to debate.

 

[Inara]

Sorry, my post was ambiguous. The bit about people being good at helping others was me.

Dr Wessely said he was worried that after the brilliant PACE trial lots of people would get 'CBT' but from people who were 'not properly trained' so it wouldn't be any good. What he did not explain is how without any trials of different techniques anyone could know what proper training would involve.

Okay, I understand, thank you!

There's a Mr. I-am-too-good-for-this-world-Wessely, ey?
Brilliant! Saying one's own work is perfect but others make it bad. (I.e. the only flaw of PACE are the participating people )

 

[TiredSam]

Brilliant! Saying one's own work is perfect but others make it bad. (I.e. the only flaw of PACE are the participating people )

When CBT and GET don't work, first blame the patients for not trying hard enough. Then blame the therapists for not doing it properly. The BPS approach and his own judgement are completely infallible, I don't think he's ever conceded one point or admitted one error.

 

[Inara]

"... ignoring reality and treating it with CBT is like putting a band aid on a gushing wound, it won't work.

"You don't deal with emotions by ignoring them or recategorizing them."

"In the past you had labour camps, now there's CBT."

Oh, and the 30% efficacy for antidepressants, which I'm sure is wrong.

Dear @Squeezy, I'm sorry you felt so offended.

I could look up the papers about the 30% success quote. But honestly, for me it's lots of work - would you be interested at all? There's also a German newspaper article who quotes this fact - maybe there's a reference I could post here.

I read in some forums about people's experiences with psychopharmaceuticals. I was SHOCKED. These were stories going into my heart, people who told they feel they lost their identities. I like myself and my feelings. I didn't want to risk loosing it.

I feel like you all use technical language to back your bias, and stand in judgement on things - true CBT and antidepressants - that you do not have real experience of.

I live in Germany. If Psychiatry is not a power complex in Israel, well, lucky you. Seroiusly. Here, it's a real big problem: forced hospitalization, forced treatments (medical, electro shocks, fixation), incapacitation (which makes you a piece of flesh without own will), cutting of social support if you do not EXACTLY as you're told. Nothing of this is some theory for me, I have to experience it. It's suffering and poverty for me. I have family members who experience and experienced this, too, amongst my niece (now 13) and my little sister who was forced into psychiatry when she was 11.

When I believed this stuff about "psychological illness" I was looking for a psychotherapist. There's no room here to tell the whole story, it wouldn't be that interesting I guess. I met about 7 therapists and 3 psychiatrists. Everyone let me know that my values and opinions are "sick" (I am a system critic and I NEVER just re-babble something, I always look for myself), and they let me know I need to be healed (learn the "good truth"). Yeah at some point I learned to be silent That's why I say re-education camps. And I'll keep to that, knowing that somewhere on this earth some people really find help.

it is EASY to malign treatments that you do not need. I think you should be careful of bias in your discussions.

Everyone is biased, obviously you, too. We all have our experiences - strictly, that is a bias. What I write is backed up by my personal experience, it does not hold generally. I then did some research and found lots of others with similar experiences. For years UN says German practice is torture and discriminates disabled persons.

Nobody wants to take away help options - I reject FORCED treatments, with the excuse "society's well-being first" (that's something from German law).

 

[Inara]

When CBT and GET don't work, first blame the patients for not trying hard enough. Then blame the therapists for not doing it properly. The BPS approach and his own judgement are completely infallible, I don't think he's ever conceded one point or admitted one error.

Officially, a theory that is not verifiable or falsifiable is not a theory in the (natural) scientific sense, at least according to Karl Popper. Example: hypothesis - there exist unicorns; fae; God; etc. Not saying these may be interesting topics to think about.

 

[Squeezy]

Oh my God, @Inara, that is all utterly horrendous. I am so sorry for all that you've been through, there in Germany. It's inhumane.

From my experience, and my friends', and online support groups here, it really doesn't seem that there is an agenda here among the psychiatric profession. I really didn't want to come to live here, but it turned out to be a great decision for my health.

Don't worry about the 30% success quote - I looked it up, and it varies from there to 50%, depending on who's talking. Unreliable figures.

I hope you've come through your horrible experience OK.

 

[Inara]

Don't worry about the 30% success quote - I looked it up, and it varies from there to 50%, depending on who's talking. Unreliable figures.

I hope you've come through your horrible experience OK.

You are more accurate with the numbers I admit that was a bit propaganda from my side.

You see that I took a certain standpoint if it's so different in Israel, you can really be happy. There are exceptions in Germany, certainly. What people like me fight for in Germany (and in UK?) is a humanistic psychiatry approach.

The question of this thread was if CBT is the gold standard for psychotherapy. The wonderful Wessely et al would say yes!

 

[alex3619]

Then we are left with:

"The Gold standard (a bias subjective) is the "treatment" for the "illness" (a made up poorly defined or normal behavioural state).

Very scientific.

Yep. This is however an issue with how EBM is commonly practised, not how its supposed to be done. These are issues on evidence that are overlooked, or deliberately thrown into the too hard basket. In fast reviews the papers involved get tick box analysis ... deep understanding of their individual issues is ignored.