Psychological therapies. Discussion thread.

This post has been copied and the following discussion moved from this thread: Paul Garner on Long Covid and ME/CFS. BMJ articles.

There it is again. The use of the term "mind-body dualism" as a way of impugning those who believe any disease cannot be made better by thinking the right thoughts. Apparently, that's how these folks define "mind-body dualism" in our current, post-truth world.

1. Aren't you AWARE that the mind and body are connected and that can influcence the other:

2. Don't you KNOW that all diseases have a psychological component?

3. Don't you REALISE that correcting your thoughts can improve your health, whatever your disease?

4. Or are you just afraid of the STiGMA associated with psychological dysfunction?

My answers.

1. Aren't you AWARE that the mind and body are connected?
No, I'm not, because that statement is based on a poor understanding of what "the mind" is. The body is a physical entity, the mind is an abstract construct that refers to some of the mental and emotional products of the body's functioning (especially those of the brain, but also the whole CNS, endocrine system, and lots more). So they are not "connected", they are one and the same.

2. Don't you KNOW that all diseases have a psychological component?
No, they have a psychological component only when it can be shown that they do so. That component is likely to be small, because our ability to modulate the cognitive and emotional products of our body's functioning is extremely limited. Its likely that even many psychiatric illnesses don't have much of a psychological component - that is, no amount of retraining, therapy, or reeducation of your thoughts, feelings and reactions will lessen your symptoms in any way (e.g., psychosis).

3. Don't you REALISE that correcting your thoughts and feelings can improve your health, whatever your disease?
Since the thoughts and feelings are the product of your body's functioning, the best way to correct these is to fix the body (the health condition).

4. Or are you just afraid of the STiGMA associated with psychological dysfunction?
F**K off.

 

That's interesting Woolie, can I ask what evidence you're basing this statement on? A lot of people do find psychological therapy to be helpful for mental health problems.

 

Sure, @Sarah94. Keith Laws has been interested for a while in whether CBT in particular has any benefits for people with schizophrenia. He argues hat most studies citing positive evidence have not had an adequate control arm, and when you select out those with a proper control arm, there is no evidence of any benefit:

https://theconversation.com/why-cbt-should-stop-being-offered-to-people-with-schizophrenia-100143

This makes sense to me. Schizophrenia is a serious, biologically-based disease. You can't address it by reframing your thoughts or changing your behaviours.

Just like any other chronic incapacitating disease, some people with schizophrenia might benefit from regular support to help cope with the effects of the disease, but in the same way that a cancer patient or a person with severe paralysis might. And there is no evidence to suggest this help needs to be "psychological". Things like relaxation sessions, or support groups might be just as helpful.

 

I think this is one of the major trip up points in the discussion over ME. 'Psychological' and 'psychiatric' are really two completely different things, as Woolie explains. The confusion is made worse by many psychiatry departments deciding to become departments of psychological medicine.

A lot of major psychiatric illness has absolutely nothing to do with psychological in the sense of being caused by inappropriate thoughts. It is the opposite inappropriate thoughts are caused by some unknown brain problem.

I am increasingly sceptical that any illness is really dealt with by 'psychological therapy'. Yes, lots of people with anxiety and depression feel comforted by being seen by someone who gives them an explanation but whether that explanation does good or harm seems a lottery to me. It is quite capable of destroying whole families.

 

I was taught as a medical student that you would not expect psychotherapy to benefit major psychiatric illness. Major psychiatric illness involves irrationality and there is not much point in trying to address irrationality with rational argument - which CBT seeks to do. From personal experience this seems to be bone out in practice.

 

Psychological and psychiatric get conflated unhelpfully all the time. Largely artefact of history regarding which branch of medicine took ownership of what condition/category of patients.

In the UK, ME is largely unclaimed by any branch of medicine - not by neurologists or immunologists or infections disease specialists or other specialism - some take an interest and try their very best for patients. But, rather sadly, largely ME knowledgeable medics failed to engage successfully with the majority of their medical colleagues in UK – have been unable to persuade research bodies to fund research - too much stigma, not enough research funding, too easy to dismiss symptoms as 'psychosomatic'. So, that left the door wide open for psychological and psychiatric musing and grabbing of ME patients as 'theirs'. It has been seductive to buy into McEvedy and Beard's speculation rather than face the difficulties posed by uncertainty, lack of knowledge and ambiguity. 30/40 years later nothing much to show for it. Lack of medical care, stigma, and little interest in ME has allowed certain groups like Wessely school thinking to run amuck with ME patients.

Overreach from support, care and reducing distress – part of what psychologists do day in day out - to claiming that CBT / 'whatever therapy is flavour of the month' can cure illness/disease is not on. This overreach is not mainstream psychology practice. If that is your perception, then that is all that it is. Perhaps you might have a limited view of what practitioner psychologists do.

From what is stated it reads as though you think all psychological therapy has little or no value. That this routinely destroys lives and is routinely harmful. Perhaps you have worded that clumsily but that is how it comes across. One example of some of the things psychologists get up to in helping people to move on from: having little understanding of the impact of trauma and subsequent behaviours: poor emotion regulation, drug taking, alcoholism, bad behaviour destroying families endlessly - sometimes generation after generation. What are you suggesting - that no one access psychological care or support to try and understand themselves, their behaviour, how they cope, to work on themselves to be able to work, have good quality relationships, improve themselves and engage in personal development, take care of themselves and their families? Kinda reads like that's what you're thinking.

Harms need to be addressed if they happen - as they do in all aspects of good clinical practice.

 

Completely agree with you Joan, well said.

 

Thanks for the questions @Joan Crawford. Let me try to answer by taking your post a bit at a time.

I understand that there is a way to provide psychological support that does not overreach, but I wonder whether one can really say overreaching is not mainstream?

I have no idea of the proportion of people seen in various contexts but this overreaching certainly seemed to be a well-established part of our rheumatological departmental activity back at least to 1990. Rheumatology patients under rheumatologists were routinely referred across to psychologists to deal with the '-psychosocial' bits of their illness. This was led by the Professor of Psychology at the Middlesex, a clinical psychologist rather than a psychiatrist I think.

In terms of private psychological therapy overreaching into theorising about causation seems deeply embedded. I don't think I have a limited view of what practicing psychologist do as I have been surrounded by psychologists all my life. My parents were close friends with people on the psychoanalytical side like Charles Rycroft and Suzanna Isaacs. I have lived in a road with almost every other house having a psychotherapy practice for the last 25 years and about half of my extended family have been under psychological therapies of various sorts at some time, both NHS and private, so I have an idea of all the various contexts I think.

I know that what I say may sound harsh. When I said it at the NICE committee someone who I think was a NICE staff member seemed a bit shocked when I said that although my criticisms related to CBT in PACE, from what I had seen reading around I was not confident that it was going to be different for CBT in other areas.

But I think it would be unfair to overstate what I am saying. I am just saying that I think we should face up to the fact that we do not know whether psychological therapies are beneficial if there are no reliable trials. We cannot just accept that psychological therapy must be good because it seems like it to practitioners. That is the BACME argument for both physio and psychology that does not stand up. Yes I am also saying that I think there can be harms, but I am not saying that I think there is more harm than good, just that it looks as if we do not know and I have seen quite a lot of psychological therapy that looks to me pretty likely to produce problems.

I would like to believe that psychological therapy has value and I have circumstantial evidence that it gets some people back to functioning when they were not but I am not at all sure that this was more than just being supported by someone who listened.

OK, so maybe people can be helped in these areas - but do we know that? In medicine we had to go back to square one and admit that having a theory about what treatment should work is not enough. It has to be supported by practical evidence. One can theorise that people do not understand the impact of trauma, but does anyone else usefully understand? Do psychological theories of trauma lead to good clinical outcomes? One member of my family was taught all about the impact of her traumas. The problem was that these traumas never existed and she was alienated from her family.

Do we really know what we mean by 'trauma'? I know that people like Dora Black sound as if they have a deep understanding of trauma and it stands to reason that at least she has he experience but does the theory do good? I appreciate that it may be extraordinarily difficult to prove reliably that it does but the whole point of my critique of PACE was that if you cannot prove reliably you are not in a position to assume. If in fact it is obvious that certain theories are helpful then there must be ways of getting reliable evidence - because 'obvious' has to mean that you have reliable evidence.

I guess that I am saying that this seems to make a lot of assumptions that maybe we are not entitled to make. Do psychological theories help build relationships and increase personal development? Do we know? I am not telling anyone what to do but I think we need to ask the questions. And I get the strong impression that I am not the only one. Various bloggers involved in CBT in one way or another seem to be pretty sceptical - although sometimes it seems motivated by a preference for a different sort of therapy.

Maybe I have seen too much of the bad side of things. Certainly, the likely destructive power of psychotherapy in a Freudian or Jungian context hit me hard when I was young. It is hard to see how certain situations were not caused by bogus theorising.

Maybe the lesson is that we desperately need to find ways of testing therapist-delivered treatments using new approaches, as Keith Geraghty suggested. Maybe we need different trial structures. We have discussed this before, but a while back. I tried to think of ways to do it in the 1990s with physio but realised that there are legal and ethical problems with trying to factor out expectation bias completely.

 

I respecfully disagree with one small word here: "just"! Being supported by someone who listened (I like the italics), is to me not 'just " a thing: 'tis a rare and precious thing… Listening to someone, truly. Hearing someone.

What I wish psychology were. Or stuck to. - Maybe the role of psychologists (I'm leaving aside psychologists who specialize in a precise field such as addictions or eating disorders or family therapy etc. and am referring only to, say, "primary psychology") - maybe their role is not to explain anything to patients. Maybe psychologists ought not to pretend to know the cause of an ailment, nor to know how to treat it. Nor pretend they are experts. Nor scientific.

Maybe their greatest value is to be just there to indeed listen. And then attempt to reflect back what they hear, with simple words, words that speak to patients, words that patients will hear and allow them to speak some more.

No theory, no causal explanations, no treatment, just wording the experience, with empathy.
This is not an expertise. Is is more a skill, an art. There are no scientific guidelines to follow. Rather, a practice cultivated over time.

- Do you really need a therapist for that? - Maybe not... But after a couple of months you might wear out your best friend's patience listening to you.
- And how do we know if that's curative? Does research prove it helps? - Probably not…
- Why prescribe therapy then? - Maybe you shouldn't… People should go to therapists only if they feel a need to. Therapists who draw patients to them are likely to be bad ones.
- Fair enough, no pretention to cure , no treatment, just … an experience of wording your life, struggles and battles and distresses and joys and all… Why not just write your memoirs instead?

Good point… And aging people often do that, but why? Is it a form of therapy? Some will say yes! But most likely it is just something they feel a need to do. And there is some gain in there. There is some gain and satisfaction in having the possibility to explore in depth your life experiences, and narrate them, some of them perhaps for the very first time ever, experiences and affects which up until then were wordless accretions of raw experiences.

Psychotherapy as an analogon of writing your memoirs, accompanied by someone who every now and then intervenes but only to help you write further on, is quite a kitsch image… that I nonetheless find quite apt for what in-depth therapy should be!

I find CBT - which is but one branch of psychology, far from covering the field entire - I find CBT and its workings on "false beliefs" and cognitions to be such a shallow entreprise compared to this. But in these modern times with many people wanting quick fixes with little reflection, CBT will deliver. At lightening speed sometimes. Like writing your memoirs in a week.

Sorry if this is long but I was very tempted following the exchange between @Joan Crawford and @Jonathan Edwards. Also, because on this group the emphasis is overwhelmingly and thankfully on rigorous scientific progress. When psychology tries to get on board obeying the same strict criteria, it usually takes on the form of a grotesque usurpation. But if psychology stays humanistic and humble, it stays noble. And essential. I guess I'm concerned about not throwing the baby out with the bathwater.

 

Hi Chris, thanks for your post. What I think you are describing is the humanistic approach to counselling and psychotherapy which how I was first trained via the MA in clinical counselling at Chester. True to Roger's person centred, humanistic approach - empathy, unconditional positive regard and congruence being key along with the client/therapist relationship and therapist personal development. This is also at the core of most counselling psychologists training. This is the bedrock of my clinical work - it is a 'working with' not 'doing to' approach.

Counselling psychology in the UK in part evolved to get way from clinical psychology approaches that was more of the later. Things have changed though as my NHS clinical psychology colleagues I have encountered have a good understanding of this. That may well be different depending on where people trained and in what modalities. Clinical psychologists have often taken a more psychodynamic approach that doesn't sit well with me but that has largely changed over the last 20 years, as I understand it, to systems, family and CBT approaches.

CBT is not one thing. That's a caricature. CBT for differing psychological conditions are different. False beliefs is not something I recognise - not how I was taught based on Beck, tfCBT models. CBT is most effective for anxiety conditions. The Wessely School CBT model for ME was not taught during my CBT training. Depending on the therapist and the client CBT can be as in-depth or light as needed by the situation/presentation and client needs. And those should be paramount at all times.

 

I don't think what you are saying is harsh at all. I don't think the baby needs to be thrown out with the bath water either. Any form of psychological support or care will only and ever be relevant to a percentage of the population that seek it out or who have difficulties that might be helpful for them. And then only by mutual consent.

I agree with you that more creativity is desperately needed in how clinical trials and outcomes are measured for psychological and therapist interventions for sure. To show objective changes in functioning and so forth and external pre and then post intervention validation of drop in diagnostic status (or not as the case may be). From memory a lot of work has been done here with, for example, Type 1 diabetes, blood glucose levels and especially with young people. The original evidence base for trauma focused therapy used more rigorous approaches e.g. external assessment and evaluation pre and post by independent clinician - similar to what goes on in medico-legal cases. Similar to the kinds of things Keith G has suggested. And that should be done using structured clinical interview and psychometrics along with observation and open discussion (only ever seen this done by psychologists - never by psychiatrists). Also, using objective measures like return to work and so forth. More recent CBT trials have tended to use none of these tools and only use changes in questionnaires and feelings aka PACE. Much is focused on schools of therapy which research themselves. You are not the only one to ask questions - these are recurring and ongoing debates that go on all the time. Lack of resources largely hampers research I suspect. Along with individual schools pushing their empires. Plus the difficulties with multiple extra layers of complexity, therapist factors and so on - this is far from straightforward and is not like the more simple measures and certainties encountered generally in the medical world.

I'm curious regarding your view that referring rheumatological patients to psychologists for psychosocial support was overreach? Surely if patients are struggling with their condition / adapting to live with it and its management then it that would be appropriate if the patient was open to this kind of support? What would the alternative have been? Leave people floundering around distressed and disorientated? When I mean overreach: I mean going beyond reducing distress, support with management and adapting to: actually suggesting patients can overcome their biomedical condition by psychological methods - that is the case with Wessely school (WS) CBT and it's been found wanting. I'm assuming that's not what your patients were referred for from your department. That overreach is what disquiets me and my colleagues like Mike Scott.

Another area of overreach is in working with psychosis and major psychiatric disorders. I come from a humanistic training background that clients need to be able to be in psychological contact to benefit from therapy. Someone in the throws of an acute psychotic episode, who is not or barely in touch with reality, would not be appropriate for therapy of any kind. But what I do have experience with in my clinic is patients who are settled on anti-psychotic medications who are able to engage in pain management, for example, but only when they are stable. Plus, I occasionally encounter patients who have been severely traumatised, especially by abusive parents, who describe hearing their critical parents voice especially when they are down. And they get diagnosed with psychosis and treated with anti-psychotics. Their presentation bears little or no resemblance to someone in an acute psychotic episode. Until psychiatric diagnosis is more rigorous and evidenced based then there will remain a wide variety of patients who come under this category - with a variety of causes including major brain disease, infections, psychological harm/trauma and so forth. This undoubtedly causes confusion and will continue to do so. Similar situation exists with bipolar and cyclothymia. [As an aside even Carl Rogers tried his person centred therapy on institutionalised psychiatric patients. Made my head spin to read about that. Violated his own work - and it didn't work at all.]

I think there are ways of obtaining and using more reliable evidence regarding pwME ironically. Using activity meters, HR monitors, physiological measures, exercise tests and neuropsychological testing, return to work (or equivalent)/reduced sickness benefits, and so forth are all fairly straightforward to measure/capture. And new technology will keep being developed to make this cheaper and easier to use. In the few cases where activity meters have been used in pwME it contradicts WS view. I have used this in evidence in medico-legal reports. If I'm being cynical perhaps this is why it has not been used or results get minimised. WS researchers are highly loss averse. Peter White's excuses re PACE and actometers was poor. But this was all done (PACE, FINE etc) in the context of MRC funding, research ethics committee oversight, and no outcry from the medical profession. Medicine has not wanted to take ownership and still largely doesn't want to do to ME - barring a few folks who put their heads up. In that context, with limited medical leadership all sorts of nonsense and psychologisation has been vented pwME's way.

Private practice psychotherapy and counselling could be pretty much anything from psychodynamic/analytic approaches to humanistic, person centred approaches depending on how the therapists were trained. Could be good, could be the wild west. Buyer beware.

I find Freudian theories and the way he and his followers' practiced was shocking. Digging into how he mistreated neurology patients and endlessly imposed his beliefs on very sick patients was vile. Richard Webster's: Why Freud Was Wrong is an excellent summary. The appendix on Hysteria used to be available on line. I see Wessely, PDW, TC, et al to be direct descendants of this approach. Vile, arrogant, odious. It's a measure of how incapable some people are at coping psychologically with uncertainty, ambiguity, chronicity and ongoing suffering. I routinely have discussions with patients with many chronic medical conditions who experience hurtful disbelief from medics, family and social world in general. This is a societal and lack of knowledge problem. Instead of facing these difficulties (uncertainty, ambiguity, chronicity and witnessing ongoing suffering), WS from a position of medical authority, chose to vent them back at the patient. At best therapists can help people in such situations to pick up the pieces. Sometimes that doesn't happen and the authorative approach gets pushed on people. That's poor therapy.

 

One of the issues as I see it is psychological interventions and those that deliver them have become (maybe they always were) an industry. Sometimes that leads to them behaving inappropriately and putting their business or potential cost savings ahead of client well being.

Twice now, I have had to intervene on behalf of two different relatives. One was basically ambushed at a clinic for something else. The team felt she wasn't handling her physical health well. There were excellent reasons for that and they were right to try to get to the bottom of it but the way they ambushed her showed no respect & guaranteed she wouldn't talj to them willingly.

On the other occasion a relative was involved in a fatal accident that wasn't their fault- they were injured and spent several months in a wheel chair and the other person died before they reached hospital. As part of an insurance claim my relative had to speak to a counsellor who was overly pushy in trying to get her to discuss the accident and have ongoing counselling, paid for by the insurance company. She didn't want that but was made to feel she was being foolish and anti-therapy by not complying. She's not anti-therapy, she just didn't want to keep going over and over something she felt terrible about but couldn't change.

From my experience psychological intervention is pushed at people. There is no recognition that it might possibly be inappropriate for some at the time, there is no monitoring of harms, indeed no apparent acknowledgement it can harm. Those who don't want it & refuse it are made to feel they are discriminating against mental health issues, are in denial and don't have the capacity to know what's best. It's a catch 22 - if you know what's best for you why would you refuse therapy, but if you choose to refuse because you know what's best for you, then you are obviously mistaken.

I've witnessed a strong element of coercive persuasion, manipulation and an attempt to place authority on the side of the mental health professional.

I do believe there is a place for counselling and mental health support and that it can be a very positive thing. I just haven't seen any examples of it &, based entirely on the experiences of my family members, think that bad practice probably puts a lot of people off.

 

I think the conversation here is very refreshing ....there is a certain taboo when it comes to talking about mental health. I’ve been lucky not to have been affected by mental health problems (I’ve been tested often enough since getting ME), but I have seen how restrictive depression, anxiety and obsessive compulsive and post traumatic stress disorders can be (friends and relatives).

These conditions are a terrible burden for sufferers and their families. I would hope that therapy of some sort should be helpful...I’m not convinced though (and this is just an impression) that there are sufficient quality standards applied to diagnosis, therapy, drug prescription and in one case electric shock therapy. This seems patchy to say the least ...I’ve also narrowly escaped being dumped into a psychiatry department as a child when I was wrongly prescribed drugs for a neurological condition. Don’t get me started on neurologists. This has left a lasting impression on me, not from a stigma point of view but because of the predatory nature of the psychiatrist (think child catcher from that film with a flying car)

I am uncertain as to how useful the therapies are, but certainly think patients need better than they are currently getting.

I am also concerned that there appears to be a rather unpleasant watering down of mental health so that it seems everyone now thinks they are on a spectrum and need help. Apparently having a normal worry about lockdown and a world wide pandemic is a mental health issue for some and others think mindfulness is about protecting yourself somehow like going for a run to keep fit. This watering down only acts to trivialise quite serious conditions and it is really beginning to get my goat.

I fear this will effectively lower standards in this area and do nothing to improve stigma and awareness. I suspect this is in part being orchestrated, but perhaps I am reading too much into it. It all feels very familiar.

 

Coming to accept one's disability, and "coming out" as having a controversial illness is psychologically difficult but also important. And I have problems with self esteem due to achieving so little in life.

It's unfortunate that psychologists and psychiatrists seem to generally have so little understanding of this and instead give advice to patients that is based on popular prejudice that has crystallized into psychological illness models. It's all coming from a place a non-acceptance and lack of understanding, and the ableist "overcoming your disability" meme.

Society's acceptance of ME/CFS is still low. The best "psychotherapy" for patients might well be society simply accepting as ME/CFS as the illness patients say it is. Complete acceptance by society should translate into an absence of neglect.

 

I wasn’t able to read all the comments, but on the subject of whether cbt is useful in treating any psychiatric illness, I would argue yes for OCD and possibly for major depression.

It doesn’t make the illness go away, but does give people tools to manage symptoms.

In the case of OCD, a particular form of cbt called exposure and response prevention is very helpful.

More recently ACT - Acceptance and Commitment Therapy has been utilized alongside ERP for OCD

CBT and ACT are both also utilized for depression.

Until better treatments are available, I think these are very useful particularly for people who do not get no or minimal benefit from psychiatric medications.

 

I think much of the time it was this sort of overreaching. BPS philosophy seems to go much wider and further back than Wessely.

To be honest I never saw any reason to refer to a psychologist for reducing distress, support with management and adapting. Our psychologists were mostly about 25, with little experience of life and no knowledge about the various sorts of arthritis. I don't see how you can guide someone through coping with a disease if you know nothing about its prognosis or impact. I saw it as my main job to deal with all this myself, since I was the person who could advise fro an informed position.

I have probably said most of what I can usefully say. I would like to think that psychologists can provide useful support but I still think that we need evidence that it is done in a useful way. As for medicine I think probably psychology has to go back to square one and get the evidence. There may be some useful evidence in diabetes or addiction but judging by what I have seen from methodology I would not be very optimistic.

I guess my main thought is that we cannot justify our treatments on the basis of background theories alone, and certainly not general beliefs. As a doctor I was legally obliged not to allow my broad belief systems to impact my practice. I realise that 'humanism' may just amount to being free from of supernatural myth and focused on being respectful but I would not want to practice medicine with any label of that form. I cannot see that one can justify starting with any other approach other than altruism as generally understood. That also then has to be cross checked with outcomes to make sure one is not 'killing with kindness' or however one might put it.

 

This seems to me a particularly big and horrifying problem for people who really need help. The idea of mental health issues is so wide and increasingly depends on a broken 'cost-benefit' analysis that there seems to be an ever decreasing will to understand and find ways to effectively deal with the kind of mental health problems that severely impact a life. Having written that I think it's even the case that there is no clear understanding of mental health even at it's most basic.

This is another problem of psychological treatment applied in a McHealth model. So many people coming through an education system that may or may not have relevance and most often with little life experience. Nothing good can be gotten from that.

My own contribution is a concern of a different kind. Not sure how to put this but:

social bonds are recognised as important for individuals and the hope is that we grow resilient and well adjusted citizens. To me part of that is being able to be there for one another. There's much more to say there but suffice it that I see pyschotherapy (while it may still have some utility for some especially when the social connections have been lost) I see psychotherapy as outsourcing this opportunity for people to connect and both parties benefit and grow and bonds are strengthened.

Saying that fully aware that not every encounter will culminate in success or that the person may need multiple people to find the person who listens best with some understanding.

Anyway, just a comment for consideration.

Also, I'm not suggesting that all problems are amenable since obviously things like schizophrenia benefit from someone who has specific medical knowledge. This is where people in the field need to spend time creating some clarity with regards to what is mental health / mental unwellness.

 

Actually, I'd like to make a caveat to my post above.

There is a growing issue around what is real or fake news. I think this can spawn or at least plug into some unhealthy beliefs that I don't know whether to call mental illness or what. But this requires sometimes more that a friendly chat as one may be in a situation of hearing only things that reinforce misguided beliefs.

But this now goes beyond anything to do with ME although relevant to a psychological therapies discussion.