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

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http://journals.sagepub.com/doi/full/10.1080/00048670903107559

 

I could not only see it happening, I've lived it.

 

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

The elephant on the couch is the assumption that negative thoughts and behaviours drive negative feelings. And changing the first two will fix the last. Why anyone would accept this assumption completely unquestioningly is beyond me. It would seem much more likely that the feelings drive the thoughts and behaviours.

 

The real problem looks to me to be in the first sentence - the assumption that there is something called a 'cognitive schema' that 'causes...' or that there are 'cognitive assumptions'. It is time psychologists admitted that nobody knows what these terms mean.

But I guess the full article is about CBT in general and the need for therapists to realise that they can do as much harm as good - which cannot be bad.

 

I'm not so sure - if the message is, 'Your patients may be so stupid that they can't implement your brilliant therapy,' then I think it could just reinforce a positive sense of 'the therapist is always right', which is the big problem from the get-go.

I find each quite plausible - does the technology exist yet to yield an answer to the question of which way round it is?

 

How do we know that the CBT therapist doesn't need CBT themselves to decide which behaviours are "right or wrong" and then if they do receive CBT how do we know that the therapist delivering it to them doesn't need it and if that therapist is receiving it how do we know that the person delivering it to them doesn't need it, and then if they are receiving it..........

And then when we get to the Wizard behind the curtain how do we know that they are not a complete bullshitter and who oversees their logic?

 

I think it boils down to the fact that patients are inevitably vulnerable, and doctors frequently in a position of having to play god, with all the power that comes with that. A sound moral compass, strong sense of responsibility, competence, etc, are crucial. Patients genuinely needing CBT will be vulnerable by definition.

 

Let' s face it. It' s a cheap option that enables a box to be ticked.

 

I agree that thoughts can contribute to certain mild states of distress. Worry about finances. Lack of confidence in your appearance. But even in these examples, I suspect there's still a mood element driving it all beneath the surface.

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

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

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

Actually, when you start to think on it, this is exactly the same kind of harm that PwMEs experience when we're told we can get better by replacing our bad thoughts with good ones.

 

Where is the 'Double Like' button?

 

Bereavement, for instance, can cause serious depression - and since that's an external event, it can only be one's cognitive/psychological reaction to it that causes the depression. It's not that people got there by having 'wrong thoughts' - but surely they did get there by having thoughts?

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

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

We know we didn't get ME by 'bad thoughts' because we know ME isn't a psychological illness. A large chunk of us don't have depression or any sign of deluded thinking. But when an illness has peculiar thinking as one of its key symptoms, I think it's understandable to look at that thinking and see if attempting to alter it can affect the illness. What's not understandable is to persist in that model if it's wrong.

But is it wrong? Is there research evidence that bears on this question?

 

But "cognitive/psychological reaction" covers a lot of ground. I'm arguing the reaction in cases like grief is primarily emotional, not cognitive.

I don't think its necessary to add in a layer of self-reflection, or negative thought patterns, to understand grief. We humans form deep attachments and can come to depend on special people for warmth, love, support security. It is a major loss when someone close dies, our world is turned upside down. And its not just us but all social species, who go into retreat for long periods in the face of such loss. You don't need to assume the person is thinking catastophically or anything.

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

No, there isn't. No-one's interested in testing this view. Everyone's interested in supporting the model that aligns with CBT and other form of psychotherapy.

 

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

I think then that there needs to be an empirical testing of the model - properly done, and by people not invested in the CBT model. I think they have a plausible model, and I think that what you're saying is also plausible. I think we have to be careful of making strong claims on either side.

 

I've now read to the end of the article. It was really good. Some nice examples of possible harms in psychotherapy:

• Psychotherapy with troubled and vulnerable psychiatric patients, which involves powerful suggestion based on a unsubstantiated models of the persons' key difficulties. e.g. In Anna O, Breuer may have "unwittingly encouraged and amplified Anna's dissociations, reified her ego fragments, and then explained Anna's symptoms with the pseudo-memories and confabulations recovered from Anna while she was hypnotized".

• Therapies that are highly confrontational, where patients are chastised for not meeting targets (e.g,m some substance abuse therapies. Or "high-risk treatment processes such as confrontation, criticism and highly emotive techniques, because they can exacerbate primary symptoms, or initiate new symptoms such as increased anxiety or anger"

• Therapies that focus on past events, rather than current issues, "may promote an externalized locus of control...". For example, if the patient is encouraged to attribute their problems to the behaviour of others, and as parents. The consequences can be "estrangement, disengagement and passive adoption of the victim role".

This one was interesting, as it touches on what happens when sick people are sent for therapy to treat their "symptoms":

 

I don't know how many different kinds of psychotherapy there are. But what has been described in the various posts and links on this thread doesn't match my experience of treatment that was referred to as psychotherapy.

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

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

 

How awful, @Arnie Pye! Its amazing just how long we put up with this sort of shit, isn't it? Because we're told they know their stuff, and we're taught to be agreeable and cooperative patients.

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

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