A) With regard to "no standards of treatment", that is not the case, at least in the US. Licensing and professional bodies for both Masters-level clinicians (LPCs, LMHCs, MFTs, MSWs and others) and Doctorates (PhDs, PsyDs) effectively mandate therapists rely on evidence based practices, and insurance companies are quick to push highly manualised behavioural therapies.
Private practice is one thing, but treatment outcomes are tracked in CMH settings as well as IP psychiatric settings.
B) Licensure is not all over the place. At a bare minimum, an independent clinician in the US will have several thousand hours of client contact (e.g. group facilitation), a thousand to fifteen hundred hours of 1:1 counselling with clients, a hundred hours of supervision, and have taken two years of graduate level coursework on psychology and psychotherapy, with the curriculum on its way to being standardised nationwide by CACREP.
Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background, and that the perceived therapeutic alliance is the strongest predictor of success.
There are problems with psychotherapy research, but they're mostly those shared with the rest of the sciences.
There’s a rub to all this in that all the good therapists are licensed, but not all licensed therapists are good. Anecdotally, therapy is at least as much art as it is science. There will always be those things that science cannot answer, that “logic” cannot provide a sufficient answer for. But yoga, meditation, art, dance, all these other things are also difficult to measure and quantify, and, we apply scientific rigor with various levels of failure to them.
How do you know someone has really meditated? You don’t. How do you know someone has had a good dance? You kinda don’t know that either.
There is a basis for understanding this from an engineering perspective, and it’s right there in what you just said — that outcomes are not correlated with educational background of the clinician. Sound like programming at all? Programming is also as much art as it is a science.
So therapy is no sure thing. That much, to me, is fine. And that’s the other rub. If you want to get something out of therapy, you’ll only get out as much as you get in. There can be no shortcuts blaming things you don’t like, nor idealizing the things you want to like. We can talk standards and rigor all day. But there’s no getting around having an internal compass of honesty, and a desire to apply that honesty to one’s life. That’s what a therapist (or therapy group) should be for you — an objective voice that questions your view of things while letting you be heard, as well as creating a safe environment for you to unwind the dark corners of the mind that are normally difficult to reflect upon on one’s own. Even there it is up to you to reflect on what happened afterwards. Your therapist cannot follow you all the way.
Programming isn’t really a science, not because it is art, but because for a discipline to be a science it needs to be based on empirical evidence and “formal sciences” like math and computer science don’t pass the test.
Programming isn’t art either, not because you can’t do art via programming, of course you can, art happens whenever human hands are involved in the production process, my point being that we’ve romanticized programming for too long and it’s unhealthy.
Programming has more to do with engineering and plumbing than it does with sciences and art.
You listed a lot of specific licensed professions, titles, and degrees.
Across much of the US and Canada, words like "therapist" and "psychotherapist" are unregulated titles and practices, if not claimed to count as one of the licensed professions
I know for sure that this is true at least in New York where my mother is a (licensed PhD-holding) psychologist, and in Quebec where I live now, but I think this is typical.
"Psychologist" and "psychiatrist" are of course regulated, as is "social worker," but the generic unregulated therapy terms lead to lots of underqualified people doing bad diagnosis and treatment.
I am only familiar with the laws of OR, WA, MA, CA, and CO – the states where I'm considering doctoral programs – but "therapist" and "counsellor" are regulated and require one have a license to advertise with them. "Life coach" is the only title I am aware of that is completely unregulated across the US.
Psychoanalytical Therapist is perhaps the caveat you're thinking of? I know in New York it is a regulated title, and it may be possible to practice independently without a Counselling or Social Work degree provided one isn't billing insurance or advertising as a "psychotherapist".
Psychoanalyst is a regulated title, as are certain mental health professional titles which include the words therapist or counselor as part of the title.
But neither therapist or counselor standing alone nor psychotherapist is regulated there. (Nor is psychoanalytical therapist, unless something like case law has found that to be too confusingly similar to psychoanalyst.)
I'm not disputing your examples from other states. Just saying that these titles are significantly ambiguous across North America because of their inconsistent status, and therefore there's no standard of treatment which one can assume for them without knowing the precise state or province in question.
In my home state Therapist is a regulated term, as is Counselor. There are two different licenses, LMHC and MFT with LMHC being a good indicator that you're not going to a quack. MFT does have some educational requirements but they're satisfied by religious vocational training. It was a helpful filter for me.
pfft I like to ask every doc I go to, what outcomes they have produced in cases like mine and how many such cases they see a year. The CBT ppl just blink at me like the question is not on their manual. And one even said no great outcomes but here are the things you should do. Why would I spend my time doing them if they haven't produced results?
I mean these are nice people with good intentions but so is a priest in a church or a temple. The whole thing feels half baked. Ya ya I know reprogramming the mind is complex and this is a work in progress. But my experience from work and coaching team sports is people follow authority figures when in doubt/outcomes are unknown. And most shrinks and counsellors in my case atleast are unable to establish authority.
+1 I'm pretty sure multiple rounds of CBT made my anxiety disorders worse. The approach attracts hyper-rationalist types who aren't willing to say anything other than "Your thinking patterns are wrong, you need to fix them." No serious discussion of trauma, identity issues, or relationships. Pure gaslighting. Recently, I finally realized that what I needed was some serious introspection and an empathetic therapist who would help me work through it. For all the bluster about psychoanalysis being quackery, I'm not sure you can disagree with its basic premise that maladaptive personality traits are likely to come from the social context you spent most of your first ~18 years in.
Wouldn't many of your thinking patterns have come from your childhood and teenage years? How did none of this come up when you did CBT? Also, how did you do CBT without serious introspection? It sounds like the therapist you did CBT with just wasn't very good.
I've found that for my anxiety ERP based therapy is much more effective because often anxiety isn't a matter of your rational brains understanding but rather trained responses of your subconscious.
Outcomes are meaningless without control groups. The providers you spoke to may not have stunning reversals of illness to show you, but keeping someone from sliding into a worse state is an important function of therapy and impossible to measure. For all you know, they may have prevented dozens of suicides that year.
Well, from the comment I was responding to, the implication I took from "no great outcomes" was "no great change, either positive or negative". But technically, yes, you're right.
It's frustrting when you ask someone how they know this works or how effective it is and they give you blank looks. It feels like a failure of informed consent.
> The CBT ppl just blink at me like the question is not on their manual.
What country? In England the IAPT programme (the main source of CBT) has extensive data collection on outcomes (probably the largest collection in the world) and a focus on getting more and better evidence to improve the service.
Chapter 3 and 6 of the IAPT manual are about evidence based practice and gathering better data:
tl;dr: CBT is somewhat effective; it's more effective if you have CBT that follows the high intensity model (14 to 20 weeks, one hour per week, face to face one to one with a qualified therapist).
>And most shrinks and counsellors in my case atleast are unable to establish authority.
If you continuously end up in situations where you're seeing mental health professionals, you might consider just accepting their authority without the need to jump through your hoops.
Speaking from experience, seems to me the GP’s need to make people jump through hoops to earn their trust is a damned important part of _why_ they need those professionals in the first place.
At a certain point you need to consider their success rate against your own. Realizing that and accepting they may be able to help is an important step.
For the most part, people see a psychotherapist because they've got problems that they feel unable to fix on their own. Awareness of resistance to the psychotherapeutic process is almost as old as psychotherapy - it's a central concept in Freudian psychoanalysis.
"You have to be willing to help yourself" is perilously close to "psychotherapy only works on people who are capable of changing of their own volition", which calls into question the entire purpose of psychotherapy. If I could change my way of thinking through sheer force of will, why would I pay a professional $100 an hour to sit and listen while I do it? It evokes the classic defence of the quack - the spoon only bends if you truly believe in the power of the mind.
If that problem is framed as "some patients are too sick to treat", then at least it shifts the burden of responsibility onto the therapist; it's not the patient's fault that the psychotherapist lacks the neccesary tools to facilitate change. Blaming the patient for having a bad attitude just makes the profession of psychotherapy look ineffectual.
It's not really about being able to change yourself, it's about wanting to change so much that you're willing to put in the work. When I did it I had to unlearn a bunch of mental habits, but I also had to change my environment and seek things that were outside of what I knew. Therapy would have done nothing for me if I had let the therapist do all the work. I'm my case the work was to find a new way of living that is aligned with who I am and what I want for myself.
When I went in I had some major anxiety problems, and by working with my therapist I was able to identify where those problems came from. I started taking steps to change how I lived so I wasn't as anxious anymore.
Blaming the patient for having a bad attitude just makes the profession of psychotherapy look ineffectual.
What sort of magic are you expecting from psychotherapy? You're paying someone to help you solve your problems. You're not paying someone to solve your problems for you.
Advertisers nudge you to do something you sort of already want to do. The amount of effort required to buy things is minimal and buying things you want to buy is usually enjoyable.
On the other hand, going to therapy is forcing yourself to do something that is difficult, sometimes painful and requires a lot of effort and resources (both time and money). I don't see the relationship between voluntarily going to therapy and advertising inducing you to buy things.
While it does require your participation for success, you are paying the professional for the tools to help yourself. And sometimes others aren’t able to help themselves, and the professional’s job is to help them discover how to.
I mean, if someone is shot, you can still surgically intervene without them having to participate. It’s true in psych that you have to help yourself, but it’s also true that’s probsbly a valid critique of the art rather than science that is psych. Talk therapy has more in common with spiritual guidance or shamanism than medicine, except where the actual medicine enters the fray in the form of drugs and surgery. If you’re willing to help yourself, talking to someone is often helpful, but that’s been known for thousands of years.
A real intervention doesn’t require someone to help themselves; an appendectomy doesn’t require patient participation and motivation.
I mean, if someone is shot, you can still surgically intervene without them having to participate.
Okay, this is clearly not what we were talking about. Sorry I was not more specific in my statement to generalize to all scenarios, ever.
Edit: I think it is also a pretty fair assumption that if someone is shot or their appendix is about to burst, they would want help. The key difference here is that someone who is shot is not capable of helping themselves - with regards to many things people go to therapy for, the only way to fix your problems is going to be taking some actions yourself.
Consent is one thing “my appendix is killing me, help!” while actually doing the work yourself is another. Obviously any intervention requires consent to really work, but once you’ve consented to the appendectomy your role ends. You don’t have to actively engage in your own surgery past the act of wanting it. By contrast merely consenting to therapy isn’t enough, you have to do a lot of hard work as well. The fact that the hard work of everything from overcoming neuroses and anxieties to battling substance abuse is the patient doing the work suggests something about the nature of therapeutic intervention as “treatment” rather than advice-giving.
> A) With regard to "no standards of treatment", that is not the case, at least in the US. Licensing and professional bodies for both Masters-level clinicians (LPCs, LMHCs, MFTs, MSWs and others) and Doctorates (PhDs, PsyDs) effectively mandate therapists rely on evidence based practices, and insurance companies are quick to push highly manualised behavioural therapies.
A giant % of therapists around my area advertise that their treatment methodology is "eclectic".
Trying to find someone who follows even CBT is almost impossible.
I have seen at least a few people advertising themselves as following Freudian principles. So there is that.
> Licensure is not all over the place.
The quality of programs that provides those licenses are. And thousands of hours of training under someone who is not very good, does not lead to a good practitioner.
I'm not saying all therapists are bad, but I'd say that picking a therapist at random will have about as good of luck as picking a mechanic at random: Greater odds of your wallet being emptied than your problem being fixed. Finding an honest and talented practitioner is hard.
> Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background
Isn't that a huge problem?
Imagine if that was the case for any other medical profession! "The surgical techniques we teach in school, and charge a lot of money and put students deep into debt for, aren't shown to be any better than someone coming off the street with a hacksaw and a really good smile."
Now that said, I've met people entering LMHC programs who obviously didn't need the credentials, their natural understanding of people was blatantly better than what 80% of their courses would cover. But those people are the obvious exception.
Private practice is one thing, but treatment outcomes are tracked in CMH settings as well as IP psychiatric settings.
B) Licensure is not all over the place. At a bare minimum, an independent clinician in the US will have several thousand hours of client contact (e.g. group facilitation), a thousand to fifteen hundred hours of 1:1 counselling with clients, a hundred hours of supervision, and have taken two years of graduate level coursework on psychology and psychotherapy, with the curriculum on its way to being standardised nationwide by CACREP.
Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background, and that the perceived therapeutic alliance is the strongest predictor of success.
There are problems with psychotherapy research, but they're mostly those shared with the rest of the sciences.