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Comment by skunkworks | Hacker News Reader

A welcome article to read after this: https://news.ycombinator.com/item?id=6346567

I hope one day we'll have a complete model for understanding depression, but for now, it's encouraging enough to know that there are different kinds that are more/less responsive to different treatments.

Also, nice to see CBT get some props. It's really effective. And as someone who often proselytizes about the wonders of therapy, I'd like to get rid of the quacks who practice "black magic" therapy i.e. a non-evidence-based mish-mash approach. They are not helping the bias against mental health services in the US.

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“Psychotherapy is an undefined technique applied to unspecified problems with unpredictable outcome. For this technique we recommend rigorous training.” -Horowitz

All therapy is "black magic" in the sense that no-one quite understands exactly how it works. CBT gets props because it's one of the few therapies that has a manual and can actually be studied scientifically.

I'm sorry but I prefer to speak with a therapist who doesn't have to consult a manual for every response he/she makes. Therapy is ultimately a human relationship, and just as messy and unpredictable as any other relationship - and subject to all the contingencies thereofe.

Just because something cannot be studied scientifically does not mean it is not effective. Evidence for the limited long term effectiveness (high relapse rates, ect) of shallow and manualized interventions like CBT is growing by the day. Compare that with more messy therapies that dig deeper (like psychodynamic) whose outcomes actually improve the longer the subjects are tracked.

The vast majority of the effectiveness of therapy is due to hope (placebo effect) and the relationship. Focusing on the "technique" is distracting and leads to a view of therapy as something that is done to you, as opposed to something that is done with you. Lasting change comes from taking personal responsibility, not from having special "scientific" techniques done to you.

That para-professionals with 2 weeks of training have outcomes as good or sometimes better than those with Ph.d's in clinical psychology is all one needs to know when deciding whether or not to categorize psychotherapy as a science.

CBT gets props because its empirical results have shown to be more effective than the traditional talk therapy approach. It's been around for a long time, has been studied enough for us to be confident that it makes a real difference, and I consider it as medicine for thoughts. Of course there's no way for us to quantify its precise method of action, so it's not that different than making the observation that the bark of a certain tree seems to reduce pain and inflammation, but if the burden of proof is to show direct causation from our thoughts and CBT to a better outlook on life, we might as well be asking about the nature of human consciousness.

CBT is a framework more than it is a manual, and not nearly as robotic as you've described. All therapy requires a human relationship to be successful. You have to trust your therapist to believe in the things they say, and that belief is a prerequisite for putting in the effort to reshape your thoughts and attitudes, but what's so robotic about a therapist asking you to explore the origin of a preconceived notion? About them asking you to be mindful of those type of thoughts? On coaching you to intercept those negative thought patterns and replace them with improved ones?

I think chalking up the efficacy of therapy to hope and placebo is a bit disingenuous. Yes, belief in change is a precursor to real change -- no therapist can help someone who isn't willing to believe or even want to change -- and in a way, the therapist's role is to guide you in your own endogenous healing process. However, there needs to be some rigor in the way they guide you to break bad patterns and replace them with better ones.

In a way, the therapist's challenge is like inception: how can I plant something in someone else's head but make them feel like they came up with it themselves? I think most of us could look at someone with low self esteem and negative thoughts and tell them what's wrong and what they should say or do or believe instead. However, that process needs rigor, and one of the best tools in the toolbox is to increase someone's mindfulness, and one of the best ways to do that is CBT.

I think overall you're a bit dismissive of it as a shallow, robotic approach when really it's a simple, repeatable, controllable frontline intervention. It's not going to work for deep-seated issues, but I think of it as almost being a prerequisite before those deeper issues can be tackled. I am of course speaking from personal experience, in both myself and what I've observed with others.

That hope and the relationship make up a much larger percentage of what causes change than technique is not my personal opinion. It's the result of a trans-theoretical analysis that was done a few years ago.

I don't recall the name of the study, but it's described in detail in "The Heart and Soul of Change".

> Lasting change comes from taking personal responsibility, not from having special "scientific" techniques done to you.

OCB, schizophrenia, PTSS disorders prove you wrong. And your comment about responsibility is ill-advised and bad attitude ; make a favour to people suffering from mental illness: don't try to comfort or coach them.

CBT gets quite a lot of props. It legitimately deserves many of them but probably gets more than it should, especially relative to "black magic" psychotherapies.

The main reason CBT is so popular in the industry is that it was designed from the ground up to be testable. CBT practitioners and CBT-friendly researchers have run a lot of tests, and they have found that CBT is effective.

For a long time, other modalities either weren't tested in this way or were only tested under CBT-friendly conditions. And this is a real black mark against them. But since CBT started eating their lunch from 2001 or so, other schools that could afford to started doing their own tests.

Guess what happened when psychoanalysts started running their own tests? If you guessed that they went home crying and gave everything up for CBT, you would be wrong. Instead, psychoanalytic-friendly researchers have found (empiricially!) that psychoanalytic treatments are effective, except for schizophrenia, just like CBT-friendly researchers found that CBT was effective for everything including schizophrenia (which really should have been a tipoff that something was amiss in the first place TBQFH). In other words, which therapy gets found to be effective depends a lot on which therapy the researcher wants to be found effective.

There are a ton of problems in measuring psychotherapy. Researcher bias is an obvious one. Ensuring that the things you're measuring are actually the things that you're supposed to be measuring (e.g. that the CBT patients are all actually getting by-the-book CBT, psychodynamic are getting psychodynamic, control are getting...what?) is another huge problem.

Across thousands of studies, the biggest variable in effectiveness of psychotherapy seems to be the therapist him- or herself. Some are drastically noticeably effective across a large number of patients and most are not. The effects of treatment modality, assuming you can pin it down at all, are seldom very significant, especially when blinds and control are used.

Other reasons CBT tends to be favored: emphasis on short duration is insurance friendly. Also, the 'cognitive' adjective implies that it has something to do with recent advances in neuroscience, which it doesn't.

(FWIW I've had both CBT and analysis, benefited from both in different ways.)

Agreed on all points. Really when I say "black magic" therapy, I'm being sloppy because what I really mean is that if you're not that good of a therapist, you shouldn't be offering anything but basic, rigorous types of therapy. I wouldn't go so far as to say that a good therapist offers a "human element", but skilled therapists are more observant, have stronger communication skills, have a more intuitive sense on when to challenge their patients, etc., and that allows them to go deeper into murkier waters than others. But to boil all of that down to "the relationship" and the "human element" feels overly reductive. There's still something quantifiable about the qualitative aspects.

The only therapies you can study scientifically (making sure everyone receives the same treatment in the treatment group), are therapies with manuals. However, only about 3% of all therapies have such manuals (CBT being one of them).

Most therapists highly individualize their approach - just because they have the same name doesn't mean they're actually doing anything similar. So claims of "empirical" proof of psychoanalysis is nonsense. The nature of what psychoanalysis is precludes that.

There actually are shorter-form therapies derived from psychoanalysis that do have manuals, and studies purporting to show their effectiveness. The point wasn't that these therapies are all that great - they probably aren't - but that measuring psychotherapy is a methodological ball of tar and prone to confirmation bias.

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