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Culture War Roundup for the week of April 29, 2024

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I went to the trouble of writing an effort post somewhere that was read by like 8 people, so I'll just reproduce the primary bit, and tack on additional commentary at the end.

Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.[8][22]

One line of research consistently finds that supposedly different forms of psychotherapy show similar effectiveness. According to The Handbook of Counseling Psychology: "Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments". The handbook states that there is "little evidence to suggest that any one psychological therapy consistently outperforms any other for any specific psychological disorders. This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes".[151]

Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.[152][153][page needed][154][155]

Outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalize from them to practicing therapists.[153][156]

However, specific therapies have been tested for use with specific disorders,[157] and regulatory organizations in both the UK and US make recommendations for different conditions.[158][159][160]

The Helsinki Psychotherapy Study was one of several large long-term clinical trials of psychotherapies that have taken place. Anxious and depressed patients in two short-term therapies (solution-focused and brief psychodynamic) improved faster, but five years long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies.[161]

Meta-analyses have established that cognitive behavioural therapy (CBT) and psychodynamic psychotherapy are equally effective in treating depression.[162]

The bolded section is the one I can't easily verify, at least not when it's 9 am and I've been up all night studying.

Specifically regarding CBT, I found the following metanalysis-

Results: A total of 115 studies met inclusion criteria. The mean effect size (ES) of 94 comparisons from 75 studies of CBT and control groups was Hedges g = 0.71 (95% CI 0.62 to 0.79), which corresponds with a number needed to treat of 2.6. However, this may be an overestimation of the true ES as we found strong indications for publication bias (ES after adjustment for bias was g = 0.53), and because the ES of higher-quality studies was significantly lower (g = 0.53) than for lower-quality studies (g = 0.90). The difference between high- and low-quality studies remained significant after adjustment for other study characteristics in a multivariate meta-regression analysis. We did not find any indication that CBT was more or less effective than other psychotherapies or pharmacotherapy. Combined treatment was significantly more effective than pharmacotherapy alone (g = 0.49).

Conclusions: There is no doubt that CBT is an effective treatment for adult depression, although the effects may have been overestimated until now. CBT is also the most studied psychotherapy for depression, and thus has the greatest weight of evidence. However, other treatments approach its overall efficacy.

And when speaking of CBT as applied to more psychiatric conditions:

We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.

Addressing the specific claims of similar efficacy to the forms of therapy based on pseudoscientific principles:

CBT for depression was more effective than control conditions such as waiting list or no treatment, with a medium effect size (van Straten, Geraedts, Verdonck-de Leeuw, Andersson, & Cuijpers, 2010; Beltman, Oude Voshaar, & Speckens, 2010). However, studies that compared CBT to other active treatments, such as psychodynamic treatment, problem-solving therapy, and interpersonal psychotherapy, found mixed results. Specifically, meta-analyses found CBT to be equally effective in comparison to other psychological treatments (e.g., Beltman, Oude Voshaar, & Speckens, 2010; Cuijpers, Smit, Bohlmeijer, Hollon, & Andersson, 2010; Pfeiffer, Heisler, Piette, Rogers, & Valenstein, 2011). Other studies, however, found favorable results for CBT (e.g. Di Giulio, 2010; Jorm, Morgan, & Hetrick, 2008; Tolin, 2010). For example, Jorm and colleagues (2008) found CBT to be superior to relaxation techniques at post-treatment. Additionally, Tolin (2010) showed CBT to be superior to psychodynamic therapy at both post-treatment and at six months follow-up, although this occurred when depression and anxiety symptoms were examined together.

Compared to pharmacological approaches, CBT and medication treatments had similar effects on chronic depressive symptoms, with effect sizes in the medium-large range (Vos, Haby, Barendregt, Kruijshaar, Corry, & Andrews, 2004). Other studies indicated that pharmacotherapy could be a useful addition to CBT; specifically, combination therapy of CBT with pharmacotherapy was more effective in comparison to CBT alone (Chan, 2006).

In the particular case of BPD, after talking to @Throwaway05 I looked into the actual benefit of DBT, and was surprised to see that it was genuinely far more effective than I expected. Somewhere around the ballpark of 50% success rates in curbing symptoms and letting quite a few of them lead entirely unremarkable and functional lives. If 50% sounds underwhelming, wait till you hear the typical cure rates I'm used to.


Is therapy and therapy speak actually harmful to people that have mental illness?

A clear no. The evidence base is nigh unimpeachable, even if, as discussed above, the most bullshit insanity inducing forms like Freudian or Lacanian psychotherapy still beat placebo.

My personal working hypothesis is that therapy acts as a decent substitute for a friend, a non-judgemental and understanding one who has seemingly endless time to listen to your problems, and is forbidden, on the pain of losing the way they make a living, from disclosing your troubles. Unfortunately, quite a few people genuinely lack actual good friends, so even such as ersatz substitute has notable effects.

This is an entirely different question from the fad we've been having for quite a few years of "therapy culture", or the insistence of people to co-opt/misuse therapy speak to lend their bullshit legitimacy. Then again, there are practising Freudian and Lacanian therapists, and few other people seem to have the same burning urge I have to burn their houses down. Even then, I must concede they beat placebo, as well as the dead horse that is repressed penis envy.

Anyway, therapy seems to beat placebo, and works synergistically with drugs, even if you cynically notice that therapy based off nonsense does much the same thing as more considered approaches, but it's not in dispute that it works. At least I have the consolation of being able to throw drugs at people instead of just talking at them as a licensed shrink in training, for all the quibbling about if SSRIs work, ain't nobody claiming their ADHD isn't being helped when they're zooted up on stimulants.

To conclude, is therapy helpful when administered by someone who knows what the fuck they're doing? Yes.

Are they/us responsible for random idiots using it as an obfuscation technique? Not really, though the upper echelons of HR are often staffed by people with degrees in psychology where I'm at.

Is it possibly a net negative for the set of {all people subjected to mealy mouthed terminology}? No clue, but you asked about the actually mentally ill, and you have my answer. No surprise that a few of them pick up on the lingo.

Wow, that is a very high-effort post!

To conclude, is therapy helpful when administered by someone who knows what the fuck they're doing? Yes.

This point is the whole thing. I notice here that a lot of people seem to have complaints about "endless therapy" and "never getting better," but reputable, well trained therapy involves a constant progression towards "being done" (well typically anyway).

I suspect this is equal parts misunderstanding and a surplus of shitty therapists, which makes sense since it's far harder to regulate, train, and assess than "traditional" medicine.

Small amounts of therapy that anyone with diligence and training can do (like motivational interviewing) can radical improve care for any specialty.

Shit is good when done well. And even more fluffy and "less evidence based" therapy modalities like psychodynamic therapy work great when done by someone who cares and knows what they are doing (and are shocking similar to CBT anyway).

But one tenet of therapy culture is that therapy is never done, that everyone should be seeing a therapist and that therapy is about not just treating dysfunction but becoming a "better person". This is what I identify about therapy culture - that for many people it is a system of morality, replacing traditional systems of morality.

I am sure that some people exist who feel this way, but all of the therapists I know (which is bounded by these people being mostly physicians, or PHD/PsyD psychologists), think that shit is nuts (and have much displeasure with the popular presentation of therapy, mental illness and so on).

Indeed. When I need to send someone to a therapist, I tell them it's a sign of both confidence and competence when they make it clear that's there's a time limit for that. Either they note you making good progress, with an end goal in sight, or they tell you straight up that you're not a good fit and send you on.

Not that people can't need prolonged therapy, but maybe I'm just jaundiced from all the girls I've spoken to who should be wearing grippy socks. But they need Jesus, or his brother in the asylum.

One wrinkle for me when trying to think about the efficacy of therapy is that the incidence of mental illness has skyrocketed in step with the wide spread adoption of therapy culture. This is supposed to be caused by increased awareness, but then you have things like Scott's Anorexia in South Korea story, that push me towards a different theory. Therapy culture is horrible, and therapy itself is mostly trash (which is why we can't make any meaningful improvements to the practice after over a hundred years), it only works in as much as it is the socially acceptably path to resolve such issues. I imagine if we could check, running amok would have been found to be an effective above placebo 'therapy' as well. Outside of a handful of mental illnesses with consistent cross cultural manifestations, everything else is either conversion disorder with people trying to fit their negative emotional states into a culturally understood framework, or increasingly, excuses for shitty behavior and to avoid accountability. The framework spawned by therapy culture in the west is particularly bad, mental health awareness is bad, stoicism is probably correct.

The framework spawned by therapy culture in the west is particularly bad, mental health awareness is bad, stoicism is probably correct.

I get that you are making a distinction between "therapy culture" and "therapy" proper, but it is worth pointing out that Stoicism's DNA is in CBT by way of REBT's influence on it, with REBT's founder Albert Ellis being influenced by (among other sources) the Stoic philosophers. So Stoicism's influence is part of modern therapy, even if it is not part of modern therapy culture.

incidence of mental illness has skyrocketed in step with the wide spread adoption of therapy culture

That is hopelessly confounded. For most of history, the only treatment for mental illnesses was beatings, blood letting, the asylum, or maybe some mercury if it was syphilitic.

They barely had the conceptual framework to understand mental illness in the first place.

Besides, we know that the stressors of modernity are bad for mental health in of themselves, just look at social media and dating apps for recent examples. Atomization of families, loss of the (false) comfort from religion and so on.

Not everything is a mass psychogenic illness. I would bet a great deal of money that things like depression, BPD, bipolar disorder and the like aren't. And therapy helps, at least when we now recognize and formally diagnose those who could need it.

My own ADHD would certainly have gone undiagnosed, as would so many other conditions (not that therapy does anything there, the drugs help).

therapy itself is mostly trash (which is why we can't make any meaningful improvements to the practice after over a hundred years), it only works in as much as it is the socially acceptably path to resolve such issues. I imagine if we could check, running amok would have been found to be an effective above placebo 'therapy' as well

I feel like my citations speak for themselves here. Is it a good thing that we have the option of paying money to talk to someone in private instead of running about with a machete? I'd be curious to hear how that's not the case.

I'm not defending therapy culture. It's infantilizing to say the least. But actual therapy works well enough that we often consider it the firstline treatment before resorting to the funny drugs. And that's a considered decision made by multiple independent bodies, on the basis of a great deal of evidence.

Wouldn't it be funny if beatings, bloodletting, alcohol and prayer actually worked?

Imagine life in 1300s Europe. There's a 30-50% chance your child will die as an infant. You might have chevauchee Englishmen/Frenchmen/Germans running around looting and killing. Sudden illness could randomly kill you. You likely work long days in the fields, famine is an everpresent danger especially if the lord decides to take your food. You might be drafted to fight in some war where you'll wait between bursts of extremely gorey, personal violence and interminable waiting as disease picks your comrades off. If you sin you face a very real and universally accepted penalty of eternal hellfire. Esoteric doctrinal differences to the church? Welcome to a world of blood and fire, brought to you by your local crusaders. Alternately, if you're in range of the Mongols you can experience blood and fire without needing any heresy. The less said about Meso-America the better.

This is a pretty stressful lifestyle! WEIRD people don't have any of these problems, only social alienation and other such high-Maslow issues. I won't dismiss the psychic damage inflicted by Microsoft PowerPoint but it's on a totally different level to ubuiquitous deaths in childbirth. Yet there's loads of anxiety, depression and so on today.

Prayer probably does work at least a little bit, and beatings can at least straighten out the crowd with a mental illness downstream of refusing to be normal.

We do at least still have beatings and alcohol, and blood letting too, if you're diagnosed with hemochromatosis.

Frankly speaking, while depression might be more prevalent today as a disease exacerbated by modernity, I can't imagine our ancestors weren't anxious or stressed the fuck out.

They barely had the conceptual framework to understand mental illness in the first place.

Are the current year frameworks better or just different?

Unless there's some identifiable treatable organic cause for the anxiety, mood or personality disorder might the patient improve just as well be guarding against and rebuking the demons of pride, envy, sloth, lust, etc? Especially if most of the available therapy interventions perform as well as each other.

Better? As far as I can tell, yes.

Unless there's some identifiable treatable organic cause for the anxiety, mood or personality disorder might the patient improve just as well be guarding against and rebuking the demons of pride, envy, sloth, lust, etc? Especially if most of the available therapy interventions perform as well as each other.

We do have identifiable organic causes for many psychiatric illnesses we did not, within living memory, once have. Subtle and variable ones, but what can other answer can you expect when asking a question that involves most psychiatric diseases under the sun?

I fail to see how the latter follows at all. It's not like therapy is the only tool in the arsenal, psychiatrists are not psychologists, we dole out meds too and once again, they work, even if some of them aren't as effective as could be desired.

Psychiatrists do dole out meds. But the efficacy (and why) is questionable. I read that exercise seems like it results in a better outcome.

Are you a psychiatrist? If so, that obviously gives you special insight but also clearly a bias.

I just went to the trouble of citing a million studies and meta analyses on the matter, what else can I add that isn't anecdotal? Exercise certainly helps, it's far from the only thing that helps. Antidepressants aren't very good drugs, but they beat placebo at the least.

Are you a psychiatrist? If so, that obviously gives you special insight but also clearly a bias.

I've been accepted into psychiatry residency in the UK, starting in a few months. But it's always been my penchant, so consider me the least biased I could possibly be, or at the least I wouldn't have chosen that subject if I felt it was fraudulent.

That is hopelessly confounded.

It is certainly confounded enough that I did not mean to imply that I have some sort of formula that accurately describes the relationship, but are you contesting that the relationship exists at all, or do you think it is not big enough to meaningful inform how we think about the efficacy of therapy? My thought process here, in simple terms, would be that a person who is having a shitty time but does not exist in therapy culture, has a less shitty time than the same person in therapy culture. So, a study that finds that people who show up with depression get better after therapy, has the problem for me, that I do not know if that person would have had an equally bad condition in the counterfactual where they don't know what depression is. Imagine if the anorexia in South Korea story is correct, and previously Korean girls never got anorexia, and now a bunch are getting it. Someone coming along and telling me that therapy does better than a placebo at treating their anorexia with super high-powered top-tier most excellent and well replicated research, is still not offering me a particularly compelling defense, if I think therapy awareness campaigns 'caused' the anorexia in the first place. See also all the stories of, trauma counseling that traumatized someone.

I'm not trying to say that the myriad forms of mental illness have no basis in real human experiences and emotional states. I just think it's possible that therapy, and the (unavoidable?) downstream therapy culture, might actually be a bad way to structure a societal understanding and response to those feelings.

Is it a good thing that we have the option of paying money to talk to someone in private instead of running about with a machete?

Maybe? It isn't easy for me to evaluate the counterfactual. I have no idea exactly how destructive a, the way to deal with bad emotions is to go a little wild and break stuff, society needs to be, the purge is (probably) too far, the way I dealt with stress as a kid (running around yelling), probably healthier than what we do now.

I don't deny the existence of mass psychogenic illness. I agree with Scott that it's the most reasonable explanation for things like bulemia, or even gender dysphoria.

I entirely reject that it covers the majority of psychiatric conditions, especially the ones I mentioned, which also happen to be amenable to therapy.

You'll find that the "incidence" of most diseases sky rocketed in short order over the past century. Mainly because if we don't know a disease like that exists, due to a lack of diagnostic tests or plain awareness, there won't be a diagnosis.

But isn’t this the whole discussion about illness v disease. There are a lot of things we call “diseases” that are diagnosed via the DSM. But is there a blood test for say anxiety? Is there a scan for depression? What about being gay (which prior DSM’s treated as a mental illness).

I know this is veering into Szasz (and Caplan’s points).

It's routine (or at least best practice) to order a whole heap of blood tests when doing a work up for someone with depression. Add on polysomnography too.

Thyroid deficiencies, sleep apnea, neurological issues like Alzheimers or Parkinsons, they all can produce depression, or be comorbid with it.

So while there's no blood test to diagnose depression-in-itself, any decent psychiatrist will figure out if there's something else wrong with the body, and treat accordingly. But in the end, we have no reliable way of pointing an instrument at someone and get DEPRESSED or NOT DEPRESSED back. Hence the whole talking to them and using standardized questionnaires, which does work mind you, even if we don't have anything significantly better once we've ruled out the body fucking with the mind in other ways.

To no one's surprise, Scott has written about this at length and I feel like there's little for me to contribute, yet.

For example, this one, though he's written more about it on ACX not that long ago.

One thing that is interesting (at least to me) is whether even if the diagnostic tests were useful once upon a time do you run into an observer effect rendering the diagnostic useless?