Article on psychological therapies and the "placebo effect"

[Woolie]

Why CBT is falling out of favour

http://www.theguardian.com/lifeands...ut-of-favour-oliver-burkeman?CMP=share_btn_tw

Researchers have found that CBT is roughly half as effective in treating depression as it used to be

The article really misses the point, I think. It considers that our measures of the effectiveness of CBT - both past and present - are valid. That is, they are good at measuring effectiveness. There's a bit about the placebo effect, but they dismiss that as an explanation for CBT's demise because the placebo effect is about heightening a person's expectations and that's a valid treatment outcome in itself.

More likely in my view:
* Most (if not all) of the placebo effect is just measurement noise, it doesn't reflect real improvement
* CBT is getting less effective because studies of its effectiveness have to be better designed now than 40 years ago. So its harder to get away with the dramatic results you could show in the 70s with a pretty dodgy design.

Have we finally got to the point where current studies are telling us the "truth" about the effectiveness of CBT? I'd say far from it. Designs are still not that great, and when they improve, effects will drop down again.

It might turn out that only some complaints benefit (maybe phobias? bedwetting?). Others not at all.

 

[alex3619]

I agree @Woolie. Science by poor methodology with inbuilt bias has to go. I hope to write a blog soon on category mistakes that I think addresses another part of the issue. Stay tuned.

 

[Bob]

FYI, older threads...
http://forums.phoenixrising.me/inde...therapy-cbt-is-becoming-less-effective.38514/
http://forums.phoenixrising.me/index.php?threads/cbt-for-depression-losing-its-efficacy.38075/

 

[Jonathan Edwards]

Why CBT is falling out of favour

http://www.theguardian.com/lifeands...ut-of-favour-oliver-burkeman?CMP=share_btn_tw


The article really misses the point, I think. It considers that our measures of the effectiveness of CBT - both past and present - are valid. That is, they are good at measuring effectiveness. There's a bit about the placebo effect, but they dismiss that as an explanation for CBT's demise because the placebo effect is about heightening a person's expectations and that's a valid treatment outcome in itself.

More likely in my view:
* Most (if not all) of the placebo effect is just measurement noise, it doesn't reflect real improvement
* CBT is getting less effective because studies of its effectiveness have to be better designed now than 40 years ago. So its harder to get away with the dramatic results you could show in the 70s with a pretty dodgy design.

Have we finally got to the point where current studies are telling us the "truth" about the effectiveness of CBT? I'd say far from it. Designs are still not that great, and when they improve, effects will drop down again.

It might turn out that only some complaints benefit (maybe phobias? bedwetting?). Others not at all.

It reminds me of the idea that science is pushing on doors that for some reason have recently been unlocked but nobody else has yet taken the trouble to push on them. I have a feeling that the CBTbabble door may have been unlocked by the fact that the psychology community are actually in a tiz about replication of all their data at present. I say this with great authority 'cos there was a programme on BBC Radio 4 about it a week ago. There was shock-absorbing material presented to avoid psychologists jumping off cliffs 'unlike some we are not knocking psychology, just investigating the fact that we seem to have a data problem', or 'it seems that the problem is not unique to psychology' (but it might be a whole lot worse than in other fields).

For me the shock absorbing is built in in a different way - all science is fragile, we can only try our best. The crime is not to recognise that. To try to put a gloss of quality on dodgy bacon.

But to come to specifics - an anecdote. David Tuller came to dinner a week or so ago and we had hardly started the conversation before it was time to respect his tansatlantic sleep hygeine with a busy morning ahead (i.e. 3 hours is just a warm up). Fortunately David should be back soon. But one thing the conversation made me come back to is that there is no dosage standardisation for CBT - so you cannot do dose response curves very easily. It is a bit like syaing that foxglove is good for heart failure. It was discovered in the 1970s that in fact foxglove is pretty bad for nearly all heart failure (it induces fatal arrhythmias and makes you see yellow) and only any use if you get the dose exactly right and use it where there is atrial fibrillation (which would have been common in clients in Withering's day due to alcohol being a staple food in winter I guess).

So prescribing CBT is a bit like saying 'go and have some foxglove tea'. And like Mars bars and everything else these days you don't get quite as much as you used to in the packet. As I have said before I also have this on very good authority because I have it in an email from a very eminent psychiatrist who has championed CBT for ME/CFS but worries that patients are not getting the right sort of CBT because they are not trained properly.

Consider that the beneficial effect of CBT might be similar to that of Morecambe and Wise, or perhaps the Marx Brothers. That is not so easy to produce on a Tuesday morning when Mrs Jones comes for her therapy session. I am not sure that since Eric died anybody has achieved the effect. If CBT is getting less effective I don't think anyone should be surprised.

The only effect I have come across that actually seems to have improved with age is the Buena Vista Social Club. Despite the original artists probably being long gone there is still a bar that calls itself the BVSC in Havana (actually not still because there never was one originally) and the music is amazing - and probably more home grown than the original pretend group. Whether it will survive the lifting on restrictions on US visitors I doubt, but who knows.And we would need to use rigorous objective outcome measures to be sure.

 

[TiredSam]

Well I liked this bit:

Perhaps every era needs a practice it can believe in as a miracle cure – Freudian psychoanalysis in the 1930s, CBT in the 1990s, mindfulness meditation today – until research gradually reveals it to be as flawed as everything else.

I would be quite happy to accept that the effectiveness of CBT as a cure for ME is now half what it used to be, also twice what it used to be and ten times what it used to be (you can muliply or divide 0 by whatever you like for all I care).

Consider that the beneficial effect of CBT might be similar to that of Morecambe and Wise, or perhaps the Marx Brothers.

I once watched a youtube video on EFT tapping, which had precisely the same beneficial effect as Morcambe and Wise.

 

[BurnA]

As I have said before I also have this on very good authority because I have it in an email from a very eminent psychiatrist who has championed CBT for ME/CFS but worries that patients are not getting the right sort of CBT because they are not trained properly.

So presumably this person can pinpoint exactly the elements of CBT which have an effect and those which dont. It's a wonder this person doesn't provide specific details.

Despite the original artists probably being long gone there is still a bar that calls itself the BVSC in Havana (actually not still because there never was one originally) and the music is amazing - and probably more home grown than the original pretend group. Whether it will survive the lifting on restrictions on US visitors I doubt, but who knows

No doubt we'll be able to judge them on a reality television programme soon enough.

 

[Marky90]

So presumably this person can pinpoint exactly the elements of CBT which have an effect and those which dont. It's a wonder this person doesn't provide specific details.

Wyller from Norway says exactly the same.. "Oh the health practioners are just not trained properly!", says the guy who`s currently wasting time researching musical therapy as a treatment option for ME/CFS, what a nutcase. But I know what that quack is planning: CBT with musical therapy as a treatment regime will likely make the adolescents report feeling "better", and the news will go around the globe; "Bieber cures ME/CFS".

No, but seriously.

 

[Large Donner]

I once watched a youtube video on EFT tapping, which had precisely the same beneficial effect as Morcambe and Wise.

You're tapping all the right points, just not necessarily in the right order.

 

[user9876]

But one thing the conversation made me come back to is that there is no dosage standardisation for CBT - so you cannot do dose response curves very easily. It is a bit like syaing that foxglove is good for heart failure. It was discovered in the 1970s that in fact foxglove is pretty bad for nearly all heart failure (it induces fatal arrhythmias and makes you see yellow) and only any use if you get the dose exactly right and use it where there is atrial fibrillation (which would have been common in clients in Withering's day due to alcohol being a staple food in winter I guess).

I think it is worse than that. CBT is really a delivery mechanism for changing beliefs. Hence its not just the amount of CBT but the content for a given CBT programme. So each CBT programme needs to be considered differently and with different patients. A further issue comes with consistency -- its not easy to measure 'dose' and content as it can be varied between therapists so its not like saying have 10mg of drug x. Maybe a bit more like having a lab with a large number of technicians each of which vaguely follows a recipe of a drug and then using those drugs for a trial.

 

[BurnA]

Have we finally got to the point where current studies are telling us the "truth" about the effectiveness of CBT? I'd say far from it. Designs are still not that great, and when they improve, effects will drop down again.

Agree.
I'm no expert on CBT but if the trained experts on CBT can identify the key element that makes it effective, surely a blinded trial could be performed whereby some patients get the full CBT treatment and others get CBT lite with all the good bits taken out.

Has it ever been compared to just talking to a psycologist who hasn't been trained on CBT ?

 

[Woolie]

'unlike some we are not knocking psychology, just investigating the fact that we seem to have a data problem', or 'it seems that the problem is not unique to psychology' (but it might be a whole lot worse than in other fields).

I agree, @Jonathan Edwards, its probably worse in Psyc. But no-one should get too smug. When Ioannidis wrote Why most published research findings are false, he wasn't talking about Psychology.

The ingredients for creating false positive findings are pretty easy to come by in many fields:

1. Strong belief in a particular theory/hypothesis or causal model, or approach/framework (in many areas of science, we're talking lifelong belief, and sometimes investment of an entire career).
2. Powerful personal incentives for supporting one's perspective (money, career advancement, etc.)
3. Publication practices that favour the publication of positive findings (significant differences) over null findings
4. A complex enough area of investigation that there is sufficient "noise" which can be capitalised upon through p=hacking, harking etc.
5. Inadequate training in good research practices.

I add that last one because it makes (non PhD) doctor-researchers especially vulnerable.

Edit: I forgot about:
6. Inadequate or poorly enforced research/reporting standards in the field

 

[Woolie]

@BurnA, @Marky90, totally agree, "They're just not doing it right" is a great escape clause, especially when there's no way of measuring "doing it right".

And then there's the individual therapist-patient relationship. The claim that you only get benefits if the proper therapist-client relationship is established. This is supposed to explain why CBT doesn't work sometimes. But you can't have your cake and eat it. If you're trying to claim "CBT works" and should be funded, then it needs to work fairly reliably and consistently. Else you should be saying "CBT might work, depending upon the patient's and the therapist's characteristics, but we don't really know what the magic formula is yet."

I like @Jonathan Edwards' "control" condition: Morecambe and Wise How about homeopathy, acupuncture, reiki therapy or iridology as a control condition? Then you could address the question "Is CBT any better than any of the other humbug out there that we feel so superior to?" If "raising expectations" is part of the treatment, then why is CBT better than these other interventions that "raise expectations"?

 

[duncan]

I suspect similar results would come from chatting with your high school football coach, or Oprah book club organizer, or pastor, or brownie leader, or Modern Family's Phil Dunphy.

 

[Large Donner]

* CBT is getting less effective because studies of its effectiveness have to be better designed now than 40 years ago. So its harder to get away with the dramatic results you could show in the 70s with a pretty dodgy design.

Researchers have found that CBT is roughly half as effective in treating depression as it used to be

So give it another 60 years and it will prove the theory that psychiatry is currently running at least 100 years behind.

 

[BurnA]

I suspect similar results would come from chatting with your high school football coach, or Oprah book club organizer, or pastor, or brownie leader, or Modern Family's Phil Dunphy.

How about comparing it to participation in online forums such as PR, I bet that is a lot more effective than CBT.

Would love to see a paper on that.

 

[Sean]

You're tapping all the right points, just not necessarily in the right order.

I have always liked the line from the apostate psychoanalyst, Jeffery Masson, who said you would probably get more therapeutic benefit from having a friendly dog in your life than from psychotherapy.

https://en.wikipedia.org/wiki/Jeffrey_Moussaieff_Masson

http://www.amazon.com/Final-Analysis-Making-Unmaking-Psychoanalyst/dp/034545278X

 

[Woolie]

I have always liked the line from the apostate psychoanalyst, Jeffery Masson, who said you would probably get more therapeutic benefit from having a friendly dog in your life than from psychotherapy.

https://en.wikipedia.org/wiki/Jeffrey_Moussaieff_Masson

http://www.amazon.com/Final-Analysis-Making-Unmaking-Psychoanalyst/dp/034545278X

I remember him! What a rebel! And punished for his sins, if I recall...

 

[Luther Blissett]

One of the crazy things is, If CBT really did work, why is it assumed that 6 sessions is some kind of magical number for everyone?

I had CBT (sort of) for a phobia, alongside exposure therapy, and saw improvement, but the 6 sessions were not long enough, so that was a waste of resources in the end. A manual turned out to be a better solution for getting any information that was helpful.

I can't see the NHS funding much CBT in the future anyway, most therapeutic options in my area have been restricted to people who are considered to be a risk to themselves or others.

 

[A.B.]

Does CBT only work when the patient wants to avoid conflict, is easily impressed, subservient to authority, or desperate to escape from reality into a comfortable illusion? Is this the magic ingredient to "effective" CBT? Others would say it's the ingredient for generating the false impression of improvement in poorly designed studies.

 

[Woolie]

Interesting thoughts, @A.B. I suppose there's a literature out there somewhere about what people show the most improvement on self-report measures. Maybe I might look some day.

Obviously, CBT for CFS is in its own special class. But I suppose all CBT requires a certain sort of unquestioning faith in the methods. If you question the details too much, you're not going to be fully on board.