"CBT: Escape From the Binds of Tight Methodology" (not on ME but similar type criticisms could be)

[Dolphin]

Cognitive Behavioral Therapy: Escape From the Binds of Tight Methodology - See more at: http://www.psychiatrictimes.com/cog...vioral-therapy-escape-binds-tight-methodology

If you can't see the second part of this, go to: www.psychiatrictimes.com/printpdf/177446‎

This is on depression. However, many of the criticisms are similar to points some of us have made about CBT's use in ME/CFS.

For example:

1. The premise of CBT that negative cognitions are the cause of MDD is the only instance in all of medicine and psychiatry where a symptom of an illness is also construed to be the cause.

This reminds me of what happens in ME/CFS: inactivity is said to be the (ongoing) cause of ME/CFS so (similar to the point they make) a symptom of an illness is also construed to be the cause.

2. The statement that CBT clinical trials are “randomized and controlled” obfuscates that the studies are not double-blind (ie , neither subjects nor therapists in psychotherapy studies are blind to the type of treatment).

This has been said of CBT trials for ME/CFS, although possibly not as much as it should be.

3. Symptoms in MDD include primary symptoms such as low mood, and negative cognitions as secondary reactions to these symptoms such as hopelessness and despair that may be easily assuaged by a psychotherapy. The person is then deemed a responder because “responder” is defined as a 50% improvement on a rating scale.

(It is possibly easier to understand what he is saying by reading the full section)
This point is about the outcome measures. Criticisms have also been made about the outcome measures used in ME/CFS CBT trials (questionnaires).

4. Patients’ response to psychotherapy can strongly differ depending on whether they have non-melancholic, melancholic, or psychotic MDD (Figure 2), and this can critically affect the results of a clinical trial.

This is interesting. I'm not sure if it is true or not but his basic point is that melancholic and psychotic MDD is more biological while non-melancholic is less so and it's more easy to treat it, or get people to give good responses on questionnaires, than melancholic or psychotic MDD. This is similar to discussions about CBT (or GET) possibly working for people with chronic fatigue but not so much for (strictly defined) CFS or ME.

Don't be put off by the graph - the piece is not mathematical.


(I can't remember where I became aware of this article so apologies for not acknowledging somebody here if somebody here mentioned it)

 

[Esther12]

It really does seem like there's a lot of quackery in the way that depression has been treated. The more I read about it, the more I think that a lot of the stigma around mental health stems from piss-poor psych research, rather than people's natural response to those with MH problems.

Here's a somewhat related blog on CBT for depression, about a meta-anaylsis which indicates (at least to me) that CBT is no better than other psych treatments, and only seems to do well in trials with poor controls:

http://www.thementalelf.net/mental-...for-adult-depression-the-winner-takes-it-all/

 

[anciendaze]

What he's referring to, in the distinction between melancholic and psychotic depression and other MDD is evidence that they are lumping patients with organic disease together with those possibly having "functional" illness, then using the same treatment methodology on all. There are plenty of papers on biological markers for severe depression, but these don't seem to have any effect on treatment. You can even use high resolution MRIs and voxel-based morphometry to show that regions of the brains of patients with chronic MDD actually shrink. This also happens in patients with chronic pain with undeniable physical cause, though the parts of the brain are different.

 

[alex3619]

In addition, because “response” in a clinical trial of MDD is defined as a 50% improvement on a rating scale, “response” can be as a result of assuaging of psychological pain thus making the patient a “responder” in a clinical trial without actually changing the underlying biologic illness of MDD.11

(my bolding)

 

[Goodness to M.E.]

This is a really good read about the history of M.E. and CFS including the attempts to have it classed as a psychological disorder by Simon Wessley and Co: http://www.meactionuk.org.uk/What_is_ME_What_is_CFS.pdf

 

[Sean]

1. The premise of CBT that negative cognitions are the cause of MDD is the only instance in all of medicine and psychiatry where a symptom of an illness is also construed to be the cause.​

This reminds me of what happens in ME/CFS: inactivity is said to be the (ongoing) cause of ME/CFS so (similar to the point they make) a symptom of an illness is also construed to be the cause.

Circularity,
I love how you always
come back to me...

- Why doth that minstrel sing so?
- For money, Sire, he wishes to die a rich man.
- Well give him this sack of gold, and then strangle him.

 

[A.B.]

CBT is an overinflated bubble that will eventually pop. The sooner it happens, the better for patients.

The article reminds me of another one which argued that:

CBT tends to produce pretty convincing results when studies are neither blinded nor placebo controlled. In these cases they are compared to ‘treatment as usual’, which may be medication, or just observation (‘watchful waiting’). However, once you put them up against another psychological therapy and blind the assessor – the effect dissapears altogether in schizophrenia. The effect size becomes minimal in depression.[/QUOTE

http://www.assumptions-violated.com/?tag=psychology-cbt-freud

 

[Valentijn]

CBT is an overinflated bubble that will eventually pop. The sooner it happens, the better for patients.

The article reminds me of another one which argued that:

Has anyone ever directly compared the results of denial-based CBT (for ME) with acceptance-based CBT (for other chronic illnesses)?

 

[Dolphin]

Has anyone ever directly compared the results of denial-based CBT (for ME) with acceptance-based CBT (for other chronic illnesses)?

In CFS, we have this study:

Jason, L.A., Torres-Harding, S., Friedberg, F., Corradi, K., Njoku, M.G., Donalek, J., Reynolds, N., Brown, M., Weitner, B.B., Rademaker, A., & Papernik, M.(2007). Non-pharmacologic interventions for CFS: A randomized trial. Journal of Clinical Psychology in Medical Settings, 14, 275-296.Free full text at: http://www.researchgate.net/publica..._Randomized_Trial/file/79e415092d1f0967a1.pdf

This compared the version of CBT from King's College (where Wessely, Chalder, etc. based) with a "cognitive therapy" intervention (but it used behavioural elements too so could be called CBT I think) devised by Fred Friedberg which involved pacing. The latter intervention did a bit better.

 

[alex3619]

CBT is an overinflated bubble that will eventually pop. The sooner it happens, the better for patients.

The article reminds me of another one which argued that:

The same was said of hysteria. That bubble popped several times. It reinflates.

 

[Snowdrop]

Here's a related article that touches on CBT. http://arachnoid.com/psychology/myth.html

 

[alex3619]

Here's a related article that touches on CBT. http://arachnoid.com/psychology/myth.html

I like the Lutus paper in general, I have been saying similar things, and am writing a book on this that says similar things. However, without getting bogged down in details, I don't think he is right on all points, and I think he is trying to appeal to things other than reason. So read it with the view that its not the complete picture.

To give some examples, the basis of much of the later argument in the paper goes to the nature of science and pseudoscience, and has been written about extensively since the 1950s, with an occasional mention going back to the 1930s. I do think Lutus makes a great point that Astrology is still with us, and still lucrative for many. Psychology will probably go the same way. However I think there will be a shift to counseling, and neurology, and of course the inevitable hybrid which might be called something like neurocounseling.

Psychogenic medicine exists as part of psychiatry that is a hybrid of mental disease and behavioural aberration. It fits neither category exactly. However its on an even longer limb over a bigger fall than most of psychiatry. Historically the number of confirmed diagnostic categories for psychogenic medicine is zero. In the against psychogenic column we have a huge list, from epilepsy and diabetes, through rheumatoid arthritis and gastric ulcers, and finally I think we are close to proving them wrong (in historical time, which is too slow for patients) for IBS, fibromyalgia, GWS (I am thinking of refusing to use CMI) and ME.

Psychogenic medicine was dying. The notion of biopsychosocial medicine was and is an attempt to revive it, an attempt that I think will resoundingly backfire, but which in the process is damaging millions of lives. Overall the biopsychosocial approach appears to be a major failure, not because the underlying philosophy is wrong, but because how it is applied is actually counter to the underlying philosophy.

 

[Bob]

I've just reminded myself of the contents of the article referred to in the opening post. The article focuses on CBT for depression, but also discusses CBT in general. It contains helpful stuff in relation to CBT research in the field of ME.

e.g. The following quotes are relevant to CBT research for ME (my emphasis):

"A study on bias in treatment outcome studies concluded that the results of unblinded randomized clinical trials (RCTs) tended to be biased toward beneficial effects if the RCTs' outcomes were subjective (as they are in psychotherapy studies) as opposed to objective."

"While a drug study can use a double-blinded placebo control, psychotherapy arms that are called controls are not a blind-placebo, the therapist is also likely a believer in the therapy approach and may transmit this hope to the patient in some way, and large uncontrolled bias is the result in these studies."

"No CBT study (no psychotherapy study) can be a double-blind study. They may be single-blinded, the rater may not know the treatment the patient received, but neither the patients, nor the therapists, can be blinded to the type of therapy given (two out of three of the persons involved in the trial, ie, all of the persons involved in the treatment, are unblinded). Moreover, the patient must be an active participant in correcting negative distorted thoughts, so they are quite aware of the treatment group they are in."


Page 1:
http://www.psychiatrictimes.com/cog...vioral-therapy-escape-binds-tight-methodology

Page 2:
http://www.psychiatrictimes.com/cog...erapy-escape-binds-tight-methodology/page/0/2

PDF (full article) (freely accessible):
www.psychiatrictimes.com/printpdf/177446
or
https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&ved=0CDkQFjAC&url=http://www.psychiatrictimes.com/printpdf/177446&ei=R-F3UoH3F8TD0QXRyoHoDw&usg=AFQjCNHndh4VlQCgqkf_6kDvgrGzMhvt_w