First, mindfulness styles used in psychotherapy are all forms of CBT so if a therapist is using it, then yes, they are doing a type of CBT therapy.

Second, CBT is the current technique that is getting studies done in its effectiveness and nothing else is being studied. It is the 'technique de jour'. Before CBT, it was brief therapy. Before brief therapy it was expressive therapies. Before that, it was Gestalt forms of therapy. In another 10 years, there will likely be a new form that is touted as the only effective form of therapy.

The irony is that really any form of psychotherapy is cognitive behavioral therapy. It seeks to assist clients in changing habituated patterns of cognition and self-talk and the concurrent behaviors that cause them distress and emotional turmoil.

With that said, as a professional in the field, I can criticize the fact that more and more therapist are of the school of whatever the client wants, give it to them. No one really wants to see unconscious motivations. No one really wants to see that they are causing much of their own misery. No one really wants to hear that they must exercise will in order to make lasting change. Habits take time to form not only bad ones but also good & healthy ones.

Therapists must be willing to challenge clients who believe they know what is best for themselves. I use MBCT (Mindfulness Based Cognitive Therapies) with great success, however, I must convince clients that while not always easy, the rewards are great. It is not a quick fix either. Take a drug for four weeks, and anyone will feel different. MBCT (as well as other CBT's) can take months of daily practice before benefits are gained and lasting change begins to set in.

I do completely agree with them that evidence-based structured therapies have in my own clinical experience been far more successful than 'therapy as an art' (it isn't one!) or 'the relationship is all that matters' (it doesn't!). It is extremely important as a therapist to keep reading the science and learning about the field - what works & doesn't work, what is popular and what is not, and advances in companion fields like neuroscience, philosophy, religion, etc. I still use other techniques and tools that are not evidence-based as no one has taken the time to test their effectiveness. I must rely on my own empirical observations and those of my trainers and teachers there.

The other problem is, and I don't think it was clearly stated in the article, is that most therapists do not know when a client is 'better' and often believe that therapy never ends. I disagree. I want my clients to accomplish their goals, feel better, think more constructively, and have happier relationships with themselves and others. Once they learn how to accomplish that, I am pleased as punch to see them 'graduate' from therapy with me.

While I don't agree with all their points, it is a good springboard for discussion with lots to still agree with. Thanks for sharing it.

the appeal for diagnosis and treatment decisions to be made on meaningful empirical evidence,
a desire for greater stability in diagnosis and treatment (less apparent trial and error),
and a wish for treatments specific to disorders as opposed to treatments reflecting a clinician's methodological preference.

While all are probably desirable I'm not sure they're easily attainable.

It is interesting to note that the conversation within the industry is on-going and that it resonates with the public's concerns.

Why?

Well, as a clinician let me address each one.

1) The mind is not the brain. That may sound odd, but it is not. We simply do not know yet how the brain and mind are fully related. We can speculate that because serotonin is involved in mood regulation that if someone is depressed, they lack enough serotonin. So we create a pill that in one of several ways regulates serotonin production or uptake. However, there is no empirical evidence that it works. We can not yet measure serotonin levels via blood draws or via spinal fluid or any other objective measure. It is still a 'best possible guess' based on self-reporting from those taking the drug that it has helped their mood regulation. And then there are the unforeseen side effects, discontinuance syndromes, and addictions to such drugs like the benzo class of anti-anxiety medications. Yet, I can also teach CBT techniques to someone, and they will also report a change in mood regulation over time as well. So do we need pills or techniques alone? Both? Why? Why not? Scientists, psychologist, psychiatrists, philosophers, and computer scientists still can not agree on a single definition of consciousness, mind, intelligence (artificial or natural), etc.

2) This leads to the second desire you state. If we are still in relative infancy with regards to the brain/mind question, then how can diagnosis and treatment be stable? Psychology is really only about 100 years old as a discipline. Why did certain treatment methods apparently work in the past but no longer now? What changed? Was it cultural? Was it biological? Why was homosexuality for instance considered a mental disorder up until the 1970's and is not today? If stability had been in play in that instance, then psychologists would not have revised their ideas of what mental health and mental disorders entail. The civil rights issue of marriage would have been a non-issue and not possible today because 'science' would have said, homosexuality is not 'normal' therefore not acceptable. Change is inevitable and that degree of desired stability will be the same balancing act it has been since psychology started. We need a certain amount of stability, and we need a certain amount of freedom to learn more, adjust our findings, and come to new conclusions.

3) Again this ties back into desire number one. Why does both an SSRI and CBT both produce results for an individual with a mood disorder? Which should be the preferred method? Psychiatrists dispense drugs so they will say an SSRI. Psychologists use non-drug methods so that will say CBT. Is one more right than the other? Should patients only have the choice of one method to treat said mood disorder? Even within each of these choices, there are further options. Not all psychiatrist use certain classes of psychotropic medications. Not all psychologists use the same exact formula of CBT - some use ACT, some use MBCT, and others use Dialectical Behavior Therapy. Which of these in either category is the 'right' method. Diagnoses change. Treatments will change as well. Techniques used to 'convert' homosexuals to heterosexuals were appropriate pre-1970. Now we look at them with shame and revulsion as being not just clinically wrong but ethically as well.

We are a long way from any of the goals you express a desire in, and bluntly I just don't think they are achievable. I wouldn't want them to be. One of the big issues that the western model of medicine has is the one-size fits all diagnosis. A diabetic is a diabetic is a diabetic. But only when a single magical number is crossed. Yet, what about the individual whose blood sugar is consistently one point off from the diagnosis? What of the long term affects on their health of elevated blood glucose? Ok, now these three patients have diabetes. Is there a one size fits all treatment plan? Of course not, because each patient is biochemically an individual. One may respond to diet and exercise and drop back into the 'normal' blood sugar range. Another may require insulin shots. The third may do better on metformin.

I find it reassuring that the conversation is occurring within the industry.

From a non-clinician's perspective and speaking only for myself…

The mind vs body thing seems to me to really be a point of view subsequent to poor understanding. Such distinctions don’t end merely with mind and body. If one walks down that path, pretty quickly you encounter conceptualizations of spirit/soul. It seems pretty clear that all available empirical manifestations of mind conform with expectations that it is an outcome of biotic activity.

As an adequately trained biologist, I’m not comfortable going down a path where I have to consider mind, soul, and body to be independent entities. I'm so uncomfortable with it, that I've refused treatments that require acceptance of 'something spiritual greater than myself'. Moreover, I don’t think discussion along that path is fundamental to identifying contributors to the existing concerns about psychiatric treatment mentioned in the OP. So, I'm going to step aside from that while acknowledging it is a fascination of many people.



It’s generally true that understanding progresses from low resolution to high resolution. It seems to me that clinical psychology is progressing in the same pattern. It’s not entirely a shuffling of fashion from one diagnostic or treatment method to another, although prevailing acceptance may introduce fashionable influences.

Some failures/mistakes/short comings of mental health treatment are going to result from and be exacerbated by the lack of understanding of the structure and function of the brain and its integration with the rest of the body.

But not all.

I’m of the opinion that clinical psychology is sufficiently advanced to take notice of and consider how possible it is to address common concerns. I rather suspect it does, and that all the things I mention below are quite well known.


So...my thoughts about empirical evidence.

The evidence available for psychiatric diagnosis is primarily discerned during clinical presentation. Most often therapists find evidence in what a client says, and the emotion expressed when they say it. Additionally issues of grooming, injury, hygiene also provide important, sometimes definitive, information.

Yet, patients can’t always express themselves very well. For example the common self-assessment of ‘how are you feeling on a scale of 1-10?’ is a capacity that is acquired and refined by patients during, not before therapy.

Unlike white blood cell counts, blood pressure, A1c, creatine levels etc., the information acquired in a therapist’s office doesn’t often come as a value on a numerical scale that’s amenable to comparisons of normal physiological ranges as are the results of the lab tests done on blood in a primary care clinic. I’m not saying it’s impossible for a therapist to get some numbers. Structured assessments that patients fill out on line and that are computer evaluated are available but not always used. I've never read about an assessment that wasn't criticized by someone as having short-comings.


The evidence that does manifest during a session must be expressed by the patient, perceived correctly, and given appropriate significance. “Symptoms” must be assessed with respect to their being deserving of clinical attention.

The nature of searching is that the seeking focuses on a search image. Although clinicians must manifest satisfactory abilities to meet certification/licensing requirements, clinicians certainly vary in their capacity to seek and find diagnostic evidence.

Diagnostic guidelines after all are just guidelines, and education and experience, as well as such things as conformational bias are in play. In the end, all evidence is not, and can’t be, equal. Some of it will be identified as diacritical.

Practical limitations push for efficiency and short cuts in decision making are human nature. Knowledge, experience (and even mistaken understanding) may suggest identities can be assumed on the basis of defining “spot” characters.

My experience suggests to me, that clinicians develop a capacity similar to that of batters in baseball who internalize all the activities of observation, perception and assessment of clues about pitches into a ‘feeling’ about what pitch is being thrown at them. In the first few minutes of an intake interview, clinicians have such a ‘feeling’ for the way a client’s presentation ‘looks’ and they take a swing at a diagnosis.

Attempts may be made to find supporting evidence, but these really are vulnerable to confirmational bias.

The question arguably becomes: is the resulting diagnosis based more about empirical presentation or the things that have confounded observation, perception, and analysis? Is it possible to separate the therapist from the diagnosis?

Even if everything goes correctly, it's still likely that clients have more than one pitch to throw. A single intake session may not reveal all the features of a client's presentation. That's likely true for patients with co-morbidities, or for patients who have fluid emotions and unstable sense of self.

An evidence based diagnosis must be made on only the available information. Early determinations can be expected to be based on incomplete evidence. That's not so much a fault as it is a characteristic of the way information is revealed over the course of therapist-client interactions.


The question being begged here is 'Does this matter at all'?

It may not, a diagnosis can be presumptive/hypothetical and there are opportunities to “get it right” later in therapy.

Moreover, having all the evidence so that the diagnosis is correctly differentiated, may make not a practical difference.

The treatment could be much the same... skills training to deal with distress from one source is much like skills training to deal with distress from another source...cathartic relief following 'getting it out' is cathartic relief, etc.

and I can't say I agree with them all.

I will clarify that when I say brain/mind, I am not referring to a soul/body duality. I am speaking to the reality that, no, we can not state emphatically that empirical manifestations of mind conform with expectations that are an outcome of biotic activity. Studies in neuro-psychology of those with several brain trauma who still retain all mental faculties disproves this for now. How does a human with half a brain still act human? If it is missing components that are necessary for 'mind' then how can it demonstrate those 'mind-aspects' without the biological component? Studies in serotonin receptors shows that there are more of these in the human GI tract than in the brain. So is 'happiness' and well-being in the gut? Are people who are depressed having not a brain chemistry problem but rather a GI tract chemistry problem?

So, it really isn't that cut and dry.

As to empirical evidence from our clients, yes, there are numerous 'scales' for assessing with numbers the states of mental health. The problem again is that human beings are not digital. We are analog. If I have a client who only meets 3 out of the 4 required 'signs or symptoms' of a particular diagnosis, then what? Are they about to manifest it? Have they in the past and now they are overcoming it? No matter how much of a scientist I am, I can not accept that human beings are simply a set of data points to be graphed. With only 3 out of 4 symptoms, that person is still suffering. By following strict guidelines that generalize to such a degree, those individuals don't get treatment. That is one of my chief complaints with the DSM.

You ask is it possible to separate the therapist from the diagnosis. I will state emphatically that no it is not possible from my experience. The consciousness of the observer of any phenomena impacts that observed phenomena whether in gross or subtle ways. Therapy unless it is just a pill given by an MD involves talking which involves relating. Communications theories show us that both members of a communication partnership impact the flow of the communication by how they communicate and what they communicate.

I do agree with your last point. To me a well-trained therapist is always revising a diagnosis. In fact, as I may have shared in another post, really a diagnosis is for the therapist not the patient. It is a way for me to know what protocol or algorithm is needed for one patient versus another. Yet, I must be flexible and not treat every patient with an eating disorder exactly the same, for example. CBT techniques have been shown to be the most empirically successful tool, however, it is still modified in subtle and not so subtle ways for each individual that utilizes it. Furthermore, yes, all forms of cathartic relief are essentially the same. But why does one patient respond to hitting a pillow until they cry whereas another one must process a dream of someone they love hurting in order to have the same emotional response and release? Because no two people are exactly a like.

We may not agree on all points, yet I am pleased with this discussion a great deal. You have given this a great deal of thought. I am curious why?

empirically demonstrable biotic features. I'm personally not inclined to get too far into traveling that landscape as my education really isn't up to the challenge (the closest I ever got to psychology was caring for pigeons and rats in a student work job)

I don't want to discourage others who would enjoy that, and if you want to develop that conversation in this group, I'm all for it.


Personally, I accept that the nature of ignorance makes experience enigmatic. Seeming conundrums, such as no 'mind' in a 'living' brain, and a functioning mind in a damaged/undeveloped brain, are things that don't trouble me so much as they seem indicative of incomplete understanding.

regarding your final inquiry...

I really haven't given this or any of my comments above a great deal of thought. I think my part has been pretty impromptu and shallow.

As to why, I engaged this because over the past few years I pushed for the creation of a group. Within my limited capacity I'm motivated to help it get the group established and populated with users. I'm willing to respond to others to accomplish that...lucky you.

and I definitely encourage you to go deeper in the study. You have the background in biology. My initial undergraduate degree was to be Pre-Med with a major in psychobiology. It was only in my Junior year that I tired as a young man of such a pressured schedule and fell in love with philosophy thereby switching my major. I have kept up my studies in the field, and I will consider starting another post about the topic for discussion if you think it would support this particular group.

We agree then that it is far from troubling, it is rather fascinating and does show us how much we both know and don't know about the brain/mind.

Thank you for the creation of this group and for an excellent discussion. I look forward to more in the future.