Therapy sentences to ponder

If you’re doing a specific therapy for a specific problem (as opposed to just trying to vent or organize your thoughts), studies generally find that doing therapy out of a textbook works just as well as doing it with a real therapist.

That is from Scott Alexander, who considers ways of saving money on mental health care.

Comments

Have you read this wonderful book? It is called Dianetics: The Modern Science of Mental Health, and it promises to solve any mental health issues you have.

Disclaimer - may not turn out to be cheaper, but at least it will keep you free from the clutches of the psychiatric conspiracy.

Sure, the Scientologists are a creepy and weird Cult. But notice what this is saying - therapists are basically useless. They are adding nothing to the process.

Now pigs rooting around under oak trees may well find the occasional acorn. So it does appear that the Scientologists are on to something here. They may well be right. After all, no talking cure works except, to a limited extent CBT. Britain was better at treat schizophrenics in 1904 than they are now. In fact Nigeria is better at treating schizophrenics than Britain is. I am willing to bet the US is no better than Britain. Nigeria's secret is to do nothing.

So in the Cult stakes, the various Talking Cures have been more Cultish - and probably done more damage to more people, than the Scientologists have. They have probably been more expensive and hence a bigger waste of money too.

Did you read the actual article, not the excerpt? (Why bother even asking.)

The author started that section this way - 'This section is on ways to do therapy if you cannot afford a traditional therapist.' Which reads a bit differently than an outright dismissal of therapists.

'They may well be right.'

My inner Thetan certainly agrees.

It would seem that those people who really need professional help are rarely aware that they need professional help. If you use therapists you "may" need help or you may simple be seeking attention. Can the book give you attention? Imagine someone states they want to commit suicide should your reply be "oh! Go read this book and you'll be fine"?

I think Tyler was trying to tell us something, or maybe just prior.

I hear cognitive behavioral therapy is good

Cannot what Prof. Cowen was trying to say, but have you heard of Dianetics: The Modern Science of Mental Health?

It will change your life - or at least let your inner Thetan get clear. No need for therapists at all.

Cannot comment on what ...

Britain was better at treat schizophrenics in 1904 than they are now.

No, they weren't. Quit talking out of your ass.

Good to see you too Art. But yes they were.

From 1894 to 1896 the North Wales Asylum, otherwise known as the Denbigh Hospital, admitted something like 45 people per year. Over 50% of them were discharged within three months to a year as "recovered" and another 30% as "relieved", that is, able to live on their own. The vast majority of patients were admitted for their first episode and then never readmitted.

In 1996 the District General mental hospital in Bangor with the long irrelevant Welsh name admitted 522 patients. 76% of them had been admitted before. And only 36% of them were discharged as recovered.

In 1896 among those admitted for their first psychotic episode, they were go on to suffer 1.23 hospitalizations in the next ten years. In 1996 the equivalent group would suffer 3.96 admissions.

The same is substantially true for the US. Between 1945 and 1955 American hospitals rejected eugenics and they did not yet have Thorazine. So between 1946 and 1950 the Warren State Hospital in Pennsylvania discharged 62% of first episode psychotic patients within twelve months and 73% within three years. Of the 216 schizophrenic patients admitted to the Delaware State Hospital between 1948 and 1950, 85% were discharged within five years and on January 1 1956, 70% were peacefully living in the community. Hillside Hospital in Queens tracked 87 schizophrenia patients discharged in 1950 and about half had no relapse within the next four years.

You know, there are a lot of places that would love those figures.

Good to see you too Art. But yes they were.

No, they weren't. Asylums could warehouse people and observe them. That's it.

Only a minority of schizophrenics require institutional care and institutional care is hideously expensive. Outpatient monitoring by family members and physicians works passably in most cases. You only had that option in 1904 with people who had a discrete schizophreniform breakdown and then recovered. About 2/3 of those suffering such breakdowns do not recover spontaneously.

In the UK we have closed down nearly all the long-term and short term psych-wards. There are, as Art says, no more "institutions" where the mentally ill live for years. Now it is all "care in the community"; which means drugs, and a once-a-week visit by the nurse to make sure you are taking them in your bedsit.

I wonder if it is kinder though. I know people who worked in them, and the institutions were not, generally, "One Flew over the cuckoos nest" dystopias. For many they were sheltered environments with activities and socialisation and care for a range of people who could not independently cope with the world. Expensive, but broadly benevolent; I'm not sure I would use "warehouses" to describe them.

As Art says, outpatient monitoring + drugs works "passably". It is definitely cheaper. It is good for those with mild symptoms, who can function independently with a bit of support. But I'm not sure that many of the former inmates are not materially worse off, especially those with the moderate to severe symptoms. Now they sit around park benches, drinking, or staring into space, or in A&E. Many have no family, or no family that cares, and now have only erratic contact with mental health staff. They are rarely violent, but....even as a Libertarian, I have to be honest and say I think institutions were kinder for many of them.

We are in a different equilibrium. Better? Worse? I'm not sure.

Art Deco - April 30, 2018 at 10:03 am 6

No, they weren't. Asylums could warehouse people and observe them. That's it.

I agree. Except where I disagree. They could warehouse people - and treat them with patience and kindness. They could provide a relatively harmless structure. They could do little else. But it does seem to have worked better than what we do now. Fewer people were treated - and vastly more people were sent home "cured".

Outpatient monitoring by family members and physicians works passably in most cases.

These days? Sedating them makes them easier for us to deal with. That does not mean they are being cured. Perhaps the brain can cope and does repair itself if it is left to heal. Drugging people with Thorazine does not do anything to the schizophrenia. It just sedates people. That is much easier on their neighbors but it is not a cure.

As I said, we used to do much better. We have better drugs now and smart doctors but they are not improving the situation.

Broadly agreed too, SMFS.

One unpleasant thing to think of in the data: UK cases for Schizophrenia and several other mental health conditions are disproportionately comprised of ethnic (non-Caucasian) minorities. That wasn't the case in 1896.

The problem with these stats in that schizophrenia was something of a catchall diagnosis. Many people diagnosed as schizophrenic in 1904 would today be diagnosed as bipolar or something else.

That may well be true. However notice they were taking in one tenth as many patients 100 years ago as they are now. So they were not over-diagnosing.

However the question would be how good are we at treating people with bipolar or the like? I think the evidence is that modern psychiatric medicine does make people worse.

Who needs professors when we have books.

My nephew age 9 was asked:
What do you learn more from, school or your mom?
I learn a lot more from mom.
What do you learn more from, your mom, or instructional videos on
You Tube?
Oh I learn a lot more from You Tube

Depends on who wrote the textbook, I suppose.

Sure. Just as the effectiveness of in-person therapy presumably depends on the skill the the therapist, the kind of therapy being offered, and whether the therapist and approach are a good fit for the patient and their issues.

So that is it. In the richest country in history, crazy people are told to read books instead of getting much needed sanity-saving treatment.

Good point Thiago. We spend little on mental health care compared to medical care. Then it comes back to bite us when we spend untold amounts of money imprisoning mentally ill people who commit crimes. Mentally ill people also consume disproportionate amounts of medical resources for reasons such as rehabilitation after suicide attempt and chronic pain treatment.

It woukd be funny if it weren't tragic.

But most of the money we spend is on the "worried well," partly because we have so many LCSWs and because the WW population has health insurance. We also spend a lot on drug rehab programs that can't seem to convince users to give up drugs, even after many attempts.

What might work instead are dorms that require sobriety and halfway houses that assure that people with organic brain diseases take their medications regularly. In addition to reducing crime and jail populations, they would be more humane.

JosieB

That's true. I had to find a therapist for someone with a serious problem - we found out later it was bipolar disorder - and all the numerous therapists in our small university city (pop 100,000) were booked up with the 'worried well'. What a nightmare! Otoh, anxiety is one of the most common mental illnesses. The working worried well usually have good insurance, but the best therapists are cash only. Talk about those service sector jobs, therapists do pretty well but they have to listen to a lot of whining. They are all booked up.

We waste, uh I mean spend, a lot of our health care dollars on the worried well and CYA.

Agreed. A degree of sheltered accommodation with a lot of structure but short of secure institutions seems like it would be useful.

Thank you. We have colleges abandoning dorms that could be repurposed and LA devoting billions to build new independent apartments for marginally functional people.

A century ago, widows (starchy widows) inherited large houses and offered room and board for single male tenants who played by the rules; those will not be replaced now, but the general idea might apply.

I forgot to put the citation for that in the original post, but see eg https://link.springer.com/article/10.1007%2Fs10488-016-0783-9 or writeup at https://qz.com/1057345/researchers-say-you-might-as-well-be-your-own-therapist/ . Same seems true in other domains, eg https://www.ncbi.nlm.nih.gov/pubmed/12579546

Who prescribes the "specific therapy" and who diagnoses the "specific problem"? I recall from last year that a group of leading mental health professionals diagnosed President Trump as mentally ill ("psychological instability") and that he poses a danger to himself and the rest of us and was in need of therapy, any therapy not only a "specific therapy". https://www.nytimes.com/2017/11/30/opinion/psychiatrists-trump.html My observation is that Trump is often in a highly agitated state, that he is unable to focus or sleep, and that he often lashes out at enemies both real and imagined. Trump himself believes he is quite sane and that he is "like, really smart". It seems as though many of those with a "specific problem" and most in need of a "specific therapy" don't know they have any problem much less a "specific problem" even when a group of leading mental health professionals tell them. Thus, they are highly unlikely to do therapy out of a text book.

So what? People said Goldwater was crazy, too, and Nixon was unstable during the Watergate Crisis. And that Muskie cried too much and that Mondale was too uninspiring and from Minnesota. Maybe Americans should stop to expect the President to be their dads and hold their hands and speak with a soothing voice.

Meh. Might as well say you can learn calculus or history or Turkish from a textbook -- no doubt some can do it with equal ease, but not most.

Particularly the ones in need of mental health services.

"Particularly the ones in need of mental health services"

And you know this for a fact, because...?

It seems to me that reading advice about strategies for dealing with personal problems (in the link Scott Alexander provided -- for drinking problems) is approximately *nothing whatsoever* like learning advanced mathematics or a difficult new language.

"Might as well say you can learn calculus or history or Turkish from a textbook"
Actually, I am not sure there is much difference between learning Calculus from a book and learning it from a teacher. As for History, people who care about it aside, exactly who is learning History from teachers right now? Not kids, it seems. As for Turkish, I guess the real constraints are time, effort and opportunity to practice.

I definitely found audio CDs and teachers helpful when learning Turkish

Yet, Turkish people learn it naturally.

But not out of a textbook.

Damnit! What's their secret? I've seen video of young kids in Ankara speaking Turkish without any of this over-priced "tuition" nonsense.

I suspect your right. Not many people benefit cold from an auto-didactic enterprise.

The thing is, the people who are most acutely problematic absent the supervision of the mental health trade (those folks at the bus station talking to their auditory hallucinations) are, if anything, injured by talk-therapy and the like. The 'mental health services' they benefit from would be someone to take an inventory and write prescriptions and from someone to visit their apartment, clean up the mess, and review their checkbook and bank statements. The former can be done by a GP if needs be and the latter by your sister (who does not require professional training).

(Without reading the study...) did it adjust for self-selection in terms of people who are willing and able to try it from a book?

Seems to me the value in therapists is having someone to bounce things off of, and who can call us on our BS in a way that sneaks past the defenses.

FWIW. I tried to relationship counselors in my past. One was a moron and pretty much waste of money, the other should have had her license revoked; I later learned she was a rabid feminist, should not be doing couples therapy for God sake.

The structural problem with marriage counseling is that counselors are commonly hired by wives to bring in a third party to get their husband to see things their way or, alternatively, to assemble a justification for serving papers on said husband. Counselors who are inclined to be fair to both parties face the prospect of losing business. Also, the professional ideology of purveyors of the talking cure incorporates the notion that the feminine mode of navigating human relations is the standard and the masculine mode is deviant. I'll wager very few people benefit from this sort of thing.

You there, stop feeling sorry for yourself, suck it up, and drive on.

Therapy applied. That will be $200.

Where's my flying car and robot maid?! Where's my free therapy bot?! Seems there's been a surge of articles about therapy chatbots since 2017. Hmm.. AlphaGo, AlphaZero, -what's next, AlphaEmo? (Free anonymous Eliza is still around apparently.)

I used free Eliza as the basis for one of the labs in an intro to computers course a few years ago. It’s amazingly simple, only about 100 lines of code.

What? You mean the b***h has been hanging out with you all this time? She said she liked talking to me!

Mental problems are endemic in the US, as indicated by general irrational behavior.
Examples abound: Homeowners install light-colored wall-to-wall carpeting and then require everyone who enters to remove their shoes. At the same time, these homeowners don't bother to remove their own shoes when they enter places of business or other buildings.
People are outraged by blood sports like cock fighting and dog fighting but have no qualms about hooking and "playing" fish and then returning them to the water. Fish torture by any standard. Encouraged by the state as well.
Since it can be seen at any time, it must be generally accepted that it's legal, safe and proper to drive an automobile with dogs ranging from the pug size to Labrador retrievers on the driver's lap. Insanity with a capital I.
People deemed by a physician to be "handicapped" are awarded premium parking places so they don't have to walk an extra 20 paces to the front door of the ice cream parlor. In other words, these handicapped, unlike every other person, don't require physical exercise.
Those that need therapy are simply the ones who exhibit irrational behavior that's less common than that of the rest of the herd.

Mental problems are endemic in the US, as indicated by general irrational behavior.

You might try looking in the mirror every once in a while between bouts of making a public nuisance of yourself.

The handicapped placard you desire for your diesel crew -cab 4x4 so you can park next to the front door of the restaurant comes from physical, not mental, deficiency.

If you're curious, here's an example study that does an analysis of using CBT books and websites to improve therapeutic outcomes:
http://www.cfp.ca/content/55/8/789

I recently worked at Woebot, a CBT chatbot - checking in with the bot is like reading a bit of the book each day, plus doing the recommended mood worksheet in it.

Studies show that bibliotherapy does work, but it works even better when people are reminded to do the readings and worksheets, and that's where digital versions of bibliotherapy can help, like chatbots. (Push notifications!)

Personally, I always have a copy of "Feeling Good" and other CBT books around for my friends to borrow, and they're happy when they return them. :)

Personally, I always have a copy of "Feeling Good"

The author in question takes as a given normative assessments of one's person that are at least contentious if not horsehockey.

studies generally find

Whatever.

The problem was delineated a generation ago by Fuller Torrey. Psychiatry after the war largely abandoned the asylum for office practice. The trouble with that would be that the people who consult with you at your office are generally the 'worried well', "who need counseling, not therapy; and counseling is a branch of education, not medicine". Torrey's view has long been that physicians needed to concentrate on inpatient care and outpatient supervision of schizophrenics and a short menu of others, and leave the rest to others.

The discretionary nature of consulting a counselor (who is trained in some aspect of clinical psychology) makes it an inappropriate candidate for financing via 3d party payment. You can cut the cost of this sort of thing by making it cash on the barrel-head in ordinary circumstances and donor-financed in others.

I think this post needs a little more context....Alexander's header was "This section is on ways to do therapy if you cannot afford a traditional therapist." IF YOU CANNOT AFFORD, not is lieu of therapy."

Also, to my reading, the findings of the study was less enthusiastic than the way Alexander presented it...

"..the findings suggest that self-help, with minimal therapist input, has considerable potential as a first-line intervention. The findings did not suggest that individual differences between therapists play a major role in psychotherapy outcome."

Of course, I may be justifying the years of training and thousands of dollars I spent in school and internships are better than a $14.95 "How to Beat that Pesky Depression" book...

The question for your customers is whether or not your services provide value. It is not an issue for the worried well since they don't have serious issues, not is it a problem for the well insured. It's a big problem for the poor and the uninsured - they can't pay. It is a tragedy for the seriously I'll - they end up on the streets or shot by cops.

Only in America...

The least espensive way to treat a drinking problem is with the sinclair method.
See www.sinclairmethod.org

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A basic problem with mental health therapy might be that practitioners are qualified/licensed by credential, as no one seems to have good methods to evaluate a therapist's actual performance. Or if they do, they're not used.

It seems reasonable to assume that any profession lacking accepted measures of performance may descend into Sturgeon's Law (i.e., that 90% of everything is crap) but, since performance is not measured, who could possibly know?

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