CBT, chronic pain, and ableism
November 13, 2021 12:34 PM Subscribe
The article reads as self-congratulatory, biased, and anti-opioid, going so far as to say that therapists are providing a “powerful salve for suffering” despite later admitting that most research only shows one-third of participants experience significant improvement. They removed the quotes they had from actual patients who received CBT and found it unhelpful or harmful.
The NYT article got a lot of press, but I found out about the editing via Twitter. Please remember that peoples' experiences are their own, and consider how your words might impact someone if you comment on theirs.
The NYT article got a lot of press, but I found out about the editing via Twitter. Please remember that peoples' experiences are their own, and consider how your words might impact someone if you comment on theirs.
I found CBT helpful when, in my late 20s, I finally got effective treatment for a lifelong anxiety disorder. I really did suffer from certain distortions of thinking, including a near-paralyzing self-consciousness, fear of judgment, etc.
It was also in my late 20s that I got a headache one day that hasn't gone away yet. I'm 56. In recent years, various of my doctors have tried to get me into "mindfulness," or referred me to therapists who specialize in treating pain patients, and yeah, wow, there is a really fine line between "mental health strategies that might help you" and "your pain is all your fault." I have yet to meet a therapist specializing in CBT or mindfulness-style pain management who can stay on the right side of it.
A couple of years ago, one of my doctors asked me if I'd ever meditated. I said, "Well, yes, but also, I'm a Quaker." I explained a little bit about how we worship, but he was not able or willing to turn off his canned lecture about mindfulness. I was like, "Look, I've been a Quaker for thirty years. I routinely sit in centered silence with others for an hour or more. Sometimes, as an experiment in extended meeting for worship, I've done it for up to three hours. I do not need to learn to meditate, thanks."
There's a thing that happens when you have a hard-to-treat condition, where if their treatments fail, doctors get angry at you. I had a really traumatic experience a few years ago when I tried a different headache specialist—my neurologist specializes in headache but doesn't offer inpatient care, and I wondered if hospitalization would help, so I switched to a clinic that also operates an inpatient headache unit. When I came back to my former neurologist, all he said was that it was good to see me again, and he asked how I was doing. I said, "Dr. So and So is an evil man," and he said, "My only consolation is that he can't live forever."
One thing that has pained me during the pandemic is the people who are suffering from long covid. The last thing I want is for one more person to enter this community of people with long-term, hard-to-define, hard-to-treat, life-altering conditions, and learning about long covid broke my heart.
posted by Orlop at 1:01 PM on November 13, 2021 [123 favorites]
It was also in my late 20s that I got a headache one day that hasn't gone away yet. I'm 56. In recent years, various of my doctors have tried to get me into "mindfulness," or referred me to therapists who specialize in treating pain patients, and yeah, wow, there is a really fine line between "mental health strategies that might help you" and "your pain is all your fault." I have yet to meet a therapist specializing in CBT or mindfulness-style pain management who can stay on the right side of it.
A couple of years ago, one of my doctors asked me if I'd ever meditated. I said, "Well, yes, but also, I'm a Quaker." I explained a little bit about how we worship, but he was not able or willing to turn off his canned lecture about mindfulness. I was like, "Look, I've been a Quaker for thirty years. I routinely sit in centered silence with others for an hour or more. Sometimes, as an experiment in extended meeting for worship, I've done it for up to three hours. I do not need to learn to meditate, thanks."
There's a thing that happens when you have a hard-to-treat condition, where if their treatments fail, doctors get angry at you. I had a really traumatic experience a few years ago when I tried a different headache specialist—my neurologist specializes in headache but doesn't offer inpatient care, and I wondered if hospitalization would help, so I switched to a clinic that also operates an inpatient headache unit. When I came back to my former neurologist, all he said was that it was good to see me again, and he asked how I was doing. I said, "Dr. So and So is an evil man," and he said, "My only consolation is that he can't live forever."
One thing that has pained me during the pandemic is the people who are suffering from long covid. The last thing I want is for one more person to enter this community of people with long-term, hard-to-define, hard-to-treat, life-altering conditions, and learning about long covid broke my heart.
posted by Orlop at 1:01 PM on November 13, 2021 [123 favorites]
It seems to me like CBT is not geared toward treating pain like hers? I find it odd that it might be construed to be applicable for that.
For many in the medical community, CBT or other similar treatments are applicable to pretty much everything they don't know how to deal with (or just don't believe the patient about). If you have basically any kind of problem that a doctor can't figure out or can't treat effectively, it's pretty likely that they'll throw CBT at it. Of course, women are more likely to suffer this kind of treatment.
We have this idea that you get sick, you go to see the doctor, they treat you and then your problem is fixed. But the reality is that for many health problems, you go see the doctor, they don't know what's going on, maybe you go see some specialists, no one knows what to do, so they say it's probably not a real illness and tell you to do CBT or meditate or something. And you just stay sick.
posted by ssg at 2:23 PM on November 13, 2021 [55 favorites]
For many in the medical community, CBT or other similar treatments are applicable to pretty much everything they don't know how to deal with (or just don't believe the patient about). If you have basically any kind of problem that a doctor can't figure out or can't treat effectively, it's pretty likely that they'll throw CBT at it. Of course, women are more likely to suffer this kind of treatment.
We have this idea that you get sick, you go to see the doctor, they treat you and then your problem is fixed. But the reality is that for many health problems, you go see the doctor, they don't know what's going on, maybe you go see some specialists, no one knows what to do, so they say it's probably not a real illness and tell you to do CBT or meditate or something. And you just stay sick.
posted by ssg at 2:23 PM on November 13, 2021 [55 favorites]
And you just stay sick.
Worse yet — here in the US, at least — we pay ridiculous amounts of money to the private sector for what is, on average, marginally poor care, as compared with industrialized, first-world nations.
posted by They sucked his brains out! at 2:30 PM on November 13, 2021 [13 favorites]
Worse yet — here in the US, at least — we pay ridiculous amounts of money to the private sector for what is, on average, marginally poor care, as compared with industrialized, first-world nations.
posted by They sucked his brains out! at 2:30 PM on November 13, 2021 [13 favorites]
CBT is just one of those things doctors have lots of difficult cases try because it costs very little, isn't very dangerous compared to a lot of pharmaceuticals or procedures, and helps some people. But it's such a frustrating and insulting suggestion to hear, as a person who's pretty sure what's wrong is physical and treatable, and so often presented so insensitively. Many pain patients are not in a mental place to embark on a CBT journey, because CBT really is just basically a formulaic gaslighting process, and that is so so understandable.
That said, I'm doing a physical therapy thing right now that has introduced some CBT concepts around reframing my pain, and while I was very skeptical I do think it's done me a little good. I've had joint pain with activity for over twenty years, and I do think I'd started letting it define me and circumscribe what the possibilities were that I could imagine for myself, and it HAS been productive for me to interrogate the stories I tell myself about my knees a little bit. It hasn't been a game changer or anything but I don't think it's been a total waste of time either. Certainly I'd rather do some CBT than get harangued about my diet or sleeping habits, two other go-to strategies for doctors who aren't sure what to do with a patient.
posted by potrzebie at 2:36 PM on November 13, 2021 [12 favorites]
That said, I'm doing a physical therapy thing right now that has introduced some CBT concepts around reframing my pain, and while I was very skeptical I do think it's done me a little good. I've had joint pain with activity for over twenty years, and I do think I'd started letting it define me and circumscribe what the possibilities were that I could imagine for myself, and it HAS been productive for me to interrogate the stories I tell myself about my knees a little bit. It hasn't been a game changer or anything but I don't think it's been a total waste of time either. Certainly I'd rather do some CBT than get harangued about my diet or sleeping habits, two other go-to strategies for doctors who aren't sure what to do with a patient.
posted by potrzebie at 2:36 PM on November 13, 2021 [12 favorites]
There have been several dozen scientific studies looking at the efficacy of CBT for pain and it's the job of the Cochrane Index to integrate all these studies taking into account sample size, and effect size. Their 2020 Featured Review on Psychological therapies for the management of chronic pain (excluding headache) in adults [Summary with links to the stats] finds:
"For CBT, where we had 59 studies to combine, there was a negligible positive effect of the intervention on pain levels, and small but robust improvements on disability and distress, all assessed by the individuals’ own reports. Evidence quality was mostly moderate, some low. The improvements in all outcomes were more marked, lasting to follow-up at 6 to 12 months, when treatment was compared with waiting list or treatment as usual than when it was compared with another treatment, such as an exercise programme, educational intervention, or support group. " and
"One of the problems in psychology trials, particularly with newer treatments such as ACT, is that trials are run by enthusiasts for the new treatment. For the next generation of trials, we need more even-handedness." That seems to wag a finger into the future at these NYT editors!?
posted by BobTheScientist at 2:48 PM on November 13, 2021 [9 favorites]
"For CBT, where we had 59 studies to combine, there was a negligible positive effect of the intervention on pain levels, and small but robust improvements on disability and distress, all assessed by the individuals’ own reports. Evidence quality was mostly moderate, some low. The improvements in all outcomes were more marked, lasting to follow-up at 6 to 12 months, when treatment was compared with waiting list or treatment as usual than when it was compared with another treatment, such as an exercise programme, educational intervention, or support group. " and
"One of the problems in psychology trials, particularly with newer treatments such as ACT, is that trials are run by enthusiasts for the new treatment. For the next generation of trials, we need more even-handedness." That seems to wag a finger into the future at these NYT editors!?
posted by BobTheScientist at 2:48 PM on November 13, 2021 [9 favorites]
small but robust improvements on disability and distress, all assessed by the individuals’ own reports.
If your whole program is based on convincing people that their thoughts about their disability are incorrect or that they can overcome their disability by thinking positively and then you ask people who recently completed your program if they feel less disabled, you're much more likely to be measuring how successful your program is at changing thoughts than how successful it is at actually improving disability. Just thinking you're better without any underlying improvement is likely to be pretty short lived and not particularly helpful. And of course, there is no blinding or placebo treatment in these trials, leading to obvious bias. There are unfortunately a lot of doctors and scientists who are very dedicated to CBT and can't seem to understand these very obvious shortcomings of such studies. Some people may be helped to reduce their distress through CBT, but these trials are fundamentally flawed such that it would be hard to say one way or another.
posted by ssg at 3:14 PM on November 13, 2021 [12 favorites]
If your whole program is based on convincing people that their thoughts about their disability are incorrect or that they can overcome their disability by thinking positively and then you ask people who recently completed your program if they feel less disabled, you're much more likely to be measuring how successful your program is at changing thoughts than how successful it is at actually improving disability. Just thinking you're better without any underlying improvement is likely to be pretty short lived and not particularly helpful. And of course, there is no blinding or placebo treatment in these trials, leading to obvious bias. There are unfortunately a lot of doctors and scientists who are very dedicated to CBT and can't seem to understand these very obvious shortcomings of such studies. Some people may be helped to reduce their distress through CBT, but these trials are fundamentally flawed such that it would be hard to say one way or another.
posted by ssg at 3:14 PM on November 13, 2021 [12 favorites]
because CBT really is just basically a formulaic gaslighting process, and that is so so understandable.
i mean come on?
posted by lalochezia at 3:36 PM on November 13, 2021 [3 favorites]
i mean come on?
posted by lalochezia at 3:36 PM on November 13, 2021 [3 favorites]
*if* the underlying assumption that the patient's thinking is distorted is correct, then of course it's not gaslighting. If it's not correct, then that's an accurate summary of the process.
posted by tigrrrlily at 3:41 PM on November 13, 2021 [15 favorites]
posted by tigrrrlily at 3:41 PM on November 13, 2021 [15 favorites]
CBT as a modality is based around gaslighting. It’s all about telling a patient that the world is safe, bad feelings are temporary, and that pain (emotional or physical) is a “faulty or unhelpful” distortion of thinking. That’s literally in CBT’s definition on the APA website.
Except that literally is not in CBT's definition on the APA website, which I bothered to click through to and read, and that's not what gaslighting means either way. "Someone disagreed with you," "someone perceived things differently from you and said so," or "someone suggested that the motives you are attributing to someone else as malicious perhaps might not be" may or may not be gaslighting, the same way someone opening you up with a scalpel may or may not be attempted murder, and the same way you dying on the operating table may or may not be the result of malpractice. Describing CBT as "gaslighting" is like describing invasive surgery as "attempted murder."
posted by mph at 3:48 PM on November 13, 2021 [37 favorites]
Except that literally is not in CBT's definition on the APA website, which I bothered to click through to and read, and that's not what gaslighting means either way. "Someone disagreed with you," "someone perceived things differently from you and said so," or "someone suggested that the motives you are attributing to someone else as malicious perhaps might not be" may or may not be gaslighting, the same way someone opening you up with a scalpel may or may not be attempted murder, and the same way you dying on the operating table may or may not be the result of malpractice. Describing CBT as "gaslighting" is like describing invasive surgery as "attempted murder."
posted by mph at 3:48 PM on November 13, 2021 [37 favorites]
Murder is all about intent, or we call it something else. I chose to focus on the effect on the patient, not the therapist's mental state.
posted by tigrrrlily at 3:57 PM on November 13, 2021 [3 favorites]
posted by tigrrrlily at 3:57 PM on November 13, 2021 [3 favorites]
*if* the underlying assumption that the patient's thinking is distorted is correct, then of course it's not gaslighting. If it's not correct, then that's an accurate summary of the process.
I believe that the underlying assumption of using CBT is that the patient can learn beneficial ways of thinking and behaving, not that their thinking is necessarily distorted. For example catastrophizing is a significant mediator between pain and anxiety and depression. So learning to modify "negative perceptions of pain" would help improve quality of life even though it is a perfectly reasonable response.
My understanding is that the most commonly accepted model of chronic pain and disability is the biopsychosocial model of where physiological, psychological, and social factors all influence each other which would similarly require a multi-faceted approach to treatment and coping.
posted by colophon at 4:00 PM on November 13, 2021 [10 favorites]
I believe that the underlying assumption of using CBT is that the patient can learn beneficial ways of thinking and behaving, not that their thinking is necessarily distorted. For example catastrophizing is a significant mediator between pain and anxiety and depression. So learning to modify "negative perceptions of pain" would help improve quality of life even though it is a perfectly reasonable response.
My understanding is that the most commonly accepted model of chronic pain and disability is the biopsychosocial model of where physiological, psychological, and social factors all influence each other which would similarly require a multi-faceted approach to treatment and coping.
posted by colophon at 4:00 PM on November 13, 2021 [10 favorites]
The biopsychosocial model sounds reasonable (of course our health is influenced by all parts of our lives), but in practice it has often been used to dismiss patients physical complaints as psychological. It's generally just window dressing on "it's all in your head".
So learning to modify "negative perceptions of pain" would help improve quality of life even though it is a perfectly reasonable response.
This is actually a somewhat testable hypothesis and so far studies overall don't show this, as I understand it. Even then, there are significant bias issues that are pretty hard to overcome in these kinds of trials, so you'd need to show a pretty significant effect to overcome those. Theory is nice, but our medical system is supposed to be evidence based.
posted by ssg at 4:08 PM on November 13, 2021 [13 favorites]
So learning to modify "negative perceptions of pain" would help improve quality of life even though it is a perfectly reasonable response.
This is actually a somewhat testable hypothesis and so far studies overall don't show this, as I understand it. Even then, there are significant bias issues that are pretty hard to overcome in these kinds of trials, so you'd need to show a pretty significant effect to overcome those. Theory is nice, but our medical system is supposed to be evidence based.
posted by ssg at 4:08 PM on November 13, 2021 [13 favorites]
Learning a better way of coping with my feelings of pain isn't going to relieve my symptoms.
Right, but there don't seem to be great options for relieving chronic pain symptoms.
Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis found that "opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo."
Nonopioid Pharmacologic Treatments for Chronic Pain again found various pharmaceuticals "associated with mostly small improvements (e.g., 5 to 20 points on a 0 to 100 scale) in pain and function."
Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review found that "exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain"
posted by colophon at 4:31 PM on November 13, 2021 [4 favorites]
Right, but there don't seem to be great options for relieving chronic pain symptoms.
Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis found that "opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo."
Nonopioid Pharmacologic Treatments for Chronic Pain again found various pharmaceuticals "associated with mostly small improvements (e.g., 5 to 20 points on a 0 to 100 scale) in pain and function."
Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review found that "exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain"
posted by colophon at 4:31 PM on November 13, 2021 [4 favorites]
The biopsychosocial model sounds reasonable (of course our health is influenced by all parts of our lives), but in practice it has often been used to dismiss patients physical complaints as psychological. It's generally just window dressing on "it's all in your head".
The existence of the term "it's all in your head" is incredibly unfortunate because it's true in the sense that pain is a product of the mind - but the implications as far as modern science has found have nothing to with how that term has been used historically, that is, as the most base dismissal of a problem someone is dealing with, which is if anything the default conclusion so many doctors end up making.
I studied pain science from around 2013-2015 - it's pretty fascinating, and it was clear then that 20 years in the future what I learned at the time was not only not going to be mainstream among the public, it wasn't even going to be mainstream in the medical field. The problems (to grossly simplify): there is no pain specialty in medicine; GPs get very little training in it; it undercuts the need for a lot of orthopedic surgery which is quite profitable; and really at the core - we don't have a full understanding how pain works, much less generalized treatment. Assuming you can find a doctor to take you seriously, sometimes you can find a basis in some physical dysfunction, but that's not very common, and once you're in the chronic realm, fairly rare.
So you end up in a situation that just reflects the culture of medicine and the broader culture itself - assembly line, cookie cutter bullshit as demanded by corporate in order to meet profit goals, mixed with cruel, old testament style proscribed suffering in the form of withholding pain medication and victim blaming.
posted by MillMan at 5:48 PM on November 13, 2021 [26 favorites]
The existence of the term "it's all in your head" is incredibly unfortunate because it's true in the sense that pain is a product of the mind - but the implications as far as modern science has found have nothing to with how that term has been used historically, that is, as the most base dismissal of a problem someone is dealing with, which is if anything the default conclusion so many doctors end up making.
I studied pain science from around 2013-2015 - it's pretty fascinating, and it was clear then that 20 years in the future what I learned at the time was not only not going to be mainstream among the public, it wasn't even going to be mainstream in the medical field. The problems (to grossly simplify): there is no pain specialty in medicine; GPs get very little training in it; it undercuts the need for a lot of orthopedic surgery which is quite profitable; and really at the core - we don't have a full understanding how pain works, much less generalized treatment. Assuming you can find a doctor to take you seriously, sometimes you can find a basis in some physical dysfunction, but that's not very common, and once you're in the chronic realm, fairly rare.
So you end up in a situation that just reflects the culture of medicine and the broader culture itself - assembly line, cookie cutter bullshit as demanded by corporate in order to meet profit goals, mixed with cruel, old testament style proscribed suffering in the form of withholding pain medication and victim blaming.
posted by MillMan at 5:48 PM on November 13, 2021 [26 favorites]
It seems to me that it's hard to tell the difference between "there's nothing physically wrong, so let's try CBT" and "there's nothing physically wrong that we can fix, so let's try CBT" and "there's nothing physically wrong that we can figure out, let's give up and try CBT."
I knew someone who was in severe pain, and as she sought treatment for it the diagnosis that seemed to stick was "it's psychosomatic, try CBT" with a side of "she's shopping around for a doctor who'll prescribe opioids." Eventually, through a combination of luck and DIY medical research, she ended up finding a treatment. But her conviction that there was something physically wrong with her ended up being seen by doctors as an impediment to her treatment, because she couldn't get better until she accepted that it was psychosomatic - and there's a kind of a catch-22 there that lets doctors dismiss the possibility that actually, there was in fact something physically wrong with her.
So, assuming that there are some people who can be helped by CBT - how to ensure that it's not seen as an escape hatch for any problem that's too difficult? How to ensure that the message is "You are hurting for legitimate reasons, even if we can't figure those reasons out, and there are ways to live better with that pain" and not "Your pain is all in your head"?
posted by Jeanne at 6:23 PM on November 13, 2021 [35 favorites]
I knew someone who was in severe pain, and as she sought treatment for it the diagnosis that seemed to stick was "it's psychosomatic, try CBT" with a side of "she's shopping around for a doctor who'll prescribe opioids." Eventually, through a combination of luck and DIY medical research, she ended up finding a treatment. But her conviction that there was something physically wrong with her ended up being seen by doctors as an impediment to her treatment, because she couldn't get better until she accepted that it was psychosomatic - and there's a kind of a catch-22 there that lets doctors dismiss the possibility that actually, there was in fact something physically wrong with her.
So, assuming that there are some people who can be helped by CBT - how to ensure that it's not seen as an escape hatch for any problem that's too difficult? How to ensure that the message is "You are hurting for legitimate reasons, even if we can't figure those reasons out, and there are ways to live better with that pain" and not "Your pain is all in your head"?
posted by Jeanne at 6:23 PM on November 13, 2021 [35 favorites]
This is not uniquely about CBT; that just happens to be what's in vogue in some countries at the moment. I live in a country where I was referred to good old psychoanalysis for pain, because apparently it was all because of something I was suppressing. That was not helpful either. Doesn't mean all these modalities don't have value in specific circumstances or for specific people; but the idea that chronic pain, fatigue, and other disabling symptoms are things most people can just think away in one way or another is like the idea that everything's a matter of chi or humors or subluxations or what have you -- potentially a very simple, appealing idea, but doesn't seem borne out by evidence, and evidence is what I want before you tell me that the reason that my condition is not responding to your treatment is because I'm not trying hard enough or am just a hypochondriac.
I actually think things like CBT can have a place if the approach is "here are tools to try to help you cope with these circumstances; may or may not work but worth giving a try" rather than "here are tools that will fix your problem, which is coming strictly from your mind, and if you say they don't help that's because you're doing it wrong or you're not really sick".
posted by trig at 6:32 PM on November 13, 2021 [24 favorites]
I actually think things like CBT can have a place if the approach is "here are tools to try to help you cope with these circumstances; may or may not work but worth giving a try" rather than "here are tools that will fix your problem, which is coming strictly from your mind, and if you say they don't help that's because you're doing it wrong or you're not really sick".
posted by trig at 6:32 PM on November 13, 2021 [24 favorites]
I also think it can be difficult for therapists who grew up on "the only disability is a bad attitude!" inspiration porn to wrap their minds around the fact that a person who says "I will be living with this pain forever" or "I cannot do [X] without losing days of my life to pain afterward" is not catastrophizing. Which isn't a CBT-specific thing; but I think it can be hard for some CBT-trained therapists to pivot from "The scary thing probably won't happen!" to "Hey, there's actually some Unavoidable Suffering here, so let's figure out how to work with it." (Which is why I get along better with ACT, but there's no modality that's immune to "the only disability is a bad attitude!")
posted by Jeanne at 7:06 PM on November 13, 2021 [41 favorites]
posted by Jeanne at 7:06 PM on November 13, 2021 [41 favorites]
I got embarrassingly deep into this comment thread before realizing it was not about CBD
posted by 3j0hn at 7:12 PM on November 13, 2021 [58 favorites]
posted by 3j0hn at 7:12 PM on November 13, 2021 [58 favorites]
I also think it can be difficult for therapists* [...] to wrap their minds around the fact that a person who says "I will be living with this pain forever" or "I cannot do [X] without losing days of my life to pain afterward" is not catastrophizing.
QFT
* and doctors, all too often
posted by trig at 7:16 PM on November 13, 2021 [15 favorites]
QFT
* and doctors, all too often
posted by trig at 7:16 PM on November 13, 2021 [15 favorites]
assembly line, cookie cutter bullshit as demanded by corporate in order to meet profit goals, mixed with cruel, old testament style proscribed suffering in the form of withholding pain medication and victim blaming.
I wish we could blame even part of this problem on for-profit medicine, but the situation is just as bad or worse in countries with public health care. Where treatment options are very centralized and the wrong people get to write the guidelines, like in the UK, this kind of thing can be arguably significantly worse because if the only game in town is rigged against you, you're pretty much better off staying home.
I think it's more a general failure mode for modern doctors, which has to do with training more than anything, layered on top of a bit of a standard of evidence mismatch between what something like a drug requires to become the standard of care versus the standards of evidence in psychology and psychiatry. If we treated people with drugs based on the level of evidence required for something like CBT, we'd all be taking handfuls of pills morning, noon and night.
posted by ssg at 7:18 PM on November 13, 2021 [17 favorites]
I wish we could blame even part of this problem on for-profit medicine, but the situation is just as bad or worse in countries with public health care. Where treatment options are very centralized and the wrong people get to write the guidelines, like in the UK, this kind of thing can be arguably significantly worse because if the only game in town is rigged against you, you're pretty much better off staying home.
I think it's more a general failure mode for modern doctors, which has to do with training more than anything, layered on top of a bit of a standard of evidence mismatch between what something like a drug requires to become the standard of care versus the standards of evidence in psychology and psychiatry. If we treated people with drugs based on the level of evidence required for something like CBT, we'd all be taking handfuls of pills morning, noon and night.
posted by ssg at 7:18 PM on November 13, 2021 [17 favorites]
My migraines are triggered by stress, so CBT (or whatever) might be helpful for me I suppose. I have an acquaintance whose migraines are triggered by sleep interruption. CBT isn't going to help him.
posted by sfred at 7:19 PM on November 13, 2021 [2 favorites]
posted by sfred at 7:19 PM on November 13, 2021 [2 favorites]
The biopsychosocial model sounds reasonable (of course our health is influenced by all parts of our lives), but in practice it has often been used to dismiss patients physical complaints as psychological. It's generally just window dressing on "it's all in your head".
I can see that happening, social determinants of health in particular are often poorly addressed. Marital quality, perceived social support and supportive work environments are associated with improved recovery and reduced disability from chronic pain but what are you actually supposed to do if those are missing in your life.
posted by colophon at 7:59 PM on November 13, 2021 [5 favorites]
I can see that happening, social determinants of health in particular are often poorly addressed. Marital quality, perceived social support and supportive work environments are associated with improved recovery and reduced disability from chronic pain but what are you actually supposed to do if those are missing in your life.
posted by colophon at 7:59 PM on November 13, 2021 [5 favorites]
I got embarrassingly deep into this comment thread before realizing it was not about CBD
Oh good, I'm not the only one!
posted by Zumbador at 8:19 PM on November 13, 2021 [8 favorites]
Oh good, I'm not the only one!
posted by Zumbador at 8:19 PM on November 13, 2021 [8 favorites]
I got embarrassingly deep into this comment thread before realizing it was not about CBD
CBT has an *other* meaning that could also lead to confusion.
posted by hippybear at 8:24 PM on November 13, 2021 [23 favorites]
CBT has an *other* meaning that could also lead to confusion.
posted by hippybear at 8:24 PM on November 13, 2021 [23 favorites]
It has been interesting to read this thread. I've found some ease from CBT and ACT strategies, but at the moment I am (apparently?) suffering from chronic pain *caused* by anxiety (gastritis). So one of the CBT strategies that used to help, that the anxiety itself cannot harm me, no longer applies.
It's hard to find a balance between accepting the situation you are in, and still doing your best to improve it.
posted by Zumbador at 9:00 PM on November 13, 2021 [10 favorites]
It's hard to find a balance between accepting the situation you are in, and still doing your best to improve it.
posted by Zumbador at 9:00 PM on November 13, 2021 [10 favorites]
Mod note: One comment removed; let's avoid armchair diagnoses of ailments in others, please!
posted by taz (staff) at 1:04 AM on November 14, 2021 [4 favorites]
posted by taz (staff) at 1:04 AM on November 14, 2021 [4 favorites]
Over the last seven years, I have been proscribed CBT four times, for stress and depression. The fourth time I was like, why do you guys think this will work now when it hasn't worked the other times? Then I paid out of pocket for psychotherapy based on a different theory (I don't remember which) and that therapist told me she thought I had PTSD and I should seek help for that. My doctor said no, that's impossible, but finally I was entered into a program and it is life-changing. It isn't like I am suddenly well and happy and free of pain, but it makes a huge difference to be in a setting where it is acknowledged that I will become a happy little worker bee again.
Yes, my chronic pain has to do with my mental health. I have nightmares and flashbacks. I wake up with fists and jaws clenched, not relaxed, of course my back and neck hurts. There is more, but the bottom line is that it makes a lot of sense.
And to get back to CBT and the worker bee: already during the second round, I strongly felt the whole thing was about productivity on every level. I needed to be more productive, the therapists could churn out "cured" patients at a high speed, my former workplace could tell the board that the frequently reported stress and unhappiness was "all in our heads".
posted by mumimor at 2:27 AM on November 14, 2021 [17 favorites]
Yes, my chronic pain has to do with my mental health. I have nightmares and flashbacks. I wake up with fists and jaws clenched, not relaxed, of course my back and neck hurts. There is more, but the bottom line is that it makes a lot of sense.
And to get back to CBT and the worker bee: already during the second round, I strongly felt the whole thing was about productivity on every level. I needed to be more productive, the therapists could churn out "cured" patients at a high speed, my former workplace could tell the board that the frequently reported stress and unhappiness was "all in our heads".
posted by mumimor at 2:27 AM on November 14, 2021 [17 favorites]
Doctors are terrible with mental health and I really don't think many of them understand what CBT can do/can't do, and where it's usefulness is.
I also wish that doctors got follow up regarding the patients they saw in the past and made some decision on, then the patient is somewhere else. But they don't. Most people don't go back to the dismissive medical professionals and say, X time later I was dignosed with y and actually treated after z, maybe you should think about that in the future.
It shouldn't be the patients responsibility to do that either. The system is inherently flawed in that way. Doctors just go about their lives thinking they are right without any pushback, and that's 1) terrifying and 2) a way in which medical professionals have a hard time modifying their experience based on outcomes.
CBT is useful for framing around actual lived experience. The basis of CBT can't deny basic facts, and that someone experiences pain is a fact. Any therapist who works by saying that the pain isn't real or is a distortion shouldn't be practicing. That's not the point of CBT. It is useful for how someone thinks about themselves as someone with chronic pain, it is useful about self esteem, self worth, it is useful to help someone self advocate in the medical setting (because just because a doctor is dismissive doesn't mean that they are right!) It is useful in setting and communicating healthy boundaries based on a persons health. Ultimately CBT does and can't do anything to address the actual medical need, no thoughts are going to help that. Yes there are strategies that help people process pain like distraction, or meditation tools, but there is no reason to keep pushing those things on people when they don't work. They will not work for everyone! None of this is perfect science, at best some people experience improvement .
I also wish that CBT therapists and doctors communicated more in the 'therapist noticed this patient is in alot of distress and persistently continues to report high levels of pain, are you sure there isn't other things you can look into or discuss?' Towards physicians.
I can absolutely see how CBT is a traumatic experience for many adults with chronic illnesses. I too have experienced trauma by mental health professionals and physicians dismissing health concerns, the navigating of both imperfect systems, and what to do next.
There should definately be more conversation and discussion about harm, and how professionals are measuring that when people are doing research with therapeutic techniques as well. Personally I don't think they are doing a good enough job with that.
posted by AlexiaSky at 2:28 AM on November 14, 2021 [14 favorites]
I also wish that doctors got follow up regarding the patients they saw in the past and made some decision on, then the patient is somewhere else. But they don't. Most people don't go back to the dismissive medical professionals and say, X time later I was dignosed with y and actually treated after z, maybe you should think about that in the future.
It shouldn't be the patients responsibility to do that either. The system is inherently flawed in that way. Doctors just go about their lives thinking they are right without any pushback, and that's 1) terrifying and 2) a way in which medical professionals have a hard time modifying their experience based on outcomes.
CBT is useful for framing around actual lived experience. The basis of CBT can't deny basic facts, and that someone experiences pain is a fact. Any therapist who works by saying that the pain isn't real or is a distortion shouldn't be practicing. That's not the point of CBT. It is useful for how someone thinks about themselves as someone with chronic pain, it is useful about self esteem, self worth, it is useful to help someone self advocate in the medical setting (because just because a doctor is dismissive doesn't mean that they are right!) It is useful in setting and communicating healthy boundaries based on a persons health. Ultimately CBT does and can't do anything to address the actual medical need, no thoughts are going to help that. Yes there are strategies that help people process pain like distraction, or meditation tools, but there is no reason to keep pushing those things on people when they don't work. They will not work for everyone! None of this is perfect science, at best some people experience improvement .
I also wish that CBT therapists and doctors communicated more in the 'therapist noticed this patient is in alot of distress and persistently continues to report high levels of pain, are you sure there isn't other things you can look into or discuss?' Towards physicians.
I can absolutely see how CBT is a traumatic experience for many adults with chronic illnesses. I too have experienced trauma by mental health professionals and physicians dismissing health concerns, the navigating of both imperfect systems, and what to do next.
There should definately be more conversation and discussion about harm, and how professionals are measuring that when people are doing research with therapeutic techniques as well. Personally I don't think they are doing a good enough job with that.
posted by AlexiaSky at 2:28 AM on November 14, 2021 [14 favorites]
I'vd had a lot of thoughts on this topic over the years, but suffice to say, CBT: A New Form of Scientism.
posted by polymodus at 5:09 AM on November 14, 2021 [1 favorite]
posted by polymodus at 5:09 AM on November 14, 2021 [1 favorite]
I... read the acronym in the headline as CBD, and idly wondered why therapists were distributing it. Carry on.
posted by heatherlogan at 7:00 AM on November 14, 2021 [2 favorites]
posted by heatherlogan at 7:00 AM on November 14, 2021 [2 favorites]
I also think it can be difficult for therapists* [...] to wrap their minds around the fact that a person who says "I will be living with this pain forever" or "I cannot do [X] without losing days of my life to pain afterward" is not catastrophizing
Dieticians and personal trainers also.
posted by flabdablet at 7:06 AM on November 14, 2021 [7 favorites]
Dieticians and personal trainers also.
posted by flabdablet at 7:06 AM on November 14, 2021 [7 favorites]
I was wondering why the new york times might have an interest in promoting CBT, and I discovered that 2020 saw "$2.4B invested in US-based digital health startups that serve behavioral health needs" (according to this site). And it just so happens that "Because cognitive behavioral therapy is structured and skill-oriented, many mental health experts think it can be employed, at least in part, by algorithm." (nytimes).
Which is just to say, there's a bunch of venture capitalists who seem to think there's a lot of money to be made in CBT.
posted by thedamnbees at 7:08 AM on November 14, 2021 [17 favorites]
Which is just to say, there's a bunch of venture capitalists who seem to think there's a lot of money to be made in CBT.
posted by thedamnbees at 7:08 AM on November 14, 2021 [17 favorites]
This is the first time I've ever seen CBT being suggested as a treatment for anything other than depression/anxiety. I have books by David D. Burns and there's no reference to pain or chronic illness (other than worry) in them at all. This really strikes me as laziness on the part of doctors. CBT isn't for everyone to begin with, and thinking it's a panacea for any issue, let alone one like chronic pain, is borderline malpractice.
posted by tommasz at 7:10 AM on November 14, 2021 [9 favorites]
posted by tommasz at 7:10 AM on November 14, 2021 [9 favorites]
chronic pain is a fact in my life and has been for over two decades. It wasn't that bad at first. I barely noticed it at first. But over time, it became a definitively life altering concern and one for which the only medical "solution" was opiate level meds.
But the rest of my life committed to a daily relationship with opiates? That's a step I wasn't ready to take.
Long story short (and it's absurdly long, a sort of picaresque wander through all manner of treatments and diagnostics and experts and whatever, some of it at least CBT adjacent), I came to the conclusion that the only way to live a non-despairing life was to cease doing those things that aggravated the pain. And yes, the things that aggravated it were specific and more or less mechanical. Lucky me, I guess. Though I still hadn't (and still haven't) got a definitive diagnosis of my "injury", I could pinpoint what aggravated its symptoms. Problem was, there was no way on earth I could live a "normal" life without having to do these aggravating things pretty much all the time. So bluntly, I finally had to give up on normal. Forever.
That was five or six years ago. Now, let's just say the pain is still real, still a god damned fact (I'm feeling it as I write this), but I've at least constructed an everyday life that allows me to do many things that matter to me, that give me purpose and meaning. That said, there's a vast amount of everyday stuff that I just can't do anymore, not with any regularity. So be it. Life is like that. Past a certain point, we all lose something we used to have. And then we lose another thing. And so on.
[Final detail. All of this is "invisible". There is no outward indication that I'm going through what I'm going through. I look okay for my age. I don't have a limp. I have no obvious scars. So yeah, I am constantly having to deal with individuals who JUST DON'T FUCKING GET IT. Every now and then, one of them gets their head torn off. Oh well, call it a symptom of my condition. Sorry in advance.]
posted by philip-random at 7:28 AM on November 14, 2021 [18 favorites]
But the rest of my life committed to a daily relationship with opiates? That's a step I wasn't ready to take.
Long story short (and it's absurdly long, a sort of picaresque wander through all manner of treatments and diagnostics and experts and whatever, some of it at least CBT adjacent), I came to the conclusion that the only way to live a non-despairing life was to cease doing those things that aggravated the pain. And yes, the things that aggravated it were specific and more or less mechanical. Lucky me, I guess. Though I still hadn't (and still haven't) got a definitive diagnosis of my "injury", I could pinpoint what aggravated its symptoms. Problem was, there was no way on earth I could live a "normal" life without having to do these aggravating things pretty much all the time. So bluntly, I finally had to give up on normal. Forever.
That was five or six years ago. Now, let's just say the pain is still real, still a god damned fact (I'm feeling it as I write this), but I've at least constructed an everyday life that allows me to do many things that matter to me, that give me purpose and meaning. That said, there's a vast amount of everyday stuff that I just can't do anymore, not with any regularity. So be it. Life is like that. Past a certain point, we all lose something we used to have. And then we lose another thing. And so on.
[Final detail. All of this is "invisible". There is no outward indication that I'm going through what I'm going through. I look okay for my age. I don't have a limp. I have no obvious scars. So yeah, I am constantly having to deal with individuals who JUST DON'T FUCKING GET IT. Every now and then, one of them gets their head torn off. Oh well, call it a symptom of my condition. Sorry in advance.]
posted by philip-random at 7:28 AM on November 14, 2021 [18 favorites]
CBT has been such an utter failure throughout my experience with various therapists, counselors, etc., that I cannot begin to fathom its use as a pain reduction tool. Such an idea strikes me as a very cruel joke. ymmv, of course.
posted by Thorzdad at 10:36 AM on November 14, 2021 [6 favorites]
posted by Thorzdad at 10:36 AM on November 14, 2021 [6 favorites]
Ologies this week is an interview with a pain psychologist who uses cbt and goes into her perspective.
I studied behavior analysis in college. I've always been amazed at how devisive it is.
posted by rebent at 11:57 AM on November 14, 2021
I studied behavior analysis in college. I've always been amazed at how devisive it is.
posted by rebent at 11:57 AM on November 14, 2021
The Ologies episode is part of why I posted this. I saw the NYT thing (and linked blog post) happen, and was really, really, really disappointed that a) they went ahead and did the Ologies episode anyway, and b) didn't have any kind of comment on what was happening in the news with CBT, and CBT has been getting pushback for awhile now.
I don't love the format of Ologies but have always really appreciated Ward's enthusiasm for science, and this makes me question what other episodes I just drank in that were maybe not vetted like they should have been.
posted by curious nu at 3:06 PM on November 14, 2021 [2 favorites]
I don't love the format of Ologies but have always really appreciated Ward's enthusiasm for science, and this makes me question what other episodes I just drank in that were maybe not vetted like they should have been.
posted by curious nu at 3:06 PM on November 14, 2021 [2 favorites]
Ah, I see. This whole thread makes me really sad that we don't have a better understanding of the uses and disuses of CBT. Like I said I studied behavior analysis in college - but for HR training stuff. So, when people criticize CBT, I suspect I might have some bad information undergirding foundational beliefs. Clearly people are getting hurt.
posted by rebent at 6:24 PM on November 14, 2021
posted by rebent at 6:24 PM on November 14, 2021
It seems to me like CBT is not geared toward treating pain like hers? I find it odd that it might be construed to be applicable for that.
This is very common, there are multiple manuals for CBT for chronic pain. I was taught about it in grad school, and it has been suggested to my partner multiple times for chronic pain.
The basic strategies of CBT are not inherently unhelpful in therapy for people with chronic pain--please note the specific wording: therapy for people with chronic pain, not therapy for chronic pain. I do not practice manualized CBT but I often find myself implementing CBT-adjacent strategies with my disabled clients. I use thought challenging all the time. The thoughts we are typically collaboratively challenging are, "I am lazy, I'm just not trying hard enough, I am making this up, I am faking." I also encourage increasing pleasurable activities in my clients because they often deny themselves those things if they don't accomplish xyz, which they rarely are able to accomplish and thus routinely deny themselves joy. I use activity scheduling because it relieves the anxiety of "I should be doing x."
But this is largely incidental to my overall approach, which is drawn from my lived experience as a multiply disabled person. There are cognitive and behavioral aspects to it, but my focus is on disabled wellness, which in my experience comes from clearly defining limitations and structuring your life within it while also continuing to work to find places where those limitations can improve with treatment. This means a lot of my work is referring people to specialists and helping them advocate for appropriate medical care. I also help identify physical causes for cognitive experiences; most common is individuals avoiding various tasks or being anxious/stressed during certain activities because of subtle motor/balance/sensory issues that they don't recognize as such but which impact them in a thousand different small ways. Pro tip: if your answer to "How many times do you have to catch your balance while putting on your pants in the morning?" is more than 1, you're not 'just clumsy.'
From some perspective everything I am doing is cognitive behavioral--we are changing your perspective on what it means to be disabled and what you should do about that. But that's only "CBT" in the way that doing anything is a mix of thoughts and behavior. What makes CBT, well, CBT, is that assertion that the distortion lies within the individual, and that you simply need to erase that distortion and that will fix things. It sort of... mmm... I could paint this, but I don't know quite how to convey it in words. Let's try: it pictures distortions as bubbling up from inside, essentially, rather than being the internalization of messages around you.
And I am sure, sometimes, that is the case. But particularly for my disabled clients, the distortion very explicitly comes from societal messages about being disabled and how they have been treated because of that. The work I do is not to tell them, "How you see and interact with the world is wrong," but rather undoing the damage done by a lifetime of being told how they see and interact with the world is wrong, and that they must "do life" in the way that abled society demands. Ungaslighting, I suppose you could call it.
And that is cognitive work, that is belief work, that is changing behavior, but I think there's a fundamental difference between that and the near-universal application of CBT that places the therapist as the rational person pointing out the flaws in a client's logic. (One thing I have never, ever seen addressed in any CBT manual: what does a therapist do if they aren't sure what the "logical" answer is? God knows we all have our own anxieties. Let me tell you, I've been super fucking glad not to be a CBT therapist in the pandemic, because I certainly can't tell you whether it's logical to be afraid of getting groceries!)
All that to say that CBT didn't have to be this way. If it placed the client's knowledge and lived experience at center, helping them unlearn the negative messages from society and find their true experience, it could be very good indeed. But instead, it centers the therapist in an almost magical fashion, as this divine bestower of rationality--the therapist knows the truth, not you. Oh yes, you can talk all you want about "it's about which thoughts are helpful and which are unhelpful" but the hairdryer incident exemplifies exactly how this is not the case for CBT (and psychotherapy as a field) today.
I am not trying to say that my way is the best way, and I'm sure I have a lot yet to learn. But I have never been able to work within a CBT framework as a therapist, despite it having some very useful strategies that I use all the time.
posted by brook horse at 6:55 PM on November 14, 2021 [30 favorites]
This is very common, there are multiple manuals for CBT for chronic pain. I was taught about it in grad school, and it has been suggested to my partner multiple times for chronic pain.
The basic strategies of CBT are not inherently unhelpful in therapy for people with chronic pain--please note the specific wording: therapy for people with chronic pain, not therapy for chronic pain. I do not practice manualized CBT but I often find myself implementing CBT-adjacent strategies with my disabled clients. I use thought challenging all the time. The thoughts we are typically collaboratively challenging are, "I am lazy, I'm just not trying hard enough, I am making this up, I am faking." I also encourage increasing pleasurable activities in my clients because they often deny themselves those things if they don't accomplish xyz, which they rarely are able to accomplish and thus routinely deny themselves joy. I use activity scheduling because it relieves the anxiety of "I should be doing x."
But this is largely incidental to my overall approach, which is drawn from my lived experience as a multiply disabled person. There are cognitive and behavioral aspects to it, but my focus is on disabled wellness, which in my experience comes from clearly defining limitations and structuring your life within it while also continuing to work to find places where those limitations can improve with treatment. This means a lot of my work is referring people to specialists and helping them advocate for appropriate medical care. I also help identify physical causes for cognitive experiences; most common is individuals avoiding various tasks or being anxious/stressed during certain activities because of subtle motor/balance/sensory issues that they don't recognize as such but which impact them in a thousand different small ways. Pro tip: if your answer to "How many times do you have to catch your balance while putting on your pants in the morning?" is more than 1, you're not 'just clumsy.'
From some perspective everything I am doing is cognitive behavioral--we are changing your perspective on what it means to be disabled and what you should do about that. But that's only "CBT" in the way that doing anything is a mix of thoughts and behavior. What makes CBT, well, CBT, is that assertion that the distortion lies within the individual, and that you simply need to erase that distortion and that will fix things. It sort of... mmm... I could paint this, but I don't know quite how to convey it in words. Let's try: it pictures distortions as bubbling up from inside, essentially, rather than being the internalization of messages around you.
And I am sure, sometimes, that is the case. But particularly for my disabled clients, the distortion very explicitly comes from societal messages about being disabled and how they have been treated because of that. The work I do is not to tell them, "How you see and interact with the world is wrong," but rather undoing the damage done by a lifetime of being told how they see and interact with the world is wrong, and that they must "do life" in the way that abled society demands. Ungaslighting, I suppose you could call it.
And that is cognitive work, that is belief work, that is changing behavior, but I think there's a fundamental difference between that and the near-universal application of CBT that places the therapist as the rational person pointing out the flaws in a client's logic. (One thing I have never, ever seen addressed in any CBT manual: what does a therapist do if they aren't sure what the "logical" answer is? God knows we all have our own anxieties. Let me tell you, I've been super fucking glad not to be a CBT therapist in the pandemic, because I certainly can't tell you whether it's logical to be afraid of getting groceries!)
All that to say that CBT didn't have to be this way. If it placed the client's knowledge and lived experience at center, helping them unlearn the negative messages from society and find their true experience, it could be very good indeed. But instead, it centers the therapist in an almost magical fashion, as this divine bestower of rationality--the therapist knows the truth, not you. Oh yes, you can talk all you want about "it's about which thoughts are helpful and which are unhelpful" but the hairdryer incident exemplifies exactly how this is not the case for CBT (and psychotherapy as a field) today.
I am not trying to say that my way is the best way, and I'm sure I have a lot yet to learn. But I have never been able to work within a CBT framework as a therapist, despite it having some very useful strategies that I use all the time.
posted by brook horse at 6:55 PM on November 14, 2021 [30 favorites]
Let me tell you, I've been super fucking glad not to be a CBT therapist in the pandemic, because I certainly can't tell you whether it's logical to be afraid of getting groceries!
I went in for an intake appointment with a psychiatric nurse (Iowa doesn't have nearly enough psychiatrists per capita, but that's another discussion) sometime in late 2020 or early 2021 and one of the questions he asked me was "Do you ever feel like you have to do something, like washing your hands more than normal?" and - look, I know what you are asking me is "do you have symptoms of OCD," but WE ALL FEEL LIKE WE HAVE TO WASH OUR HANDS MORE THAN NORMAL. I don't think he was as amused as I was.
posted by Jeanne at 7:14 PM on November 14, 2021 [7 favorites]
I went in for an intake appointment with a psychiatric nurse (Iowa doesn't have nearly enough psychiatrists per capita, but that's another discussion) sometime in late 2020 or early 2021 and one of the questions he asked me was "Do you ever feel like you have to do something, like washing your hands more than normal?" and - look, I know what you are asking me is "do you have symptoms of OCD," but WE ALL FEEL LIKE WE HAVE TO WASH OUR HANDS MORE THAN NORMAL. I don't think he was as amused as I was.
posted by Jeanne at 7:14 PM on November 14, 2021 [7 favorites]
I've heard the distinction made between supportive and coercive cbt for chronic illness. Supportive looks like what brook horse is talking about: helping the person deal with all the ableism that they swim in, challenging unhelpful thoughts such as "I'm worthless now" and "it's my fault I'm disabled". Coercive therapy on the other hand tries to convince a person that their experience of being ill, in pain or disabled is made up and that they need to stop having these "unhelpful cognitions", with the implication being that it is the person's fault for being disabled. It's absolute abuse, it's very common and I have no idea how is not against some sort of practitioner code of ethics.
There's a programme in the nhs called IAPT which is meant to be an easy way for people to access talking therapy. It's cbt offered mostly by phone or in groups and now they're looking at doing it by app. It was originally designed for people who have depression or anxiety.
However, now it's also offered as a first line treatment for people who have "hyperchondriosis", IBS, mecfs, and any other "medically unexplained symptoms" or MUS. As anyone who has ever had a slightly unusual condition such as endometriosis or lupus can tell you, it can take years of seeing doctors and specialists to finally get diagnosed. Until that time of diagnosis, if you are a person who goes to see your doctor and complains of abdominal pain, unusual fatigue or other "non-specific symptoms", you now officially have MUS and your treatment is now cbt to gaslight you that none of it is real and you aren't actually feeling anything unusual. It's barbaric.
There was an interesting article published last year that goes into some detail about the problems with this approach.
posted by mosessis at 3:42 AM on November 15, 2021 [12 favorites]
There's a programme in the nhs called IAPT which is meant to be an easy way for people to access talking therapy. It's cbt offered mostly by phone or in groups and now they're looking at doing it by app. It was originally designed for people who have depression or anxiety.
However, now it's also offered as a first line treatment for people who have "hyperchondriosis", IBS, mecfs, and any other "medically unexplained symptoms" or MUS. As anyone who has ever had a slightly unusual condition such as endometriosis or lupus can tell you, it can take years of seeing doctors and specialists to finally get diagnosed. Until that time of diagnosis, if you are a person who goes to see your doctor and complains of abdominal pain, unusual fatigue or other "non-specific symptoms", you now officially have MUS and your treatment is now cbt to gaslight you that none of it is real and you aren't actually feeling anything unusual. It's barbaric.
There was an interesting article published last year that goes into some detail about the problems with this approach.
posted by mosessis at 3:42 AM on November 15, 2021 [12 favorites]
the hairdryer incident exemplifies exactly how this is not the case for CBT (and psychotherapy as a field) today
That's a wonderful story, almost archetypal, to the extent that if it were anybody but Scott Alexander telling it in order to buttress a larger point and hairdryers being specifically mentioned in the ADAA fact sheet on OCD, I might even think it was true.
In particular, the part where a bunch of highly qualified psych doctors dump buckets of condescension on the "just take it with you" intervention is very truthy. Human brains are the weirdest structures on the planet, and psychiatry remains a field where even the genuine experts are still mostly telling Just So stories about how what works actually does.
posted by flabdablet at 3:44 AM on November 15, 2021 [2 favorites]
That's a wonderful story, almost archetypal, to the extent that if it were anybody but Scott Alexander telling it in order to buttress a larger point and hairdryers being specifically mentioned in the ADAA fact sheet on OCD, I might even think it was true.
In particular, the part where a bunch of highly qualified psych doctors dump buckets of condescension on the "just take it with you" intervention is very truthy. Human brains are the weirdest structures on the planet, and psychiatry remains a field where even the genuine experts are still mostly telling Just So stories about how what works actually does.
posted by flabdablet at 3:44 AM on November 15, 2021 [2 favorites]
if you are a person who goes to see your doctor and complains of abdominal pain, unusual fatigue or other "non-specific symptoms", you now officially have MUS and your treatment is now cbt to gaslight you that none of it is real and you aren't actually feeling anything unusual. It's barbaric.
When all you have is a CBT hammer, everything looks like a nail. Except that in this case the splaining tends to be not so much along the lines of "You know, if we could just get that out of there" as "you know, if we just drove that all the way in, it wouldn't snag your sweaters any more."
posted by flabdablet at 4:34 AM on November 15, 2021 [2 favorites]
When all you have is a CBT hammer, everything looks like a nail. Except that in this case the splaining tends to be not so much along the lines of "You know, if we could just get that out of there" as "you know, if we just drove that all the way in, it wouldn't snag your sweaters any more."
posted by flabdablet at 4:34 AM on November 15, 2021 [2 favorites]
Human brains are the weirdest structures on the planet, and psychiatry remains a field where even the genuine experts are still mostly telling Just So stories about how what works actually does.
My point is not about whether that specific incident is literally true but how it illustrates the predominant attitude in the field which is absolutely present. My favorite question to ask in every therapy class was, “If someone has a phobia of flying, but simply decides not to fly anywhere, does it need to be treated?” The answer was always yes. People fell over themselves to explain how this was illogical and wrong and needed to be fixed even if it caused the client no distress except when on a plane (which they simply would not get on). This was especially true in my CBT classes. The client does not get to decide what is helpful and what is unhelpful; that power resides with the therapist. I have personally witnessed many Hairdryer Incidents, though my examples would be less dramatic. I don’t care whether this literally happened exactly as said—a short story can still exemplify the issue I’m speaking about, which is a phenomenon any disability or neurodiversity focused therapist can tell you about.
posted by brook horse at 5:46 AM on November 15, 2021 [11 favorites]
My point is not about whether that specific incident is literally true but how it illustrates the predominant attitude in the field which is absolutely present. My favorite question to ask in every therapy class was, “If someone has a phobia of flying, but simply decides not to fly anywhere, does it need to be treated?” The answer was always yes. People fell over themselves to explain how this was illogical and wrong and needed to be fixed even if it caused the client no distress except when on a plane (which they simply would not get on). This was especially true in my CBT classes. The client does not get to decide what is helpful and what is unhelpful; that power resides with the therapist. I have personally witnessed many Hairdryer Incidents, though my examples would be less dramatic. I don’t care whether this literally happened exactly as said—a short story can still exemplify the issue I’m speaking about, which is a phenomenon any disability or neurodiversity focused therapist can tell you about.
posted by brook horse at 5:46 AM on November 15, 2021 [11 favorites]
If your takeaway is “this is too pat” that’s true but doesn’t mean doctors don’t act like this all the time. It is rarely Just So but it doesn’t need to be to be present and harmful. Like this is literally the whole field of autism treatment basically. “Little Anna cries and screams when we do this.” “Maybe don’t do that?” “No no no, we just need to use rewards to stop her screaming.”
posted by brook horse at 5:57 AM on November 15, 2021 [6 favorites]
posted by brook horse at 5:57 AM on November 15, 2021 [6 favorites]
doesn’t mean doctors don’t act like this all the time
Quite so. It's truthy to the point of being absolutely plausibly true, which is what makes it such a great story. Crystallizes the issue perfectly.
posted by flabdablet at 6:03 AM on November 15, 2021
Quite so. It's truthy to the point of being absolutely plausibly true, which is what makes it such a great story. Crystallizes the issue perfectly.
posted by flabdablet at 6:03 AM on November 15, 2021
Ok. I am too autistic and it is too early for me to parse this interaction properly lol. Good vibes to you.
posted by brook horse at 6:04 AM on November 15, 2021 [2 favorites]
posted by brook horse at 6:04 AM on November 15, 2021 [2 favorites]
The closest I've ever felt to being hazed by a therapist was by one practicing CBT. I was there for chronic depression and because I had friends and the internet and a GP telling me it worked, I gave it a shot and ended up on a very, very dark end of the street psychologically speaking.
A couple of years ago, a different (young, male) GP suggested my stomach issues were some combination of IBS and nerves/anxiety/stress about being an overweight single woman turning 40 and repeatedly tried to get me to "get more exercise" (when I was actually training for a half-marathon)) and reconsider CBT and meditation as treatment. And he (and the rest of his practice) was so convinced of this, he never bothered to order any x-rays, ultransounds etc. So he never noticed the Gall Bladder until I ended up in the ED having it out, or the diverticulitus until I ended up back in the hospital a year later or that the reason I wasn't getting better from the Diverticulitis on the other end of the hospital stay was hospital-caught C. Diff.
Suffice to say, I have a different GP.
I know CBT works for some people and some things. But it often feels like the laziest prescription for patients doctors don't like/don't trust/don't have time for.
posted by thivaia at 8:00 AM on November 15, 2021 [10 favorites]
A couple of years ago, a different (young, male) GP suggested my stomach issues were some combination of IBS and nerves/anxiety/stress about being an overweight single woman turning 40 and repeatedly tried to get me to "get more exercise" (when I was actually training for a half-marathon)) and reconsider CBT and meditation as treatment. And he (and the rest of his practice) was so convinced of this, he never bothered to order any x-rays, ultransounds etc. So he never noticed the Gall Bladder until I ended up in the ED having it out, or the diverticulitus until I ended up back in the hospital a year later or that the reason I wasn't getting better from the Diverticulitis on the other end of the hospital stay was hospital-caught C. Diff.
Suffice to say, I have a different GP.
I know CBT works for some people and some things. But it often feels like the laziest prescription for patients doctors don't like/don't trust/don't have time for.
posted by thivaia at 8:00 AM on November 15, 2021 [10 favorites]
I thought this was about CBD, which I have found helpful for minor aches and pains. Phew!
posted by clark at 3:11 PM on November 15, 2021
posted by clark at 3:11 PM on November 15, 2021
If your whole program is based on convincing people that their thoughts about their disability are incorrect or that they can overcome their disability by thinking positively and then you ask people who recently completed your program if they feel less disabled, you're much more likely to be measuring how successful your program is at changing thoughts than how successful it is at actually improving disability. Just thinking you're better without any underlying improvement is likely to be pretty short lived and not particularly helpful. And of course, there is no blinding or placebo treatment in these trials, leading to obvious bias. There are unfortunately a lot of doctors and scientists who are very dedicated to CBT and can't seem to understand these very obvious shortcomings of such studies. Some people may be helped to reduce their distress through CBT, but these trials are fundamentally flawed such that it would be hard to say one way or another.
posted by ssg
This kind of flawed methodology doesn't answer whether the patients are actually better, or are just reporting that they are better. It fails to answer the key questions of causation and causal direction.
––––––––
There's a programme in the nhs called IAPT which is meant to be an easy way for people to access talking therapy. It's cbt offered mostly by phone or in groups and now they're looking at doing it by app. It was originally designed for people who have depression or anxiety.
However, now it's also offered as a first line treatment for people who have "hyperchondriosis", IBS, mecfs, and any other "medically unexplained symptoms" or MUS. As anyone who has ever had a slightly unusual condition such as endometriosis or lupus can tell you, it can take years of seeing doctors and specialists to finally get diagnosed. Until that time of diagnosis, if you are a person who goes to see your doctor and complains of abdominal pain, unusual fatigue or other "non-specific symptoms", you now officially have MUS and your treatment is now cbt to gaslight you that none of it is real and you aren't actually feeling anything unusual. It's barbaric.
posted by mosessis
Watch out for FND (Functional Neurological Disorder). That is the official or preferred label now, I think. The journals are filling up with Just So stories using this label. It is a flood of methodologically bankrupt shit, and the rest of medicine need to wake the fuck up to what is happening here and the consequences if it is not stopped.
posted by Pouteria at 12:02 AM on November 16, 2021 [3 favorites]
posted by ssg
This kind of flawed methodology doesn't answer whether the patients are actually better, or are just reporting that they are better. It fails to answer the key questions of causation and causal direction.
––––––––
There's a programme in the nhs called IAPT which is meant to be an easy way for people to access talking therapy. It's cbt offered mostly by phone or in groups and now they're looking at doing it by app. It was originally designed for people who have depression or anxiety.
However, now it's also offered as a first line treatment for people who have "hyperchondriosis", IBS, mecfs, and any other "medically unexplained symptoms" or MUS. As anyone who has ever had a slightly unusual condition such as endometriosis or lupus can tell you, it can take years of seeing doctors and specialists to finally get diagnosed. Until that time of diagnosis, if you are a person who goes to see your doctor and complains of abdominal pain, unusual fatigue or other "non-specific symptoms", you now officially have MUS and your treatment is now cbt to gaslight you that none of it is real and you aren't actually feeling anything unusual. It's barbaric.
posted by mosessis
Watch out for FND (Functional Neurological Disorder). That is the official or preferred label now, I think. The journals are filling up with Just So stories using this label. It is a flood of methodologically bankrupt shit, and the rest of medicine need to wake the fuck up to what is happening here and the consequences if it is not stopped.
posted by Pouteria at 12:02 AM on November 16, 2021 [3 favorites]
I think we are going to see long Covid become a huge battleground between patients and those in the medical establishment who think anything they don't immediately understand must be psychosomatic.
There are many millions of people worldwide who have long-term symptoms after Covid infection. Already, I've seen all kinds of noise from doctors, scientists and the general public about how those people aren't really sick, it's all in their heads, they'll be helped by CBT and graded exercise therapy, and so on. But long Covid is clearly very real. We don't really know how common it is, how long it typically lasts or what the long-term prognosis is, but there are clearly a very significant number of people who have been sick for a long time.
I think we'll either see a big change once the scale of the problem becomes apparent and the medical system can't just dismiss these people anymore or we'll see a concerted effort to discredit patients' own experiences beyond what we've seen before and millions of people being left potentially disabled and ignored.
posted by ssg at 11:53 AM on November 16, 2021 [4 favorites]
There are many millions of people worldwide who have long-term symptoms after Covid infection. Already, I've seen all kinds of noise from doctors, scientists and the general public about how those people aren't really sick, it's all in their heads, they'll be helped by CBT and graded exercise therapy, and so on. But long Covid is clearly very real. We don't really know how common it is, how long it typically lasts or what the long-term prognosis is, but there are clearly a very significant number of people who have been sick for a long time.
I think we'll either see a big change once the scale of the problem becomes apparent and the medical system can't just dismiss these people anymore or we'll see a concerted effort to discredit patients' own experiences beyond what we've seen before and millions of people being left potentially disabled and ignored.
posted by ssg at 11:53 AM on November 16, 2021 [4 favorites]
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Thanks for posting this, I'm glad I read it. I had an undiagnosed condition for a few years that really took a lot out of my life and was continually frustrating. She sounds like an amazing advocate both for herself and others. Weird NYT editorial stuff going on there, apparently.
posted by hippybear at 12:55 PM on November 13, 2021 [1 favorite]