A commenter at Marginal Revolutions touts his or her status as an expert on talk therapy and then writes this:
The first thing is that talk therapy is in general not effective for most people. And I know the paper under examination showed that it’s more effective than antidepressants, but in general, most people do not generally stick with talk therapy. They get a benefit at a reasonably low rate for a reasonably short period of time…
Moreover, there’s some pretty strong evidence that talk therapy or at least CBT [cognitive behavioral therapy] is becoming less effective over time – the effect sizes in studies & meta-analyses are going down. And there could be reasons for that that aren’t an indictment of the therapeutic model.
So for example, the modern world could just be becoming more stressful and the therapy is less equipped for it… It could be that as the treatment becomes more popular, rather than the more advanced or cutting-edge therapists using it, it’s used by an increasingly broad set of therapists that include low-skilled or ineffective ones.
So there are a lot of reasons that may not have to do with the merits of CBT as an approach, but the data are reasonably convincing on that front.
I think a lot of people are making a reasonably rational choice that, especially if they’re not going to stick with it for a long period of time, even starting therapy is a low-value proposition.
George Ainslie (the psychologist) has this kind of notion of playing a prisoner’s dilemma with your [future] self… let’s just say I want to start an exercise habit… there are a lot of parallels with exercise and talk therapy.
If I knew for a fact that I was going to stop doing it after one month, it actually doesn’t make sense to start at all. Right, because the benefits of accrued will pretty rapidly deteriorate and it’ll be as if I never did it…
People are not just considering, “Should I try talk therapy?”, they’re considering, “Will I do this for a sufficiently long period of time, or especially can I afford it for a long period of time, to where I will get and maintain the benefits from doing it?”
And many people do in fact have misinformation about how quickly they can experience certain types of benefits, and how much work is involved – it’s clear that there’s a lot of work involved, and many people don’t want to do that work.
From an operant conditioning standpoint, the experience of a therapy session is frankly more punishing than it is rewarding (for many people, a lot of the time). Like any negative stimulus, they’re going to engage in behaviors that cause that stimulus to be experienced at a lower rate.
Sometimes the benefits don’t accrue during the session, they accrue afterwards. It takes a lot of work to experience them and [can] involve emotional trauma to even retrieve them.
It’s not consistent with people’s ROI [return on investment] calculation, or what they would like to see in their ROI calculation. Again, it’s really similar to physical exercise – we know physical exercise works. It works better than antidepressants. It accrues all the benefits that this paper Cowen cited discovered in terms of energy and mood and earnings and so on and so forth.
But people still don’t engage in exercise, and in fact I think the rate of physical activity is actually on the decline, in the industrialized world at least.So, it’s more complex than “Does the behavior accrue benefits if you do it consistently?” It’s also not entirely about access because many forms of physical activity are free, and as the paper examines the seeking of talk therapy is not super sensitive to [price].
So it goes beyond the mere cost of the service, although the cost of the services is definitely prohibitive for a large cross-section of people.
My experience from watching friends and relations is that talk therapy helps some people sometimes, but I know only one person who seems to have been changed in an important way by it and I have seen at least one case it which it clearly made the patient worse. This matches the data as I understand it, which is all over the place.
The history of Cognitive Behavioral Therapy fascinates me. Twenty years ago there were a bunch of what looked like really good, robust studies showing that it worked better than either other therapeutic techniques or drugs, but studies being done now do not find this to be so. Scott Alexander once speculated that maybe this was because the ideas behind it were novel, so 20 years ago they were genuinely new to patients, but now many people have encountered them in a basic way so most of whatever positive effect they might have is already diffused across society.
As I think my readers know, I regard mental health as the most serious challenge facing humanity in our time. I feel this way because I despair about all the ways we try to help people – we have nothing, so far as I can see, that changes the reality that it totally sucks to be crazy or depressed.