Tuesday, September 1, 2020

Talk Therapy

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.


David said...


Your comment on the article puzzles me, because you seem to be switching the terms of the discussion. It seems to me pretty clear the author is arguing that talk therapy works, yes it does, but only if people put in the work to do it, and most people aren't willing to do that. The author keeps making an analogy to exercise. The author's point is that the problem lies in the people, not the method of treatment. Your comment seems to imply that talk therapy itself is the problem, which is not what the author is saying.

It may simply be that there's not much an outside person can do to help a mentally ill person, absent real initiative and drive from that person. The illness comes from inside, and the person has to WANT to get better from the inside, in a very committed way. Even then, treatment isn't going to "cure" anything. Again, it's like exercising: if you stop exercising, your health will deteriorate. Trying to apply the medical "cure" model to mental illness may simply be misguided. I would say looking for a person to change in a substantial way is also in most cases misguided. You can't expect mental health care to change who a person is.

My own experience, in myself and many family members, is that both psychotropic medications and talk therapy can help immensely. But they can't "cure" a person.

David said...

On the other hand, a recent NYT opinion piece (https://www.nytimes.com/2020/08/28/opinion/sunday/brain-machine-artificial-intelligence.html) discusses new therapies that could effect something like mental health cures. These are experimental implants that can alter, in an increasingly specific and targeted way, the brain's electro-magnetic and chemical activity. The idea is that if a person is, say, prone to anger, the anger-spots in their brain can be interfered with electrically when they start to act up, so as to eliminate the impulse to anger. Experiments seem to indicate the method successfully curbs various undesirable behaviors. The angry person doesn't get so angry, or angry at all. But subjects often report feeling as though they are "no longer themselves." Patience given psychotropic medications often (but not always, it should be acknowledged) report the same unpleasant sensation of not being themselves.

This can suggest scenarios in which we are all alike, all polite but not unctuous, punctual but not brusque, curious but always about the right, productive things, good-humored but not prone to reading XKCD when we should be working, assertive but not aggressive, etc., etc. The idea has obvious dystopian qualities. Managers scrambling to motivate their workers would love it. But imagine an implant that could curb the impulse to believe in conspiracy theories . . .

G. Verloren said...


I'm with you on this. Talk therapy clearly works, but then again so does working out at a gym with a trainer, assuming a) you are both willing and able to stick with it, b) your trainer is actually qualified and knows what they are doing, and c) your training regimen is properly tailored to you as an individual.

The problem chiefly seems to be getting the stars to align, so to speak, and having all the different factors that need to go right, go right.

Talk therapy has an uphill battle compared to medication, because it's so much more involved and is so much more of an investment. Anyone can get in the habit of taking a few seconds to swallow a couple pills once or twice a day, but talk therapy is nowhere near as simple.

1) You have to have the free time to see a therapist. 2) You have to have the motivation to see a therapist. 3) You have to be able to afford to see a therapist. 4) You have to be able to find the right therapist for you...

...5) The right therapist has to have the free time in their schedule to see you. 6) The right therapist has to be physically close enough for you to go see them. 7) You and the right therapist have to be able to match schedules, on top of both having the time to see each other...

...8) You have to do some really serious thinking about deeply confusing and uncomfortable parts of your own mind that your defense mechanisms actually work to prevent you from wanting to do. 9 You then have to try to make sense of all that and come to the proper realizations about it. 10) And you also have to rely on deeply flawed language as your own means of grappling with all that, and your only avenue of receiving guidance from your therapist...

...11) You also need to consistently be able to be in a frame of mind where all of that is not only possible, but also actually productive and resultant in long-term change and progress. Which probably means 12) you need to be on some medication anyway to help rebalance your brain chemistry to make being in that frame of mind in the first place even remotely realistic...

It's a massive world of difference in investment, without a commensurate difference in payoff. Talk therapy is effectively a luxury treatment for people wealthy and stable enough to afford the time, money, and energy, and despite being orders of magnitude more complex and troublesome, it's not proportionally more effective.

It's still useful, and when it works properly it can do some astonishing things and really, genuinely save people's lives... but it's not efficient.

John said...

When it comes to assessing the effectiveness of any medical technique, whether patients can stick with the required regimen is not just a side issue, it is the first thing; a regimen that works but that most patients find unendurable shows up in the literature as a failure, and rightly so. If you starve yourself, you will lose weight; does that mean we just say, "we have the solution to obesity right here?" No, because most people can't or won't.

And I actually dispute whether therapy would work for the people who quit, since they might have quit because they could see it wasn't working for them. In a scientific sense we simply have no data on that question. Even Freud said that analysis was a complete failure with 1/3 of patients.

And I agree with G that finding the right therapist is like getting the stars to align; when we sought out therapy for one of our sons it was a nightmarish struggle to find someone who both took our insurance and was accepting new patients, and when we finally found someone our son hated him and after a couple of sessions refused to go back.

David said...


I think, though, you're proving my original point. You were using a long quote from an author who does not condemn talk therapy as a technique, but who tries to explain why it doesn't work in many cases, to support your own animus.

I would say that the fact that talk therapy works for some people means that it is a valid approach. Lots of therapies for a variety of illnesses don't work in all cases, and yet they are still worth pursuing.

Most people can't or won't diet and lose weight. But does that mean that offering dieting as a solution to obesity is bad? Does that mean that trying it is bad? No. It works in some people, and it's a good thing to start with.