Cognitive-Behavioral Therapy Declining
Jul. 12th, 2015 05:37 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
ysabetwordsmithThis article talks about the declining effects of cognitive-behavioral therapy. I am fascinated to explore why something that used to work pretty well is now not working as well.
I can think of some possibilities not mentioned in the article:
1) The longer a therapy is around, the wider it is known. That means more people have access to it before official therapy. You can go online and find CBT theory, techniques, thought distortions and how to fix them, worksheets, and other tools. This raises the chance that someone already knows CBT and has tried at least some of its methods before seeking professional help. So if the therapist then does more CBT, it looks less effective measured from the start of therapy, because the client already did some of that stuff and got whatever benefit they got from it earlier. In this case, CBT only has a high rate of helpfulness for people who really need guidance and/or advanced techniques that don't work well alone.
2) CBT is terrific at treating certain types of problems, but mediocre or useless for others. If you have bad tape, this is a go-to therapy for fixing that, and you should definitely try it. Same with any other logical or practical problem. It's also ideal for people who do better with facts, logic, numbers, or other objective things than with subjective things. But if you are feeling unheard, your emotions are bent, unacknowledged memories are gumming up your subconscious, or your biochemistry is out of whack, then CBT is not ideal for those problems and won't help much. It is possible that certain types of problem are more or less common in different decades. If the problems presenting now are something other than logical/practical ones, this therapy will seem less useful overall.
Bottom line: If you have head problems that you need help with, start by identifying them as best you can. Then look at the available options for treatment. Each type of treatment is good at some things and bad at others. Pick one that's a good match for your problem(s). Try it for a while. If it doesn't help, drop it and try something else.
I can think of some possibilities not mentioned in the article:
1) The longer a therapy is around, the wider it is known. That means more people have access to it before official therapy. You can go online and find CBT theory, techniques, thought distortions and how to fix them, worksheets, and other tools. This raises the chance that someone already knows CBT and has tried at least some of its methods before seeking professional help. So if the therapist then does more CBT, it looks less effective measured from the start of therapy, because the client already did some of that stuff and got whatever benefit they got from it earlier. In this case, CBT only has a high rate of helpfulness for people who really need guidance and/or advanced techniques that don't work well alone.
2) CBT is terrific at treating certain types of problems, but mediocre or useless for others. If you have bad tape, this is a go-to therapy for fixing that, and you should definitely try it. Same with any other logical or practical problem. It's also ideal for people who do better with facts, logic, numbers, or other objective things than with subjective things. But if you are feeling unheard, your emotions are bent, unacknowledged memories are gumming up your subconscious, or your biochemistry is out of whack, then CBT is not ideal for those problems and won't help much. It is possible that certain types of problem are more or less common in different decades. If the problems presenting now are something other than logical/practical ones, this therapy will seem less useful overall.
Bottom line: If you have head problems that you need help with, start by identifying them as best you can. Then look at the available options for treatment. Each type of treatment is good at some things and bad at others. Pick one that's a good match for your problem(s). Try it for a while. If it doesn't help, drop it and try something else.
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(no subject)
Date: 2015-07-13 08:42 am (UTC)Because if that information is floating about somewhere, well we'd have some of the answer on if cbt is waning in effectiveness as that article suggests.
And as an aside... grumbles... I'm not too sure if their assumption about people having no drive to change is really appropriate for a site talking about therapy. That statement, as well as the sparsity of data/facts in the whole makes me inclined to take the lot with a spoonful of salt.
Thoughts
Date: 2015-07-13 08:51 am (UTC)There don't seem to be universal standards. Based on my observations, some so-called therapists are doing a really half-assed job. I suspect that higher quality individuals and organizations may set a standard for asking what clients have already tried. But I have repeatedly heard from people whose therapists have a set routine they go through, and will not permit any deviations, even if people have already tried the same things and that didn't work. Objections are met with nonsense like, "You have to want to get better. I can't help you if you won't do the work."
>>Because if that information is floating about somewhere, well we'd have some of the answer on if cbt is waning in effectiveness as that article suggests.<<
That would be useful, yes.
>> And as an aside... grumbles... I'm not too sure if their assumption about people having no drive to change is really appropriate for a site talking about therapy. That statement, as well as the sparsity of data/facts in the whole makes me inclined to take the lot with a spoonful of salt.<<
Fair point. It is true that some people have no drive to change. However, those people show up in therapy only if forced or pressured by someone else. They don't seek it out. Telling people in therapy that they don't want to change, and/or that it's their fault if the therapy isn't helping, is common but very cruel.
(no subject)
Date: 2015-07-13 01:54 pm (UTC)The discussion about a lack of drive for change is at least attributed to a particular (historical) individual rather than given by the authors as something they believe in. I don't think the article is endorsing that perspective, personally. That said, the article is about as good as science reporting gets these days, which is to say that it's pretty unimpressive but at least doesn't get obvious facts wrong like the actual topic of the study. It does link to the study itself, which means that if you can get through the technical terms, you can decide exactly what the study is saying yourself.
My guess is that there are a lot of factors at play. One of those is that the kinds of people who end up as part of mental health studies are often people whose treatment isn't going well. Early CBT studies would have been deployed in an environment where no one had already had CBT treatment. More recent studies would be done among patients who had already had CBT and had it fail on them--so of course it wouldn't work this time around either. (This is sort of a variant of the cultural exposure hypothesis.)
(no subject)
Date: 2015-07-13 01:13 pm (UTC)I also think back in the 80s and 90s, it was less okay for people to seek out therapists for things like PTSD, dissociative disorders, schizotypal disorders and other types of disorders. Or alternatively, I wonder if there was a higher institutionalisation rate for people with those disorders than there is now (it's harder for people to get inpatient treatment these days because the cost of outpatient therapy is cheaper - at least in Australia - than it is for inpatient therapy).
But...CBT was always useless for me. It felt like...a bandaid at best. And a crude tool at worst. As a logical person, I actually loathed it, because I couldn't see the logic in 'lying to myself to make myself better' given that self-deception was the reason I had such bad self-hatred issues in the first place (a conundrum and a paradox, and one easily solved by bypassing the cerebral cortex and getting down into deeper areas of the brain first).
I also think our media as osmotically absorbed so much of CBT into its own sort of character development arcs. There are so many shows that have characters see therapists, or talk to one another and bring up things like 'it's okay to cry / it's okay to get angry / this self-maligning that you do, it's not healthy, have you tried doing this.' People are exposed to CBT and other therapeutic techniques not just through self-research or the medical world anymore, but very much in the cinema, especially through blockbusters like Good Will Hunting (it's not necessarily accurate therapy, but its popularity does suggest that the world was ready to start 'hearing' more therapeutic techniques en masse some time ago). (My favourite unit at university was Psychology, Psychoanalysis and Cinema and I did that in the late 90s and it's still very relevant).
And also like you say, I do wonder if the tools for measuring its effectiveness needs to be titrated for a more therapy-aware society.
I guess as well, there are so many people who go into get a clin. psych degree who really should not be therapists. I've met clinical psychologists - while I was at university - who were abusive, who were manipulative, who were like 'oh I can handle those crazies but not *those* crazies.' I'm talking upwards of fifteen students in their second year, who were all really fucking unsuited to doing the degree, and were literally doing it because they a) wanted the paycheck and b) in some cases believed that they could literally fix anyone.
I don't actually really love the curriculums taught to clinical psychologists in Australia. And I've never had much success with them because the first stick they try to hit you with - usually clumsily - is the CBT stick. Followed by vague or specific guilt-tripping that 'it's not working because YOU'RE resistant.' (Bullshit).
So...
So it doesn't surprise me that the actual data says experienced psychologists yield better results than inexperienced. They're more likely to have done additional courses and education and learned more techniques. They have an idea of what works. And perhaps they're the ones that actually genuinely *can* help people, as opposed to the many who just want the paycheck and enjoy the grandeur of thinking they can fix everyone while getting rich.
If I sound cynical about clinical psychologists and therapists and CBT it's because I've seen 19 of them since 1997, and only started doing well with any of them about 6 years ago. I've been emotionally abused by two therapists - one worked in the school system and wanted me to be her surrogate daughter, the other was a clinical psychologist who started off with good boundaries and ended up talking about swingers parties (edit: with a view to using this as evidence that she could 'fix' my touch phobia by wink wink nudge nudge).
Eh so my general thoughts on the industry right now is that I am really not surprised that things don't seem to be going so great, now that the industry has exploded, and there's a lot of mediocrity going around amongst a more therapy-savvy audience who need more in depth assistance and support.
(no subject)
Date: 2015-07-13 02:06 pm (UTC)It's really frustrating.
(no subject)
Date: 2015-07-13 02:17 pm (UTC)Oh yeah, I'm in complete agreement about the importance of the rapport between patient and therapist. Unfortunately, for most of my 'needing therapy' life, I've been locked into Australian welfare schemes where I was often limited to one or two therapists who were underpaid and not very excited about doing their jobs. I couldn't 'shop around.' (I tend to find that posts on Tumblr for example that suggest doing this, are very unaware of financial privilege and how that impacts a person's ability to do this in certain countries - especially Australia, where copays and so on aren't really a thing). When I quit out of seeing clin. psychs (best decision I ever made - not that I recommend others do what I did there lol) and started looking at psychotherapists who placed particular emphasis on therapeutic rapport, expressive therapies, sand therapy, DBT, parts therapy and a few other things, things got better. I mean, I am in a situation where I can only afford to see a therapist a max of once a month because insurance for mental health in Australia doesn't work like it does in the USA, but at least I can see a good one. And I now maintain that seeing a great therapist once a month is WAY better than seeing a terrible one under a government welfare scheme more often - but not everyone even has the privilege of doing that, and that's the thing - some of those people need access to a range of therapists the most.
I think a lot of people don't really know - as per the mystery you mentioned - that they hire a therapist for a goal, and that they're not entering into some mysterious bond where the therapist authoritatively 'fixes' them and they passively wait for that to happen. I've known people who have been in therapy for some 10+ years look at me in shock when I say 'you know you can fire your therapist if they're not helping you, right?' Who literally have *no idea* they have that kind of agency in the therapeutic relationship while they're in one. That's horrifying. It also means they're not really being supported in believing they do have agency, or that these sorts of things might be being glossed over. Which I think perpetuates that whole 'mystery of therapy' thing - even people *in* therapy, *experienced* as clients, don't know a great deal about the mechanics of termination or looking for the best therapist for them.
There's a lot of frustrating things about I think the system that's in place, the mysteries attached to it (replete with stigma and taboo), and also the myths perpetuated within the industry by some clients and therapists alike (CBT can help everyone / there are quick cures for everything / etc.) It definitely doesn't work like IKEA furniture! Heh. I like the analogy.
Thoughts
Date: 2015-07-14 02:13 am (UTC)American insurance often works the same way, and similar problems are had if you live where there are few therapists in driving distance. It does tremendous damage and makes it harder to fix things later even if competent help becomes available.
>>And I now maintain that seeing a great therapist once a month is WAY better than seeing a terrible one under a government welfare scheme more often - but not everyone even has the privilege of doing that, and that's the thing - some of those people need access to a range of therapists the most.<<
Agreed. Some therapists are worse than useless, so then the problems just get worse and usually the victim is blamed for that. Oh, but they don't want you to commit suicide; you're not allowed to leave until people have gotten all possible use out of you. 0_o
>> I think a lot of people don't really know - as per the mystery you mentioned - that they hire a therapist for a goal, and that they're not entering into some mysterious bond where the therapist authoritatively 'fixes' them and they passively wait for that to happen. <<
That's because a lot of people aren't doing that. If you have a problem and go to a therapist saying "I want you to fix X" or "I need to be able to do Y," then great. Also great if your therapist starts by saying, "First I need to know what is bothering you and what your goals are. Then we will figure out how to get from here to there together." I've written a few of those examples.
But that's not what happens to many people. They are forced into therapy by court, or dragged in by a parent or spouse, and TOLD a goal -- usually with threats if they fail to perform as demanded. That's not therapy, it's abuse. But they aren't permitted to run away or to get real help. Sometime it's very obvious abuse, but often it is insidious gaslighting and they go for years without realizing what problems it has caused.
>>I've known people who have been in therapy for some 10+ years look at me in shock when I say 'you know you can fire your therapist if they're not helping you, right?' Who literally have *no idea* they have that kind of agency in the therapeutic relationship while they're in one. That's horrifying.<<
See above re: the use of force. Not everyone has agency, or has their agency respected. And when it's violated early enough, often enough, and the penalties are severe enough for struggling -- many people stop and just lie there while the therapist and others in power basically masturbate on them.
>> There's a lot of frustrating things about I think the system that's in place <<
Agreed. But I think it's good to dump the techniques out in public where people can really see what goes into them, and it's not a black box anymore. You can agree or disagree with facts, but not when they're vague. The more people know, too, the more they can fix problems while still minor and not need a therapist at all. It's like knowing basic first aid, wash injuries so they don't get infected. We need to learn emotional first aid, because most people know bupkis about that.
Also...
Date: 2015-07-13 07:08 pm (UTC)And forced therapy has an abysmally low success rate anyhow. It's less about fixing anything than it is about looking like you're trying to do something.
All of that ties back into your rapport issue.
(no subject)
Date: 2015-07-13 03:21 pm (UTC)I can understand this. The antidote to self-deception for me was truth, truth, more truth - which hurts like blazes but gets the job done. (Is still getting the job done, after the therapeutic relationship was test-suspended and never resumed.)
>>...in some cases believed that they could literally fix anyone. <<
This is becoming a red flag for me: if someone professes this belief, I tend to get very suspicious of them.
Also, IDK because: have not studied this. When you look at therapeutic techniques in media, do they seem to be well-executed? I wonder if people get the belief that fixing a mind is like assembling Ikea furniture from a cardboard-cutout portrayal that doesn't hint at the difficulties one will encounter going in unprepared.
(no subject)
Date: 2015-07-13 03:40 pm (UTC)I can get behind that, but only if it resonates as being the truth. And sometimes unpacking a bad record in one's head that has something like 100 responses to a CBT technique needs more than just words. Which I'm fine with, because eventually the words help too. But thought stopping is not so useful as an initial way to broach an issue for me. It doesn't feel like truth until I know what's going on beneath.
When you look at therapeutic techniques in media, do they seem to be well-executed?
Almost never.
That doesn't mean they're without use, or that they don't have truth to them (someone who sees Good Will Hunting and experiences a kind of resonance and validity and then goes and seeks out a therapist - like, it's not well-executed therapy, but it's done a good thing), it's just that portraying therapists with ridiculously bad boundaries is somewhat the norm. There's been a decent use of a therapist with Olivia Benson towards the end of Law & Order: SVU, and otherwise... like for example, the western version of In Treatment is both a really good show, about a therapist with miserable boundaries who tries his hardest. He sees a therapist in turn (a supervisor) who has *terrible* boundaries, and it's not until the last season that you come to see (if you haven't seen it earlier) he is both a) too invested in his clients b) takes their downfalls too personally and c) that his previous supervisor (played by Diane Weiss) was like...not good for him pretty much at all. Even The United States of Tara didn't do so well on a few fronts, while doing well on others. Not enough for me to recommend it based on how they represented therapy though.
But it's a great show, lol. Gabriel Byrne is incredible. It's a well-executed show. But it doesn't shine a very good spotlight on what healthy therapy should be.
Good representations of healthy therapy in television and cinematic media are rare. You're more likely to find it in fanfiction, I think, and I've encountered some stuff which has made me think 'oh yeah, this is real.' Therapy tropes common to media are things like 'the one big cry will help fix everything,' and 'your therapist treating you as more special than their other clients will give you a better chance of recovering' (that's a dangerous thing to transmit in media - though I can tolerate that a bit more in shows like My Mad Fat Diary, which at least make an effort to show a therapist establishing boundaries with a client for their own protection).
It was one of my areas of special interest at university, how media intersected with mental health representation (specifically, trauma recovery - I also hate the way that media tends to represent flashbacks, but that's a whole other thing). I am both drawn to and excited by and disappointed in mental health representation in the fictional media. I think it's good that it's there. I think there's a lot of unhealthy stuff and some shitty tropes. I think it's getting better over time. I think the media's 'general literacy' around mental health is expanding like it is in society overall. It's a complicated area, for sure. But overall - not well-executed, and often poorly researched. And in comedy shows like Episodes (which I love), downright offensive.
Thoughts
Date: 2015-07-14 01:43 am (UTC)Frequently true. Some people need to work with the subconscious, and that's a very different branch.
>> it's just that portraying therapists with ridiculously bad boundaries is somewhat the norm. <<
I don't think that's the norm in practice, although it's common in entertainment. I do think it is a widespread problem that deserves attention.
On the other hoof, panic about boundaries has grossly undermined even the potential for human connections. Minors have almost no privacy left. As a result, the chance that a freaking-out teen with a serious problem will talk about it to TWO adults in an office with the door open approaches zero. So more problems go untreated. With adults, the result is often a therapist so standoffish that the client can't form rapport even if they want to, so only surface work gets done, and therefore little progress is made.
Peer counseling evolved in part because some people can't or won't discuss intimate personal issues without an intimate personal connection. That rarely comes up in nonfiction or fiction, the awareness that there's a whole swath of people completely unserved by the hypervigilant boundaries of the mainstream.
>>Good representations of healthy therapy in television and cinematic media are rare. <<
Sadly so. But when the available therapy options are rarely great, it's probably best not to overrepresent that and raise expectations unreasonably. Sure there are stupendous therapists out there. Your chance of actually obtaining one is based largely on how rich you are and how big a city you live in.
>> It was one of my areas of special interest at university, how media intersected with mental health representation (specifically, trauma recovery <<
... what recovery? I've seen almost exclusively one of two versions: the person is irretrievably broken and the story is about how they destroy everything they touch, or the person blows off severe trauma and keeps going as if nothing is ever wrong. There is no attention paid to people sustaining serious psychological injuries and then slowly recovering from that.
>> I also hate the way that media tends to represent flashbacks, but that's a whole other thing). <<
It's often poor. I think my leading favorites are Arrow and Fury Road. Arrow wins for having two complete storylines woven together, in the way that the past bleeds over the present -- the whole point to PTSD is how the intrusive memories make it impossible to stay in the present. Fury Road wins for having plot impact in terms of Max's flashbacks preventing him from accomplishing some of his goals.
I write PTSD and PDSD based on a wide range of experiences and observations. So the flashbacks and other symptoms (hypervigilance, sleep disturbances, etc.) differ from one character to another. Some are full-sensory flashbacks while others are intrusions of one or two senses, or even emotions.
I am curious about what you hate in media portrayals of flashbacks, what you would change. Have I hit what you're looking for yet? Because if not, the bonus fishbowl just got set with "anything goes" as a theme, so you could ask for whatever you'd like to see in the way of flashbacks or other symptoms done right.
>> But overall - not well-executed, and often poorly researched. <<
Prevailingly true.
I have done a LOT of research into various theories, therapies, and techniques because some of my characters need and get professional help, while a great many more are trying to patch up themselves and each other as best they can. Plus of course Terramagne just has an overall higher awareness of mental health and how to treat mental injuries on the spot so they are less likely to turn into serious problems. In comparison, our level of expertise is like knowing how to splint a broken bone, but not knowing to wash off road rash so it doesn't get infected. 0_o
Some of my renditions are of bad therapy, some good, occasionally both. Cassandra got put through the wringer with suppression therapy to make her superpower go away (which did not work, so her parents used more aggressive methods later) and that makes it hard for her to rely on the much more competent help she finds later.
Re: Thoughts
Date: 2015-07-14 12:13 pm (UTC)Well, as I said in my response, fanfiction normally does a far better job than visual media - so fics like yours and other people's are doing a great job. :)
But as for television/cinema media, I am so fucking tired of jump cuts and juxtaposition where the past memories go through all post-production (desaturation, saturation, filters etc.) to make it very clear to an audience 'OH LOOK AT THIS DISTURBING MEMORY AREN'T YOU DISTURBED TOO'. (I've been informed that Mad Max does a lot of this to disorient, but it's such a damned cliche. Like, yes, it can be effective, and, yes, that's *sometimes* what visual flashbacks are like, but...eh).
It's effective (I remember the resonance I felt the first time I saw the technique back in the late 80s), but it's troped and lazy and cliched and no one tends to push past it in the visual mediums, especially in scriptwriting. It completely ignores things like sensory flashbacks: what about someone experiencing mysterious but serious gut pain for several days that happened to coincide with witnessing a show about stomach surgery, while they themselves have experienced traumatic hospital experiences? Sensory flashbacks are very common, yet hardly acknowledged. Where's a character who talks about phantom pains and goes through years of trying to explore chronic illnesses and many invasive tests only to one day learn that sensory flashbacks with no attending visual flashbacks happen? Ditto auditory and olfactory flashbacks (which are sometimes stronger and more pervasive than visual flashbacks for some people - and yet can be undiagnosed for ages, or misdiagnosed as atypical migraines).
I mean yes it makes sense that visual mediums would lean too heavily on visual flashbacks - it's what the format is for. But you meet someone who has PTSD and knows a bit about their own disorder and still don't understand olfactory/auditory/sensory flashbacks are a thing because it's just about never reflected back to them in mainstream media representations of PTSD (for me, PTSD also encompasses C-PTSD and PDSD there, as well). It's disappointing.
But then, since it's my area of personal interest, I've specifically consumed an awful lot of media based solely on representations on trauma and post-trauma and trauma recovery, so you do end up with a sense of 'same shit different day.' Sometimes it's done better, sometimes it's done worse. If I'm going to write a text including visual flashbacks, I have a rule for myself to include at least one sensory / auditory / olfactory flashback as well.
Anyway, fanfiction is definitely making strides where mainstream visual media is not.
Re: Thoughts
Date: 2015-07-14 08:12 pm (UTC)Yay!
>> But as for television/cinema media, I am so fucking tired of jump cuts and juxtaposition where the past memories go through all post-production (desaturation, saturation, filters etc.) to make it very clear to an audience 'OH LOOK AT THIS DISTURBING MEMORY AREN'T YOU DISTURBED TOO'. (I've been informed that Mad Max does a lot of this to disorient, but it's such a damned cliche.<<
Valid point about how that is overdone.
I think it's interesting to compare examples, though. Arrow makes the flashbacks much flatter and colder, so they feel like derealization to me. Fury Road makes them warped and wavering, like mirages -- and there are audio whispers that sometimes precede the visual distortions. So it's more like depersonalization. Oliver feels like his world is coming apart; Max feels like HE is coming apart.
>> Like, yes, it can be effective, and, yes, that's *sometimes* what visual flashbacks are like, but...eh).<<
What I haven't seen, and I think this would work better in a visual format than print, is the kind of flashback where you can't distinguish the weird memory trip from ordinary experience. That's what makes this type of flashback so dangerous. It's not an instant replay of something you know is a memory. But it's not exactly a hallucination either. It's bleedover from memory into current experience, kind of like when you're dreaming and the phone rings so you dream about a phone ringing -- or an alarm going off.
>> It completely ignores things like sensory flashbacks: what about someone experiencing mysterious but serious gut pain for several days that happened to coincide with witnessing a show about stomach surgery, while they themselves have experienced traumatic hospital experiences? Sensory flashbacks are very common, yet hardly acknowledged. Where's a character who talks about phantom pains and goes through years of trying to explore chronic illnesses and many invasive tests only to one day learn that sensory flashbacks with no attending visual flashbacks happen? <<
That makes sense. I could write that. Nobody really covers body memories -- the only place I've heard them mentioned much is material for sexual abuse survivors. And I've already got a character, the Rescuer, who specializes in helping abused people.
>> Ditto auditory and olfactory flashbacks (which are sometimes stronger and more pervasive than visual flashbacks for some people - and yet can be undiagnosed for ages, or misdiagnosed as atypical migraines). <<
Also true. I have a complete description for a character I haven't introduced yet. Jerryrigger has severe PDSD from kidnapping, mad science torture, and isolation. But she's far more a tactile person than visual. I suspect that her flashbacks are coming through as body memories, smell/taste, and occasionally audio more than visual. Her senses have been heightened, and she has a problem with conventional food now. I doubt that much of it is coherent enough to form complete scenes that play out. Flickers, flashes, jarring little details that keep knocking her off balance. That would be really interesting to write.
Tuesday, July 21 is the "anything goes" fishbowl so either of these would fit there. I'm always up for exploring different sensory portrayals.
>> But you meet someone who has PTSD and knows a bit about their own disorder and still don't understand olfactory/auditory/sensory flashbacks are a thing because it's just about never reflected back to them in mainstream media representations of PTSD <<
Yes, that's a problem. I've had people write to me and ask if stuff I'm describing is real, because they've experienced it but nobody else has written about it.
>> (for me, PTSD also encompasses C-PTSD and PDSD there, as well). It's disappointing. <<
I tend to shorthand the same way. Stress disorders are distinct yet overlapping, kind of like eating disorders.
>> But then, since it's my area of personal interest, I've specifically consumed an awful lot of media based solely on representations on trauma and post-trauma and trauma recovery, so you do end up with a sense of 'same shit different day.' Sometimes it's done better, sometimes it's done worse. <<
I've read a lot about it too, for similar reasons.
>> If I'm going to write a text including visual flashbacks, I have a rule for myself to include at least one sensory / auditory / olfactory flashback as well. <<
I tend to focus on individual characters and try to map out their unique pattern of experience. Because PTSD has a yard-long list of symptoms, but they don't always manifest the same way. Like almost everyone has sleep disorders, of which the most common are nightmares and insomnia. But some people sleep almost all the time, some have night terrors, some can't remember their dreams anymore, etc. So too with intrusive memories. Some are full-immersion flashbacks, many are just sensory fragments, and some are repetitious ideas like abruptly viewing the grocery store as an ambush site and you can't stop comparing it to ones you remember. If I'm doing it right, each character's 'style' of PTSD should be recognizable yet particular to their experiences.
>> Anyway, fanfiction is definitely making strides where mainstream visual media is not. <<
That's good to hear.
Huh, it gives me another idea, though -- fanfic has a lot of podcasting. That would be a natural place to explore audio flashbacks. You could make a separate soundtrack for the flashbacks. To make it coherent, you'd have to bend the physics a little: use a binaural recording so that you could play the flashback into one ear and the 'regular' narrative into the other. Occasionally switch back and forth. If you had the regular narrative playing in stereo most of the time, and switched to a split track during flashbacks, it should be comprehensible but still eerie.
One of the things I found impressive about Mad Max was the way his auditory flashbacks used surround-sound to skitter around the sides and back, not really in front of him like the main dialog. It was the equivalent of seeing something from the corner of your eye, only in sound.
(no subject)
Date: 2015-07-14 07:55 pm (UTC)Fair enough! I had to use words to break through resistance so that I could /get/ to the subconscious stuff - before a good therapist and some serious internal work showed me the way, the words were basically an emergency brake - I had to stop the runaway train so I could go fix the tracks. (That thing about positive affirmations? Yeah, I still can't because they just seem hokey and and they trip the BS-o-meter even if they're factually true.)
It's based on your recommendations that I want to see United States of Tara at all, hah. Your treatment of media absolutely fascinates me.
Given that a lot of people don't read fanfiction or a lot of original fiction (
I like your point below about sensory flashbacks. (Also a serious "oh!" moment on some of those - did not, actually, realize that some of that is a possibility and it explains things. The More You Know.) Since I'm currently working on a gigantic fanfic with several characters who've been rather badly traumatized (literal world-ending events in game got sort of blown off) I'll make notes to myself to include these. Since recovery is a main theme of the fic, it'll fit right in.
Thoughts
Date: 2015-07-15 07:04 am (UTC)That makes sense.
>>(That thing about positive affirmations? Yeah, I still can't because they just seem hokey and and they trip the BS-o-meter even if they're factually true.)<<
Not all techniques work for everyone.
>>Given that a lot of people don't read fanfiction or a lot of original fiction (
I would like to see more good representation also.
>>Since I'm currently working on a gigantic fanfic with several characters who've been rather badly traumatized (literal world-ending events in game got sort of blown off) I'll make notes to myself to include these. Since recovery is a main theme of the fic, it'll fit right in.<<
I hate it when stories completely ignore character trauma.
Thoughts
Date: 2015-07-14 01:56 am (UTC)Very sensible. That also fixes gaslighting.
>>...in some cases believed that they could literally fix anyone.
This is becoming a red flag for me: if someone professes this belief, I tend to get very suspicious of them. <<
Closely related is anyone without a gauge and an exit plan. How will we know if the treatment is helping, having no effect, or actively making matters worse? What are the signs for stopping because it is making matters worse? For stopping when it's done all the good it can? If they don't have that -- especially if they claim you're not allowed to have that because it would make the treatment ineffective -- then run awaaayyy.
>>When you look at therapeutic techniques in media, do they seem to be well-executed? <<
No, most are badly done. Media portrayals show a lot of the mistakes that actual therapists make.
>>I wonder if people get the belief that fixing a mind is like assembling Ikea furniture from a cardboard-cutout portrayal that doesn't hint at the difficulties one will encounter going in unprepared.<<
That's the flip side, where the media will make it seem like therapy is a quick easy fix, when it's not.
I have seen very little portrayal of therapy that was well done and effective. I've written a few myself -- Hadyn and her therapist, for instance, focus on one little piece at a time and that's a great approach for kids. You can't tackle something as big as "My father molested me and my superpower immolated him and our house" all at once. But you can explore something like "I had a birthday and it made me think about growing up and sexuality and I don't know how to feel about that."
Re: Thoughts
Date: 2015-07-14 08:00 pm (UTC)It certainly helps to spot it, and to figure out the extent of the damage before doing other things to fix it. One tool in the toolkit, really.
>>How will we know if the treatment is helping, having no effect, or actively making matters worse?<<
That's a good point! I live in a world of design/test/check/retest and tend to forget that not everyone does, and particularly in the wild and hairy world of mental injury and illness, not having this sort of a pattern in effect seems like a good way to run right off a cliff.
>>Media portrayals show a lot of the mistakes that actual therapists make. <<
..which can be useful as an anti-pattern but is a disaster when trying to assess when one needs help, and what kind, and to what extent. Gah.
Your stuff is pretty awesome. Honestly? Came for the Avengers, stayed for the good representations of mental harm and recovery.
This is incidental to this conversation, but I owe you thanks: I took training last week for my company's emergency handling plans, and am adding EFA to my study list in earnest, largely because of your writing.
Re: Thoughts
Date: 2015-07-15 05:54 am (UTC)If I didn't keep that process snugly in hand, I'd be dead by now. My body and mind are too far from the bell curve to take anything for granted. Everything new is effectively an untested experiment. My whole frigging life is a science experiment.
>>...which can be useful as an anti-pattern but is a disaster when trying to assess when one needs help, and what kind, and to what extent. Gah. <<
Yeah, that has its ups and downs. I have tried to portray at least a few good examples of therapy, but honestly, a majority of stories I hear are bad.
>> Your stuff is pretty awesome. Honestly? Came for the Avengers, stayed for the good representations of mental harm and recovery. <<
Thank you! That is exactly what I hope to accomplish with the fanfic, attracting new readers.
>> This is incidental to this conversation, but I owe you thanks: I took training last week for my company's emergency handling plans, and am adding EFA to my study list in earnest, largely because of your writing. <<
:D I am so delighted that I managed to turn you onto that. Yay, patch import!
This is my favorite handbook:
http://www.bluedolphinpublishing.com/firstaid.htm
There is not a lot of EFA in this world yet, but there are a few books and courses on it.
Re: Thoughts
Date: 2015-07-16 10:40 pm (UTC)Sympathies - that's a rough spot to be in. I'm not quite that far from the bell curve, but it's enough to make supposedly-mundane things nontrivial a pretty good chunk of the time. (If you ever want to rant about this, I'm open to it.)
>>This is my favorite handbook:<<
I've purchased a copy. :)
Re: Thoughts
Date: 2015-07-16 10:49 pm (UTC)*hugs* Thanks.
>> I've purchased a copy. :) <<
Yay! I haven't found a good advanced volume yet, but that one is awesome beginner-to-intermediate stuff that covers all the everyday basics. I'm glad I could turn you onto it.
Thoughts
Date: 2015-07-13 08:38 pm (UTC)Consider also that there have been changes in some societies that break more people. Frex, in America, the military more often deploys people on multiple tours of duty, which makes PTSD skyrocket -- really it's PDSD then, in many cases, chronic rather than acute exposure doing the damage. Another thing we've lost is employment stability. Jobs are very precarious now, which makes people variously anxious or depressed. Those are natural responses to unnatural situations. And kids, we used to have large extended families that were pretty stable, but now that's mostly gone too. So there is less of a support network all around, and that does damage. Those broken people wash up in therapy, not just with mental illnesses, but with mental injuries which may require different handling.
>> Or alternatively, I wonder if there was a higher institutionalisation rate for people with those disorders than there is now (it's harder for people to get inpatient treatment these days because the cost of outpatient therapy is cheaper - at least in Australia - than it is for inpatient therapy). <<
Definitely true. America closed almost all of its facilities and has switched to housing the mentally ill in prisons. Or just murdering them.
>>As a logical person, I actually loathed it, because I couldn't see the logic in 'lying to myself to make myself better' given that self-deception was the reason I had such bad self-hatred issues in the first place <<
Lying to yourself never works. That's what makes certain things like positive affirmations challenging to apply. They do work, but you have to figure out something which is both plausible and useful to say to yourself. There isn't always something like that you can find.
An issue with CBT is that it assumes all the negative things in your head are wrong. That's not always accurate. If you are surrounded by people who hate you, then saying "Oh, they don't really hate me, that's an exaggeration" will just get you hurt.
>> There are so many shows that have characters see therapists, or talk to one another and bring up things like 'it's okay to cry / it's okay to get angry / this self-maligning that you do, it's not healthy, have you tried doing this.' <<
Things like that are ... partially true. A huge part of the problem is bait-and-switch where people are told that it's okay to do or feel things, then punished when they try it. People are far more willing to say "It's okay to cry" than to sit with a crying friend. They want to make the crying stop, not facilitate expression of emotions. The latter is something that certain therapies are good for -- but CBT isn't one of them. It's about thoughts and actions far more than feelings. People are also told to "get help" and that they're bad for not doing so or for resisting unhelpful services -- but there is little to no protection for those who go through with it. That can absolutely cost you your job, home, family, etc. So of course people resist, because the stakes are extremely high and the pay off dubious.
>> I guess as well, there are so many people who go into get a clin. psych degree who really should not be therapists. <<
Absolutely.
>>I've met clinical psychologists - while I was at university - who were abusive, who were manipulative, who were like 'oh I can handle those crazies but not *those* crazies.' I'm talking upwards of fifteen students in their second year, who were all really fucking unsuited to doing the degree, and were literally doing it because they a) wanted the paycheck and b) in some cases believed that they could literally fix anyone.<<
At one point, we had a magical student who was also studying counselor stuff at a local college. So we got invited to the graduation ceremony. ZOMGWTFBBQ. About a third of the entire population of that room was untrained empaths. The number of trained empaths was: myself, my partner, our two students, and one teacher. Suddenly all the stories about people crying in class made a lot more sense. 0_o It was a fucking disaster.
No wonder I spend so much time cleaning up after this profession.
>>If I sound cynical about clinical psychologists and therapists and CBT it's because I've seen 19 of them since 1997, and only started doing well with any of them about 6 years ago.<<
Alas, I have heard many such stories. There are some good counselors, but there seem to be far more mediocre or terrible ones.
Re: Thoughts
Date: 2015-07-14 07:11 am (UTC)Re: Thoughts
Date: 2015-07-14 07:29 am (UTC)Some people have more. They can feel other people's emotions, like feeling heat from a fire; and if they're not careful, take on those emotions themselves. Some can influence other people's emotions by projecting their own feelings.
Well, it takes practice to learn how to manage those perceptions, distinguish other people's feelings from your own, and use the abilities to your advantage instead of getting run over by them. There are ways to shield out external emotions and keep yours on an even keel. It is a lot easier to learn this stuff if you have someone to teach you. Without that, empathy is one of the abilities that can turn into a life-wrecking disaster.
Empaths are often very compassionate people, drawn to the caring professions. In a culture that does not routinely teach how to handle empathy, the result of this can be ... a room full of psych students and their families and the damned faculty too all bawling their eyes out because nobody has the emotional regulation skill to handle the heterodyne effect of cramming that many empaths into a theatre room. 0_o
Re: Thoughts
Date: 2015-07-22 12:14 am (UTC)Re: Thoughts
Date: 2015-07-14 12:46 pm (UTC)True, though the rates of PTSD (and complex forms of PTSD) still remains staggeringly high amongst those experiencing abuse at home (children more than adults, and adult rape and domestic violence survivors more than the military).
Media awareness of PTSD tends to skyrocket in tandem with the military, because the media validates (as much as the government doesn't want to) military PTSD (which happens globally in lower incidents when compared to incidents of PTSD in home abuse situations) likely due to connections to the patriarchy vs. validating incidents of PTSD in the home environment. Since they are statistically more often caused by men, and that kind of patriarchy is invisibilised, invalidated, and then responsibility to deal with it is more likely to be placed upon the victim.
Shows and fics about military or military-type PTSD tend to have more traction, even though they represent a less common cause for PTSD overall. Complex PTSD is still most commonly caused by systemic long-term child abuse, and *most* of all by long-term systemic child sexual abuse. That will always trump the military in terms of statistics (unless we suddenly come a long way in actually shining a spotlight on domestic child abuse and home abuse and actually manage to reduce it to a point where military personnel do actually get the disorder more often abroad than at home). There's a lot of things to take into account when you look at the cultural visibility of PTSD, and misogyny plays into it a huge amount. Especially into what kinds of people get PTSD and how it's portrayed in an episode or film.
One has to take into account that a media culture is often more willing to validate PTSD in context of war (because a country is often dependent on validating a country going to war in the first place, so PTSD becomes a 'noble injury' or illness, which is also ridiculous when one looks at how countries tend to universally treat their mentally ill war vets - the visual media is pretty confused there, lol).
I mean, considering that to date, more people in the US military get PTSD from being raped or assaulted by their own colleagues, than by witnessing violence or by being hurt by the enemy: how many shows and movies outside of SVU can you count that actually address 'military acquired PTSD caused by troops assaulting another troop?' There's more visual pieces about child abuse related PTSD than there are about that.
So...where the media shines a spotlight is not necessarily where the biggest problems are.
Not really a cohesive reply, I know. Just kind of thinking out loud about how the changes in society that 'break more people' aren't actually always where you think they are. One only need consider the skyrocketing numbers of people getting PTSD from chemo treatment re: cancer, to realise that. After all, it's an issue hardly anyone really knows about, and some people still struggle to realise that repeated chemo treatments can caused complex forms of PTSD.
Re: Thoughts
Date: 2015-07-15 02:57 am (UTC)Also true.
Hrm ... of the sexual abuse survivors I write, the Rescuer and Hadyn have gotten good therapy after the fact. Over in Path of the Paladins, it's rape rather than abuse; Ari has gotten good support, but Gailah has had a rougher time.
I've got a character sheet for one in Polychrome Heroics that hasn't been introduced yet, touching on the issue of rape in the military. Stiletto started out in the Army because they recruited her for her Healing ability, only it turns out she has no real interest in that. When someone raped her bunkmate and the Army refused to do anything about it, Stiletto fragged the rapist and ran off to become an assassin. Where she is much happier, go figure. Not exactly PTSD but some seriously fucked-up shit anyhow.
>> Media awareness of PTSD tends to skyrocket in tandem with the military, because the media validates (as much as the government doesn't want to) military PTSD (which happens globally in lower incidents when compared to incidents of PTSD in home abuse situations) likely due to connections to the patriarchy vs. validating incidents of PTSD in the home environment. <<
I agree. People are far more open to talking about war than about rape.
>> Since they are statistically more often caused by men, and that kind of patriarchy is invisibilised, invalidated, and then responsibility to deal with it is more likely to be placed upon the victim. <<
Also true.
>> Shows and fics about military or military-type PTSD tend to have more traction, even though they represent a less common cause for PTSD overall. Complex PTSD is still most commonly caused by systemic long-term child abuse, and *most* of all by long-term systemic child sexual abuse. <<
Don't forget bullying for children; and abusive bosses, a common cause of PDSD in adults.
>> There's a lot of things to take into account when you look at the cultural visibility of PTSD, and misogyny plays into it a huge amount. Especially into what kinds of people get PTSD and how it's portrayed in an episode or film. <<
Sadly so. And the type of PTSD can influence the type of symptoms: body memories are more common with survivors of sexual or medical abuse, whereas combat veterans have more issues with audio stuff.
>> One has to take into account that a media culture is often more willing to validate PTSD in context of war (because a country is often dependent on validating a country going to war in the first place, <<
That's a good point.
>>so PTSD becomes a 'noble injury' or illness, which is also ridiculous when one looks at how countries tend to universally treat their mentally ill war vets - the visual media is pretty confused there, lol). <<
Much of the system is devoted to denying claims for PTSD so they don't have to pay for it. Obviously that makes the problem worses. They they are upset when veterans commit suicide instead. They don't want to take care of people, but refuse to let them leave: the classic dynamic of an abuser. They try to convince people that it's okay to have PTSD on one hand, but without guaranteeing any protections on the other, so that the stigma and costs remain very high. People are not stupid. They know it's a trap. Once you admit to having a problem then society will flush you down the crapper. These people have been trained to keep putting one foot in front of the other until they drop, so that's exactly what most of them do.
>> I mean, considering that to date, more people in the US military get PTSD from being raped or assaulted by their own colleagues, than by witnessing violence or by being hurt by the enemy: how many shows and movies outside of SVU can you count that actually address 'military acquired PTSD caused by troops assaulting another troop?' There's more visual pieces about child abuse related PTSD than there are about that. <<
Pretty much none that I can think of. Huh, I need to write out that piece about Stiletto and company.
Not to mention the time someone shot up Buraq despite him being marked as a medic, and by the time Rampart went charging over there to deal with it, someone on the enemy side had already fragged the sniper and thrown him over the wall. Most folks in Terramagne take medical neutrality rather more seriously.
>>So...where the media shines a spotlight is not necessarily where the biggest problems are. <<
Sadly so. I'm trying to fill in some gaps.
>> Not really a cohesive reply, I know. Just kind of thinking out loud about how the changes in society that 'break more people' aren't actually always where you think they are. <<
I've spotted some, but others are outside my areas of expertise.
>> One only need consider the skyrocketing numbers of people getting PTSD from chemo treatment re: cancer, to realise that. After all, it's an issue hardly anyone really knows about, and some people still struggle to realise that repeated chemo treatments can caused complex forms of PTSD. <<
PTSD from medical cases is very common, and most people don't realize that. It's especially high surrounding surgery because they like to use mindwipe drugs so people won't remember all the horrible things that happen. Well, once you start messing with human memory like that, it tends to go extremely haywire. And sometimes that can't be fixed. Another factor on the medical side is plain old helplessness. It's bad enough to have your body rebelling, before you get trapped somewhere you have zero power and other people often view you as a nuisance. Helplessness is one of the leading risk factors for PTSD -- people can survive amazingly bad circumstances as long as they feel that they have some influence over what happens to them. That would be the easiest variable to change, but it requires work and money, two things that hospitals do not want to spend extra on patients. And then they wonder why about a third of their serious casualties are having PTSD afterwards.
Effectiveness
Date: 2015-07-15 12:12 am (UTC)For me, setting observable reality against my brainweasels has been somewhat helpful, but I seem to be reaching the end of things it will fix. The trouble is, this entire setup lends itself to an internal argument, so instead of doing things, my brain will start debating the relative merits of the argument in an extremely aggressive, ad hominem manner, and it quickly devolves into telling myself how awful I am. I'm trying to stop that, and just go with "NOPE! NO ARGUING! DOING THINGS NOW!" but it's marginally effective at best. I have a really hard time doing homework, because trying sets off the argument, and it's so much easier not to think about it.
Honestly, a lot of what I get out of therapy is a neutral person who doesn't know anyone else I know and can be honest with me. A lot of the time we end up spending most of the session dealing with immediate problems, which doesn't leave time for more long-term stuff.
Even though I know I can fire my therapist, it's very hard for me to do, because I don't think there's someone better out there, or that I can judge that effectively, and intakes are more expensive than regular sessions. Most of my therapists have been mediocre, but my psych-meds people have mostly been bad. Everyone is just really invested in me being normal and healthy at bottom. Maybe it's because I am, and I think I'm supposed to feel better, but it's mostly disorienting.
It's been theorized that I'm an empath, but if it's true then I've buried it really thoroughly. Of course, I did manage to create shields so strong that they were hurting me, so that's less outside the realm of possibility than it should be, but I'd think that taking down those shields would've also unburied the empathy. But I'm very good at forgetting things.
(no subject)
Date: 2015-07-12 11:19 pm (UTC)Which adds up to the same as possibility 1, but with the cause and effect reversed.