Cognitive-Behavioral Therapy Declining
Jul. 12th, 2015 05:37 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
This 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.
(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.