Private practice is one thing, but treatment outcomes are tracked in CMH settings as well as IP psychiatric settings.

B) Licensure is not all over the place. At a bare minimum, an independent clinician in the US will have several thousand hours of client contact (e.g. group facilitation), a thousand to fifteen hundred hours of 1:1 counselling with clients, a hundred hours of supervision, and have taken two years of graduate level coursework on psychology and psychotherapy, with the curriculum on its way to being standardised nationwide by CACREP.

Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background, and that the perceived therapeutic alliance is the strongest predictor of success.

There are problems with psychotherapy research, but they're mostly those shared with the rest of the sciences.

How do you know someone has really meditated? You don’t. How do you know someone has had a good dance? You kinda don’t know that either.

There is a basis for understanding this from an engineering perspective, and it’s right there in what you just said — that outcomes are not correlated with educational background of the clinician. Sound like programming at all? Programming is also as much art as it is a science.

So therapy is no sure thing. That much, to me, is fine. And that’s the other rub. If you want to get something out of therapy, you’ll only get out as much as you get in. There can be no shortcuts blaming things you don’t like, nor idealizing the things you want to like. We can talk standards and rigor all day. But there’s no getting around having an internal compass of honesty, and a desire to apply that honesty to one’s life. That’s what a therapist (or therapy group) should be for you — an objective voice that questions your view of things while letting you be heard, as well as creating a safe environment for you to unwind the dark corners of the mind that are normally difficult to reflect upon on one’s own. Even there it is up to you to reflect on what happened afterwards. Your therapist cannot follow you all the way.

Programming isn’t art either, not because you can’t do art via programming, of course you can, art happens whenever human hands are involved in the production process, my point being that we’ve romanticized programming for too long and it’s unhealthy.

Programming has more to do with engineering and plumbing than it does with sciences and art.

Across much of the US and Canada, words like "therapist" and "psychotherapist" are unregulated titles and practices, if not claimed to count as one of the licensed professions

I know for sure that this is true at least in New York where my mother is a (licensed PhD-holding) psychologist, and in Quebec where I live now, but I think this is typical.

"Psychologist" and "psychiatrist" are of course regulated, as is "social worker," but the generic unregulated therapy terms lead to lots of underqualified people doing bad diagnosis and treatment.

Psychoanalytical Therapist is perhaps the caveat you're thinking of? I know in New York it is a regulated title, and it may be possible to practice independently without a Counselling or Social Work degree provided one isn't billing insurance or advertising as a "psychotherapist".

Psychoanalyst is a regulated title, as are certain mental health professional titles which include the words therapist or counselor as part of the title.

But neither therapist or counselor standing alone nor psychotherapist is regulated there. (Nor is psychoanalytical therapist, unless something like case law has found that to be too confusingly similar to psychoanalyst.)

I'm not disputing your examples from other states. Just saying that these titles are significantly ambiguous across North America because of their inconsistent status, and therefore there's no standard of treatment which one can assume for them without knowing the precise state or province in question.

I mean these are nice people with good intentions but so is a priest in a church or a temple. The whole thing feels half baked. Ya ya I know reprogramming the mind is complex and this is a work in progress. But my experience from work and coaching team sports is people follow authority figures when in doubt/outcomes are unknown. And most shrinks and counsellors in my case atleast are unable to establish authority.

> The CBT ppl just blink at me like the question is not on their manual.

What country? In England the IAPT programme (the main source of CBT) has extensive data collection on outcomes (probably the largest collection in the world) and a focus on getting more and better evidence to improve the service.

Chapter 3 and 6 of the IAPT manual are about evidence based practice and gathering better data:

https://www.england.nhs.uk/wp-content/uploads/2018/06/the-ia...

The data sets are here: https://digital.nhs.uk/data-and-information/publications/sta...

The latest (Jun 12 2018) says this

---begin quote---

Key Facts

In April 2018 there were:

-- 119,304 new referrals;

-- 85,145 referrals that entered treatment;

-- 47,296 referrals that finished a course of treatment, of which;

-- 89.4 per cent waited less than 6 weeks and 98.9 per cent waited less than 18 weeks to enter treatment;

-- 44,222 started their treatment at caseness, with 51.9 per cent moving to recovery.

---end quote---

There's some jargon there, but that's explained in the executive summary: https://files.digital.nhs.uk/D3/B3FC5F/iapt-month-apr-2018-e...

tl;dr: CBT is somewhat effective; it's more effective if you have CBT that follows the high intensity model (14 to 20 weeks, one hour per week, face to face one to one with a qualified therapist).

If you continuously end up in situations where you're seeing mental health professionals, you might consider just accepting their authority without the need to jump through your hoops.

"You have to be willing to help yourself" is perilously close to "psychotherapy only works on people who are capable of changing of their own volition", which calls into question the entire purpose of psychotherapy. If I could change my way of thinking through sheer force of will, why would I pay a professional $100 an hour to sit and listen while I do it? It evokes the classic defence of the quack - the spoon only bends if you truly believe in the power of the mind.

If that problem is framed as "some patients are too sick to treat", then at least it shifts the burden of responsibility onto the therapist; it's not the patient's fault that the psychotherapist lacks the neccesary tools to facilitate change. Blaming the patient for having a bad attitude just makes the profession of psychotherapy look ineffectual.

When I went in I had some major anxiety problems, and by working with my therapist I was able to identify where those problems came from. I started taking steps to change how I lived so I wasn't as anxious anymore.

What sort of magic are you expecting from psychotherapy? You're paying someone to help you solve your problems. You're not paying someone to solve your problems for you.

On the other hand, going to therapy is forcing yourself to do something that is difficult, sometimes painful and requires a lot of effort and resources (both time and money). I don't see the relationship between voluntarily going to therapy and advertising inducing you to buy things.

A real intervention doesn’t require someone to help themselves; an appendectomy doesn’t require patient participation and motivation.

Okay, this is clearly not what we were talking about. Sorry I was not more specific in my statement to generalize to all scenarios, ever.

Edit: I think it is also a pretty fair assumption that if someone is shot or their appendix is about to burst, they would want help. The key difference here is that someone who is shot is not capable of helping themselves - with regards to many things people go to therapy for, the only way to fix your problems is going to be taking some actions yourself.

A giant % of therapists around my area advertise that their treatment methodology is "eclectic".

Trying to find someone who follows even CBT is almost impossible.

I have seen at least a few people advertising themselves as following Freudian principles. So there is that.

> Licensure is not all over the place.

The quality of programs that provides those licenses are. And thousands of hours of training under someone who is not very good, does not lead to a good practitioner.

I'm not saying all therapists are bad, but I'd say that picking a therapist at random will have about as good of luck as picking a mechanic at random: Greater odds of your wallet being emptied than your problem being fixed. Finding an honest and talented practitioner is hard.

> Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background

Isn't that a huge problem?

Imagine if that was the case for any other medical profession! "The surgical techniques we teach in school, and charge a lot of money and put students deep into debt for, aren't shown to be any better than someone coming off the street with a hacksaw and a really good smile."

Now that said, I've met people entering LMHC programs who obviously didn't need the credentials, their natural understanding of people was blatantly better than what 80% of their courses would cover. But those people are the obvious exception.

But no amount of standards and licensing can help one who's slowly killing himself due to their conditons.

If anything, increased red tape will only raise prices and do nothing to the quality of help.

Source: own experience. $/hour never correlates to help/hour, and any regulation just drives $ up, no positive effect on help/$.

I think it's because no one knows shit wrt psychology, tons of books written nonwithstanding. It's all intuition. And those tons of books written which I read because I took my condition seriously only reinforce this opinion.

May the peace be with you. You don't want to take a look at the other side.

I don't know that there's convincing evidence that medically-certified talking is any more effective than any other talking (if that talking is without significant ulterior motive.) There is, however, evidence that talking about your problems helps. Therefore there is a case to be made that getting people talking about their issues is more important than the qualifications of the people they talk about those issues to. Hell, in 12-step programs and other support groups, people with similar problems just talking to each other clearly helps.

I would take issue issue with the word "clearly", as there is controversy, at least according to Wikipedia (which you referenced). Perhaps "arguably" is a better word.

https://en.wikipedia.org/wiki/Twelve-step_program#Effectiven...

> It would be an error to assume the effectiveness of twelve-step methods at treating problems in one domain translates to all or to another domain, therefore readers are directed to relevant sections in each group's article.

[2] https://en.wikipedia.org/wiki/Effectiveness_of_Alcoholics_An...

> While newer studies have suggested an association between AA attendance and increased abstinence or other positive outcomes, older studies and studies done outside of the United States have not

Things like cognitive behavioral therapy and other methods.

Every therapist learns about it.

Nothing is 100% effective on every person. But on large groups it has statistically positive impacts on study vs control groups.

Therapy is hard and it only works if the client works at it. They can even work at it on their own, but they must work at it. Bibliotherapy, using a CBT workbook, works as well as a therapist if you actually do it but a therapist is an expensive means of ensuring you follow a programme.

> Is Professional Training Worth the Bother? A Review of the Impact of Psychotherapy Training on Client Outcome

> Abstract This article reviews the research literature on the effectiveness of paraprofessional counsellors and the impact of psychotherapy training on client outcome. Methodological and conceptual difficulties that have hampered previous research in this area are noted, and several well‐designed individual studies are highlighted. The existing evidence supports the efficacy of paraprofessional counsellors, although professional training may lead to better outcome in specific areas, such as greater client retention, briefer therapy, and better overall wellbeing for clients. However, methodological limitations of the research prohibit definitive conclusions. Guidelines for future research are offered.

I'm not a scientist, so correct me if I'm wrong, but it seems that science is by far the best method of finding truth within pretty small parameters. A law of physics. The effects of one particular chemical on a certain kind of animal. Etc. For complicated things the best thing you can do is make a really simple model of it and draw a conclusion from that. The other details are anecdotes. Again, people say to avoid trusting anecdotes, but it's what we live by all the time day to day.

So when it comes to psychotherapy, it's an art form. Especially given the multiple incompatible schools of thought. It's not that much of a science. If a lot of people swear by it, well, maybe it's a placebo (though what would that even mean for psychotherapy?). Or maybe there's something to it for a decent number of people.

Even picking a roofing contractor (or anything else that merely has to do with money or material possessions), I may not demand all the trappings of the scientific method, but, if possible, I want at least some of them, like data, and borrowing methodologies and reasoning. Relying on the advice/authority of a single other person is unappealing, unless I believe that other person actually did the research I would have done.

Sometimes, though, it's not possible. If a tree fell through the roof, it may not matter who the "best" one is, only the good-enough one available now.

For things like schizophrenia maybe we can help.

But for things like 'depression' we're still walking around in the dark, notwithstanding good progress on some specific things.

I’ll speak from personal experience: the most effective psychotherapy treatment I’ve received is very “unconventional,” with emphases on philosophy, meditation, and physical activity in nature. Those experiences have hugely impacted me in positive ways.

When an entity doesn’t know how to standardize or effectively certify, but does so anyway, we get quack systems as a result.

A. This either true or not true depending on how you look at it. There are standards of treatment, but the differential evidence in favor of any given treatment is usually poor except in some cases so it is difficult to justify any particular approach. There is no reason to mandate a specific treatment from a licensed professional if there's no strong evidence in favor of it over any other.

B. Licensing requirements are all over the place, but in some ways they are overly stringent. The licensing requirements per se aren't the problem, they're the admitting standards of certain programs, and the abuses of for-profit degree programs, which can actually be quite predatory. By the time a psychologist is licensed, the level of clinical training experience required by most states is probably equivalent to a psychiatrist. Many psychologists with bio backgrounds from reputable PhD programs (note many of these students do neuroscience or genetics research of some sort) have the odd experience at a particular point in their careers of being unlicensed but being more familiar with psychiatric issues (including drugs) than first or second-year psychiatry residents.

The meta-analysis in this piece is interesting, but not novel. Similar things have been shown in other meta-analyses in the past.

If you asked me to summarize the literature on therapy from a meta-analytic perspective, this is what I would say:

There is strong evidence that therapy is effective, from all sorts of randomized controlled designs with all sorts of controls (behavioral, pharmeceutical controls of all sorts).

There is little evidence of differential efficacy between therapies overall. This means that, e.g., there is no real evidence that CBT is more efficacious than psychodynamic therapy, despite what you might think or have been told. There is some evidence that for very specific targeted outcomes (e.g., reduction of a particular type of behavior), some therapies are better, but not for general outcomes.

There is evidence of publication bias. If you adjust for this, the positive effect of therapy does not go away, but it does reinforce the lack of differential efficacy. CBT and behavioral studies as a literature show the largest publication bias in previous second-order meta-analyses. (I want to point out that drug therapies also have problems with publication bias, as do all sorts of other scientific studies. This is a problem with science at the moment.)

The effect of individual therapist dwarfs that of therapy type. That is, there is strong evidence that there are very good therapists, but we don't really understand what they are doing.

There is some evidence that therapist-client match and cohesiveness, is important. So if you don't feel like things are working with your therapist, try a different approach. Incidentally, this is also true of drugs; trials show that people might fail with one drug but succeed with another.

I want to point out that treating (or hell, assessing and measuring) mental illness is a difficult problem, regardless of how you approach it. The ambiguities in the field are not because people are just stupid. There are very intelligent people who have been working on these things from many angles, and things are complicated and multilayered, from genes to social systems. Many good ideas just don't work, or don't work the way you'd think.

There is also the "reproducibility crisis" which can be very closely related to publication bias, since a reproduced result may be even less remarkable than a negative result.

> The ambiguities in the field are not because people are just stupid. There are very intelligent people who have been working on these things

At the risk of sounding flippant, I am reminded of the {Forrest Gump} quote "Stupid is as stupid does" (which is, of course, an update of earlier aphorisms with similar meaning).

To whit, in light of all the well-understood, self-admitted, fundamental problems with science at the moment, that are at least partially due to the behavior of the participants, at what point is the innate intelligence of those participants no longer a defense against an accusation of "just stupid"?