Kodi Arfer / Wisterwood

Why psychotherapy is so weird; or, One problem with the crazy leading the crazy

Topic List
#001 | Kodiologist |
I've already complained at length on this humble forum about how psychotherapists tend to be estranged from science, and the reader is no doubt aware that therapists are divided into many cults—I mean, camps, each with its own One True Way to conceive of and treat mental illness. Many of these camps are attributed to single founding figures: Sigmund Freud was the father of psychoanalysis, Carl Rogers was the father of person-centered therapy, Albert Ellis was the father of rational-emotive therapy, Aaron Beck was the father of cognitive therapy, Steve Hayes was the father of acceptance-and-commitment therapy, and so on.

What is remarkable is how many of these paternal figures invented their therapies more or less in the process of treating their own mental illness. An article in Time magazine [1] characterizes Hayes as crippled by anxiety until he (presumably) became more mindful and accepting, and Beck as overcoming his fear of tunnels by challenging his irrational thoughts. A New York Times article [2] quotes Marsha Linehan, the mother of dialectical behavior therapy and a sufferer of borderline personality disorder, as saying "But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got." And the Wikipedia article "Wet nurse" says that Steven Pinker speculated in his book How the Mind Works that "Sigmund Freud's theories about the Oedipal complex were the result of Freud being raised by a wet-nurse, rather than his mother, because this dissociation from his mother would have prevented the Westermarck effect from taking hold." In the face of all these stories, it seems a reasonable hypothesis that the typical way in which therapies are invented is through the introspection and personal experience of the therapist.

To show how this phenomenon can be particularly problematic, let's think about something entirely different for a moment: computer programming. Haskell is an awesome, deep, powerful programming language, but the sophistication comes at the price of a steep learning curve. Particularly infamous are monads, a feature of Haskell that underlies operations as basic as I/O and can be very useful but are legendarily difficult to understand. You may be able to find on the Web as many tutorials about monads in particular as about Haskell in general, each with its own approach. The Haskell wiki has a whole catalog of the darn things [3]. Extreme creativity is common: Eric Kow, for example, compares monads to space suits and containers of nuclear waste.
#002 | Kodiologist |
Seeing as demand for these monad tutorials continues unabated, one might imagine that the tutorial-writers are doing something fundamentally wrong. Brent Yorgey [4] puts it like this:

…imagine the following scenario: Joe Haskeller is trying to learn about monads. After struggling to understand them for a week, looking at examples, writing code, reading things other people have written, he finally has an "aha!" moment: everything is suddenly clear, and Joe Understands Monads! What has really happened, of course, is that Joe's brain has fit all the details together into a higher-level abstraction, a metaphor which Joe can use to get an intuitive grasp of monads; let us suppose that Joe's metaphor is that Monads are Like Burritos. Here is where Joe badly misinterprets his own thought process: "Of course!" Joe thinks. "It's all so simple now. The key to understanding monads is that they are Like Burritos. If only I had thought of this before!" The problem, of course, is that if Joe HAD thought of this before, it wouldn't have helped: the week of struggling through details was a necessary and integral part of forming Joe's Burrito intuition, not a sad consequence of his failure to hit upon the idea sooner.

But now Joe goes and writes a monad tutorial called "Monads are Burritos," under the well-intentioned but mistaken assumption that if other people read his magical insight, learning about monads will be a snap for them. "Monads are easy," Joe writes. "Think of them as burritos." Joe hides all the actual details about types and such because those are scary, and people will learn better if they can avoid all that difficult and confusing stuff. Of course, exactly the opposite is true, and all Joe has done is make it harder for people to learn about monads, because now they have to spend a week thinking that monads are burritos and getting utterly confused, and then a week trying to forget about the burrito analogy, before they can actually get down to the business of learning about monads.

Joe had a mental problem of sorts, and he managed to solve it, but he is mistaken about how he solved it. Worse, he's unlikely to ever be corrected. For, I imagine that the readers of Joe's tutorial will be left with a better impression of the tutorial, and will be better affected by it, than Yorgey predicts. Will the burrito analogy be all they need? By no means. But by reading that tutorial, they'll inevitably work with monads some more and think about monads some more, and over time, after reading a lot of other tutorials and writing code and scratching their heads, they'll come to understand monads, just as Joe did originally. All the silly quirks of the tutorials had nothing to do with it. The learner just stumbles to the understanding themself.

My idea is that this is what happens with psychotherapy. All psychotherapies are about equally effective (or so Bruce Wampold argues in The Great Psychotherapy Debate), despite their exaggerated differences, and none are silver bullets, but people manage to get something out of them from what makes psychotherapy psychotherapy—talking to someone you have faith in about your problems, thinking critically about your problems, and so on. In order to create psychotherapies that treat mental illnesses more effectively and more reliably than a burrito analogy can explain monads, we'll need to stop relying so heavily on introspection and determine precisely how mental illness is brought under control.

Considering the huge range of possible causes of mental illness, I'm betting that good psychotherapies will be much more narrowly specialized on problems (but still much less subject to variation between patients in method and in results) than PCT, RET, CBT, ACT, DBT, and the rest of the alphabet soup we have today.
#003 | Kodiologist | | (edited)
[1] Cloud, John. (2006, February 13). The third wave of therapy. Time, 167: 58–67. Retrieved from http://www.time.com/time/magazine/article/0,9171,1156613-1,00.html

[2] Carey, Benedict. (2011, June 23). Expert on mental illness reveals her own fight. New York Times. Retrieved from http://www.nytimes.com/2011/06/23/health/23lives.html

[3] http://www.haskell.org/haskellwiki/Monad_tutorials_timeline

[4] Yorgey, Brent. (2009, January 12). Abstraction, intuition, and the "monad tutorial fallacy". Retrieved from http://byorgey.wordpress.com/2009/01/12/abstraction-intuition-and-the-monad-tutorial-fallacy/

"A wise spellweaver always writes in pencil."
#004 | PaperSpock |
This reminds me of my biggest pet peeve concerning psychology (and if I remember right, sociology as well). Too often the solution to some debate discussed in my psychology classes and textbooks is that both sides are right. It would seem to me that really, both ideas are wrong, in that neither can fully explain the phenomenon that they are supposed to. Perhaps they are valid under certain conditions, but then, finding out when which explanation holds should be a priority in those trying to answer the question at hand.
Fame is but a slow decay.
-Theodore Tilton
#005 | Kodiologist |
Yeah, that kind of relativism is a pain. It would be better for the textbooks to say "But controversy about which theory is right continues" than make it seem like the difference is merely one of perspective. Psychology is young enough that students shouldn't be surprised to find a lot of questions still open.

"A wise spellweaver always writes in pencil."
#006 | willis5225 |
Interesting. It would explain a lot of the nonsense that comes out when these sainted figures try to generalize from their conclusions to an audience that's predisposed to listen sympathetically. That sort of breakthrough really does take on (on a personal level) a kind of Gospel truth, and it's easy enough to take your conclusions to the extremes of nonsense without having an echo-chamber of the like-minded. (And as a disclaimer, I'm only talking about Freud and only about his work on myth, because it's the only thing I've read, and it's so profoundly dumb, but there's no need to rehearse that here.) (Also I should point out that I'm predisposed to listen to you sympathetically.)

As a counterpoint, another mental health program started by the sufferers of the relevant mental health illness is AA. While it's similar in that it demands religious acceptance of its foundational precepts, it's actually kind of a model for a targeted, prescribed regimen like you're suggesting. The twelve steps are only used to treat one illness (addiction) (I mean kind of), and the actual therapeutic treatment is anarchical and therefore highly personalized. It only has a 10% success rate, but then I wonder what the success rate of a given burrito metaphor is (whether the burrito actually helps or you just happen to be contemplating it at the moment everything "clicks").

Also, as a non-expert I've only ever heard good things about CBT. But that may be selection bias, or it may be that it's an adaptation of a much older burrito metaphor (i.e. Epictetian stoicism).
Willis, it seems like every other time you post, I need to look up a word that's in the OED or Urban Dictionary but not both.
#007 | Kodiologist |
From: willis5225 | Posted: 1/5/2012 8:54:08 AM | #006
Also I should point out that I'm predisposed to listen to you sympathetically.

Aww, I wuv you too, Wil.

For me, thinking about success rates of methods to treat addictions raises the question of how much success depends on perseverance. The tricky part, of course, being that if you had perfect willpower, you would by definition not be addicted to anything, so surely we should judge treatments in part on how well people can follow through with them.

Also, as a non-expert I've only ever heard good things about CBT.

Same here. Admittedly, the various therapies are only very roughly "about equally effective". What's nice about CBT is that not only is it highly empirically driven, it makes intuitive sense. The idea, after all, is just to junk your bogus beliefs and fix your stupid habits. This is much less silly than, for example, thanking your mind for your painful thoughts, as one is encouraged to do in ACT.

"A wise spellweaver always writes in pencil."
#008 | HeyDude |
I can't add anything academic here, but the saying in AA goes, "It works if you work it."

I submit that no system works if you don't use it (until they invent something that can be used on you without your consent, I suppose). So, I think the effectiveness of a system should be judged by how well it works for the people who use it.

So "just stop" has an effectiveness rate at treating addiction of 100%. If you can do it, obviously it works. "Try nothing new at all" has an effectiveness of 0% or near. I think that makes the most sense to rate effectiveness in that manner.

The 12 Steps, from what I know anecdotally through addicts, works all or most of the time if you persevere through all 12 steps.
#009 | willis5225 |
Kodiologist posted...
The tricky part, of course, being that if you had perfect willpower, you would by definition not be addicted to anything...

I think you can get around that by constructing addiction as a thing that subverts willpower. It's been a while since I studied the psychology addiction, and even then it was like 1/3 of an undergrad semester, but that seems consistent with the way we ought to understand it. The substance is almost a second force of will, especially while it's active in one's system. How strong one's original will is can certainly factor into the transaction, but so does a biological predisposition to addiction.

Not that I'm proposing we say "nope, unanswerable" and wash our hands of the question, but they're separate concerns at work.

HeyDude posted...
I submit that no system works if you don't use it (until they invent something that can be used on you without your consent, I suppose). So, I think the effectiveness of a system should be judged by how well it works for the people who use it.

I've heard similar approaches to evaluating diets: that the ease pleasantness of staying on a diet should be treated as the major benchmark of success.

Makes sense.
Willis, it seems like every other time you post, I need to look up a word that's in the OED or Urban Dictionary but not both.
#010 | Kodiologist |
Well, "willpower" isn't a well established term in psychology, but the way I use it, I refer not to a generalized capacity for self-control (which I'm not sure exists, considering how practicing self-control in one domain tends not to help with other domains (abstaining from masturbation hasn't increased my tolerance for pain)) but just how well you can control yourself considered as a dependent variable. So "having perfect willpower" means exactly "having no trouble controlling yourself", whether that's because you have magical powers of self-control or because you're simply never ambivalent.

"A wise spellweaver always writes in pencil."
#011 | willis5225 |
Oh. Well alright then.
Willis, it seems like every other time you post, I need to look up a word that's in the OED or Urban Dictionary but not both.