Farhad Dalal - Statistical Spin, Linguistic Obfuscation: The CBT Evidence Base
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- Опубліковано 15 жов 2024
- In this presentation I will subject elements of CBT research to a critique on its own terms - that is, from within the very 'Scientific' paradigm that CBT aspires to. I will begin arguing that as the 'third wave' of CBT (Mindfulness, CAT, ACT, DBT, etc) starts to give weight to ways of thinking that it previously disparaged, it comes to look more and more like the other psychotherapies that CBT seeks to distinguish itself from. I liken this process to that of colonisation and its way of appropriation.
Next, I take issue with manualisation itself, to say that the insistence that clinicians should stick closely to manualised protocols is driven by the needs of researchers (which is to keep control of the 'variables' in their experiments) rather than in the clinical interests of patients.
In the main part of the paper I will attend to the science behind the research and the ways that it gets written up. First up is the problem of 'publication bias', which when combined with the research requirements of NICE, constitutes a betrayal of the ideals of Science itself. Next, I will look closely at two interlinked well regarded research papers that demonstrate the efficacy of Mindfulness Based Cognitive Therapy, and are widely cited as examples of good research. A close reading of these papers will show that the picture is not as convincing as their abstracts would have us believe.
Farhad Dalal is a psychotherapist and Group Analyst in private practice in Devon. He also works with organizations. He was Associate Fellow at the University of Hertfordshire's Business School. Currently, he is Visiting Professor at the PhD School, Open University of Holland. He was invited to give the Annual Foulkes Lecture in 2012. He has been studying and writing on the themes of psychotherapy, discrimination, equality and diversity for over twenty five years. He lectures and teaches internationally. He has published three books, Taking the Group Seriously, Race, Colour and the Processes of Racialization, and his most recent book Thought Paralysis: The Virtues of Discrimination, is a constructive critique of the Equality movements
www.dalal.org.uk
Interesting talk - I've been "treated" with CBT by 5 separate psychologists, all of whom claimed it was 100% effective - when I pointed out it hadn't worked for me the response was that I obviously didn't do it right, and it would work this time (each one claimed to have their own spin on it, but they were all exactly the same). I get the impression that while CBT practitioners will teach you about confirmation bias, they will only talk about cases with positive outcomes and explain how negative outcomes are down to patient interaction or a lack of sessions. Again, great lecture!
Thanks Aidan!
Maybe you would allow me to interview you for my book?
Which part of the world are you in?
Farhad
When you have someone saying that their technique will "cure all ails" then you know you're dealing with snake oil. The reason why people are so critical of this "therapy" is that it's put on such a pedestal. They've created a culture where the only outlook on mental illness is this distorted perspective. It seems authoritarian.
You could try Focusing -oriented therapy. It worked for me and seems to work for my clients !
@@ironjohnlad I agree. I discovered focusing first in therapy and shortly after when I read Gendlin's book Focusing. The book basically explained why therapy was working for me because Focusing was what I was doing in the therapy session, unbeknownst to me.
These therapists suck. They are simply trying to spread the dharma and are indoctrinated by their Buddhist gurus. Michelle Haslam in her interview about the Kadampa Buddhist cult explains the mindfulness cult perfectly. Rather than empathy or competency, they throw statistics at you and gaslight your personal experiences. It’s narcissism, Freud highlights the necessity for analysts to have analysis themselves, whereas with these therapists they are not required the same rigour of inner work. Even Jung said that only the wounded physician heals. I find a lot of these CBT try to hide behind the ideals scientism without being scientific themselves. The most scientific thing about depression is that the chemicals are imbalanced in the brain, speculation on human thoughts and immaterial minds has no place in neuroscience. Its all dopamine, cortisol, cortexes, adrenaline, epinephrine, oxytocin.
These excellent books include critiques of CBT: “Cultures of Healing” by Robert Fancher, “The Death of Psychotherapy” by Donald Eisner, and “The Undiscovered Mind” by John Horgan. Also check out “The Myth of Psychotherapy” by Thomas Szasz.
Thank you!!
eternamente agradecido contigo Spider!
Fantastic presentation - well done.
Excellent, excellent presentation.
I have had several clients who have not benefited CBT but have really benefited from Focusing -Oriented Therapy ! Unlike CBT it really is effective !
Great lecture, thank you!
Great talk and topic. 12:30 "The language use in literature, and journal abstracts, are mostly without caveats..." Is there strong evidence for this? It would seem likely and damning that in abstracts, important trial population details will be minimized, and overlooked by the type of "evidence gathering" that doesn't go beyond abstracts... But in the body of any half-decent, peer-reviewed paper, (industry sponsored or not) the methods section has their inclusion and exclusion criteria spelled out, usually more than half decently. I'm basing this observation on my stint as a medical writer sifting through papers in the pharmaceutical industry. It's a strong, damning point that Dalal makes but one that I would like to see backed up.
Apart from CBT, isn't this criticism valid for all social sciences using statistical tools for research??
DEFINITeLY!
No
Thanks for the talk Farhad. I'm a clinical psychologist primarily working with CBT, and yes, in a mostly 'third wave' way.
Your talk contains many valid criticisms (eg CBT is indeed oversold sometimes and in some areas needs to be re-evaluated), however I'm concerned that there are some straw men here, and this seems common in critiques of CBT. They include (as I interpret the talk):
*Second wave (as opposed to third wave) CBT is all about control*
There is a risk that poor CBT collaborates with people in reinforcing unworkable attempts to control emotions and cognitions. However, the core of CBT for symptoms like panic attacks and OCD is that we need to help the person let go of unworkable control strategies and realise that the things that they fear happening, are not going to happen.
And it then takes behavioural change to get a long term cognitive change.
That said, the focus in third wave CBT makes this much more explicit and also in a way that is trans-diagnostic. I think this has been done because often second-wave CBT was done badly by people (for example) who did not understand the underlying principles.
*CBT involves an unthinking acceptance of diagnosis and simplistic chemical imbalance ideas.*
In my experience the vast majority of clinical psychologists have serious doubts about the utility of diagnostic systems and also reject the disproven or unsupported chemical imbalance theories (eg serotonin deficit causing depression). Indeed, some may go too far in the other direction, unthinkingly tearing down diagnoses that people have found personally useful.
The rise of trans-diagnostic models also argues against psychologists being fixed to diagnosis (or more cynically demonstrates the need for academics to generate more models).
*CBT as the equivalent of drug treatment.*
Well yes sometimes, and this is shown up in some of the RCTs that we run.
It's not really how most of us think of it though, I think clinical researchers felt they had to copy the drug study methodology to get taken seriously and get published.
*Some other non-straw-man thoughts*
*RCT problems.*
Yes, important. However psychologists, according to the best of my knowledge, have been much better at publishing their trials than drug companies, and their is much less evidence of publication bias (and no examples that I know of, of the worst kind of deception that B Goldacre reports from pharma).
We still have MUCH work to do in teaching the essential importance of pre-registration, trial registries etc.
Sometimes it seems like the old generation need to retire first.
I've never seen a CBT trial that threw away 80% of the original sample!
-24% (extra people who had 50% reductions in symptoms)
That's the degree of additional benefit of CBT over treatment as usual with an antidepressant - which is pretty good if true. Of the TAU effect, normally placebo or regression to the mean accounts for about 90% of drug treatment. By standards of treatment for depression (which is hard), that 24% extra is not bad (a pretty good separation from placebo+doctors chats+drug treatment).
-CBT has been shown to help. (RCP quote)
Yes it has, and it's highly effective for things like phobias, panic attacks, PTSD and OCD, and sadly rather less effective for depression and bipolar (obviously I'm not quite ready to abandon the use of diagnostic terms - just to hold them lightly).
We're still working on how to make it more useful, and yes, that does involve picking up approaches from other therapies (that have sometimes been maligned by CBT therapists).
I work in Ecuador, and many of my clients have seen multiple therapists who don't have the foggiest how to effectively treat people with OCD symptoms, that to me, is a crime when there are effective treatments.
*Teasdale Paper (2000)
* I think your criticisms are in general, very valid and I understand your anger at the way the paper presents the data. Most importantly, mindfulness may well have negative side effects (long ago in research I met someone who told me that mindfulness had triggered a manic episode). I teach Questionable Research Practices (QRPs) and certainly see some here. In our CBT doctoral training, we were invited to tear apart this very paper, and as I remember had very similar reservations. I'd add the issue that the subset analysis should be played DOWN, not UP, as I don't think it was a primary hypothesis. I don't remember if the paper had actual p-hacking or if it was possible to even tell (without trial pre-registration it is actually not possible to be certain).
Just a few thoughts on the paper.
*Prevent vs Reduce*
I'm sorry, but this seems like silly semantics, and you make a big deal of it. At an individual level a therapy may *prevent* a relapse. At a group level, it's only ever going to reduce the probability, unless it was a 100% effective intervention, which does not exist. Anyone reading these papers should understand that.
Take vaccines as an analogy: you prevent disease in some, you reduce the overall infection rate.
*Commonness of relapse.*
Yes, Teasdale and other CBT researchers FULLY accept that CBT is not a panacea, and most of us really want to improve the response in depression - hence trying new approaches. We acknowledge that relapse is too common, especially in those with multiple prior episodes... hence the trial of MBCBT.
*1/2 people extra out of 10 had a prevention of relapse*
IF TRUE, that would still be welcome.
*39% reduction*
Come on! Your statisticians knew exactly how to calculate it, and you've done it yourself, although you've not explained it in the standard way. (66-40)/66*100 = 39%.
That's how you calculate a percentage difference. It's a 39% improvement. It's a pretty normal way or reporting results (it's not muddled, it's GCSE maths).
If I can run at 10mph and you can run at 12mph, you are 20% faster than me, but 2mph faster, it's the same thing.
That said, the other way of reporting the results is equally valid, it might be more understandable, but I'm not sure - there are many better ways of reporting the results. I like the 2 out of 10 version for example.
On Treatment/CBT resistant. Fully agree, terrible, misleading and blaming terms.
I (CBT clinical psychologist) was so angry about it, I wrote a blog article about it. medium.com/@ferguskane/the-patient-did-not-respond-to-the-drug-98e19149a554
And on chemical imbalances:
ferguskane.com/blogs/after-reading-this-your-brain-will-never-be-the-same/
I've just realised that this talk is from sometime ago. I came to it from here: www.madinamerica.com/2019/02/new-book-deconstructs-ideology-of-cognitive-therapy/#comment-149388
I guess you'll get a few more visits.
Ur response is laughable, because you clearly don’t see that “normal” statistical practises take place within a social climate with very clear political ideologies. These political leanings get integrated into any mainstream profession as they replicate the political dynamics that produced whatever profession is bring “improved” upon in the first place. They don’t aim for change they aim for a continuation of th status quo. Ur blind naivety in the face of this leaves you without a framework with which to qualitatively analyse the way these dynamics may evolve in replication and so you just take the practises at face. Rendering you yourself complicit in the ongoing manifestations of political oppression that have us needing therapy in th first place.
@@granmasgarage2541 Sociology is better than CBT. It addresses neoliberal capitalism, inequality, social structures, cultural beliefs and SYSTEMIC causes for anxiety, as opposed to blaming the victim for being illogical and trying to prevent anxiety. Depression is a symptom of society, and anxiety is a symptom of neo-capitalism not illogical thoughts. Negative thoughts about people who are harmful help protect us from harm. Michelle Haslam in her interview about Kadampa Buddhist cult explains this perfectly well.
CBT - soft thought control.
Very informative talk and delivered excellently. Can I point out (I might be being pedantic but given that this is an important presentation spelling mistakes should be eliminated) your spelling and pronunciation of Asthma is not "Astha-ma".
Yikes
Nice pfp. I find it ironic that a Yume nikki fan is enjoying learning about the failures of how others try to "fix" their "illness".