There's a fascinating paper (which I'll try to track down) comparing therapist efficacy in NHS providers in the UK that showed that the best therapists (top 10 percent or so) were vastly better than the median therapist, and then multiple times better again than the absolute dregs (who actually seemed to do harm to their patients). This of course doesn't answer your question at all, because there was no clear explanation for why the best were the best. But it was fascinating on the question of how much difference it makes how good your therapist is. The answer seemed to be not too much in the middle, where the 25% percentile therapist was almost as helpful as the 75% therapist, but a great deal at the top and bottom.
Think it’s the Wampold and Brown study from 2005 in Journal of Consulting and Clinical Psychology. They found the most skilled 25% of therapists are twice as effective as the least skilled 25%. Recently wrote a book on getting good therapy that distils a lot of the research:
That's probably it. I got pretty into Wampold's stuff. I'll check out the book you did. Sounds immensely useful. My memory is that the difference in therapist efficacy got much more extreme at the high and low ends.
This is what keeps me away from therapy. 90% of everything is crap and - if the psychology students I run into in university are anything to go by - this applies even more to therapists than to science fiction writers.
And it’s such an investment in time and money to even know if they are any good before you decide to move on. I would certainly go for therapy if I knew my therapist was going to be good.
But to be clear, the evidence of that study is consistent with what Paul writes here: most therapy is helpful. There are some bad therapists who are worse than nothing, but that's the real worst of the worst. Even the 25th percentile therapists are helpful to people. I would think that if you, say, get a recommendation for a therapist from someone whose judgement you trust, who has seen that therapist, the odds are quite good that you'll benefit.
Thank you! I did forward this article to several friends and asked for advice. Two were dead set against therapy. Another friend (pro-therapy) said that therapy works really well for specific conditions (depression, anxiety, eating disorders etc) that are on a typical therapists "recipe list". But you really do need a good therapist for something out of the ordinary. I'm more like Tony Soprano than a young man with depression. I wonder if you could comment on that.
Take my advice with a grain of salt - I've researched it as a journalist, been in therapy a few times, and am married to a therapist, but I'm not a true expert on these things. I haven't read the book that Graham Johnston links to below, but it looks like it would be useful on the topic:
My two cents is that even a decent therapist can be helpful if you're in a space to work on yourself. My own work hasn't been on any specific condition but rather about trying to grow as a person, work through childhood issues, improve relationships, etc. I've done a few different stints of a few years each, with three different therapists, along with a few years in group therapy with other men. I'd say one of the therapists was truly gifted. The other two were solid, maybe above average but not exceptionally so.
I think it's all been helpful, but I've been very open to the process and not everyone is. If you can find one of the truly exceptional therapists, and have the time and money (many of the really good ones don't take insurance) to see them for a while, then they'll benefit you enormously, almost regardless of what the issue is.
Really severe mental illness -- schizophrenia, other pyschotic disorders -- is an exception to that. But for most of what the "worried well" deal with, a good therapist is a godsend.
Thank you, Daniel. I really appreciate this. You have given me the encouragement to go looking. The book looks interesting too and I will give it a go.
I have access to a free therapy session through my cancer charity. Perhaps I will go see her and ask her to recommend a therapist.
Go for it! fwiw there are programs in most places (via the city or the local mental health clinics) that offer free or very low cost therapy. You're not going to get the primo grade A therapy, but you might find someone decent.
My contention is that, for run of the mill stressor, at least, focusing on the problem is much more harmful than traditional "put it out of your head and finish the dishes." I say this because of mind viruses. How many times has one either liked or disliked something and, after exposure to new, irrelevant data, switched their perspective for no appreciable reason? Exposure to an idea that something is wrong when it is in fact transitory has led many people down a path of victimhood, if you will, or, similarly, the application of a label leaves people feeling trapped by destiny, unable to escape the feeling that its not their fault, that they are just going to have to deal with being a "said label" the rest of their life. We are over-therapied as a nation. In certain situations, it is extremely beneficial, such as those with medical issues like psychosis or OCD, bit many would benefit from simply moving forward and letting time and work heal all wounds, as was tradition until the age of the expert class.
I'd like to see a randomized trial where people get a fake diagnostic test, the treatment group are assigned to therapy, but the control group get assigned a "bill-of-health" diagnosis, are told that their difficulties are normal and that according to the test results they are capable of dealing with their difficulties by themselves. Then a time is set where they are expected to report back to a regular doctor what did they do to address their problems. And a second control group is assigned everything in the first control group plus a daily 1-hour nature walk and no phone or screen time after 10pm. Let's see therapy compete with that!
There is an BBC/Discovery docuseries called How Mad Are You that put 10 people in a manor to be diagnosed with disorders by a team of psychiatrists. The kicker was that 5 had prior diagnoses and 5 did not. The team of professionals were to figure out who had been previously labeled and who had not, complete with the correct diagnosis. It's eye opening how wrong they were.
People are too complicated to be accurately put in static boxes.
> How many times has one either liked or disliked something and, after exposure to new, irrelevant data, switched their perspective for no appreciable reason?
Can you elaborate on what this referencing or how it connects to your main point?
Vegetarianism comes immediately to mind. Donald Trump. Personally, popcorn shrimp; I had a job as a prep cook as a young man. I had to devein a bunch of medium sized shrimp in preparation for an upcoming special we were serving. After doing so, the idea of eating miniature "popcorn shrimp," which I'd always loved, was repulsive as I could not get the idea of ingesting lots of little missed bits of shrimp fecal matter out of my head, much the same way one time fans of Donald Trump or meat began to hate them after being exposed to the idea that, respectively, a falsehood about Russia as a form of disinformation or the realization that meat was once a living animal.
Those latter two are the perfect examples of how one's perspective can be altered by exposure to new information, and doubly so because the former is based on a widely reported suggestion of mere information and the other something which demonstrates totally life altering behavioral changes.
I am reminded of a Phillip K Dick story (actually, I think it was 'do androids dream of electric sheep'), in which everyone had a mood box next to their bed, on which they could dial up the emotional state that they wanted: "I need to feel like going to work" etc. The PKD twist was that the box also needed a setting to make people want to choose a setting. Such a world (A brave new world?!) sounds somehow inherently depressing, which is obviously the point.
While I accept that feelings of depression and anxiety can become pathological, it seems to me that they are, more often than not, normal responses to shitty situations and experiences. I'm not sure that we make the world a better place by banishing them. Your zappy helmet, Paul, causes me some consternation.
I also have concerns about the medicalisation of psychology and our tendency to make diagnoses a part of our identity. I think this is particularly concerning with children. Psychologists have a lot to answer for there. But that is another comment.
It's a good comment, and I agree--sometimes sadness and anxiety are legitimate responses to life. But therapists aren't dummies, and the cases that they are concerned with are where, as you put it, things get pathological. If a minor setback at work puts me in such a depressive state that I can't get out of bed even to use the toilet, or when I have to wash my hands with scalding water 100 times a day, well, bring on the zappy helmet!
Regarding revolutions in talk therapy I think there are several groups of researchers and clinicians that at least claim to be developing new and better versions of talk therapy. The two "third wave" CBT therapies that come to mind are "Acceptance Commitment Therapy" - supposedly based around a specific theory of language and thought called relational frame theory that emerged in the 90ies/early 2000s - and metacognitive therapy, also developed in the 90ies/early 2000s from basic research about executive control of attention and thoughts. I think both of these are interesting and there's a lot of enthusiasm around them, but whether they're significantly different from previous talk therapies I think will depend a lot on who you're asking.
This strikes me as a fair, thoughtful, and self-aware analysis.
I've known people for whom therapy really helped. But starting with family therapy when I was a kid and through until after I had a bad accident and was fired, therapy has never helped me. Antidepressants, though, changed my life. (Stories: https://www.losingmyreligions.net/ )
Great post. I personally have gotten a lot out of therapy, particularly with one therapies I saw on and off for 10 years. That said, without antidepressants I would be dead. I was very excited about ketamine when it first started making news but it proved ineffective for me.
Measurement based care is an empircally proven trans diagnostic approach which, if implemented, could make a big difference in outcomes on a population basis.
Thanks for this challenging set of thoughts. I have to say that in the area of ‘personality disorder’ there has been a huge shift over the past 40 years specifically (perhaps that where all the energy was). The shift is not just in the 1:1 therapeutic techniques but in the recognition of the importance of groups and a team approach to treatment rather than a lone therapist. The results are DBT (which you mention) and MBT (mentalization based treatment).
My personal experience is that the seeking out of solutions to my problems in pharmaceuticals or therapists was largely misguided. Most of my persistent problems were just not solvable. And only reason turned out to be a reliable guide in figuring which were solvable and how they could be solved. The issue with pharmaceuticals is that they interfere with proper judgment. The issue with therapists is that they dispense bad advice just as often as good advice, while wearing a facade of knowledge and friendship. The first question with every problem should be, will the problem go away if we change the environment, such as a new job, new partner, new friends? (read "Lost Connections" by Johann Hari). But very few therapists recommend a path to problem-solving that does not reserve a role for the therapist, through the diagnosis of a "disease" that requires "treatment".
It's like, the therapist goes, "if they come to me, they must be suffering, and if they are suffering they must be sick", while the truth is that suffering is functional. It's what drives us to work towards an objectively better future for ourselves. It's an error to try to cure suffering. Curing suffering is like putting on blinds and then going out for a drive.
I'll repeat (with edits) a response I gave above. I agree that sometimes suffering is a legitimate responses to life--functional, as you put it. But sometimes it's not. If a minor setback at work puts me in such a depressive state that I can't get out of bed even to use the toilet, or when I have to wash my hands with scalding water 100 times a day, well, effective treatment is just what you want. (and note that some people experience terrible suffering even if their life, by objective standards, is going very well.)
Look, obviously there is such a thing a pathology. I'm not denying that. It's just that I can't even imagine a therapist declining to provide services because the patient did not show a pathology. Everyone gets a diagnosis (and a prescription). They probably can't bill the insurance otherwise. Therapists act as if a diagnosis is an inherit good. As if you're always better off if you have one. The only question is which one fits best. I'd like to see for once someone come out from a therapist with the diagnosis: human.
Reading some of the other comments and reflecting again on my own experience I realized I took it too far. The trend may be for over-diagnosis, but there’s plenty of variance around that trend.
Great post. I think it’s crucial to be honest about the state of mental health treatment. I have a question and a comment…
Is rTMS research and deployment getting the funding it needs to make rapid progress? I have seen professional opinions that it should be among the first line treatments now but good luck finding a clinic that you may or may not be able to afford.
TEAM CBT by Dr. David Burns has some interesting innovations (rapid assessments at each appointment to gauge progress or lack therof and paradoxical agenda setting) but I’ve not heard of it being incorporated into any RCTs. Metacognitive therapy is another interesting form of third wave CBT that needs expanded deployment and research.
Botox for depression is another slice of research that just seems to languish. Frustrating given salience of depression as a significant contributor to disability and suffering.
Paul, I imagine you've read it, but Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness by Anne Harrington takes a pretty similar tac to your post. Any thoughts on it?
As a student in Clinical Mental Health Counseling, I can only offer my perspective at this time. It seems to me that psychology, in general, is beginning to understand the concept that no two people are the same. This includes psychopathology. ADHD is not just (insert whatever exactly ADHD is). ADHD is a presentation of similar behaviors molded by the individual showing very different symptoms. Treatments can follow a guideline, but it is always the job of the clinician, working alongside the client, to determine goals and outcomes, thereby discovering the path forward. Logotherapy may benefit one depressed person and horribly ruin another, psychopharmacology included, talk therapy, CBT, you name it.
This begs the question, as clinicians should we begin taking steps towards specialization or is a general practitioner the better route?
I’m having trouble getting going with my book and the sub stack because at the end of my therapy about 30 years ago… rather than talking to me, my brain was therapist threatened me that I could not talk about my story publically…. This has led to a subtle trauma…..
Treating the whole person is essential not just little pieces - everything has to be tied together by the individual by them connecting the dots…. leading towards discovering their true self.
There's a fascinating paper (which I'll try to track down) comparing therapist efficacy in NHS providers in the UK that showed that the best therapists (top 10 percent or so) were vastly better than the median therapist, and then multiple times better again than the absolute dregs (who actually seemed to do harm to their patients). This of course doesn't answer your question at all, because there was no clear explanation for why the best were the best. But it was fascinating on the question of how much difference it makes how good your therapist is. The answer seemed to be not too much in the middle, where the 25% percentile therapist was almost as helpful as the 75% therapist, but a great deal at the top and bottom.
very neat -- thanks, I'll check it out.
Think it’s the Wampold and Brown study from 2005 in Journal of Consulting and Clinical Psychology. They found the most skilled 25% of therapists are twice as effective as the least skilled 25%. Recently wrote a book on getting good therapy that distils a lot of the research:
https://www.amazon.co.uk/gp/aw/d/1915220335/ref=tmm_pap_swatch_0?ie=UTF8&qid=&sr=
That's probably it. I got pretty into Wampold's stuff. I'll check out the book you did. Sounds immensely useful. My memory is that the difference in therapist efficacy got much more extreme at the high and low ends.
This is what keeps me away from therapy. 90% of everything is crap and - if the psychology students I run into in university are anything to go by - this applies even more to therapists than to science fiction writers.
And it’s such an investment in time and money to even know if they are any good before you decide to move on. I would certainly go for therapy if I knew my therapist was going to be good.
But to be clear, the evidence of that study is consistent with what Paul writes here: most therapy is helpful. There are some bad therapists who are worse than nothing, but that's the real worst of the worst. Even the 25th percentile therapists are helpful to people. I would think that if you, say, get a recommendation for a therapist from someone whose judgement you trust, who has seen that therapist, the odds are quite good that you'll benefit.
Thank you! I did forward this article to several friends and asked for advice. Two were dead set against therapy. Another friend (pro-therapy) said that therapy works really well for specific conditions (depression, anxiety, eating disorders etc) that are on a typical therapists "recipe list". But you really do need a good therapist for something out of the ordinary. I'm more like Tony Soprano than a young man with depression. I wonder if you could comment on that.
Take my advice with a grain of salt - I've researched it as a journalist, been in therapy a few times, and am married to a therapist, but I'm not a true expert on these things. I haven't read the book that Graham Johnston links to below, but it looks like it would be useful on the topic:
https://www.amazon.co.uk/gp/aw/d/1915220335/ref=tmm_pap_swatch_0?ie=UTF8&qid=&sr=
My two cents is that even a decent therapist can be helpful if you're in a space to work on yourself. My own work hasn't been on any specific condition but rather about trying to grow as a person, work through childhood issues, improve relationships, etc. I've done a few different stints of a few years each, with three different therapists, along with a few years in group therapy with other men. I'd say one of the therapists was truly gifted. The other two were solid, maybe above average but not exceptionally so.
I think it's all been helpful, but I've been very open to the process and not everyone is. If you can find one of the truly exceptional therapists, and have the time and money (many of the really good ones don't take insurance) to see them for a while, then they'll benefit you enormously, almost regardless of what the issue is.
Really severe mental illness -- schizophrenia, other pyschotic disorders -- is an exception to that. But for most of what the "worried well" deal with, a good therapist is a godsend.
Thank you, Daniel. I really appreciate this. You have given me the encouragement to go looking. The book looks interesting too and I will give it a go.
I have access to a free therapy session through my cancer charity. Perhaps I will go see her and ask her to recommend a therapist.
Go for it! fwiw there are programs in most places (via the city or the local mental health clinics) that offer free or very low cost therapy. You're not going to get the primo grade A therapy, but you might find someone decent.
My contention is that, for run of the mill stressor, at least, focusing on the problem is much more harmful than traditional "put it out of your head and finish the dishes." I say this because of mind viruses. How many times has one either liked or disliked something and, after exposure to new, irrelevant data, switched their perspective for no appreciable reason? Exposure to an idea that something is wrong when it is in fact transitory has led many people down a path of victimhood, if you will, or, similarly, the application of a label leaves people feeling trapped by destiny, unable to escape the feeling that its not their fault, that they are just going to have to deal with being a "said label" the rest of their life. We are over-therapied as a nation. In certain situations, it is extremely beneficial, such as those with medical issues like psychosis or OCD, bit many would benefit from simply moving forward and letting time and work heal all wounds, as was tradition until the age of the expert class.
I'd like to see a randomized trial where people get a fake diagnostic test, the treatment group are assigned to therapy, but the control group get assigned a "bill-of-health" diagnosis, are told that their difficulties are normal and that according to the test results they are capable of dealing with their difficulties by themselves. Then a time is set where they are expected to report back to a regular doctor what did they do to address their problems. And a second control group is assigned everything in the first control group plus a daily 1-hour nature walk and no phone or screen time after 10pm. Let's see therapy compete with that!
There is an BBC/Discovery docuseries called How Mad Are You that put 10 people in a manor to be diagnosed with disorders by a team of psychiatrists. The kicker was that 5 had prior diagnoses and 5 did not. The team of professionals were to figure out who had been previously labeled and who had not, complete with the correct diagnosis. It's eye opening how wrong they were.
People are too complicated to be accurately put in static boxes.
> How many times has one either liked or disliked something and, after exposure to new, irrelevant data, switched their perspective for no appreciable reason?
Can you elaborate on what this referencing or how it connects to your main point?
Vegetarianism comes immediately to mind. Donald Trump. Personally, popcorn shrimp; I had a job as a prep cook as a young man. I had to devein a bunch of medium sized shrimp in preparation for an upcoming special we were serving. After doing so, the idea of eating miniature "popcorn shrimp," which I'd always loved, was repulsive as I could not get the idea of ingesting lots of little missed bits of shrimp fecal matter out of my head, much the same way one time fans of Donald Trump or meat began to hate them after being exposed to the idea that, respectively, a falsehood about Russia as a form of disinformation or the realization that meat was once a living animal.
Those latter two are the perfect examples of how one's perspective can be altered by exposure to new information, and doubly so because the former is based on a widely reported suggestion of mere information and the other something which demonstrates totally life altering behavioral changes.
I am reminded of a Phillip K Dick story (actually, I think it was 'do androids dream of electric sheep'), in which everyone had a mood box next to their bed, on which they could dial up the emotional state that they wanted: "I need to feel like going to work" etc. The PKD twist was that the box also needed a setting to make people want to choose a setting. Such a world (A brave new world?!) sounds somehow inherently depressing, which is obviously the point.
While I accept that feelings of depression and anxiety can become pathological, it seems to me that they are, more often than not, normal responses to shitty situations and experiences. I'm not sure that we make the world a better place by banishing them. Your zappy helmet, Paul, causes me some consternation.
I also have concerns about the medicalisation of psychology and our tendency to make diagnoses a part of our identity. I think this is particularly concerning with children. Psychologists have a lot to answer for there. But that is another comment.
It's a good comment, and I agree--sometimes sadness and anxiety are legitimate responses to life. But therapists aren't dummies, and the cases that they are concerned with are where, as you put it, things get pathological. If a minor setback at work puts me in such a depressive state that I can't get out of bed even to use the toilet, or when I have to wash my hands with scalding water 100 times a day, well, bring on the zappy helmet!
Regarding revolutions in talk therapy I think there are several groups of researchers and clinicians that at least claim to be developing new and better versions of talk therapy. The two "third wave" CBT therapies that come to mind are "Acceptance Commitment Therapy" - supposedly based around a specific theory of language and thought called relational frame theory that emerged in the 90ies/early 2000s - and metacognitive therapy, also developed in the 90ies/early 2000s from basic research about executive control of attention and thoughts. I think both of these are interesting and there's a lot of enthusiasm around them, but whether they're significantly different from previous talk therapies I think will depend a lot on who you're asking.
This strikes me as a fair, thoughtful, and self-aware analysis.
I've known people for whom therapy really helped. But starting with family therapy when I was a kid and through until after I had a bad accident and was fired, therapy has never helped me. Antidepressants, though, changed my life. (Stories: https://www.losingmyreligions.net/ )
Thanks Dr. Bloom
Great post. I personally have gotten a lot out of therapy, particularly with one therapies I saw on and off for 10 years. That said, without antidepressants I would be dead. I was very excited about ketamine when it first started making news but it proved ineffective for me.
Measurement based care is an empircally proven trans diagnostic approach which, if implemented, could make a big difference in outcomes on a population basis.
Thanks for this challenging set of thoughts. I have to say that in the area of ‘personality disorder’ there has been a huge shift over the past 40 years specifically (perhaps that where all the energy was). The shift is not just in the 1:1 therapeutic techniques but in the recognition of the importance of groups and a team approach to treatment rather than a lone therapist. The results are DBT (which you mention) and MBT (mentalization based treatment).
Thanks for this- it’s astute both about the field’s strengths and its current stagnation. Here’s my and a colleague’s recent modest attempt to move the needle (at the level of theoretical integration, which is where I think progress is most needed): https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2021.698655/full
My personal experience is that the seeking out of solutions to my problems in pharmaceuticals or therapists was largely misguided. Most of my persistent problems were just not solvable. And only reason turned out to be a reliable guide in figuring which were solvable and how they could be solved. The issue with pharmaceuticals is that they interfere with proper judgment. The issue with therapists is that they dispense bad advice just as often as good advice, while wearing a facade of knowledge and friendship. The first question with every problem should be, will the problem go away if we change the environment, such as a new job, new partner, new friends? (read "Lost Connections" by Johann Hari). But very few therapists recommend a path to problem-solving that does not reserve a role for the therapist, through the diagnosis of a "disease" that requires "treatment".
It's like, the therapist goes, "if they come to me, they must be suffering, and if they are suffering they must be sick", while the truth is that suffering is functional. It's what drives us to work towards an objectively better future for ourselves. It's an error to try to cure suffering. Curing suffering is like putting on blinds and then going out for a drive.
I'll repeat (with edits) a response I gave above. I agree that sometimes suffering is a legitimate responses to life--functional, as you put it. But sometimes it's not. If a minor setback at work puts me in such a depressive state that I can't get out of bed even to use the toilet, or when I have to wash my hands with scalding water 100 times a day, well, effective treatment is just what you want. (and note that some people experience terrible suffering even if their life, by objective standards, is going very well.)
Look, obviously there is such a thing a pathology. I'm not denying that. It's just that I can't even imagine a therapist declining to provide services because the patient did not show a pathology. Everyone gets a diagnosis (and a prescription). They probably can't bill the insurance otherwise. Therapists act as if a diagnosis is an inherit good. As if you're always better off if you have one. The only question is which one fits best. I'd like to see for once someone come out from a therapist with the diagnosis: human.
Reading some of the other comments and reflecting again on my own experience I realized I took it too far. The trend may be for over-diagnosis, but there’s plenty of variance around that trend.
Great post. I think it’s crucial to be honest about the state of mental health treatment. I have a question and a comment…
Is rTMS research and deployment getting the funding it needs to make rapid progress? I have seen professional opinions that it should be among the first line treatments now but good luck finding a clinic that you may or may not be able to afford.
TEAM CBT by Dr. David Burns has some interesting innovations (rapid assessments at each appointment to gauge progress or lack therof and paradoxical agenda setting) but I’ve not heard of it being incorporated into any RCTs. Metacognitive therapy is another interesting form of third wave CBT that needs expanded deployment and research.
thanks for the comment. (as for the question, sorry, I don't know current funding levels for TMS.)
Botox for depression is another slice of research that just seems to languish. Frustrating given salience of depression as a significant contributor to disability and suffering.
Paul, I imagine you've read it, but Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness by Anne Harrington takes a pretty similar tac to your post. Any thoughts on it?
As a student in Clinical Mental Health Counseling, I can only offer my perspective at this time. It seems to me that psychology, in general, is beginning to understand the concept that no two people are the same. This includes psychopathology. ADHD is not just (insert whatever exactly ADHD is). ADHD is a presentation of similar behaviors molded by the individual showing very different symptoms. Treatments can follow a guideline, but it is always the job of the clinician, working alongside the client, to determine goals and outcomes, thereby discovering the path forward. Logotherapy may benefit one depressed person and horribly ruin another, psychopharmacology included, talk therapy, CBT, you name it.
This begs the question, as clinicians should we begin taking steps towards specialization or is a general practitioner the better route?
Can’t seem to correct typos with Sub-stack. My therapist threatened me……
I’m having trouble getting going with my book and the sub stack because at the end of my therapy about 30 years ago… rather than talking to me, my brain was therapist threatened me that I could not talk about my story publically…. This has led to a subtle trauma…..
Treating the whole person is essential not just little pieces - everything has to be tied together by the individual by them connecting the dots…. leading towards discovering their true self.