Towards a scientifically unified therapy

nature_scienceToday’s edition of Nature has an excellent article on the need to apply cognitive science to understanding how psychological therapies work.

Psychological therapies are often called ‘talking treatments’ but this is often a misleading name. Talking is essential, but it’s not where most of the change happens.

Like seeing a personal trainer in the gym, communication is key, but it’s the exercise which accounts for the changes.

In the same way, psychological therapy is only as effective as the experience of putting changes into practice, but we still know relatively little about the cognitive science behind this process.

Unfortunately, there is a traditional but unhelpful divide in psychology where some don’t see any sort of emotional problem as biological in any way, and the contrasting divide in psychiatry where biology is considered the only explanation in town.

The article in Nature argues that this is pointless and counter-productive:

It is time to use science to advance the psychological, not just the pharmaceutical, treatment of those with mental-health problems. Great strides can and must be made by focusing on concerns that are common to fields from psychology, psychiatry and pharmacology to genetics and molecular biology, neurology, neuroscience, cognitive and social sciences, computer science, and mathematics. Molecular and theoretical scientists need to engage with the challenges that face the clinical scientists who develop and deliver psychological treatments, and who evaluate their outcomes. And clinicians need to get involved in experimental science. Patients, mental-health-care providers and researchers of all stripes stand to benefit.

The piece tackles many good examples of why this is the case and sets out three steps for bridging the divide.

Essential reading.
 

Link to ‘Psychological treatments: A call for mental-health science’.

10 Comments

  1. Posted July 18, 2014 at 1:14 am | Permalink

    This is especially pertinent today as prescriptions for psychiatric conditions continue to increase, even when the efficacy of the drugs prescribed in many cases has not been proven. Antidepressants are a perfect example. Antidepressants have been shown to not be more effective than a placebo for most of the population who experiences symptoms of depression. Their effectiveness is most convincing in those who are extremely depressed, but this doesn’t make up the majority of those who take the drugs. Yet, psychiatrists are more inclined than ever to prescribe them for people who, up until the recent changes in the DSM, wouldn’t even meet the criteria for MDD. Cognitive behavioral therapy, on the other hand, can be very effective in treating even less severe cases of depressive symptoms. Too often, however, doctors are prescribing a pill without helping the patient to learn any skills to allow them to manage the disorder on their own. We need a combination of both approaches, and until that is the standard approach I believe a significant portion of the patient population will continue to not receive the medical care most beneficial for them.

  2. Posted July 18, 2014 at 4:36 am | Permalink

    Some great points there. But the “evidence base” for existing psychotherapies is overstated. The existing studies are so riddled with biases, conflicts of interest, research design flaws (e.g., failure to use active control groups that adequately control for placebo and expectation effects and demand characteristics), statistical method flaws, failure to track harmful side-effects, etc. that they amount to a pile of nothing.

    Until we understand how psychotherapies “work” or cause harm, we are playing dice with human lives: http://trytherapyfree.wordpress.com/2014/06/12/playing-dice-with-human-lives-intervening-without-evidence/

    Consumers deserve better. It’s great that this is coming to light.

  3. Posted July 18, 2014 at 6:16 am | Permalink

    Right, trytherapyfree. Before you can analyze HOW psychotherapy works, you have to ask if it works at all. In the typical study of psychotherapy effects, the experimental group is vetted against a waiting list control. That is fraud. Being in a waiting list is bad for your health. So this is a nocebo control group that guaranties a positive effect. If big pharma would test their new drugs against a waiting list, they would be crucified. You must instill the same hope and expectation in the control group as in the experimental group. My bet: Psychotherapy, in the best case scenario, is just a placebo. A costly one.

    http://blogs.discovermagazine.com/neuroskeptic/2013/12/17/waiting-list/#.U8i5heN_tA2

  4. Daniel
    Posted July 18, 2014 at 4:39 pm | Permalink

    Another article on the bias in psychotherapy research:
    Is psychotherapy for depression any better than a sugar pill?
    By James Coyne PhD

    http://blogs.plos.org/mindthebrain/2013/06/25/is-psychotherapy-for-depression-any-better-than-a-sugar-pill/

    I will appreciate your more informed comments.

  5. Posted July 19, 2014 at 9:06 pm | Permalink

    Thanks for flagging this up, Vaughan. It’s an interesting article, but I find myself unconvinced. This isn’t just because of some of the assumptions and descriptions offered (e.g. fatal illness as “unconditional stimulus” … do the authors mean “unconditioned response”?) but because the entire article might in fact be built upon a false premise. I’d argue that, rather than “We don’t really know”, the answer to the question “How does one human talking to another … bring about changes in brain activity and cure or ease mental disorders?” is more likely to be “Because it can bring about changes in behaviour” (Longmore & Worrell, 2007).

    The authors do acknowledge very briefly that therapy targets behaviour, but their focus seems to be on how it might better target cognition. While I absolutely endorse their call for cognitive science and clinical psychology to work more closely together, this will be a long, slow process, and I’m unconvinced that therapy is on the cusp of an optogenetic breakthrough. Until such time as technologically augmented treatments become the norm, might it be that current advances in behavioural psychology already point the way towards process-focused, evidence-supported, widely applicable approaches (e.g. Hayes et al., 2013)?

    Pace the previous commentators’ criticisms, a wealth of evidence suggests that cognitive behavioural therapy can, and does, work for many people. However, it could, and should, work better for more. There is much we can do to improve it based on what we already know, rather than what we are yet to discover.

    References:
    Longmore, R.J., Worrell, M., 2007. Do we need to challenge thoughts in cognitive behavior therapy? Clin.Psychol.Rev. 27, 173–187.
    Hayes, S.C., Levin, M.E., Plumb-Vilardaga, J., Villatte, J.L., Pistorello, J., 2013. Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy 44, 180–198.

  6. jamzo
    Posted July 22, 2014 at 12:36 am | Permalink

    thought they had a good argument until they used it to advocate a new discipline

    “It is time to use science to advance the psychological, not just the pharmaceutical, treatment of those with mental-health problems”

    this is an agenda that could bring disparate groups together

    unfortunately their solution is yet another narrow specialized group

    i think they need to prove the need to a new discipline…

  7. Daniel
    Posted July 23, 2014 at 4:32 pm | Permalink

    Another article in favor of psychotherapy.

    The efficacy of long-term psychodynamic psychotherapy, fluoxetine and their combination in the outpatient treatment of depression.

    http://www.ncbi.nlm.nih.gov/pubmed/25041333?dopt=Abstract

  8. Sandy
    Posted July 26, 2014 at 6:00 am | Permalink

    The psychological environment in which we live is sick. Talk therapy or drugs are not going to fix that.

  9. simonmoon
    Posted August 4, 2014 at 12:51 am | Permalink

    I’m not convinced that “psychological therapies” are treating one class of phenomenon. We know that tumors or endocrine problems or other metabolic aberrations can have psychological/behavioral consequences, while PTSD, for instance, is clearly a result of experience.
    Research will have to continue in a variety of directions until we know more clearly what we’re talking about.


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