March 21, 2023 05:20 PM
Believe those who are seeking the truth. Doubt those who find it.--Andre Gide
There is so much nonsense out there that it would take a compendium of volumes the size of Wikipedia to do it justice, but I have condensed it to three myths that permeate every aspect of mental health and the pablum fed to the public even by credible sources in the media. The first blog presented the myth of psychiatric diagnosis and the second addressed the myth of the magic pill. This blog, perhaps, hits a little closer to home for many of us—our love affair with our models.
Models of psychotherapy often profess to have captured the true essence of psychological dysfunction as well as the best remedies. They claim to be the silver bullet cure for whatever ails you, especially the latest headliner of psychological ills, trauma. Simply load the silver bullet into your psychotherapy revolver and shoot the psychic werewolves terrorizing your clients. This is, of course, empirically vacuous because the treatment itself accounts for so little of outcome variance, while the client and the therapist— and their relationship—account for so much more. The fact of the matter is that psychotherapy is decidedly a relational endeavor, one that is wholly dependent on the participants and the quality of their interpersonal connection, far more consequential than the therapist’s favorite model.
The Dodo Verdict
Over the years, new schools of therapy have propagated like rabbits and arrive with the regularity of new series on Netflix—now adding to over 500 models and techniques. Despite the herculean efforts of legions of model worshipers, no one has succeeded in declaring any religion to be the best. These findings have been creatively summarized by quoting the dodo bird from Alice’s Adventures in Wonderland who said, “Everybody has won and all must have prizes,” first articulated back in 1936 by the amazing Saul Rosenzweig. The so called “dodo verdict” has proven to be the most replicated finding in the psychotherapy literature.
The dodo verdict means that because all approaches appear equal in effectiveness, there are factors in operation that overshadow any presumed differences among approaches that truly account for how people change, the so called, common factors: client, alliance, expectancy, technique, and feedback. The dodo verdict applies to all approaches that have actually done research, even the current favorite in the field of trauma, eye movement desensitization and reprocessing (EMDR). EMDR shows advantage over wait list controls but not reliably over other approaches. Complicating these findings, as reported in Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (Barkham et al., 2021) is that both review/meta-analytic studies of EMDR were rated as containing low or very low-quality evidence. This doesn’t mean that EMDR isn’t helpful or that it may not be useful to learn, but rather that it is not better than anything else despite the cottage industry of certified therapists, supervisors, etc. that has emerged and overrun social media.
And then there are the approaches promising the world that have little to no empirical support, no methodologically sound study addressing the impact in psychotherapy with real clients. Nevertheless, they are quite good at convincing the masses of their magic, especially those unencumbered by critical thought. It is truly amazing what therapists believe, the circulated nonsense that has no empirical support, beyond being trumpeted by “experts” who therapists worship as ultimate authorities.
For example, consider Internal Family Systems (IFS), an approach to psychotherapy that identifies multiple sub-personalities (managers, exiles, firefighters, and the self), families within each person’s mental system. These sub-personalities consist of wounded parts and painful emotions (Exiles), usually from childhood, and parts that try to control and protect (Managers and Firefighters) the person from the pain of the wounded parts. The sub-personalities are often in conflict with each other and with one’s core Self, a concept that describes the confident, compassionate, whole person that is at the core of everyone. IFS focuses on healing the wounded parts and restoring harmony by changing the dynamics that create discord among the sub-personalities and the Self.
Here is how it is described on the official IFS website:
Internal Family Systems is a powerfully transformative, evidence-based model of psychotherapy…IFS is a movement. A new, empowering paradigm for understanding and harmonizing the mind and, thereby, larger human systems. One that can help people heal and helps the world become a more compassionate place.
Wow, not only a psychotherapy approach, but a way to make the world a better place. I am not sure whether to laugh, cry, or barf. The evidence-based part, of course, is a fabrication, and certainly not the way we typically understand “evidence.”
The “evidence” consists of one study using IFT with rheumatoid arthritis patients and one study with 17 clients diagnosed with PTSD. The more details you know about these studies, the more ridiculous it becomes. A total of 79 adults with a diagnosis of rheumatoid arthritis participated in the first study (39 in the intervention group and 40 in the control group). The mean age was 58 years. Approximately 90% of the sample was female and 92% was white. The rheumatoid arthritis education group served as a minimal-attention control, meeting once as a group and then, thereafter, receiving monthly mailed educational information about rheumatoid arthritis. The treatment condition consisted of 12 group and 15 individual sessions with an IFT therapist. The comparison, then, was 27 encounters v. 1. Not surprisingly, they found better results in the IFT group on joint pain, physical functioning, and self-compassion.
First, what this has to do with psychotherapy is completely a mystery but there is a whole legion of therapists who are convinced it is evidence-based. Second, how representative of a psychotherapy population is 39 mostly white, 58-year-old female participants? Not much. Finally, saying that your approach is better than nothing, after 27 sessions of indoctrinating people in your model, is not very impressive.
And the second study is not even a comparison to a wait-list control or anything else. It simply provides IFT to 17 folks diagnosed with PTSD by true believer therapists who provided 16 90-minute sessions. Four clients (24%) dropped out and the “study” found significant benefits on PTSD and other symptoms. Basically, this study found something that has long been known. Psychotherapy works! But it didn’t really say anything about the unique benefits of IFT. Do these two studies warrant the “evidence-based” description?
Typically, when an approach is deemed as evidence-based, it means it is supported by scientific evidence—it has been proven to work in randomized controlled trials published in peer reviewed journals. A number of these types of trials measuring a particular therapy, not one or two studies, leads to a clear consensus as to its effectiveness. When you have a therapy that has undergone rigorous research standards and still shows consistently positive outcomes then you have found an evidence-based practice. That doesn’t apply to IFT or to many of latest fashions in the therapeutic boutique.
Of course, there is nothing wrong with IFT or the variety of mind/body, vagal nerve, etc., therapies out there with little to no real evidence. Each might be just the ticket for a given client. Because an approach is not evidence-based does not mean that it doesn’t have something to offer. But there is nothing inherently right about any of them either.
Don’t be beguiled by the myth of the silver bullet cure.
Instead, spend your time in therapy commensurate to the impact of the elements known to create change: client factors, the alliance, hope and expectancy, and then model and technique. And don’t forget to check in with your client about their progress and the alliance with Better Outcomes Now, a measure-based care system that is truly evidence based.