Where Psychotherapy Goes Wrong

In my post of November 4, 2014, I discussed something called the fundamental attribution error. As described by Richard Nisbett and Lee Ross, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.” That post discussed how this error results frequently in mistaken conclusions that are drawn based on studies of people with personality disorders.

It is also the main reason why psychotherapy has not really progressed much as a science in the last 25 years or so.  The 1980's and early 1990's were a period of amazing creativity in the field, during which new ways of looking at human behavior and new interventions to help change that behavior seemed to be coming out every day. In particular, family systems thinkers began to realize that the causes of behavioral problems like self-destructiveness, as well as the causes of symptoms like chronic dysphoria and anxiety, do not reside entirely within the heads of the people coming for help.  

Some of it can be a normal and adaptive response to a very abnormal interpersonal environment. The "attachment" literature, which is fairly strong, shows that kin behavior has a huge effect on the psychological stability and the relationships of all human beings.  Much more so, I always say, than the food pellets and electric shocks favored by behaviorists.

Due to the wide variety of independent factors listed in the masthead of this block, family systems ideas have, unfortunately, been left behind to a significant degree, and therapists are back to looking at people as if their problems were "all in their heads."

Critics blasted systems ideas by focusing disingenuously on areas about which family systems theorists were completely wrong - like the genesis of such real brain diseases as schizophrenia (and yes, the evidence that schizophrenia is truly a brain disease is overwhelming, so spare me the "myth of mental illness" bullcrap). They pulled the usual slick ploy of making arguments based on black and white thinking: if family systems theorists were wrong about some things, then they must have been wrong about everything.

Because the effectiveness of psychotherapy interventions meant to change interpersonal behavior are hard to prove in a treatment outcome study, the systems people were also accused of being unscientific. As if observation were not the first step in the scientific method! (So much for much of what we know about astronomy). "Outcome studies" were touted as definitive proof of various treatment methods, despite the fact that they are extremely limited in their overall validity because there are almost an infinite number of variables that cannot be controlled. And they cannot be double blinded. And the therapists who are participating are not all doing exactly the same thing.

And the studies that are touted show only exceedingly modest effects in those subjects who do improve, as well as showing that a significant percentage of subjects did not get better at all.

Then there is another important fallacy that psychologists discuss: confusing an inference about an observation with the observation itself. Or, in other words, jumping to conclusions, and then acting like the those conclusions are facts. Andrew C. Papanicolaou, Ph.D, a neurobiologist at the University of Tennessee Health Science Center where I used to work, observes,  "Scientific discourse is unique in that it aims to maintain clear distinctions among assumptions, hypotheses and facts and treat each of them appropriately. Although this aim is often attained, it is rarely attained fully and occasionally is not attained at all."

Especially in psychiatry and psychology.

There's this rather big issue of what is really going on with patients, as opposed to what looks like is going on.  If you do not think people have hidden ulterior motives for their behavior, secrets about themselves that they don't want to share, and lack a complete understanding of the behavior of all of those around them who affect their lives, then I am afraid you are living in an alternate universe.

But still, therapists observe their client's performance, and confuse it with ability, as described in a previous post. Even when therapists look at what is basically interpersonal behavior, they make this error. Good examples of this are two of the current "evidenced-based" therapies for borderline personality disorder (BPD), Schema Therapy and Mentalization-Based Therapy. Both posit that people have mental models of how to behave in the interpersonal world, as well as of the motives and intentions of other people in their world. 

In schema therapy, the theory correctly asserts that these mental models or schemas are built up in childhood through interactions with primary attachment figures. It then goes about trying to change those schemas that it identifies as "maladaptive."  Surely, they are maladaptive in some ways, but that they serve no adaptive purpose at all is just assumed.

Although these therapists have started to look at how the primary attachment figures of their patients are behaving in the present , I have not seen much about the fact that schemas are continually updated (through the Piagetan process of assimilation and accomodation) during a person's ongoing interactions with those attachment figures. To understand what is really happening, you also have to look at the schemas of those other people.  The schemas of the various players in the family drama interact with one another!

Mentalization therapy also deals with a person's mental models of the motivations and intentions of other people, but just assumes that the mental models of their patients with BPD are distorted. This is based entirely on the way the patients respond to others, while completely ignoring the motivations and intentions on which that behavior is based. Maybe the patient wants other people to think they have distorted mental models. Why? Because they are playing the role of spoiler. The incorrect assessment of the accuracy of the patient's mental models is confused with the feigned actions of that patient.

Sorry, but we cannot read minds. You have to look at both the behavior and the history of everyone involved, and even then you can get a highly distorted picture yourself. So therapists should quit accusing their patients of what they themselves are doing - distortion.

People who have a history together base their behavior on that entire history, not just what is going on at any particular moment.  And when they talk, they can leave a lot out (ellipsis) and still understand each other, because they both already know what both of them already know. An outside observer does not know these things, and therefore their conclusions based entirely on what is said in front of them can be way off.

Of course, it is true that a therapist can never be absolutely certain of anything. For that, you would not only need a movie camera with sound on all participants 24 hours a day like in the Truman Show, but this equipment would have to be in place throughout the entire lifetime of the patient since birth!  

Still, the more information therapists can gather on the whole picture, the more likely it will be that they will better understand what might be going on and figure out what can be done to change it.

But first, they have to stop their myopic focus on that which is going on entirely in the patient's head.

Looking Back on an Abusive Childhood from an Adult’s Perspective

I recently read a book by a woman who independently discovered a technique used extensively in a form of psychotherapy called schema therapy. Schema therapy was devised by my colleague Jeff Young.

Beth Louise, the author, writes that she had spent years “…trying to fool myself.  Hiding from my past, from myself, and from everyone else…Trying hard to fake it. Trying hard to survive.  And to forget. Always trying, but never quite getting there.”

When later on she had children of her own, she felt the past welling up inside her, and the memories returning. At some point she took out a pen and wrote a letter to the child of her past - from the perspective of her adult self. She envisioned herself as an observer of that child rather than as that child.  She was not reliving the past, but observing it.

When the process became too painful, she would stop it temporarily, but then return to the disturbing images. She continued on this path and found it extremely healing. Since she was already a writer, she soon found that she had a book that others might be interested in. The resulting manuscript is now available as an e-book, In Shadow and Strength. Her hope is to “inspire others to forge their own paths towards healing.”

Her writings capture in a remarkable way the thoughts and emotions that take hold of a child who is in the middle of a spiral of abuse and neglect.

Reading it, victims of abuse can learn a powerful new technique to help themselves come to terms with their past, while non-victims can better appreciate the terror, guilt, helplessness and uncertainty experienced by abused children everywhere.

Little did she know that the process she had discovered was already a very powerful therapy technique - one that is central to schema therapy. In therapy, however, the therapist takes more of a leadership role by using “guided imagery.” He or she sometimes accompanies the patient on their “trip,” and may even have the patient imagine the therapist in the picture commenting on the action or talking to the participants.

In various sections of her book, Ms. Louise reveals how a child can come to believe that her environment is somehow a normal one, despite observing other children and parents interacting in a healthier family.

She talks about the feeling that perhaps there is something wrong with you, the victim, and how this belief can lead to a sense a guilt about somehow being responsible for what is happening to you. How this guilt can also serve to protect the image of the abusive and neglectful parent.

She reveals how a former abuse victim may go through life hiding her guilt, shame, and trauma, so that others might think there is nothing at all wrong. How doing so makes her feel herself to be a fraud or an impostor. How she believes herself to be counterfeit.

She brilliantly describes the child’s belief that, even when the parents are acting in a loving way, the good times are really just manufactured for the benefit of outside observers, and how they therefore felt phony.

She tears the shroud off the absolute terror and helplessness that comes from living in a chaotic environment with a highly unpredictable, depressed and angry mother.

A beautifully written book without any hint of sensationalism or exhibitionism, I highly recommend In Shadow and Strength.

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder, Part I

The purveyors of Cognitive-behavioral psychotherapy (CBT), one of the large number of “schools” of thought in the fields of psychology and psychiatry, like to tout their randomized controlled outcome studies (RCT’s) as proof that theirs is the most “evidenced based” type of psychotherapy. When it comes to the psychotherapy of borderline personality disorder (BPD), which provides a microcosm for almost every type imaginable of behavioral/relationship issues that are confronted by psychotherapists, two of the most studied paradigms are actually related more to what many psychologists consider to be the opposite type of psychotherapy: humanistic/psychodynamic psychotherapy.  Those models are called transference-focused psychotherapy, TFP, and mentalization-based treatment, MBT.  

A third “empirically validated treatment” called schema-focused therapy (SFT), while based initially on some CBT concepts, takes quite a detour from those and employs techniques adapted from a number of alternate psychotherapy schools.

Actually, the one type of RCT-studied therapy for BPD that is most associated with CBT, dialectical behavior therapy (DBT), also borrows considerably from other schools of thought.  Not only that, but it really has been shown to be effective only for a couple of BPD symptoms, most notably self-injurious behavior (SIB) such as self-cutting.

John F. Clarkin is a highly respect psychotherapy researcher who has perhaps the most experience of anyone in the field.  He recently published an article in the Journal of Personality Disorders (Vol, 26 (1), Feb. 2012, pp. 43-62) entitled, “An Integrated Approach to Psychotherapy Techniques for Patients with Personality Disorder.  In it, he makes what I consider several extremely important and crucial points in the debate about the various treatment ideologies.

John Clarkin, Ph.D.

First, he points out, the empirically "validated" models often focus only on symptoms and not on the more important and enduring aspects of personality. In fact, in longitudinal studies of affected individuals, the personality disorder criteria and symptoms change over time, often all by themselves, while their interpersonal dysfunction does not change very much at all.  This implies that that, while symptom reduction is important, it is the interpersonal issues that should be the major long term focus in therapy. The heart of the matter in personality disorders is the patient’s conception of self and others.  The ultimate goal of treatment should be interpersonal functioning that allow for pleasure, interdependence, and intimacy in relationships.

Second, the literature on outcome studies is based on average scores on symptom-based outcome measures. This covers up the obvious fact that in any treatment, some patients change and some do not.  This is further complicated by the issues of “comorbidity.”  Patients with BPD, for instance, often meet criteria for one or more additional personality disorders, not to mention additional psychiatric disorders. And even within the definition of a single personality disorder, many different combinations of traits are possible to arrive at the diagnosis. Much more so than in any other field of medicine, patients with personality disorders are highly unique. Therefore, no one treatment can or will work for everyone.

Third, as Clarkin states, “A close examination of the treatment manuals…suggests that each manual contains some strategies that are unique and essential to the treatment, and some that are common (sometimes with different jargon) with other approaches."

A fourth important point he makes is that all of these therapies consist of multiple interventions, and the studies do not show which ones are important and which ones are not, or even more importantly, which ones may even be counterproductive: “…most probably contain low doses of effective practices, ancillary but important aspects that make delivery of the treatment more palatable, superstitious behaviors (those we think that matter but do not), and factors that impede or fail to optimize therapeutic change.”

A fifth point he makes that I would like to mention is that it is the delivery of the techniques that is often more important than the techniques themselves.  Techniques can be done skillfully, “…or in an abrasive, authoritarian, or uninterested aloof way.  There is plenty of research data that suggests that the skill of the therapist can be, in many instances, far more important to good results that an individual techniques."  Clarkin adds, “The therapist is not a technique-dispensing machine. Many of the techniques are applied common sense, and could be read out of a book."

Last, let us not forget that the receptivity of the patient is another major factor in whether or not therapy is successful.  If patient factors are not taken into account, the effectiveness of any technique “approaches zero.”  Furthermore, despite the rejection of the concept of transference by CBT therapists, “Some patients with severe needs for attachment with no relationships outsider of treatment may become intensely attached to and preoccupied with the therapist in ways that are detrimental to growth.”

In short, it makes a lot more sense to integrate the various techniques across treatment strategies from the treatment manuals in a way that tailors them to the particular patient in front of the therapist.  Throughout treatment, individual decisions must be made, which takes a skillfull therapist indeed. 

Of the four treatment paradigms that have been subjected to RCT’s, in my opinion schema focused therapy does the best job. Of course, the concepts of "mental schemas" and “mentalization” share much in common. (I will not be defining them in this post).  

My own model, unified therapy, has not been subjected to an outcome study. I applied for an “exploratory” grant to get some initial (pilot) data and was of course turned down by the National Institute of Mental Health. That may or may not have something to do with the fact that the only family-systems-oriented reviewer on my NIMH review committee was replaced at the last minute by DBT founder Marsha Linehan. Someone on the panel accused me of not being “mindful” enough.  I wonder who that might have been?

  

But maybe I’m just being paranoid. As Nassir Ghaemi says, the NIMH's "...limited funding is sparingly distributed: the highly conservative, non-risk-taking nature of NIH peer review is well-known." The study most likely to be accepted by the NIMH is one that has either already been done, or whose outcome is not really in doubt.

To be fair, doing meaningful psychotherapy outcome studies is diabolically difficult. In my book, How Dysfunctional Families Spur Mental Disorders, I went into great detail about a lot of the reasons for this. I’ll summarize what I said in part II of this post.

The Cognitive Behavioral Mafia

I recently posted on my Psychology Today blog what I had written in a previous post from this blog, The Limits of Cognitive Therapy.  In it, I had the audacity to criticize one very prominent technique used in Cognitive Behavioral Psychotherapy (CBT), and discussed how it neglects a type of cognition that is central in personality pathology (the family myth). I also complained that CBT therapists grossly exaggerate the strength of their evidence base from randomized controlled psychotherapy outcome studies while simultaneously blocking funding research into other forms of treatment.

Researchers who look at other psychotherapy techniques and are members of the Society for Psychotherapy Research (a group I used to hang with for several years), refer to the "cognitive behavioral mafia" at the NIMH, which systematically blocks grants for research into other therapy schools.  Leading trauma researcher Bessel van der Kolk couldn't get a psychotherapy research grant at one point because of it!

They also blocked me from getting a small grant to study my therapy paradigm, unified therapy.  The grant I had applied for was supposed to be for researchers to get preliminary data – called pilot data – for new ideas.  Although the rejection I got did point out some very valid things I needed to change with the proposed study design (and would have been readily agreeable to doing so and then resubmitting the grant proposal), their biggest criticism of my proposal was that I did not have any pilot data! 

Writing two books on psychotherapy and having 20 years of clinical experience (at that time) did not count at all.  I did not get a low score, I got no score. Roughly translated: faggetaboutit.

In response to my Psychology Today post, not surprisingly The CBT folks went on the attack.  In fact, another blogger on Psychology Today named Robert L. Leahy posted a rebuttal on his blog. I was accused of being a – horror of horrors – psychoanalytic psychotherapist, which I of course am not in the least.

While I can see how many people might have mistaken my post, because of my broad style, for an attack against the entire CBT treatment model - which if you read the post carefully it decidedly is not - I was accused of mischaracterizing the entire field because I was talking about one specific although very central intervention they use.

Cognitive therapy pioneer Albert Ellis called it active disputation and the other cognitive therapy pioneer Aaron Beck called it collaborative empiricism. Interestingly, some other commenters implied that the technique I focused on  is no longer being used at all by the other main innovator of CBT, Aaron Beck.   This is patently untrue.  He just changed the name to cognitive restructuring  or guided discovery.

In the post, I had given an example of a family myth in action in a psychotherapy case.  In the early 1980’s, I was trying out a technique from paradoxical psychotherapy called reframing, in which a family member labels something as bad and the therapist changes the valence to good.  For instance, an acting out child is described as the savior of the parents marriage because he or she is distracting them from their arguments.  (Technique used best by family systems therapy pioneer Salvador Minuchin). 

I was accused by the critics of “arguing with my patient” and that I was both doing and oversimplifying the cognitive therapy technique. Some of them also seemed to dismiss Albert Ellis in favor of Beck, as Ellis definitely did argue with patients until he died, although in a very empathic way. 

Salvador Minuchin

This contention might be true if one’s definition of argument is limited to the type of argument seen in Monty Python’s argument clinic:

 “Yes it is.”

“No it isn’t!” 

“Yes it is!”

 “No it isn’t!” 
 

What Beck does instead is examine the “empirical evidence” for the patient’s “irrational” thoughts to see if it is consistent with the facts.  That, my friends, is a form of argument (as is reframing –also not merely contradicting the patient).

From a discussion of cognitive therapy on Psych Central: “Cognitive-behavioral therapy, in a nutshell, seeks to change a person's irrational or faulty thinking and behaviors by educating the person…”  They won’t get an argument from me.

Another thing I was accused of was that I did not acknowledge that CBT has changed from the early days and has become a much more complete treatment, even though my original post clearly stated:

It is interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in severe personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  

This criticism was actually one I considered to be fair, and I quickly acknowledged that CBT has evolved considerable from its early days.  However, I pointed out that the evolution mostly consisted of stealing, slightly reinterpreting, and renaming concepts and techniques from other psychotherapy schools.  Even the central psychoanalytic concept of transference, vehemently denied by both behavior therapy and cognitive therapy since their inception, is merely redesignated as “the client's underlying schema about themselves and others.”

Speaking of schemas, the critics particularly complained that I wasn’t acknowledging them because I said that both Beck and Ellis (not CBT in general) have both said repeatedly that they believe that human beings are fundamentally irrational.  The concept of schemas, or mental models of how relationships and other things in the world are supposed to work, did not originate completely within CBT circles. 

Mardi Horowitz was one of the first widely read psychotherapists to talk about it - and he was psychoanalytically-oriented.  The concept of life scripts, which are basically several schemas linked together to form a plan for one’s life, was originated by another therapy school called transactional analysis.

I also happen to know Jeff Young, who is the main champion of using cognitive schemas in therapy.  He had in fact been a protégé of Aaron Beck, and was one of the cognitive therapists in the big NIMH collaborative study on depression in the 80’s (which incidentally also found interpersonal therapy equally effective to CBT in "depression"). Jeff personally told me that many of his former colleagues in cognitive therapy circles turned on him when he started to talk more about issues such as the effects of child abuse.

It is also true that Jeff Young had to go to Holland to get funding for a psychotherapy outcome study of schema therapy.

Another person commenting accused me of "whining" about the CBT mafia because I mentioned that I was blocked by them from getting research funding.

Still another thing that I was accused of doing was denigrating psychotherapy research in general, which is also something I did not do.  I had merely opined that the CBT people were over-selling the strength of their research results. 

Critics immediately jumped into my favorite form of sophistry: circular reasoning.  They basically made the point that because cognitive therapy was scientifically proven (not!), money should not be wasted on studying other paradigms!  In other words, why do we need more studies when we're already convinced.

Many of the critics also seemed to be saying that CBT was some sort of monolithic entity and did not acknowledge that there are several sub-schools of CBT which all approach patients differently  and which argue among themselves about who is right.  There is ACT, REBT, DBT, and schema therapy, to name but a few.  Schema therapy in particular is quite unlike the original form of cognitive therapy, as it not only looks at the developmental origins of so-called irrational ideas but sees the origins as central to the actual therapy. 

At least one critic went on to accuse me of being unscientific because I was not using CBT therapy exclusively with my patients, as well as being possibly unethical because I used "unscientific" treatments:  “It is also clear you practice a therapy with no established evidence base. An eclectic mix that where you've picked and chosen what you like from different schools without the package being subject to evaluation. Overall this sounds like deeply unethical (and potentially dangerous) clinical practice.”

Oh, like that isn't what all therapists do - including CBT therapists who pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them without having their "whole package" subject to evaluation. Of course, by the critic's reasoning, the originators of all the CBT techniques were all unethical because they undoubtedly tried them out on patients before packaging them for outcome studies.

This critic illustrates another point of confusion: a basic misunderstanding of psychotherapy research. As I said, CBT therapists in treatment studies pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them and then subjecting the "whole package" subject to evaluation. Since every therapist in the study is doing something somewhat different with each patient, a truly scientific evaluation of “the “package” would be quite a feat!

In fact, outcome research does not focus on specific techniques but on some overall strategies. Finding out which techniques were valuable and which superfluous on their menu of interventions would require something called dismantling studies, which are few and far between. Psychotherapy process research, on the other hand (of which there is a huge literature that dwarfs the outcome research) does focus on specific techniques, and often shows that techniques used by more humanistic and relational therapies are highly effective for certain therapeutic goals.

Adherence to the therapy model by the different therapists participating in an outcome study is another big issue. If it is measured at all, it almost always shows wide variation. There is usually no "red line" by which, if a therapist's adherence to the model goes below a certain point, his or results are not included in the study! So what really worked?  We don't know. 

The critics on both Psychology Today blogs seem to be proving my point that CBT grossly exaggerates its science base. When I and another commenter pointed out specific and highly significant weaknesses in their literature, the silence was deafening.

Also noteworthy that not a single critic had anything to say about the issue that was the main point of my blogpost – the existence and importance of family myths. I asked them for references where this issue or where any social psychological concept that was similar had been discussed by CBT therapists. Not a word.

To my knowledge, cognitive therapists have never written about how many allegedly irrational ideas are held collectively by kin groups.  Ignoring collective phenomena is actually a problem with almost all forms of individual psychotherapy, because therapists are entirely wrapped up only with what goes on inside people's heads.

The sole complaint of the only critic that even mentioned family myths was that I had not brought it up until the tenth paragraph of my original post. (That was because I had to explain some concepts from cognitive therapy before my criticism would make sense). So sue me.

I was too lazy to quote a bunch of studies to demonstrate the weaknesses in their science, and I figured they would merely cherry pick some counter-examples and then summarily declare victory.  However, another reader came to my rescue.

****Submitted by Philip on November 26, 2011 - 6:34am.

I have been reading a number of outcome studies recently because I am seriously worried by claims that 6 to 20 sessions of cognitive behavioural therapy are sufficient to cure such disorders as major depression and anorexia nervosa.

Allow me to summarize, briefly, the findings of a meta-analysis of CBT for bulimia nervosa. The rate of recovery for patients who completed treatment was found to be around 45%. This is quite substantial - a substantial minority of patients recover after and average of 12 sessions of CBT or behaviour therapy (they are equivalent in effect). It should be noted that there is very little follow-up data by which to judge whether or not these patients remained well.

However, consider the following:

20% of patients dropped out of treatment. 40% of patients who were initially considered for inclusion in the studies were excluded from treatment. This is because, as Dr Allen correctly noted, such studies exclude co-morbid patients (those with multiple diagnoses). Thus, the treatment samples are composed of less complex cases.

As an aside, most outcome studies of CBT for depression exclude around 60-70% of patients - again, because these cases are considered too complex to treat with CBT.

Back to bulimia. On average, after completing treatment, patients continued to binge/purge twice per week. So, although the treatment resulted in a statistically significant reduction in symptoms, many - perhaps most - patients remained symptomatic.

Thus, 45% of a restricted sample (which excluded severely disturbed patients bulimia, patients with bulimia and drug or alcohol addictions, suicidal patients with bulimia and patients with 'borderline personality' disorder and bulimia) reportedly recovered (with little follow up data to support this conjecture).

One of the authors of a study reporting these results concluded that CBT is the "treatment of choice" for Bulimia Nervosa. It is the only treatment that has been adequately studied. This is what Dr. Allen is referring to when he notes that the credentials of CBT are exagerated.

If we actually think about Bulimia in the real world - where most patients have severe co-morbid disorders, and 50% also have a borderline pattern of symptomalogy - these studies tell us little about the efficicy of CBT. In the lingo of researchers, outcome studies have little 'external validity'.

Why is it that researchers are unwilling to apply CBT to complex or co-morbid cases? They claim it is because they want to exercise experimental control - they want their studies to have internal validity. That is, they want to know which treatment works for which disorder.

It is also very likely that, were researchers to attempt to treat severely disturbed patients with CBT, they would fail to obtain results which reflect well on CBT. They also would have a hard time getting their work published, for journals do not like to publish null [negative]-findings.

If one is willing to read the research carefully, and has a basic education in statistics and research methods, the evidence supporting the effectiveness of CBT is very modest. Indeed, CBT contains a smaller and less diverse 'evidence base' than does cotemporary psychoanalytic psychotherapy.

What CBT has more of than other psychotherapies is outcome research. However essential outcome studies are, they "prove" nothing about the validity CBT. For all they show, the patient might be cured because of a placebo effect or because of cognitive restructuring. Same same but different.

This is called, by the way, the dodo bird effect: the finding that all treatments are equivalent (whether they be behavioural therapy, CBT, 'psychodynamic' therapy, interpersonal therapy and so on). That's what outcome studies tell us. And we don't know why. It seems that the debate is only just starting, and some have already declared CBT the winner.

Thanks, Philip.

When it comes to getting people to change their behavior, thoughts and feelings, there is always a multitude of ways to skin the proverbial cat.  And every patient responds to interventions differently. This is where social sciences differ from hard sciences like physics.

"CBT therapists are superior to therapists from all other schools of thought, so come see us." This exaggeration of the research results by CBT folks looks a lot like the same phenomenon seen in drug studies these days: it isn’t so much science as marketing.

Neural Plasticity

As I discuss in detail in my upcoming book, one way that some "biological" psychiatrists twist the truth in order to justify their belief that certain behavioral problems are due to brain disorders has to do with the neuroscientists' new toy, the Functional MRI (fMRI). fMRI machines, because they measure magnetic fields, can map both brain structure and brain function because the iron in blood that passes through the brain creates a magnetic field.

What researchers do is to use fMRI to compare certain brain structures and brain activity, particularly in the primitive part of the brain called the limbic system, in some diagnostic group with matched controls or "normals." For instance, an important brain structure called the left amygdala is smaller, on average, in patients who exhibit the signs of borderline personality disorder (BPD) than in "normals."

Of course, they are comparing averages, so the left amydala in some BPD patients is larger than those of the average "normal." Notice also that the scientists only occasionally compare different diagnostic with each other. Differences in amygdalar size and activity are found in any number of different diagnostic groups in psychiatry.

The more annoying source of misleading conclusions is that when a difference is found between a diagnostic group and "normals," that difference is automatically labeled an abnormality. If a patient has an abnormality, then of course they must have a brain disease. Actually, these scientists do not know if what they have found is an abnormality or not. What makes the use of the term abnormality totally misleading is that the brain, particularly in terms of limbic system structures, is plastic. This means that, in the normal brain, these structures can change in size to reflect activities that become important to a given individual. The changes can be very quick and substantial.

For example, in the February 2010 issue of the Archives of General Psychiatry (Volume 67 [2] pp. 133-143), Pajonk, Wobrock, Gruber et. al. found that after just three months of a vigorous exercize program, the size of a brain structure called the hippocampus increased an average of 16% in normals! It is also true that the part of the brain that controls finger movements is, on average, much larger in concert violinists than in non-musicians. The conclusions that the so-called biological psychiatrists would be, I guess, that both being a concert violinist and engaging in vigorous exercize are diseases!

Well-known personality disorder researcher and schema therapist Arnoud Arntz has told me that he has some unpublished preliminary evidence that the amygdala changes seen in BPD are reversible with three years of Schema Psychotherapy (a therapy method developed by Jeffrey Young). Thus, these so called "abnormalities" may in fact be conditioned responses from living in a chaotic and invalidating family environment. Not only may they be quite normal, they may be adaptations to the enviroment.