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Jan 21, 2019

I hope you've enjoyed these episode on Common Therapist Errors, and I apologize in advance if any of the ideas I'm proposing in today's podcast seem "over the top" or simply off base.

I teach with great passion, but I'm not always right! Fortunately, my esteemed host, Dr. Fabrice Nye, challenges me quite a bit, and he is almost always right. Hopefully, you will enjoy our dialogue and the chance to think a bit more critically about psychotherapy. 

And when you find I've made an error, or said something offensive to you, I hope you will put it in perspective. I'm kind of a mixed bag, to be honest. I believe I have a lot to offer, but I've got tons of flaws, too! I fight my flaws, but not always with success.

For better or worse, here are today's therapist errors! 

1. Confusing psychoeducation with psychotherapy. Pyschoeducation can be helpful, but it's rarely curative. Effective psychotherapy requires much more.

Here are some examples of helpful psychoeducation:

  • Teaching people about the list of ten common cognitive distortions from David's book, Feeling Good: The New Mood Therapy
  • Teaching people how to pinpoint their negative feelings at any moment in time using David's Daily Mood Log
  • Teaching people that your thoughts, and not external events, create all of your positive and negative feelings
  • Explaining the Five Secrets of Effective Communication
  • etc. etc. etc.

Psychotherapy means helping people CHANGE the way they think and feel, or helping people develop more loving and satisfying personal relationships. That requires a great deal of therapeutic skill and hard work on the part of the patient--during sessions and between sessions. it also requires a warm and trusting therapeutic alliance.

2. Belief in Gurus. Believing that the individuals who start schools of therapy are nice and well-balanced individuals! David describes conversations with the late Albert Ellis, PhD, who argued that many, and arguably most, are incredibly narcissistic and manipulative. Sometimes, individuals who appear incredibly charming and brilliant and inspiring have a dark underbellies they are keeping hidden!

David argues that it might be more desirable to have a science-based, data driven, systematic approach to psychotherapy, as opposed to a field dominated by therapeutic schools, which sometimes function almost like competing cults.

3. Reverse / “backward” statistical reasoning. Most therapists who work with patients with Borderline Personality Disorder as well as Multiple Personality Disorder, as well as patients who are prone to violence, believe that childhood trauma, deprivation, or abuse is the main cause of these problems. They believe this because patients with those diagnoses frequently describe traumatic experiences in their past, so they assume those experiences caused the patient's disorder. 

This is a statistical and conceptual error, because most individuals who experienced traumas when growing up never developed Borderline Personality Disorder or Multiple Personality Disorder. This is not to say that traumas are unimportant—traumatic experiences at any phase of life can be very damaging. What this DOES mean is that most psychiatric problems have other causes. 

What are those other causes? They are not known, for the most part.

This information is not easy for many people to accept. For example, I just found this statement on WebMd:

“As many as 99% of individuals who develop dissociative disorders have recognized personal histories of recurring, overpowering, and often life-threatening disturbances at a sensitive developmental stage of childhood (usually before age 9)."

Here’s another web comment:

“Several studies have shown that a diagnosis of BPD is associated with child abuse and neglect more than any other personality disorders [78], with a range between 30 and 90% in BPD patients [79].”

The same source also stated that:

“. . . Widom and collaborators [12] followed 500 children who had suffered physical and sexual abuse and neglect and 396 matched controls, and they observed that . . . the presence of a risk factor, such as adverse childhood events, was not necessary or sufficient to explain the reason why some individuals developed BPD symptoms in adulthood, whereas others did not.”

If you are interested, you can find the references to these studies at the end of this blog.

Here is one way of understanding this error. Childhood sexual abuse is far more common in the population (typically estimated in the range of 15% of men and 25% of women), and if you add childhood trauma or neglect, these percentages in crease even more. AT the same time, the incidence of Borderline Personality Disorder or Dissociative Identity Disorder are typically estimated around 1%. That means that most individuals who have experienced childhood sexual abuse, neglect or trauma do not develop these disorders. 

I do not in any way mean to minimize the importance of trauma, sexual abuse or neglect. The impact of these experiences can be profound and can include physical as well as psychological problems.

My only point, and perhaps it is an overly humble one, is that we simply do not know the causes of most (or any) of the problems listed in the DSM5 (Diagnostic and Statistical Manual of the American Psychiatric Association.) I think it is great that we have many treatments that can be helpful and effective for individuals, but it might not further our cause to jump to conclusions about the causes of things based on what we see before our eyes when we are doing clinical work.

Sometimes, seeing is believing, but sometimes, our "seeing" can be misleading. 

I hope I have not offended anyone! 

4. Believing in Mental Disorders. Do the so-called Mental Disorders” described in the DSM actually exist? Or are they simply the fabrics of our imagination?

Years ago, Thomas Szasz, a psychiatrist and psychoanalyst, wrote a popular and controversial book called The Myth of Mental Illness, in which he claimed that mental disorders do not exist. David argues that Szasz was only partially right. Most of what we see in the DSM are simply arbitrary constructs, and not real "disorders." For example, most people worry about things from time to time. Worrying is unpleasant but normal, and there is a wide range of worrying in the population. Some people rarely worry, and some people almost constantly worry, and most of us are in-between. 

The American Psychiatric Association will take the group who worry the most, and give them a label of "Generalized Anxiety Disorder." But there is no such "thing." It is not a real brain disorder. The same problem afflicts a great many of the so-called "disorders" listed in the DSM. These are problems, not brain disorders.

However, there are several real brain disorders, such as schizophrenia, Bipolar I Manic-Depressive Illness, and Alzheimer's Disease. These are disorders of brain tissue or wiring, and are not simply variants of normal human behavior or experience. 

When I work with individuals, I measure the severity of symptoms and say things like this, "Jim, I can see you tend to be very shy (or depressed or anxious, or whatever.)" I do not say, "Jim, I want you to know you have a brain disorder called "Social Anxiety Disorder," because I feel that is potentially upsetting to the patient and not really "true." In addition, shyness can be fairly easily treated in most cases without medication.

Most non-MD therapists do not make the mistake of confusing symptoms with "mental disorders." It seems likely to me (David) that psychiatrist are more likely to make this mental error, since psychiatry, as I understand it, is emulating the medical model of diagnosis followed by medication treatment or some other kind of biological intervention. 

5. Ignoring a Diagnostic Evaluation. Most therapists skip a formal diagnostic evaluation, because the DSM is so difficult to work with, and since a formal diagnostic interview can be frustrating and time-consuming. And, as I pointed out in my discussion of the previous error, it is somewhat misleading to tell patients they have mental disorders, like "Generalized Anxiety Disorder" or "Social Anxiety Disorder," when, in reality, the patient is simply shy or has a tendency to worry a lot.

And yet, there can be significant negative consequences of NOT doing a thorough initial evaluation of the patient's many symptoms, since you can easily overlook something important, like drug or alcohol abuse, or suicidal or violent urges in new patient.

The EASY Diagnostic Survey provides a fresh and helpful option. patients can complete it on their own, between sessions, and it automatically diagnoses more than 50 of the most common "disorders" in DSM5. Then the therapist can review it during a session and assign the diagnoses in less than ten minutes in most cases.

This provides the therapist with an accurate map of the patient's problems. You do not have to think of them as a variety of "mental disorders," but rather as areas of suffering and difficulty. I don't tell myself I'm treating "Generalized Anxiety Disorder," but rather treating a human being who is troubled by constant and excessive worrying--and fortunately, that is very treatable!

Therapists who are interest in purchasing a license to use the EASY in your clinical work can check this link