For our resident psychologists

[danimal]

Originally Posted by MikeWaters

Many of the psychiatrists I know in private practice don't deal with insurance or managed care at all. Cash-only. If you want to bill your insurance, you do it on your own.

To take insurance, you have to pay someone to take care of that process, and that's at least 30k out of your pocket right there.

Managed care only works in the 15min med check model, which as I have said before, has a place. But not everyone wants to do that (both patients and MDs).

The problem is that your clients have to be finanancially sound. Only so many people can be supported that way.

[OhioBlue]

Originally Posted by danimal

I hope you're right, OhioBlue. I worry though that it's a decision that psychologists won't be making. Managed care will make it. Psychologists who don't prescribe will end up getting reimbursed at a lower level -- it won't be cose effective enough for them. 9 out of 10 psychologists can disagree with it, they'll just end up poorer for it. It will no longer be worth getting a phd when you can get paid the same to be a social worker.

People like you, who work at counseling centers (at least I think you do) at Universities, may be better off because you don't deal with managed care. But for those who deal with managed care, I think the writing is on the wall.

Edit---sorry this was supposed to quote Mike's post about CBT.

I could go on for a while on this topic, so I'll try to be concise. I have no problem with CBT per se. I have a problem with mindless implementation of any set of techniques at the expense of the effort it takes to try to understand the person in front of you. I have a problem with therapists that, when faced with the complexity and ambiguity of trying to help another human being, assuage their own anxiety by just picking up their favorite hammer and assuming everyone is a nail. I have a problem with those who sing the praises of CBT or other similar techniques but whose eyes glaze over with confusion when you ask them about the implications and philosophical assumptions of what they're doing and why. IMO, some of the most dangerous therapists out there are those who use technique for technique's sake, with no ability to explain why they are doing what they are doing. The ones that are constantly looking to fill up their tool belt with cute little in-session activities and techniques, and take a flavor-of-the-month approach to their client's problems. I believe that fortunately, sometimes these therapists succeed in spite of themselves, because thankfully our clients are often capable of distilling from the therapy experience those things that are actually helpful to them. But it's interesting to me that, despite every camp's efforts to prove the greater efficacy of their approach (CBT, DBT, Cognitive, dynamic, etc etc etc), the meta-analytic research simply does not bear that out. In other words, we're not very good as a profession at identifying how it is that we're actually most helpful to people (see anything by Bruce Wampold, or google therapy and the Dodo Bird effect).

I hope that explains my position a little better. I use cognitive and behavioral principles all the time in my work, and successfully.

[MikeWaters]

there are many things that are common to almost all therapies that are helpful. Positive regard, therapeautic alliance. Someone just danged listening to you and giving a damn.

CBT in many way requires more effort in my opinion. You have to be more verbal, you have to explore their worldview, their cognitions. CBT is hardly plug and play in my opinion. Because everyone has a different set of issues, beliefs, and behaviors.

The dangerour therapist can be the one that knows more about the philosophy that you would ever care to listen to, and is very invested in that school or this school, etc. I picked up a Freudian journal once, started reading an article. It made Sleeping in EQ writing seem like a kids book. So much jargon, back story, etc. as to be meaningless but to about 200 people in the country.

I'm much more interested in efficacy that philosophy. One needs to be careful not to say "I won't use a SSRI because I don't understand how it really treats depression, despite a lot of evidence to show that if helps people."

You look at most discoveries in medicine, and it was efficacy that was noted, and mechanism was explored secondarily.

[danimal]

Originally Posted by OhioBlue

I could go on for a while on this topic, so I'll try to be concise. I have no problem with CBT per se. I have a problem with mindless implementation of any set of techniques at the expense of the effort it takes to try to understand the person in front of you. I have a problem with therapists that, when faced with the complexity and ambiguity of trying to help another human being, assuage their own anxiety by just picking up their favorite hammer and assuming everyone is a nail. I have a problem with those who sing the praises of CBT or other similar techniques but whose eyes glaze over with confusion when you ask them about the implications and philosophical assumptions of what they're doing and why. IMO, some of the most dangerous therapists out there are those who use technique for technique's sake, with no ability to explain why they are doing what they are doing. The ones that are constantly looking to fill up their tool belt with cute little in-session activities and techniques, and take a flavor-of-the-month approach to their client's problems. I believe that fortunately, sometimes these therapists succeed in spite of themselves, because thankfully our clients are often capable of distilling from the therapy experience those things that are actually helpful to them. But it's interesting to me that, despite every camp's efforts to prove the greater efficacy of their approach (CBT, DBT, Cognitive, dynamic, etc etc etc), the meta-analytic research simply does not bear that out. In other words, we're not very good as a profession at identifying how it is that we're actually most helpful to people (see anything by Bruce Wampold, or google therapy and the Dodo Bird effect).

I hope that explains my position a little better. I use cognitive and behavioral principles all the time in my work, and successfully.

Few psychologists that i speak with are familiar with Wampold or most psychotherapy research. The simply do what they were taught to do -- CBT. That's the problem with being both a research and a professional degree. Few people are well informed by both.

[danimal]

Originally Posted by MikeWaters

there are many things that are common to almost all therapies that are helpful. Positive regard, therapeautic alliance. Someone just danged listening to you and giving a damn.

CBT in many way requires more effort in my opinion. You have to be more verbal, you have to explore their worldview, their cognitions. CBT is hardly plug and play in my opinion. Because everyone has a different set of issues, beliefs, and behaviors.

The dangerour therapist can be the one that knows more about the philosophy that you would ever care to listen to, and is very invested in that school or this school, etc. I picked up a Freudian journal once, started reading an article. It made Sleeping in EQ writing seem like a kids book. So much jargon, back story, etc. as to be meaningless but to about 200 people in the country.

I'm much more interested in efficacy that philosophy. One needs to be careful not to say "I won't use a SSRI because I don't understand how it really treats depression, despite a lot of evidence to show that if helps people."

You look at most discoveries in medicine, and it was efficacy that was noted, and mechanism was explored secondarily.

But there's no evidence that CBT is more effective than other approaches.

[MikeWaters]

Originally Posted by danimal

But there's no evidence that CBT is more effective than other approaches.

than no other therapies? I'll bet I can show that is wrong.

[danimal]

Originally Posted by MikeWaters

than no other therapies? I'll bet I can show that is wrong.

Well, it's more effective than birthing therapy and other wacko stuff. But compared to emotion focused therapy (humanistic), brief psychodynamic therapy, or other generally accepted approaches, the results are consistently equivalent.

[OhioBlue]

Originally Posted by MikeWaters

there are many things that are common to almost all therapies that are helpful. Positive regard, therapeautic alliance. Someone just danged listening to you and giving a damn.

CBT in many way requires more effort in my opinion. You have to be more verbal, you have to explore their worldview, their cognitions. CBT is hardly plug and play in my opinion. Because everyone has a different set of issues, beliefs, and behaviors.

The dangerour therapist can be the one that knows more about the philosophy that you would ever care to listen to, and is very invested in that school or this school, etc. I picked up a Freudian journal once, started reading an article. It made Sleeping in EQ writing seem like a kids book. So much jargon, back story, etc. as to be meaningless but to about 200 people in the country.

I'm much more interested in efficacy that philosophy. One needs to be careful not to say "I won't use a SSRI because I don't understand how it really treats depression, despite a lot of evidence to show that if helps people."

You look at most discoveries in medicine, and it was efficacy that was noted, and mechanism was explored secondarily.

It's hard to explain what I mean in this forum, and I sense that I'm probably not doing a very good job. I don't mean that I sit and talk philosophy with all my clients. In fact, I don't ever do that. I'm with you on minutiae, unneeded intellectual exercise, jargon, etc. I'm just saying that in the enterprise of helping people--who are in their very nature quite complex--you better darn well have a good understanding of why you do what you do, what the costs and benefits are, and what the underlying assumptions about truth and the world are. So a journal article said CBT works. Okay, what do they mean by 'works?' From a cognitive-behavioral philosophy, what do we care about? What don't we care about? Why or why not? What is de-emphasized in favor of changing how one thinks? What if changing how someone thinks brings only temporary relief, while they're actively practicing those techniques, but can't possibly hold up in the long-term in other important areas having to do with quality of life? What does a CBT approach assume about the primacy of thought to emotion? Is it reductionistic in any way? Is it deterministic in a linear way, or can it allow for teleological action? How does it address the quality of one's relationships with others in their world? etc etc etc.

That's before we even get to the complexity of the person sitting in front of us, and how that whole picture interacts with the treatment modality we might intend to use.

As for CBT not being plug and play, that's good if it's true for you. I assure you that for many many clinicians, that is not the case, and plug and play is most assuredly what happens.

Lastly, you are going to do what you're most comfortable with, but allow me to implore you (and me and us) to continue to make efforts to combine conclusions about efficacy with critical thinking about those same conclusions (ie, philosophy). I don't necessarily mean reading Kierkegaard or Heidegger, I mean the enterprise and practice of critical examination beyond the surface level. I need not point out the dangers evident throughout our world's history in imposing practices based on assumptions about their efficacy, without ever critically thinking about them. There is a place, and a need, for both. To ignore the philosophy side is in my humble opinion to be lazy and unprofessional.

[OhioBlue]

Originally Posted by MikeWaters

than no other therapies? I'll bet I can show that is wrong.

I think we all know that in our field it is possible, easy even, to comb the research out there and find things that will justify just about any position. We all also know that despite what we were taught in research method classes, people do research intent on finding things, and voila they do.

The literature on efficacy of therapy outcomes is full of disagreement and debate. EST and EBP folks put a lot of money into justifying their position and ultimately hope to change policies so that we all end up with tx manuals and protocols based on DSM diagnoses. The other side argues that it's all bunk, that we're identifying specific ingredients responsible for change that just don't hold up in the final analysis. That's before we even get to what I believe is one of the biggest questions we don't like to deal with in our field--and that is, what do we mean when we say a treatment works?

If you want to read an interesting book, pick up Wampold's The Great Psychotherapy Debate. THere's plenty others out there, but he tears apart the outcomes research and shows convincing meta-analytic results.

Then go and read the responses to Wampold, and his critiques.

Then decide for yourself. But at least notice that there is hardly anything in our fields upon which we universally agree, or which we ratify as 'Truth.'

Which is all the more reason to critically examine why we do what we do, and know the costs/benefits, implications of our practices. The responsibility to help other people is a huge one, an honorable one (most times), and bears IMO significant weight to not gloss over the difficult questions.

I'm off to watch the game. Fascinating discussion, I loved it. It would be fun to get us all together sometime for lunch.