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Psychotherapy is not harmless: on the side effects of CBT
The structured nature of cognitive behavioural therapy (CBT) and its clearly defined principles (based on the links between thoughts, feelings and behaviours) make it relatively easy to train practitioners, ensure standardised delivery and measure outcomes. Consequently, CBT has revolutionised mental-health care, allowing psychologists to alchemise therapy from an art into a science. For many mental-health conditions, there is now considerable evidence that CBT is as, or more, effective than drug treatments. Yet, just like any form of psychotherapy, CBT is not without the risk of unwanted adverse effects.
A recent paper in Cognitive Therapy and Research outlines the nature and prevalence of these unwanted effects, based on structured interviews with 100 CBT-trained psychotherapists. 'This is what therapists should know about when informing their patients about the upcoming merits and risks of treatment,' write Marie-Luise Schermuly-Haupt of the Charité University of Medicine in Berlin and her colleagues.
The researchers asked each CBT therapist (78 per cent of whom were female, average age 32, with an average of five years' experience) to recall their most recent client who had taken part in at least 10 sessions of CBT. The chosen clients mostly had diagnoses of depression, anxiety or personality disorder, in the mild to moderate range.
The interviewer – an experienced clinical psychologist trained in CBT – followed the checklist of unwanted events and adverse treatment outcomes, asking each therapist whether the client had experienced any of 17 possible unwanted effects from therapy, such as deterioration, new symptoms, distress, strains in family relations or stigma.
The therapists reported an average of 3.7 unwanted events per client. Based on the therapists' descriptions, the interviewer then rated the likelihood of each unwanted event being directly attributable to the therapeutic process – making it a true side effect (only those rated as 'definitely related to treatment' were categorised as such).
Following this process, the researchers estimated that 43 per cent of clients had experienced at least one unwanted side effect from CBT, equating to an average of 0.57 per client (one client had four, the maximum allowed by the research methodology): most often distress, deterioration and strains in family relations. More than 40 per cent of side effects were rated as severe or very severe, and more than a quarter lasted weeks or months, though the majority were mild or moderate and transient. 'Psychotherapy is not harmless,' the researchers said. There was no evidence that any of the side effects were due to unethical practice.
Examples of severe side effects included: 'suicidality, breakups, negative feedback from family members, withdrawal from relatives, feelings of shame and guilt, or intensive crying and emotional disturbance during sessions'.
Such effects are not so surprising when you consider that CBT can involve exposure therapy (ie, gradual exposure to situations that provoke anxiety); discussing and focusing on one's problems; reflecting on the sources of one's stress, such as difficult relationships; frustration at lack of progress; and feelings of growing dependency on a therapist's support.
The longer that a client had been in therapy, the more likely she was to have experienced one or more side effects. Also, and against expectations, clients with milder symptoms were more likely to experience side effects, perhaps because more serious symptoms mask such effects.
Interestingly, before the structured interviews, the therapists were asked to say, off the top of their heads, whether they felt that their client had had any unwanted effects – in this case, 74 per cent said they had not. Often it was only when prompted to think through the different examples of potential side effects that therapists became aware of their prevalence. This chimes with earlier research that's documented the biases which can lead therapists to believe that therapy has been successful when it hasn't.
Schermuly-Haupt and her colleagues said a conundrum raised by their findings was whether unpleasant reactions that might be an unavoidable aspect of the therapeutic process should be considered side effects. 'We argue that they are side effects although they may be unavoidable, justified, or even needed and intended,' they said. 'If there were an equally effective treatment that did not promote anxiety in the patient, the present form of exposure treatment would become unethical as it is a burden to the patient.'
There are reasons to treat the new findings with caution: the results depended on the therapists' recall (an in-the-moment or diary-based methodology could overcome this problem), and about half the clients were also on psychoactive medication, so it's possible that some adverse effects could be attributable to the drugs rather than the therapy (even though this was not the interviewer's judgment). At the same time, though, remember that the researchers used a conservative estimate of side effects, only considering those that were 'definitely' related to therapy by their estimation, and ignoring those that they considered 'rather' or 'most probably' related.
The researchers concluded that: 'An awareness and recognition of unwanted events and side effects in all therapies will benefit patients, improve therapy or reduce attrition, analogous to the benefit of measurement-based monitoring of treatment progress.'
This is an adaptation of an article originally published by The British Psychological Society’s Research Digest.
This article was originally published at Aeon and has been republished under Creative Commons.
These alien-like creatures are virtually invisible in the deep sea.
- A team of marine biologists used nets to catch 16 species of deep-sea fish that have evolved the ability to be virtually invisible to prey and predators.
- "Ultra-black" skin seems to be an evolutionary adaptation that helps fish camouflage themselves in the deep sea, which is illuminated by bioluminescent organisms.
- There are likely more, and potentially much darker, ultra-black fish lurking deep in the ocean.
The Pacific blackdragon
Credit: Karen Osborn/Smithsonian<p>When researchers first saw the deep-sea species, it wasn't immediately obvious that their skin was ultra-black. Then, marine biologist Karen Osborn, a co-author on the new paper, noticed something strange about the photos she took of the fish.</p><p style="margin-left: 20px;">"I had tried to take pictures of deep-sea fish before and got nothing but these really horrible pictures, where you can't see any detail," Osborn told <em><a href="https://www.wired.com/story/meet-the-ultra-black-vantafish/" target="_blank">Wired</a></em>. "How is it that I can shine two strobe lights at them and all that light just disappears?"</p><p>After examining samples of fish skin under the microscope, the researchers discovered that the fish skin contains a layer of organelles called melanosomes, which contain melanin, the same pigment that gives color to human skin and hair. This layer of melanosomes absorbs most of the light that hits them.</p>
A crested bigscale
Credit: Karen Osborn/Smithsonian<p style="margin-left: 20px;">"But what isn't absorbed side-scatters into the layer, and it's absorbed by the neighboring pigments that are all packed right up close to it," Osborn told <em>Wired</em>. "And so what they've done is create this super-efficient, very-little-material system where they can basically build a light trap with just the pigment particles and nothing else."</p><p>The result? Strange and terrifying deep-sea species, like the crested bigscale, fangtooth, and Pacific blackdragon, all of which appear in the deep sea as barely more than faint silhouettes.</p>
David Csepp, NMFS/AKFSC/ABL<p>But interestingly, this unique disappearing trick wasn't passed on to these species by a common ancestor. Rather, they each developed it independently. As such, the different species use their ultra-blackness for different purposes. For example, the threadfin dragonfish only has ultra-black skin during its adolescent years, when it's rather defenseless, as <em>Wired</em> <a href="https://www.wired.com/story/meet-the-ultra-black-vantafish/" target="_blank">notes</a>.</p><p>Other fish—like the <a href="http://onebugaday.blogspot.com/2016/06/a-new-anglerfish-oneirodes-amaokai.html" target="_blank">oneirodes species</a>, which use bioluminescent lures to bait prey—probably evolved ultra-black skin to avoid reflecting the light their own bodies produce. Meanwhile, species like <em>C. acclinidens</em> only have ultra-black skin around their gut, possibly to hide light of bioluminescent fish they've eaten.</p><p>Given that these newly described species are just ones that this team found off the coast of California, there are likely many more, and possibly much darker, ultra-black fish swimming in the deep ocean. </p>
How long should one wait until an idea like string theory, seductive as it may be, is deemed unrealistic?
- How far should we defend an idea in the face of contrarian evidence?
- Who decides when it's time to abandon an idea and deem it wrong?
- Science carries within it its seeds from ancient Greece, including certain prejudices of how reality should or shouldn't be.
Plato used the allegory of the cave to explain that what humans see and experience is not the true reality.
Credit: Gothika via Wikimedia Commons CC 4.0<p>When scientists and mathematicians use the term <em>Platonic worldview</em>, that's what they mean in general: The unbound capacity of reason to unlock the secrets of creation, one by one. Einstein, for one, was a believer, preaching the fundamental reasonableness of nature; no weird unexplainable stuff, like a god that plays dice—his tongue-in-cheek critique of the belief that the unpredictability of the quantum world was truly fundamental to nature and not just a shortcoming of our current understanding. Despite his strong belief in such underlying order, Einstein recognized the imperfection of human knowledge: "What I see of Nature is a magnificent structure that we can comprehend only very imperfectly, and that must fill a thinking person with a feeling of humility." (Quoted by Dukas and Hoffmann in <em>Albert Einstein, The Human Side: Glimpses from His Archives</em> (1979), 39.)</p> <p>Einstein embodies the tension between these two clashing worldviews, a tension that is still very much with us today: On the one hand, the Platonic ideology that the fundamental stuff of reality is logical and understandable to the human mind, and, on the other, the acknowledgment that our reasoning has limitations, that our tools have limitations and thus that to reach some sort of final or complete understanding of the material world is nothing but an impossible, <a href="https://www.amazon.com/dp/B01K2JTGIA?tag=bigthink00-20&linkCode=ogi&th=1&psc=1" target="_blank" rel="noopener noreferrer">semi-religious dream</a>.</p>
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