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.
What can 3D printing do for medicine? The "sky is the limit," says Northwell Health researcher Dr. Todd Goldstein.
- Medical professionals are currently using 3D printers to create prosthetics and patient-specific organ models that doctors can use to prepare for surgery.
- Eventually, scientists hope to print patient-specific organs that can be transplanted safely into the human body.
- Northwell Health, New York State's largest health care provider, is pioneering 3D printing in medicine in three key ways.
A recent study gives new meaning to the saying "fake it 'til you make it."
- The study involves four experiments that measured individuals' socioeconomic status, overconfidence and actual performance.
- Results consistently showed that high-class people tend to overestimate their abilities.
- However, this overconfidence was misinterpreted as genuine competence in one study, suggesting overestimating your abilities can have social advantages.
Is this proof of a dramatic shift?
- Map details dramatic shift from CNN to Fox News over 10-year period
- Does it show the triumph of "fake news" — or, rather, its defeat?
- A closer look at the map's legend allows for more complex analyses
Dramatic and misleading
Image: Reddit / SICResearch
The situation today: CNN pushed back to the edges of the country.
Over the course of no more than a decade, America has radically switched favorites when it comes to cable news networks. As this sequence of maps showing TMAs (Television Market Areas) suggests, CNN is out, Fox News is in.
The maps are certainly dramatic, but also a bit misleading. They nevertheless provide some insight into the state of journalism and the public's attitudes toward the press in the US.
Let's zoom in:
- It's 2008, on the eve of the Obama Era. CNN (blue) dominates the cable news landscape across America. Fox News (red) is an upstart (°1996) with a few regional bastions in the South.
- By 2010, Fox News has broken out of its southern heartland, colonizing markets in the Midwest and the Northwest — and even northern Maine and southern Alaska.
- Two years later, Fox News has lost those two outliers, but has filled up in the middle: it now boasts two large, contiguous blocks in the southeast and northwest, almost touching.
- In 2014, Fox News seems past its prime. The northwestern block has shrunk, the southeastern one has fragmented.
- Energised by Trump's 2016 presidential campaign, Fox News is back with a vengeance. Not only have Maine and Alaska gone from entirely blue to entirely red, so has most of the rest of the U.S. Fox News has plugged the Nebraska Gap: it's no longer possible to walk from coast to coast across CNN territory.
- By 2018, the fortunes from a decade earlier have almost reversed. Fox News rules the roost. CNN clings on to the Pacific Coast, New Mexico, Minnesota and parts of the Northeast — plus a smattering of metropolitan areas in the South and Midwest.
Image source: Reddit / SICResearch
This sequence of maps, showing America turning from blue to red, elicited strong reactions on the Reddit forum where it was published last week. For some, the takeover by Fox News illustrates the demise of all that's good and fair about news journalism. Among the comments?
- "The end is near."
- "The idiocracy grows."
- "(It's) like a spreading disease."
- "One of the more frightening maps I've seen."
- "LOL that's what happens when you're fake news!"
- "CNN went down the toilet on quality."
- "A Minecraft YouTuber could beat CNN's numbers."
- "CNN has become more like a high-school production of a news show."
Not a few find fault with both channels, even if not always to the same degree:
- "That anybody considers either of those networks good news sources is troubling."
- "Both leave you understanding less rather than more."
- "This is what happens when you spout bullsh-- for two years straight. People find an alternative — even if it's just different bullsh--."
- "CNN is sh-- but it's nowhere close to the outright bullsh-- and baseless propaganda Fox News spews."
"Old people learning to Google"
Image: Google Trends
CNN vs. Fox News search terms (200!-2018)
But what do the maps actually show? Created by SICResearch, they do show a huge evolution, but not of both cable news networks' audience size (i.e. Nielsen ratings). The dramatic shift is one in Google search trends. In other words, it shows how often people type in "CNN" or "Fox News" when surfing the web. And that does not necessarily reflect the relative popularity of both networks. As some commenters suggest:
- "I can't remember the last time that I've searched for a news channel on Google. Is it really that difficult for people to type 'cnn.com'?"
- "More than anything else, these maps show smart phone proliferation (among older people) more than anything else."
- "This is a map of how old people and rural areas have learned to use Google in the last decade."
- "This is basically a map of people who don't understand how the internet works, and it's no surprise that it leans conservative."
A visual image as strong as this map sequence looks designed to elicit a vehement response — and its lack of context offers viewers little new information to challenge their preconceptions. Like the news itself, cartography pretends to be objective, but always has an agenda of its own, even if just by the selection of its topics.
The trick is not to despair of maps (or news) but to get a good sense of the parameters that are in play. And, as is often the case (with both maps and news), what's left out is at least as significant as what's actually shown.
One important point: while Fox News is the sole major purveyor of news and opinion with a conservative/right-wing slant, CNN has more competition in the center/left part of the spectrum, notably from MSNBC.
Another: the average age of cable news viewers — whether they watch CNN or Fox News — is in the mid-60s. As a result of a shift in generational habits, TV viewing is down across the board. Younger people are more comfortable with a "cafeteria" approach to their news menu, selecting alternative and online sources for their information.
It should also be noted, however, that Fox News, according to Harvard's Nieman Lab, dominates Facebook when it comes to engagement among news outlets.
CNN, Fox and MSNBC
Image: Google Trends
CNN vs. Fox (without the 'News'; may include searches for actual foxes). See MSNBC (in yellow) for comparison
For the record, here are the Nielsen ratings for average daily viewer total for the three main cable news networks, for 2018 (compared to 2017):
- Fox News: 1,425,000 (-5%)
- MSNBC: 994,000 (+12%)
- CNN: 706,000 (-9%)
And according to this recent overview, the top 50 of the most popular websites in the U.S. includes cnn.com in 28th place, and foxnews.com in... 27th place.The top 5, in descending order, consists of google.com, youtube.com, facebook.com, amazon.com and yahoo.com — the latter being the highest-placed website in the News and Media category.
If you thought your mother was pushy in her pursuit of grandchildren, wait until you learn about bonobo mothers.
- Mother bonobos have been observed to help their sons find and copulate with mates.
- The mothers accomplish this by leading sons to mates, interfering with other males trying to copulate with females, and helping sons rise in the social hierarchy of the group.
- Why do mother bonobos do this? The "grandmother hypothesis" might hold part of the answer.
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