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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.
Innovation in manufacturing has crawled since the 1950s. That's about to speed up.
Richard Feynman once asked a silly question. Two MIT students just answered it.
Here's a fun experiment to try. Go to your pantry and see if you have a box of spaghetti. If you do, take out a noodle. Grab both ends of it and bend it until it breaks in half. How many pieces did it break into? If you got two large pieces and at least one small piece you're not alone.
But science loves a good challenge<p>The mystery remained unsolved until 2005, when French scientists <a href="http://www.lmm.jussieu.fr/~audoly/" target="_blank">Basile Audoly</a> and <a href="http://www.lmm.jussieu.fr/~neukirch/" target="_blank">Sebastien Neukirch </a>won an <a href="https://www.improbable.com/ig/" target="_blank">Ig Nobel Prize</a>, an award given to scientists for real work which is of a less serious nature than the discoveries that win Nobel prizes, for finally determining why this happens. <a href="http://www.lmm.jussieu.fr/spaghetti/audoly_neukirch_fragmentation.pdf" target="_blank">Their paper describing the effect is wonderfully funny to read</a>, as it takes such a banal issue so seriously. </p><p>They demonstrated that when a rod is bent past a certain point, such as when spaghetti is snapped in half by bending it at the ends, a "snapback effect" is created. This causes energy to reverberate from the initial break to other parts of the rod, often leading to a second break elsewhere.</p><p>While this settled the issue of <em>why </em>spaghetti noodles break into three or more pieces, it didn't establish if they always had to break this way. The question of if the snapback could be regulated remained unsettled.</p>
Physicists, being themselves, immediately wanted to try and break pasta into two pieces using this info<p><a href="https://roheiss.wordpress.com/fun/" target="_blank">Ronald Heisser</a> and <a href="https://math.mit.edu/directory/profile.php?pid=1787" target="_blank">Vishal Patil</a>, two graduate students currently at Cornell and MIT respectively, read about Feynman's night of noodle snapping in class and were inspired to try and find what could be done to make sure the pasta always broke in two.</p><p><a href="http://news.mit.edu/2018/mit-mathematicians-solve-age-old-spaghetti-mystery-0813" target="_blank">By placing the noodles in a special machine</a> built for the task and recording the bending with a high-powered camera, the young scientists were able to observe in extreme detail exactly what each change in their snapping method did to the pasta. After breaking more than 500 noodles, they found the solution.</p>
The apparatus the MIT researchers built specifically for the task of snapping hundreds of spaghetti sticks.
(Courtesy of the researchers)
What possible application could this have?<p>The snapback effect is not limited to uncooked pasta noodles and can be applied to rods of all sorts. The discovery of how to cleanly break them in two could be applied to future engineering projects.</p><p>Likewise, knowing how things fragment and fail is always handy to know when you're trying to build things. Carbon Nanotubes, <a href="https://bigthink.com/ideafeed/carbon-nanotube-space-elevator" target="_self">super strong cylinders often hailed as the building material of the future</a>, are also rods which can be better understood thanks to this odd experiment.</p><p>Sometimes big discoveries can be inspired by silly questions. If it hadn't been for Richard Feynman bending noodles seventy years ago, we wouldn't know what we know now about how energy is dispersed through rods and how to control their fracturing. While not all silly questions will lead to such a significant discovery, they can all help us learn.</p>
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Women today are founding more businesses than ever. In 2018, they made up 40% of new entrepreneurs, yet in that same year, they received just 2.2% of all venture capital investment. The playing field is off-balance. So what can women do?
In a recent study, researchers examined how Christian nationalism is affecting the U.S. response to the COVID-19 pandemic.
- A new study used survey data to examine the interplay between Christian nationalism and incautious behaviors during the COVID-19 pandemic.
- The researchers defined Christian nationalism as "an ideology that idealizes and advocates a fusion of American civic life with a particular type of Christian identity and culture."
- The results showed that Christian nationalism was the leading predictor that Americans engaged in incautious behavior.
A pastor at the chapel of the St. Josef Hospital on April 1, 2020 in Bochum, German
Sascha Schuermann/Getty Images<p>Christian nationalists, in general, believe the U.S. and God's will are tied together, and they want the government to embody conservative Christian values and symbols. As such, they also believe the nation's fate depends on how closely it adheres to Christianity.</p><p style="margin-left: 20px;">"Unsurprisingly then, in the midst of the COVID‐19 pandemic, conservative pastors prophesied God's protection over the nation, citing America's righteous support for President Trump and the prolife agenda," the researchers write.</p><p style="margin-left: 20px;">"Correspondingly, the link between Christian nationalism and God's influence on how COVID‐19 impacts America can be seen in proclamations about God's divine judgment for its immorality―with the logic being that God is using the pandemic to draw wayward America <em>back </em>to himself, which assumes the two belong together."</p><p>The logical conclusion to this kind of thinking: America can save itself not through cautionary measures, like mask-wearing, but through devotion to God. What's more, it stands to reason that Christian nationalists are less likely to trust the media and scientists, given that these sources are generally not concerned with promoting a conservative, religious view of the world.</p><p>(The researchers note that they're unaware of any research directly linking Christian nationalism to distrust of media sources, but that they're almost certain the two are connected.)</p>
Predicted values of Americans' frequency of incautious behaviors during the COVID‐19 pandemic across values of Christian nationalism
Perry et al.<p>In the new study, the researchers examined three waves of results from the Public and Discourse Ethics Survey. One wave of the survey was issued in May, and it asked respondents to rate how often they engaged in both incautious and precautionary behaviors.</p><p>Incautious behaviors included things like "ate inside a restaurant" and "went shopping for nonessential items," while precautionary behaviors included "washed my hands more often than typical" and "wore a mask in public."</p><p>To measure Christian nationalism, the researchers asked respondents to rate how strongly they agree with statements like "the federal government should advocate Christian values" and "the success of the United States is part of God's plan."</p><p>The results suggest that, compared to other groups, Christian nationalists are far less likely to wear masks, socially distance and take other precautionary measures amid the COVID-19 pandemic.</p><p style="margin-left: 20px;">"Christian nationalism was the leading predictor that Americans engaged in incautious behavior during the pandemic, and the second leading predictor that Americans avoided taking precautionary measures."</p><p>But that's not to say that religious beliefs are causing Americans to reject mask-wearing or social distancing. In fact, when the study accounted for Christian nationalist beliefs, the results showed that Americans with high levels of religiosity were likely to take precautionary measures for COVID-19.</p>
Limitations<p>Still, the researchers note that they're theorizing about the connections between Christian nationalism and COVID-19 behaviors, not documenting them directly. What's more, they suggest that certain experiences — such as having a family member that contracts COVID-19 — might change a Christian nationalist's behaviors during the pandemic.</p><p style="margin-left: 20px;">"Limitations notwithstanding, the implications of this study are important for understanding Americans' curious inability to quickly implement informed and reasonable strategies to overcome the threat of COVID‐19, an inability that has likely cost thousands of lives," they write.</p>
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