[naasking]

I think the preying part of therapy is that there's just no defined stop condition. There's no such thing as "healthy" in mental health. You get chemo until you go into remission or you die. You take blood pressure meds until you have a better lifestyle and body composition and don't need them anymore, etc. There's no analogue for "you're healthy now, go away so I can help others", and so therapy goes on forever until the patient stops for whatever reason.

[cbsmith]

> I think the preying part of therapy is that there's just no defined stop condition.

There's no defined stop point for physical development either... Top performing athletes still have trainers, and nobody sees that as a problem. If it's mental development though, it must have a stop point?

[renewiltord]

Top performing athletes are better than me at being athletes.

Meanwhile, the more therapy someone does, the more miserable they are compared to me. I’m the Usain Bolt of mental health compared to them. Makes me think their trainer is an idiot.

[cbsmith]

> Meanwhile, the more therapy someone does, the more miserable they are compared to me.

Is this based on empirical statistical analysis, or are you maybe projecting your perception on to anecdotes? How are you quantifying misery? What are the units? Are there people that are less miserable than you? Do you know how much therapy they've done, or if they've done therapy at all?

> I’m the Usain Bolt of mental health compared to them. Makes me think their trainer is an idiot.

There's a lot of people that think they're Usain Bolt. Most of them are not.

[renewiltord]

I suppose we’ll see in the next twenty years. I rate my chances and I don’t rate those of the chronically therapized. But hey, let the chips fall where they may.

[detourdog]

The stop point is obvious to the individual and the therapist. I'm dealing with someone that prefers to stop rather than actually self-reflection.

There is nothing stopping them from exiting therapy. The therapist may be aware that the person is still a basket case but if they are non-violent they are free to roam.

[naasking]

> The stop point is obvious to the individual and the therapist.

It's not at all. There are plenty of stories of people who realized that therapy was just causing them to ruminate on their problems, and that the therapist was just milking them for years before they wised up and walked away. That's not what I call "obvious".

[nathanasmith]

>There are plenty of stories of people who realized that therapy was just causing them to ruminate on their problems

This is precisely why I stopped going.

[detourdog]

I think either the therapist or the patient was not devoted to therapy.

[naasking]

No true Scotsman eh? Classic for a reason!

[detourdog]

Considering we are discussing a licensed professional I think your argument is weak. Second I allowed for the failure of the therapist in their duty.

[cbsmith]

Exactly.

[naasking]

What a ridiculous analogy. "Athlete" is a career. Is someone making a career of being in therapy?

> If it's mental development though, it must have a stop point?

What is being developed, exactly?

[cbsmith]

> What a ridiculous analogy. "Athlete" is a career.

The athlete is the extreme example, but there are obviously people who are not career athletes that don't have a defined stop point with employing a trainer (maybe you could say "death" is the stop point).

Most everyone who goes to spinning class isn't a career athlete. Some of them are terribly out of shape, and some of those people just want to get in shape. Others may already be in shape, but see the spinning class as a way to either improve or maintain their conditioning. None of this is deemed ridiculous.

I'm curious, it's considered the norm to regularly see a doctor or dentist, do you think they're preying on their patients?

> What is being developed, exactly?

Mental health. There's obviously a more involved answer, but if you don't know it already, it's unlikely I'll be able to educate you with a comment on social media.

[naasking]

> but there are obviously people who are not career athletes that don't have a defined stop point with employing a trainer

And many of them are being bilked as well. The fitness industry is notoriously filled with hucksters and scams, and "trainers" rarely have any real training in kinesiology or exercise science.

> I'm curious, it's considered the norm to regularly see a doctor or dentist, do you think they're preying on their patients?

Once a year for a health checkup. Is that the norm for therapy?

> Mental health. There's obviously a more involved answer

The more involved answer is that "mental health" is not well-defined, so it's not developing anything. The only therapies that have shown to have any empirical validity, like CBT, train the user in tools to change their own behaviour and thinking, then it's on the user to employ the tools. Does a family doctor call you in once a week and watch you take the pills that address your physical ailment?

The best analogy for psychiatric therapy is physical therapy for recovering from an injury or surgery, except physical therapy has a well-defined end condition, which is when you understand how to do the exercises yourself. Then it's on you to do them. This is just not the norm for "mental health" therapy.

[sdwr]

Nail on the head, thanks. I'm deeply uncomfortable with anything that combines paying for a service with a social element. Feels like an unstable equilibrium.

I guess the skill is riding the line, but that doesn't feel very enjoyable.

[cbsmith]

> I'm deeply uncomfortable with anything that combines paying for a service with a social element.

I think I don't know what you mean by that. That sounds like you're uncomfortable with renting out party venues.

[cbsmith]

> And many of them are being bilked as well. The fitness industry is notoriously filled with hucksters and scams, and "trainers" rarely have any real training in kinesiology or exercise science.

Many people are being bilked for almost any service one might name. There are tons of products and services with no defined stop point (heck, pretty much the entire CPG category is for products and services with no defined stop point). There are tons of products & services where the vast majority of customers are unable to discern if they are being scammed or not. Heck, when you order sushi there's notoriously a far from trivial chance that you're not getting the fish that you thought you were getting. We don't think of restaurateurs as being hucksters and scam artists (some no doubt are, but it's ridiculous to paint them all with the same brush).

My point isn't that it's impossible that they are being bilked. It's that there are all kinds of products & services that people get with no defined stop point, where customers could unknowingly be scammed, but we don't consider that to be evidence that they are being bilked. There are products and services that are beneficial for the customer even if there is no defined problem and no defined end point.

For your typical customer, spinning class isn't a class you go to until you achieve some goal. It's a service provided to help you do exercise you no doubt wanted to do anyway, in a community/context that you wanted to do it in, with the guidance of someone who ostensibly knows how to structure the process better than you do. You could very well do the spinning all by yourself, or you could organize a spinning class on your own, but you pay the professional because you expect to get better results without expending as much time or energy yourself.

Sure, there are people who claim that, if you just take the spin class, you will lose 100 lbs or become an Olympic athlete, and those people are absolutely hucksters and scam artists. There are people that will tell you that voting for the right/wrong politician will change your life (either for the better or worse). There are people who will tell you that buying gold will ensure financial security and make you a fortune. There are scams about buying jewelry. There are investment funds that claim to be able to consistently beat the market, or that will protect your money through any market collapse... and in all those cases there's no defined stop point. The product is the prop, not the scam. Sure, in the context of the scam the prop isn't worth it, but that doesn't mean anyone offering the prop is scamming you. Physical training services, votes, gold, jewelry, investment funds, etc. aren't all bunk.

> Once a year for a health checkup. Is that the norm for therapy?

So now it's the frequency that's the issue, rather than not having a defined stop point?

> The more involved answer is that "mental health" is not well-defined, so it's not developing anything.

That's your answer. That's not my answer, and it's not the answer.

> The best analogy for psychiatric therapy is physical therapy for recovering from an injury or surgery, except physical therapy has a well-defined end condition, which is when you understand how to do the exercises yourself.

I don't think you appreciate how limited your perspective on this is. Not everything is a problem that can be fixed.

This presumes that the only possible physical therapy service is education. My mother suffers from late-stage dementia. She is at risk for falling whenever she walks, and performing more involved physical activities absolutely requires guidance. It is literally impossible to educate her out of this situation, so the only stop point for the service is death. While family does sometimes provide these services for her, there's little doubt that the professionals we hire to provide these services for her are able to do the job better and more consistently than we can; there's little doubt that she is physically and mentally healthier as a consequence of their services, and that her physical & mental health would begin to decline within days of terminating those services. Now, I don't know that their particular form of physical therapy is empirically valid, and I guess they could be scamming us, but in the vast majority of cases, providing these services is not a scam. It's offensive to claim otherwise.

Now, my sister-in-law has the reverse situation: she has a physical problem and requires mental health services. She suffers from COPD that will kill her unless something else gets to her first. Above and beyond the physical condition, it is very hard for her to cope with it mentally. Again, family provides her with support, but it's not enough. She employs a mental health therapist to address her anxiety, depression and suicidal ideation. There's maybe some feint hope that the therapist will educate her to a state where she no longer experiences suicidal ideation, but nobody expects the anxiety & depression to go away, because COPD is an anxiety and depression invoking condition... a well educated, rational, COPD patient can be anxious and depressed. You could say that, with or without professional service, the failure rate is nearly 100% (helpful to consider in the context of comments about the failure rate for mental health therapy). So there's no defined stopping point for the therapy short of death. In this particular case, it's a CBT therapist, but even if it wasn't, what she needs is more than education; she needs support. While we can't rule out that she's being scammed, in the vast majority of the cases, providing these services is not a scam. It's offensive to claim otherwise.

> The more involved answer is that "mental health" is not well-defined, so it's not developing anything.

I'll try one last metaphor:

Nutrition is not well defined. We have broad ideas about what is and isn't good for you, but the specifics of what is "good nutrition" are variable & contextual; while one can have well defined nutritional goals, many people do not. There's a ton of "nutritionists" who have no formal training, who don't exercise science. There are short order cooks with no formal training, who don't exercise science. If a grocer has formal training, it is far more likely in business or marketing than anything involving nutrition. There is no defined stop point where you no longer need food. There are plenty of scams involving nutritional guidance or foods (just the categories "health food" and "diet plans" are littered with scammers). Despite all that, there is no compelling argument that restaurants, chefs, grocers, or other nutritional services are intrinsically scammers. I'm pretty sure that, if I don't eat, my health will deteriorate, and I have a hard time believing that a professional either guiding my nutritional choices or outright providing nutrition for me is intrinsically scamming me. They could well be providing me a valuable service where I get better nutrition with less time and effort than if I tended to it without them.

I get it. You are convinced therapy is intrinsically a scam, and part of the reason for that is most customers for therapy cannot reliably discern if they are being scammed or not. I'm far from an expert on the subject, so for all I know, you are right. However, the arguments you are presenting are not compelling arguments.

[naasking]

> So now it's the frequency that's the issue, rather than not having a defined stop point?

You have a physical problem, you go to the doctor and he fixes the problem or gets you the information you need to manage your problem. That's the stop point for medical intervention.

You have a mental health problem, you go to a therapist for a mental health intervention, and now you're in weekly therapy for years. Not so much an intervention, more like a new part time job.

Yearly checkups is not a counterpoint to this general trend. A yearly mental health checkup could be totally reasonable, but that's not the norm.

> Not everything is a problem that can be fixed.

The real issue here is that you keep bringing up outliers like your mother's palliative care and I keep talking about the norm, ie. that most people in therapy are not like your mother. Therapy has become fashionable. Everyone is "working on themselves" and plenty of therapists like patients that are well off and so can pay regularly.

> I get it. You are convinced therapy is intrinsically a scam

No, that's not the point I'm making. At best, you could maybe case what I'm saying as "the therapy industry/fad is a scam, and plenty of therapists, psychologists and psychiatrists are feeding into it".

There are people that legitimately need therapy to develop coping strategies to address trauma or retrain maladaptive behaviours, because even as ineffective as it sometimes is, it's better than nothing. My point is that a lot of people who go to therapy probably don't need therapy, and even if they do they don't need as much as they think they do, the techniques in therapy are not very effective even in the best case, and that therapists are not incentivized to stop seeing patients that are paying them well and triage to cases that need more urgent intervention and probably can't pay them regularly.

Part of this is probably because of the US's dysfunctional medical system, and another part is because psychology and psychiatry has not had a good track record for empirically sound practices. It's getting better but has some ways to go.

[jodrellblank]

I sometimes recommend Dr David Burns' Feeling Good podcast[1], and he is big on measuring and testing and stop points. Instead of 'tell me about your mother' his style of Cognitive Behavioural Therapy (CBT) is called TEAMS in which the T stands for Testing, and it involves:

- Patient choosing a specific mood problem/feeling they want to work on.

- A mood survey, where the patient rates their own level of e.g. anxiety, depression, fear, hopelessness. (e.g. out of 5 or 10).

- Therapy session, following his TEAMS CBT structure. Including patient choosing how much fear they'd like to feel (e.g. they want to keep a little bit of fear so they don't endanger themselves, but don't want to be overwhelmed by fear, 5% or 20%, say).

- A repeat of the mood survey, where the patient re-assesses themselves to see if anything has improved. There's no units on the measures because it's self-reported, the patient knows if the fear is unchanged, a little less, a lot less, almost gone, completely gone, and that's what matters.

That gives them feedback; if there is improvement within a session they know something in the session helped, if several sessions go by with no improvement they know it and can change things up and move away from those unhelpful approaches in future with other patients, and if there is good improvement - patient is self-reporting that they are no longer hopeless about their relationship status, or afraid of social situations, or depressed, to the level they want, then therapy can stop.

He's adamant that a single 2hr session is enough to make a significant change in many common mood disorders[2], and this "therapy needs to take 10 years" is a bad pattern and therapists who don't take mood surveys and before and after every session are flying blind. With feedback on every session and decades of experience, he has identified a lot of techniques and ways to use them which actually do help people's moods change. I liken it to the invention of test cases and debuggers (and looking at the output from them).

[1] Quick list: https://feelinggood.com/list-of-feeling-good-podcasts/ more detailed database: https://feelinggood.com/podcast-database/

[2] no, internet cynic, obviously not everything and presumably not whatever it is you have.

[naasking]

I agree some therapists are starting to come around on this, but even what you describe is somewhat flawed due to placebo effects, eg. some always feel better from any kind of talk, probably as a result of someone paying attention to their problems.

You might be able to overcome this effect by quantitatively tracking this across many sessions to some degree, but I think it's still always the patient that has to walk away, and never the therapist who says, "you're good, go on now".

[fatbird]

I think you're mistaken, at least in a lot of cases. All CBT based therapies I've had have started with a clear discussion about what the problem is, and what the solution looks like in terms of my happiness and mental well-being. In all cases, my therapist has "graduated" me, telling me that they don't think I need to continue (or having me say that I'm comfortable now stopping regular therapy).

CBT and its derivatives very strongly attend to individual effectiveness and view therapy that goes on endlessly as a sign that the real problem isn't being addressed, and that no therapy is considered effective unless it ends. Individual therapists might be bad actors, but the field itself is now admirably focussed on finite, positive results.

[naasking]

Sounds like a great improvement, but I would hesitate to call it the norm. The therapy industry is booming.