[jodrellblank]

As I sometimes repeat on HN, Dr David Burns started giving his patients a survey at the start and end of every session, to rate how he was doing as the therapist and to rate their feelings, on a scale of 1-5.

Reasoning that if he's not good it would show up in patients thinking he's bad, and not feeling any better. And then he could tune his therapy approaches towards the ones which make people feel better and rate him as more understanding and listening and caring. And he criticises therapists who won't do that, therapists who say patients have been seeing them for years with only incremental improvements or no improvements.

Yes there's no objective way to measure how angry or suicidal or anxious someone is and compare two people, but if someone is subjectively reporting 5/5 sadness about X at the start of a session and wants help with X, then at some point in the future they should be reporting that number going down or they aren't being helped. And more effective help could mean that it goes down to 1/5 in three sessions instead of down to 4/5 in three years, and that's a feedback loop which (he says) has got him to be able to help people in a single two-hour therapy session, where most therapists and insurance companies will only do a too-short session with no feedback loop.

[SideburnsOfDoom]

> Reasoning that if he's not good it would show up in patients thinking he's bad, and not feeling any better.

This is like a questionnaire on how much stronger you feel after working out at a gym: you often don't, you feel tired.

Both gym and talking therapy (when done correctly) will push you slightly out of your comfort zone, and aim to let you safely deal with moderate amounts of something that you find really hard. So as to expand your capabilities.

"I feel good" immediately after is utterly the wrong metric.

Being more capable / feeling better some time later is the more reliable indicator, like progress at a gym.

And also this is why an agreeable statistical word generator LLM is not the correct tool for the job.

[jodrellblank]

No it isn't, it's like a questionnaire on how hungry you are before and after dinner. If you eat carrot air and parsley and your hunger stays the same, dinner was a failure. If you eat bread and soup and your hunger diminishes a bit, it helped but you might need more dinner.

> "will push you slightly out of your comfort zone, and aim to let you safely deal with moderate amounts of something that you find really hard."

You can listen to some of those sessions and see that this is not what Dr Burns does[1]. His model is: it's not events which make us feel down, it's the thoughts we have about those events. You can see it yourself when you are stressing about something for ages, and someone gives you a bit of information "the surgeon says it all went well" and your worry leaves like a switch was flipped. You don't debug an integer overflow by progressively increasing int32 to int33 to int34, you spend the time understanding the problem and then you quickly change int32 to int64 and the program handles larger numbers instantly.

If we can't let go of negative thoughts then we get stuck with lots of them, it's why people repeat certain things like "I hate him", "It's my fault and I deserve to be punished", "I'm a failure", "I'm a loser nobody loves me", "I'm a bad mother", "I'm a coward" or whatever - on mental loop, minute after minute sometimes for years or decades, retriggering the same pattern of negative feelings every time. He sets up an environment where the patient is willing and able to work with him (empathy) and guides the patient to see the reasons why they can't let go of those thoughts and how they could let go, and with a click of understanding the thought leaves, and that's a moment of near-instant transformation not a progressive overload, and that specific thought is fixed, and then they do another and another until the patient is happy they have been helped with the thing they wanted help with.

[1] mostly, sometimes for anxiety he does use exposure therapy

[SideburnsOfDoom]

> No it isn't, it's like a questionnaire on how hungry you are before and after dinner.

I think that it should be clear from the above extended metaphor that I fundamentally disagree with this idea, and so dismissing it with "No it isn't" will do nothing at all for me.

That it does nothing for me is also a refutation of the idea that therapy is always easy "someone gives you a bit of information, like a switch was flipped, done": No, it isn't.

Few architectural refactorings are "int32 to int64" quick. My experience is that sometimes you have to work through stuff. To dig. Habits that are learned over decades aren't that easily changed. Like a gym session, if it's always easy then you're not doing the work.

Reassurance can work, but IMHO you'll be back soon enough, as the root cause hasn't been addressed, just the symptom.

But this is not my field and I don't have much more to say on the topic, except that if chugging some simple agreeable affirmations are all that you need, by all means listen to the LLM. The sycophancy machine can do that.

[jodrellblank]

> "I think that it should be clear from the above extended metaphor that I fundamentally disagree with this idea, and so dismissing it with "No it isn't" will do nothing at all for me."

I'm citing a medical doctor and clinical psychologist with decades of experience who has recorded a hundred hours of training podcasts, and linking actual therapy sessions that you can listen to, and you're saying "no it isn't" with nothing to back that up except "you reckon it isn't".

> "the idea that therapy is always easy "someone gives you a bit of information, like a switch was flipped, done": No, it isn't. Habits that are learned over decades aren't that easily changed."

Nobody said it was always easy. Yes they are. People try to quit smoking cold turkey three times a week for five years. Then they read Alan Carr's "The Easy Way to Quit Smoking" and then they don't want to smoke anymore and there's no talk of "quitting" because they aren't smokers and non-smokers don't need to quit. With the right understanding, the viewpoint flips and the mind is changed. Same with overweight people who try dieting for years and then have a health scare and sometimes that switches it so they change instantly (and sometimes it doesn't). Most things won't easily change a habit, like most changes in code won't fix a specific bug. But some changes can, and we should look for them.

> "Like a gym session, if it's always easy then you're not doing the work."

This is some Puritanical suffering-culture, or some one-upmanship manliness culture. This is the reason I mentioned the int32 to int64, sometimes it might require searching to find insight, but there's no points for searching harder and trying harder, if you can have the same insight in two hours instead of two years, that's good not bad. The Universe doesn't give points for "doing the work" and brute-forcing a solution instead of a quicker solution (I suspect one of your beliefs does).

> "Reassurance can work, but IMHO you'll be back soon enough, as the root cause hasn't been addressed"

This is strawmanning or not understanding; this is addressing the root cause and not reassurance; the step of "paradoxical agenda setting" gets to the heart of why reassurance doesn't work. Someone who says "I lost my job, I didn't work hard enough, I am a loser" doesn't get helped by reassuring them that they are not a loser. It might be that they have a deep-seated value that "hard work is good" and they are getting into a human race condition where "reassurance that you aren't a loser" goes to "if I can think I'm a winner even when I don't try, then laziness can be winning, and I don't want that. I won't go there. So I reject the reassurance and return to my belief that I am a loser".

The fix is trace that loop and find the sticking point, and find a working technique to unstick it. Which is case-by-case individual, but somewhere like "I understand that feeling like a loser is the flip-side of my belief that hard work is good. How does my brain implement hard-work-is-good? By making hard work feel good and lazy work feel bad. This feeling-bad is the mechanism of how my ideal works! I actually want to keep the bad feeling because that's one of the things which guides me to work hard, and I value that. I can't get rid of one without getting rid of the other. What I've done is try to grab tightly to one side of this (hard work is good) and push away the other side (I'm a loser because I didn't work hard) but they're the same thing, so grabbing it hard is pulling it back while pushing it away. Brain has responded by dialing it up to 11 and shouting "LOSER" all the time louder and louder because I'm trying not to listen. It doesn't make sense to judge a whole self as a winner or loser, people have lots of components some good and some bad. It doesn't make sense to say "I didn't work hard" at work because there were times when I did work hard. So actually I want to keep the feeling "I am a loser if I don't work hard" because it encourages me to work harder (which I value). I want it dialled down instead and focused on individual areas of life, not judging all of me all the time".

and with that understanding clicking, finally listening to the thought that's been running around, accepting it as a thing you asked for, that reminds you of something else you value, it 'suddenly' calms down. Acknowledged. Part of you, accepted, integrated, welcomed.

> "if chugging some simple agreeable affirmations are all that you need, by all means listen to the LLM. The sycophancy machine can do that."

Can you see this as the typical HN cynicaler-than-thou putdown? Maybe the reader will think you're a really tough C++ programmer who only values science and muscles, instead of a woke hippy gullible loser? But you don't look tough for changing "therapy skills developed over decades" into "simple agreeable affirmations" you just look like you don't understand and are embarrassed.

[SideburnsOfDoom]

> I'm citing a medical doctor and clinical psychologist

I'll give you that one, because although technically you're not citing it here, you do elsewhere in the thread.

> you're saying "no it isn't"

I appreciate that you might not like those words, but they're literally your words, so.

> This is some Puritanical suffering-culture, or some one-upmanship manliness culture.

Pfft. I agree that quicker results are better, all other things being equal, but that's all very facile.

> The fix is trace that loop and find the sticking point,

Not everything is like that.