Further results on the return to talk therapy

By Tyler Cowen

Here was my original post, here is an email response from a specialist in the area, channeled by a reader:

The issue is really, really complicated. I have a lot of data on it because I spent time with Mark Goldenson, interviewing a lot of folks segmented by those who chose to seek mental health assistance from a clinician, those who stayed with that treatment versus those who turned away relatively early, and those who experienced severe mental health conditions that make them think that they should have seen a therapist, but ultimately chose not to, for reasons other than economic ones.

And we also talked to clinicians on the other side of that equation.

So between that and knowing the literature reasonably well, I have a lot of perspective on this.

The first thing is that talk therapy is in general not effective for most people. And I know the paper under examination showed that it’s more effective than antidepressants, but in general, most people do not generally stick with talk therapy. They get a benefit at a reasonably low rate for a reasonably short period of time…

Moreover, there’s some pretty strong evidence that talk therapy or at least CBT is becoming less effective over time – the effect sizes in studies & meta-analyses are going down. And there could be reasons for that that aren’t an indictment of the therapeutic model.

So for example, the modern world could just be becoming more stressful and the therapy is less equipped for it… It could be that as the treatment becomes more popular, rather than the more advanced or cutting-edge therapists using it, it’s used by an increasingly broad set of therapists that include low-skilled or ineffective ones.

So there are a lot of reasons that may not have to do with the merits of CBT as an approach, but the data are reasonably convincing on that front.

I think a lot of people are making a reasonably rational choice that, especially if they’re not going to stick with it for a long period of time, even starting therapy is a low-value proposition.

George Ainslie (the psychologist) has this kind of notion of playing a prisoner’s dilemma with your [future] self… let’s just say I want to start an exercise habit… there are a lot of parallels with exercise and talk therapy.

If I knew for a fact that I was going to stop doing it after one month, it actually doesn’t make sense to start at all. Right, because the benefits of accrued will pretty rapidly deteriorate and it’ll be as if I never did it…

People are not just considering, “Should I try talk therapy?”, they’re considering, “Will I do this for a sufficiently long period of time, or especially can I afford it for a long period of time, to where I will get and maintain the benefits from doing it?”

And many people do in fact have misinformation about how quickly they can experience certain types of benefits, and how much work is involved – it’s clear that there’s a lot of work involved, and many people don’t want to do that work.

From an operant conditioning standpoint, the experience of a therapy session is frankly more punishing than it is rewarding (for many people, a lot of the time). Like any negative stimulus, they’re going to engage in behaviors that cause that stimulus to be experienced at a lower rate.

Sometimes the benefits don’t accrue during the session, they accrue afterwards. It takes a lot of work to experience them and [can] involve emotional trauma to even retrieve them.

It’s not consistent with people’s ROI calculation, or what they would like to see in their ROI calculation. Again, it’s really similar to physical exercise – we know physical exercise works. It works better than antidepressants. It accrues all the benefits that this paper Cowen cited discovered in terms of energy and mood and earnings and so on and so forth.

But people still don’t engage in exercise, and in fact I think the rate of physical activity is actually on the decline, in the industrialized world at least.So, it’s more complex than “Does the behavior accrue benefits if you do it consistently?” It’s also not entirely about access because many forms of physical activity are free, and as the paper examines the seeking of talk therapy is not super sensitive to [price].

So it goes beyond the mere cost of the service, although the cost of the services is definitely prohibitive for a large cross-section of people.

How does ketamine or any other substance relate to this?

I think it relates very favorably in that people may actually have the opposite misconception around psychedelic-assisted therapy. They might view regular talk therapy as something where they’re going to have to do this tedious hour a week for months before they get any benefits or they solve any problems in their lives.

[With ketamine] they probably think that they’re going to do one ketamine session, and all of their issues are going to be solved right their PTSD is cured and they no longer experience any symptoms of anxiety, depression, etc… It’s probably a little bit overhyped in the minds of people who have only casually exposed themselves – they’re seeing an article in The New Yorker, or they’re seeing it on a blog, or someone goes on a podcast and talks about an experience. They’re not looking at it with the measured view of someone from the Johns Hopkins team or whatever. So I think that it does work in your favor….

People may overestimate the level of benefit they’re likely to achieve and it seems like the medicine is doing the work, rather than them. Even though I know that that isn’t really the case….

By the way, fun stuff from that research sprint we did with Goldenson  – the average person in our cohort (who did ultimately get therapy), put it off for over two years.

It was a pretty wide range – some people sought help after, perhaps, six weeks I think was the shortest. Nobody has a bad day or think they’re experiencing depression or experiencing dysfunction in their work life or their romantic life or whatever it is and goes straight to a therapist…

They also tend to do a fair bit of research – they research different therapeutic methods and kind of choose one that fits their personality or their values, almost more so than efficacy.

And most of the people who ended up with a stable relationship with a provider trial between two and five different folks.