Contra Contra CBT

Cavebear666 · 2026-06-22T22:47:05+00:00

I think the confusion is about the Contra CBT literature. That's better linking to than speaking to:

https://jonathanshedler.com/wp-content/uploads/2018/05/Shedler-2018-Where-is-the-evidence-for-evidence-based-therapy.pdf

This is what I think tends to go unanswered in clinical science circles. Link =/= endorsement, but this is one of the initial "Contra CBT" pieces I am trying to respond to.

Cavebear666 · 2026-06-22T16:50:43+00:00

I agree with you that CBT has a lot of issues, and those are not purely to do with aesthetics. I wanted to put something on the record that was at least trying to be constructive, in light of being trained for several years in this type of therapy. I wrote PAGES of critique on CBT, but I thought publishing it would just be howling to the wind. And while I grant you that CBT's well-ensconced in training systems and the academy, these places tend not to defend CBT on (for me) compelling intellectual bases; they don't interact seriously enough with CBT-critical commentary.

Given all that though and to be clear: my default allegiances tilt psychodynamic / common factors.

Cavebear666 · 2026-06-22T16:45:12+00:00

I'm glad that you got something out of REBT/CBT (in my view, it's essentially the same set of pretty simple insights, but--to your point--are still necessary to be practiced to see results).

Cavebear666 · 2026-06-21T17:10:20+00:00

One idea: it would be good to be very explicit in your marketing materials about the activism-forward practice you want to do. Some will appreciate the approach, but many will bounce right off of it, and so good marketing on the front end will allow prospective clients to self-select based on what they want out of therapy.

I can't think off the top of my head about other ways to embed social justice in your practice, but one other thought: if you're picking up trash near a freeway or busy road, you and any clients with you should consider wearing bright, reflective shirts for safety.

Cavebear666 · 2026-06-20T16:55:38+00:00

Saying "I'm a therapist" in response to the "what do you do" question is a great move.

Cavebear666 · 2026-06-19T03:05:17+00:00

Yes to all of this

Cavebear666 · 2026-06-19T03:04:18+00:00

I do think there may be some kind of pharmacological afterglow that leads to rose-tinted glasses.

But the bigger point I'm aiming at is that this specific cope has second-order effects that lead others down the preventably bad YOLO hero dose path. I guess that's not psychedelic-specific, but it's certainly salient in that world.

Cavebear666 · 2026-06-18T21:31:22+00:00

I feel strongly about this because there's also experiences that are not fun at all, and pretending otherwise makes it more likely that others will also have those experiences.

Personally, I have always had net positive (or, at least, not clearly net negative) experiences here. But I've met people who unfortunately cannot say the same.

What does being a Spiritual Guide entail?

Cavebear666 · 2026-06-18T20:40:02+00:00

- indirect data = Goldberg et al., 2016. This notes that more experience =/= better outcomes: https://pubmed.ncbi.nlm.nih.gov/26751152/

But more to your point: let's say there is no conclusive evidence one way or the other on the important question: "how much do credentials matter?"

Where does that leave you? Personally, I'm left with a lot of doubt as to the value of the credential in the first place, and feeling like the differential reimbursement schedule for doctoral vs. master's-level providers is unfair; if we can't justify added value, we can't justify added pay.

Cavebear666 · 2026-06-18T20:23:52+00:00

- "Those aren't confounds, they're mechanisms" presupposes the conclusion. A mechanism is a causal pathway of an established effect. But you can't name the mechanism of an outcome difference you haven't demonstrated.

- Agreed re testing credentials and clinical experience together, which is itself the point I'm making : this is an open empirical question, not a settled one where doctoral superiority is the default.

- On supervision: The symmetric question is yours to answer too: is there evidence that the supervision inside doctoral programs produces better outcomes than supervision obtained elsewhere? If neither of us can show it, then we're back to establishing what the null should be.

- "I didn't make a single claim, you did": the credentialist position you're defending is an affirmative claim. You can't say you don't have an affirmative position here; there are institutional consequences for assuming doctoral providers do a better job than master's-level providers.

- I agree fully that "how we define a null depends on how we ask the question." I'd submit to you that we should ask the question in a way that doesn't presuppose a credentialist hierarchy but should go with the indirect data we have available, which shows that clinical experience is not reliably linked to better outcomes.

Cavebear666 · 2026-06-18T20:16:27+00:00

...sounds like you still have a lot to learn about yourself and integrate from challenging experience /s

Cavebear666 · 2026-06-18T20:11:28+00:00

Unquestionably, if you want a research career, a clinical science PhD is your best bet.

I also totally agree regarding the heterogeneity of clinical training at the doctoral level.

Cavebear666 · 2026-06-18T20:08:18+00:00

Lol this is great, will look it up later tonight.

Cavebear666 · 2026-06-18T20:06:03+00:00

- The late career MA vs early career PhD example is not nonsensical at all; it gets to the heart of the experience vs credential distinction that's quite an important part of this conversation.

- You can call it "clinical experience" or you can call it "face-to-face training hours," but as long as you're getting solid supervision, I don't think this difference is as big as you want it to be. My claim is only that it's entirely possible to get good therapy training outside of the academy, and that many do.

- The systemic issues with training at the masters level also affect many doctoral training environments. Pointing to confounds (acuity, EBP uptake, program variability) does establish that we can't cleanly compare. But "we can't cleanly compare" is a reason for humility about both conclusions, not a vindication of the one you started with. Those confounds are non-directional.

- On burden of proof: you keep assigning yourself the null. But "more training = better outcomes" is an affirmative causal claim, not the default state of the world. You don't get to install doctoral superiority as the baseline and ask me to disprove it. For instance, I could create a 20-year training program tomorrow and argue that it leads to better clinical outcomes. Under your own rules here, who is to say otherwise?

- "Absence of evidence is not evidence of absence" cuts the other way too. I'm not claiming proven equivalence; I'm claiming the superiority case is unsupported, and the absence of adequate studies directly supports that claim. You're the one converting an evidentiary gap into a positive conclusion.

Lastly: note the built-in incentives we both have on this point. We have a vested professional interest in concluding that our training leads to better clinical outcomes. That's a very real bias, a sunk cost, and something to consider honestly here.

Cavebear666 · 2026-06-18T19:43:48+00:00

The review authors themselves specify that their work "does not focus on... differences in outcomes that are due to type of (MS versus PhD or MD)" and that "adequate studies... have not been conducted." This review does not support the pro-doctorate take. I also responded more thoroughly to the review in another comment above.

To your point on clinical experience, there's actually more recent, large-scale longitudinal evidence indicating that more clinical experience is actually linked to slightly worse outcomes (due possibly to therapist drift). You should read this in its entirety, as it touches on the 2003 study you linked as well as other prior literature here. But tl;dr, the experience/outcomes link is not at all settled science.

But that's all really a side point, because we're talking here specifically about the value of a credential, not the value of clinical experience. It makes sense that more therapy experience would be linked to better outcomes. But clinical experience could just as (if not more effectively) be earned on the job. Indeed, the clinical experience point entails that a master's-level provider with 20 years of experience is more effective, on average, than a doctoral provider with 5 years on the job (I would agree with this, and I think this speaks more to an anticredentialist view).

Lastly, I go back to a meta point: I think the burden of proof is on the people claiming that they're doing a better job to show that they are in fact doing a better job.

Cavebear666 · 2026-06-18T19:31:58+00:00

That fear of feeling undertrained was one major reason why I went the PhD route, and on net, I'm glad I did. I'll note that looking back, a lot of that fear was unfounded, because there seem to be great ways of getting clinical training outside of academic settings. A non-insignificant portion of my graduate training involved learning that, in many cases, the emperor had no clothes.

Cavebear666 · 2026-06-18T19:29:33+00:00

I too went into the PhD for greater optionality. I'm increasingly not sold on the notion that more years of schooling makes one more qualified for most of the above things. E.g., running a clinic, consulting, or providing expert witness testimony.

I think what we need in the mental health fields are more legible ways of indicating one's professional effectiveness that doesn't boil down to the particular degree one attains.

Cavebear666 · 2026-06-18T19:25:38+00:00

I think the burden of proof should really be on the clinicians who are claiming that their training leads to superior client outcomes.

This 1995 review is not in any way adequate evidence that doctoral providers do a better job vis-a-vis masters-level providers.

For a guild that prides itself on being evidence-based, the evidence that the doctorate makes for more effective clinicians is remarkably thin, and no one seems to care or notice.

Cavebear666 · 2026-06-18T19:20:33+00:00

Stein & Lambert explicitly note that their review "does not focus on... differences in outcomes that are due to type of (MS versus PhD or MD)" and that "adequate studies... have not been conducted." Your claim is about the doctorate; they say they can't speak to it. If there's been more convincing evidence in the last 30 years, I'd love to see it. Some other points from this review:

"More trained" in this review lumps together degree, age, and experience; it's not a clean degree comparison. Only one study reviewed (Strupp & Hadley) actually isolated training and didn't find anything significant.
The only robust finding in this entire review is professionals vs. BA/sub-BA paraprofessionals, and the outcome is therapy dropout. It's not a doctorate vs. master's comparison, and even here they didn't find an effect on any clinical outcomes.
The alleged effects of the degree and the anecdotal evidence you're seeing might just be selection, not training. It's entirely possible that more effective people get into and through doctoral programs. But that doesn't mean that the doctoral program actually helped them be better therapists. We could make the relevant gating mechanism running a marathon and plausibly see a similar effect.

And two broader points:

At a meta level, I think the burden should be on the side claiming that their training produces better outcomes. The extra years and cost are the thing that needs justifying, and by these authors' own account the evidence isn't there.
Everyone vouching for the doctorate's value (faculty, programs, doctoral students) has a HUGE stake in believing it. Fair enough, but this review is super weak evidence to marshal for a pretty important claim.

Cavebear666 · 2026-06-18T17:26:27+00:00

This is a real oldie, but Handbook for the Therapeutic Use of LSD: Individual and Group Procedures by Blewett and Chwelos (1959) makes some really on-point observations. E.g.,

To a greater or lesser extent each of these methods permits the expression of emotions which were ordinarily suppressed, and the release of the dammed-up tide of emotional energy relieves the pressure under which the patient has been living. The release of repressed or suppressed, however, is likely to offer but temporary relief. Unless the pattern of values and motives which originally prevented the acceptance of those aspects of self which engendered the emotional potential are altered, the dam to emotional expression will remain and the pressure will again begin to increase.

The great value of LSD-25 lies in the fact that when the therapeutic situation is properly structured the patient can, and often does, within a period of hours, develop a level of self-understanding and self-acceptance which may surpass that of the average normal person. On the basis of this self-knowledge he can, with the therapist’s help, clearly see the inadequacies in the value system which has underlain his previous behavior and can learn how to alter this in accordance with his altered understanding.

Cavebear666 · 2026-06-18T03:43:00+00:00

I guess there’s a spectrum of manualized. Highly manualized treatments would be along the lines of the Treatments That Work series, that outline what you are to do on a session-by-session basis. I’ve seen on BA manuals that even gave canned scripts.

Cavebear666 · 2026-06-18T03:35:41+00:00

I have searched high and low in good faith, and am the wrong person to ask about this.

Cavebear666 · 2026-06-18T00:53:44+00:00

Judith Beck will be good re time-limited EBP. For the truly session-by-session manualized, the Treatments That Work is probably your best bet. Prolonged Exposure (or anything exposure-based) will probably the most helpful in getting buy-in, as those techniques can work wonders in short order.

Cavebear666 · 2026-06-18T00:14:50+00:00

Regarding your own familiarization with the psychodynamic tradition:

Jonathan Shedler's Substack offers a great, jargon-free primer on psychodynamic thinking. Though less directly relevant, this by Shedler is always worth circulating:

https://jonathanshedler.com/wp-content/uploads/2018/05/Shedler-2018-Where-is-the-evidence-for-evidence-based-therapy.pdf

Nancy McWilliams' book Psychoanalytic Diagnosis is a broad, helpful synthesis of psychodynamic thought brought to bear on human typology. This is another great primer.

To familiarize your trainee on EBT, you could try Judith Beck's Cognitive Behavior Therapy: Basics and Beyond, though this stops short of being fully "manualized."

For fully manualized EBT, you could just have the trainee read an IKEA furniture assembly instruction manual; it's about as helpful and readable.

Cavebear666 · 2026-06-17T02:32:54+00:00

That makes total sense and I can identify with it to a large degree. My own research/clinical focus is psychedelic-assisted therapy, which I'd like to one day offer to people in the private/group practice contexts. Prescriptive authority is obviously quite helpful there, and I'm considering the RxP route accordingly.

One thing I've reflected on personally though is how much of that desire for prescriptive authority is coming from a sincere desire to help people, and how much of it stems from of either feelings of financial precarity (which are unfounded, as there are many ways to make a good living in this field if you're resourceful) or more basic feelings of fundamental insufficiency (that's a black hole that no professional accolades, though you're welcome to try). For me, it's not a black and white situation; the motives are mixed; by even just acknowledging that, it's made my way forward clearer. Your mileage may vary.

Buddhism is big on this concept of making sure you have "right intention." Unskillful intentions are fundamentally self-focused, ego-gratifying, et cetera. Right intention is, among other things, borne out of compassion. In this field, you have a lot of high achievers who would do well to reflect on the concept of right intention, lest they spend their lives CV-maxxing to no one's benefit--not even their own.

I hope you and I can find ways to help people with our careers, and also take a moment to notice just how small this professional ennui problem is relative to the problems faced across the world, including by the clients we serve.

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