Med school students assigned to improve most-used medical Wikipedia entry

None whatsoever. You’ve caught me: my entire profession is a joke predicated on a lie. Thank goodness you saved me from embarrassing myself with this ill-thought-out project.

No, that’s not what I said nor what I intended. I’m of the understanding the evidence is weak at best and in many cases entirely lacking - perhaps you can put me right?

These days Wikipedia has become the dominant resource for people looking up information; and also information on trans and/or autistic people.

I’ll let that sink in for you.

There’s a whole body of research and meta-analysis of research on various therapy and counseling modalities.

Pretty much all available evidence supports the broad conclusion that therapy is better than no therapy. That’s the good news. It’s better to get therapy than to be put on a waiting list, to be given individual or group psychoeducation, to be assigned to read a book (bibliotherapy) about your problem, or to be given medication.**

Attempts to distinguish whether any particular model is “best” or “best for a particular problem” are more complicated. Some have called the “therapy is better than no therapy” conclusion the “Dodo Award” after the character in Alice in Wonderland: “All have won, and all must have prizes.” Certainly, it would seem like a good thing to know whether any particular approach might be more likely to help you than another when you’re trying to pick a therapist.

The search for Empirically-Supported Treatments has mostly favored cognitive-behavioral approaches, which show very strong evidence of effectiveness with simple phobias and anxiety disorders, as well as general effectiveness with some other diagnoses. CBT also tends to show well for other diagnoses, but the field gets muddy quickly because CBT is also the easiest “fit” with the parameters of EST research. If you “operationalize” something in behavioral terms (e.g. you define “depression” as “scoring more than 12 points on this 20-point scale asking about depressed behaviors”), it’s very easy to say that a treatment is effective if it decreases those behaviors. But is “scoring only 10 points on that scale” the same thing as “not being depressed”? A purely behavioral description isn’t always an appropriate or complete one, but it sure makes CBT score well in the EST framework.

What about more nebulous therapy outcomes, like “improving a couple’s relationship” or “having better sex” or “living comfortably with bipolar disorder?” Behavioral measures aren’t necessarily going to effectively capture the whole of what “improvement” or “success” looks like, particularly in couple or family problems where people might define the problems and their desired outcomes differently. A classic example of this problem is evaluating marital therapies and only considering them “successful” if the couple stays married - sometimes an agreement to divorce with as much dignity and respect as possible is also a “successful” outcome. And is a couple who stays together “successful” if they last another 6 months? 1 year? 2 years? 5 years? How long do you have to follow up to declare “success” for your therapy in that model? But if I’m a client wanting to keep my marriage intact (and functional), I don’t want to hear that a therapy is “successful” if most people who got it stayed together for another year after therapy and then became unhappy or broke up.

What about a complex presentation, where parents are concerned about their 17-year-old who is using drugs, fighting with them all the time, and threatening to drop out of school? If, after family therapy, the kid is no longer using drugs, and the family is getting along better, but the kid still drops out of school, was therapy “effective”? Empirically Supported Treatments are supposed to match specific treatment modes with specific problems they treat effectively, but this basically limits research to straightforward, definable presenting problems without complicating factors (e.g. substance abuse with mental health problems and relationship problems).

Hopefully you can see the problems here, anyway.

However, the focus has broadened in the field to also look at Evidence-Based Practice, which allows inclusion of common factors research (regardless of the model, what factors seem to be common to most or all successful therapy relationships?), models with more complex concepts and interventions than CBT, and more complex presenting problems. There’s also been much work done in process research - looking at therapy sessions individually and across a course of treatment to determine what moments were most important for helping change to occur, what was most significant about a given session or course of therapy to the client(s), what therapist factors are most relevant to change, etc.

One good example is Emotionally Focused Therapy. EFT is a couple therapy approach (now being expanded to family therapy) that was developed with continuous process research input. The whole time the model was being developed, researchers were doing in-depth qualitative and quantitative research on tapes of therapy sessions, reports from clients during the course of therapy, reports from therapists, and follow-up with clients after completion. All that data was used to continually focus and refine the model into its couple therapy form, and the same process has been used to adapt it for couples with trauma and now with families. (There’s also research going on into whether the model needs adaptation for same-sex couples, couples from outside North America, etc.) Meanwhile, they’ve been continuously gathering long-term outcome data - I believe the first 20-year followups will be available sometime soon.

The end result is that EFT helps 73% of distressed couples move out of distress into a “healthy/satisfied” range, and 89% of couples experience some improvement. (They’ve found that the folks who improve but don’t get “well” are often couples with trauma, which is why they’ve been adapting the model for them.) CBT with couples has comparable effects at the end of a course of therapy. But the difference comes in the follow-ups: 6 months after therapy ends, 50% of the couples who get CBT are back to their pre-therapy state (i.e., they look just as distressed as they did before they got any help). The effects of EFT, on the other hand, appear to be basically stable at 6 months, 1 year, 5 years, 10 years, and 15 years of follow-up. A summary of research is here (pdf).

So to say that evidence for therapy is “weak at best” is entirely incorrect. Evidence that therapy works is quite strong in fact.

Some specific therapies are exceptionally well-supported with a large body of evidence for their effectiveness with specific problems; some specific therapies have a modest amount of evidence that they work in a general sense; some - particularly some that are trendy, marketing gimmicks, pseudo-science related, etc. - have no specific evidence for their use at all and yet may still fall under the general “therapy is better than no therapy” umbrella. (Living in the Bay Area, there is much more of that last category than I’d like, and of course it these that often have motivated practitioners using Wikipedia as a marketing opportunity, which was the point of my original comment.)


** Medication plus talk therapy has been found to be more effective for depression than medication alone OR talk therapy alone. However, a new wrinkle in the research just emerged: If you have depression AND relationship problems, and the depression emerged first, medication plus individual talk therapy has a good chance of helping. But if the relationship problems emerged first, individual therapy has a good chance of making things WORSE. Medication plus couple therapy is helpful in both cases. My students had a heck of a time getting their heads 'round that one last week in our first week of the semester, but they’re catching on.


[quote=“thaum, post:23, topic:21488, full:true”]I’ll let that sink in for you.

It has. It hasn’t addressed the way it reinforces bigotry. It is a dangerous situation.


Wow, quite a reply - thanks!

I love the way the people bitching about Wikipedia’s editing policies and editor caste have provided no evidence whatsoever that these medical entry edits have been reverted, rejected, or otherwise blocked.

It is fine to complain about the process, that is how democracy is supposed to work, but be specific, be precise, provide evidence. Otherwise it is little more than axe grinding.

Well, that’s a good example of why I’d like to improve the representation family therapy (as well as general counseling and psychotherapy) on Wikipedia.

What, I’m supposed to go through and point to all the edits and flame wars and harassment, triggering myself to satisfy your (in)curiousity?

Wikipedia is a public system like a court of law or representational democracy. You should be able to point to matters of public record, yes, otherwise we’re all just taking your word for it. That is the only way it can work.

You could also cite other articles with specific examples. Democracy can be an ugly system, but it is always public, so the ugliness cannot hide and fester.

Wikipedia is supposed to respect users’ privacy. Because it was supposed to respect my privacy, I was able to discuss some of the violence I’ve suffered, and some of my medical history. Because it has not addressed bullying, I suffered harassment [as described above] and attempts to force me to out myself. No I am not going to trigger myself to satisfy you. No I am not going to share my username with you, or with everyone here, or with anyone I don’t already know.

I doubt my experience is unusual anyway. I experienced ongoing harrassment the whole time I was editing there. I had someone attempt to force me to out myself in the first week. I suggest that if you are so enthusiastic about Wikipedia, you edit there, and if you have privileges which protect you from harassment, you watch how other editors are being treated. And you could check the talk pages for articles on trans issues, disability issues etc., you could check the conflict resolution pages, you could look at the controversies regarding misnaming Chelsea Manning, and how some editors harassed trans and pro-trans editors, you could look at the dehumanization there, and you could look at the attempt to ban any discussion of transphobia.

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