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Skeptical inquirer article

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Article from Skeptical Inquirer about psychotherapy and evidence-based practice

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Skeptical inquirer article

  1. 1. Whenthe ShrinksIgnoreScience, JAMESD.HERBERTand RICHARDREDDING n t793, there was an outbreak of yellow fever in Philadelphia.BenjaminRush,aleadingcolonialphysi- cianandsignerof the Declarationof Independence,ac- ceptedthe conventional wisdom that the condition should be treated with bloodletting. This treatment contributed to the demiseof many of his patients.Nevertheless,asthe epidemic waned, Rush was more convinced than ever of the effi cacyof his methods. When Rush'spatients recov- ered,he attributed their recoveryto his intervention. When they died, he chalked it up to the inevitable courseof the disease. Medical practicehascomealongway sinceRush.Antibiotics and vaccines,to nametwo obviousexamples,havebeen transformative.Without exception,these advanceshavebeendrivenby the appli- cationofscienceto healthcare.Science substitutescontrollbdscientificdataand statisticalpredictionsfor thepractitioner's intuition and clinical lore, which are prone to biasesin decisionmaking, as Rush illustrated. By promulgating practiceguidelines, institutions like the United Kingdom's National Institute for Clinical Effec- tivenessand the United States'Com- parativeEffectiveInstitute work to cod- i$' medicalpracticebasedon the best availablescientific evidence.But not everyoneis sanguineabout dethroning practitioners'judgment in favor of sci- ence,and spirited defensesof clinician autonomyhaveemergedin both thepro- fessionalliterature (Hagemoser 2009) andthe popularpress(Greenfield2010). But consider recent casesinvolving mentalhealthcare.A fatherlost custody of his child becausethe mental health evaluationof the parentrelied upon the scientificallyunfounded Rorschach"ink- blot" test.A depressedpatient experi- enced severeside effects from antide- pressant medications but was never informed aboutthe option of equallyef- fectivetreatmentslike cognitive-behav- ior therapy.And a number of therapists promise that repeatedlytapping (yes, tapping!)on their patientswill cureseri- ousdisordersandaddictionsby adjusting the body'sinvisible"energyfield" (Gau- diano and Herbert 2000). One of our own patients suffered from severeobsessivecompulsivedis- order.He would spendhours eachday showeringandwashinghis handsuntil they bled.He soughttreatmentfrom a psychoanalyst,who insisted that his symptomsreflectedunconsciousdrives that he must "work through." After his symptomsgraduallyworsenedover .'i Skepticallnquirer I sepcmbrr/ocrober 201t 13 SueThem JamesD.Herbert,PhD,is professorofpsgchologg andassociatedeanofthe CollegeofArtsandSci- encesatDrexelUniversitg inPhiladelphia. RichardE.Redding,JD andPhD,isprofessorand associatedeanatChap- manUniversitgSchoolof Lawandprofessorofpsg- chologgatChapmanUni- versitg.
  2. 2. severalyearsof this analysis,he even- tually sought behavior therapy and within weekswas completely cured of his condition. Although many psychologicalin- terventionsmay be ineffectivebut oth- erwise benign, researchhas demon- stratedthat otherscanbe quite harmful (Lilienfeld 2007).Crisis debriefing is promoted to decreasepost-traumatic stressreactionsfollowing atrauma,but in fact it actuallyincreasesthe risk of suchproblems(McNally et al.2003). So-called"attachmenttherapies"have led to the death of severalchildren (Mercer et al. 2003).Facilitated com- munication, a techniquepromoted as allowing otherwise severelyimpaired individuals with autism to communi- catefluently via typing on a keyboard while a facilitator supportshis or her hand or arm, hasled to parentsbeing falselyaccusedof sexualabuse(Herbert et al. 2002; Romanczyk et al. 2003). These areonly a few potentially harm- firl interventions.Despitedataillustrat- ing their potentially harmful effects, they remain surprisingly popular and continueto beused. Suchpracticesrepresentthe tip of the icebergof apersistentproblemin mental health care:the chasmbetweenscience and practice.To closethat gap,several stepsmustbe taken.Of coursewe need malpracticereform,but not asit is usu- ally conceived.Theperniciouseffectsof frivolous malpracticesuitsin encourag- ing unnecessarydiagnosticand inter- ventionproceduresarewidely discussed. But when mental health practitioners usemethods that aretotally lacking in scientificsupport,particularlywhen the treatmenthasbeendemonstratedto be harmfirl andevidence-basedalternatives are available,they should be liable for malpractice. Yet unlike lawsuits against other medicalprofessionals,lawsuitsagainst psychiatrists and psychologistshave beenexceptionallyrare-and successful suitseven rareLMental health practi- tionershavebeenableto escapeliability by relying on prevailing community practices-no matter how misguided- to definethe permissiblestandard(s)of care.A defendant canalwaysround up some likeminded community practi- tioners who will testifr that the proce- dure in question is widely practiced, evenif it is scientificallyunfounded. Although suitsagainstmentalhealth professionalsremain uncommon, liti- gants can and should make use of a Supreme Court case to make their claimsviable.ln Daubertv.MerrellDoas Pltarmaceuticals(1993),the Court nrled that expert testimony must be based upon reliable "scientific knowledge" rather than common practice.Thus, when a mental health professionalis suedfor treatinga patientwith harmfirl or unscientifictechniques,expertwit- nessescalledupon to describethe pre- vailing standardof caremust basetheir testimonyon science.No longercande- fendantsarguethat they met the stan- dard of caremerelybecausethey em- ployed techniquesoften usedby others in the profession., We acknowledgethat clinical practice is complexandoften doesnot lend itself to a simple application of scientifically establishedtreatmentprotocols.For ex- ample,patientsdo not alwaysfit neady into diagnosticcategories;this requires cliniciansto useinterventionsestablished for closelyrelatedconditions.Patientsdo not alwaysrespondto first-line evidence- basedinterventions,thereforemodifica- tionsof anestablishedtreatmentor even a different approachmay be necessary. Evidence-basedtreatmentsmay not yet be establishedfor some disordersor symptoms,so modificationsof estab- lished treatment strategiesor even a novelor experimentalapproachmay be required.Moreover,in the caseof psy- chotherapy,evenrelatively straightfor- ward casesnecessarilyinvolvesomede- greeoftailoring of the treatmentto each individual'sunique circumstances.Each ofthesescenariosrequiresjudiciousclin- icaljudgment.But suchjudgmentshould alwaysbe informed by the bestavailable scientific evidence.Clinical judgment doesnot representa carteblancheto es- capescrutiny or legalliability. A relatedissueis informed consent. Despitebeingethicallymandated,men- tal health practitioners rarely obtain fully informed consentfrom their pa- tients for their interventions.An inter- estingissuecenterson the questionof whether cliniciansshouldbe permitted to offer servicesthat arecompletelyde- void of scientific support aslong asthe Whenmentalhealthpractitionersuse methodsthataretotallglackingin scientificsupport,particularlgwhenthe treatmenthasbeendemonstratedto beharmfulandevidence-based alternativesareavailable,theushould beliableformalpractice. 14 votume3stssue5| Skepticallnquirer
  3. 3. patient is fully informed of this fact, is informed of anyknown risksassociated with the treatment,is informed of alter- native options, and is paying out-of- pocket rather than through aprivate or governmentalinsurer.Without resolv- ing this particularissue,it is clearthat cliniciansshouldalwaysobtain firlly in- formed consent,and suchconsentbe- comesevenmoreimportant the further one deviatesfrom scientificallyestab- lishedpractices. It will taketime for caselaw to sort through the nuancesof these real- world complexities.ln the meantime, clinicianscan minimize their risk of malpracticeliabiliry by using scientifi- cally supported procedureswhenever possible,ensuringthat modificationsto establishedtreatmentsarescientifically informed, avoiding interventions that havebeenshown to be harmful while providing little or no benefit,and ob- taining fully informed consent,espe- cially for experimental procedures. In contrast,by seekingrelief through the courts,not only canconsumerswho havebeenharmedby unscientificmental health practicesseekappropriatedam- ages,but theycanalsoexertapositivein- fluence on the field as a whole by en- couragingscientificallybasedpractice. In addition to malpractice suits, other changesareneededto placerou- tine clinicalpracticeon strongerscien- tific footing.We need an unequivocal commitment to scientific practice by professionaI organtzations,third-party payers,and statelicensureboards.Or- ganizattonssuchasthe American Psy- chologicalAssociationpaylip serviceto scientificstandards,but theyleavegap- ing loopholesthat allow psychologists to practiceall kinds of pseudoscientific nonsense.All too often psychiatrists, psychologists,and other mentalhealth clinicians use unproven and even demonstrablyharmful assessmentand treatmentprocedures,evenwhen alter- nativescientificallysupportedmethods are available.A key principle inherent in health-carereform is that in orderto 0rganizationssuchastheAmerican PsuchologicalAssociationpaglip servicetoscientificstandards,buttheg thatallow allkindsof n0nsense. loopholes practice leavegaping psUchologiststo pseudoscientific savecostsandimproveoutcomes,med- ical practice should be driven by the bestscientificevidence(The Hastings Center 2009).That principle should alsobeappliedto mental healthprofes- sionals,particularly becauseresearch has found a number of psychological and psychiatricinterventionsto be ef- fective(sometimesmore sothan treat- mentsfor physicaldisorders). Next,we needuser-friendly practice guidelinesthat are basedon the best availablescientificevidenceand arefree of undueinfluencefrom interestgroups. Reflectingthe influenceof the pharma- ceuticalindustry,the American Psychi- atric Association'sguidelines for the treatment of depression^re heavily skewedtoward drug therapiesdespite many scientific studies showing that certain forms of "talk therapy,"such as cognitivebehaviortherapy,yield longer- lastingeffectswith fewercomplications. (Of course,the bestguidelinesarenot overlyrigid but allow the practitionerto tailor them to an individual patient's unique clinical picture.) Finally,we must improve consumer education.Paradoxically,the growth of the Internet and advertisingof pharma- ceuticalsrnakesinformation more avail- ableto consumersbut alsomakesit more difficult to filter good sciencefrom po- tentially harmfirl pseudoscience. Eachofthesestrategieshasanimpor- tant role to play,but malpracticesuits againstmental healthprofessionalsmay become the critical. motivating force be- hind change, so that the shrinks, too, are guided by sciencerather than their mod- em-day versions of bloodletting. References Daubert a. Merrell Dow Pharmaceuticals, Inc. 1993.509U.S.579. Gaudiano,8.,andJ.D.Herbert.2000.Can we re- ally tap our problemsaway?A critical analysis of Thought F-ieldTherapy. SrcurrtcRt- IN- (LUIRLR2a@) $uly / Augtst) : 29-36. Greenfield,S.2010.In defenseof physicianau- tonomy. Wall StreetJournal (September 7): 423. Hagemoser,S. 2009. Braking the bandwagon: Scrutinizing the scienceand politics of em- pirically supportedtherapies.TheJournal of PsychoIogy743: 601-14. The Hastings Center. 2009. Cost Control and Health Care Reform: Act 1. Garrison, New York. Herbert,J.D., I.R. Sharp,and B.A. Gaudiano. 2002. Separatingfact from fiction in the eti- ology and treatment of autism:A scientific review of the evidence.Scientific Revieu of Mental HealthPractice7(1):B-a3. Lilienfeld, S.O. 2007. Psychologicaltreatments that causeharm. Perspectioeson Prychological Science2(1): 53-70. McNally, RJ., R.A. Bryant,andA. Ehlers.2003. Does early psychologicalintervention pro- rnoterecoveryfrom posttraumaticstress?Psy- chologicalSciencein thePublicInterest4(2):45- 79. Mercer,J.,L. Samer,and L. Rosa.2003.Attach- ment 7'herapyonTrial.Westport, Connecticut: Praeger. Rouranczyk,R.G., L. Arnstein, L.V. Soorya,and J. Gillis. 2003. The myriad of controversial treatmentsfor autism:A critical evaluationof efticacy.In S.O.Lilienfeld, SJ.Lynn, andJ.M. Lohr (Eds.), ScienceandPseudosciencein Clin- icalPslchol0gy,363-98.New York Guilford. Skepticallnquilet'I September/OctobcrZOU15