When mental health practitioners use methods that are totally lacking in scientific support, particularly when the treatment has been demonstrated to be harmful and evidence-based alternatives are available, they should be liable for malpractice. Organizations like the American Psychological Association claim to support scientific standards but leave loopholes that allow psychologists to practice pseudoscientific nonsense. Several steps must be taken to close the gap between science and practice in mental healthcare, including malpractice reform, improved guidelines based on evidence, consumer education, and a commitment to scientific practice by professional organizations.

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. 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. 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.
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