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Science and Pseudoscience in Clinical Psychology
The Guilford Press Copyright © 2004 The Guilford Press
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Chapter One Science and Pseudoscience in Clinical Psychology
Initial Thoughts, Reflections, and Considerations
SCOTT O. LILIENFELD STEVEN JAY LYNN JEFFREY M. LOHR
As Bob Dylan wrote, "The times they are a-changin'." Over the past several decades, clinical psychology and allied disciplines (e.g., psychiatry, social work, counseling) have borne witness to a virtual sea-change in the relation between science and practice. A growing minority of clinicians appear to be basing their therapeutic and assessment practices primarily on clinical experience and intuition rather than on research evidence. As a consequence, the term "scientist-practitioner gap" is being invoked with heightened frequency (see foreword to this volume by Carol Tavris; Fox, 1996), and concerns that the scientific foundations of clinical psychology are steadily eroding are being voiced increasingly in many quarters (Dawes, 1994; Kalal, 1999; McFall, 1991). It is largely these concerns that have prompted us to compile this edited volume, which features chapters by distinguished experts across a broad spectrum of areas within clinical psychology. Given the markedly changing landscape of clinical psychology, we believe this book to be both timely and important.
Some might contend that the problem of unsubstantiatedtreatment techniques is not new and has in fact dogged the field of clinical psychology virtually since its inception. To a certain extent, they would be correct. Nevertheless, the growing availability of information resources (some of which have also become misinformation resources), including popular psychology books and the Internet, the dramatic upsurge in the number of mental health training programs that do not emphasize scientific training (Beyerstein, 2001), and the burgeoning industry of fringe psychotherapies, have magnified the gulf between scientist and practitioner to a problem of critical proportions.
THE SCIENTIST-PRACTITIONER GAP AND ITS SOURCE What are the primary sources of the growing scientist-practitioner gap? As many authors have noted (see Lilienfeld, 1998, 2001, for a discussion), some practitioners in clinical psychology and related mental health disciplines appear to making increased use of unsubstantiated, untested, and otherwise questionable treatment and assessment methods. Moreover, psychotherapeutic methods of unknown or doubtful validity are proliferating on an almost weekly basis. For example, a recent and highly selective sampling of fringe psychotherapeutic practices (Eisner, 2000; see also Singer & Lalich, 1996) included neurolinguistic programming, eye movement desensitization and reprocessing, Thought Field Therapy, Emotional Freedom Technique, rage reduction therapy, primal scream therapy, feeling therapy, Buddha psychotherapy, past lives therapy, future lives therapy, alien abduction therapy, angel therapy, rebirthing, Sedona method, Silva method, entity depossession therapy, vegetotherapy, palm therapy, and a plethora of other methods (see also Chapter 7).
Moreover, a great deal of academic and media coverage of such fringe treatments is accompanied by scant critical evaluation. For example, a recent edited volume (Shannon, 2002) features 23 chapters on largely unsubstantiated psychological techniques, including music therapy, homeopathy, breath work, therapeutic touch, aromatherapy, medical intuition, acupuncture, and body-centered psychotherapies. Nevertheless, in most chapters these techniques receive minimal scientific scrutiny (see Corsini, 2001, for a similar example).
Additional threats to the scientific foundations of clinical psychology and allied fields stem from the thriving self-help industry. This industry produces hundreds of new books, manuals, and audiotapes each year (see Chapter 14), many of which promise rapid or straightforward solutions to complex life problems. Although some of these self-help materials may be efficacious, the overwhelming majority of them have never been subjected to empirical scrutiny. In addition, an ever-increasing contingent of self-help "gurus" on television and radio talk shows routinely offer advice of questionable scientific validity to a receptive, but often vulnerable, audience of troubled individuals (see Chapter 15).
Similarly questionable practices can be found in the domains of psychological assessment and diagnosis. Despite well-replicated evidence that statistical (actuarial) formulas are superior to clinical judgment for a broad range of judgmental and predictive tasks (Grove, Zald, Lebow, Snitz, & Nelson, 2000), most clinicians continue to rely on clinical judgment even in cases in which it has been shown to be ill advised. There is also evidence that many practitioners tend to be overconfident in their judgments and predictions, and to fall prey to basic errors in reasoning (e.g., confirmatory bias, illusory correlation) in the process of case formulation (Chapter 2). Moreover, many practitioners base their interpretations on assessment instruments (e.g., human figure drawing tests, Rorschach Inkblot Test, Myers-Briggs Type Indicator, anatomically detailed dolls) that are either highly controversial or questionable from a scientific standpoint (see Chapter 3).
Still other clinicians render confident diagnoses of psychiatric conditions, such as dissociative identity disorder (known formerly as multiple personality disorder), whose validity remains in dispute (see Chapter 5, but see also Gleaves, May, & Cardena, 2001, for a different perspective). The problem of questionable diagnostic labels is especially acute in courtroom settings, where psychiatric labels of unknown or doubtful validity (e.g., road rage syndrome, sexual addiction, premenstrual dysphoric disorder) are sometimes invoked as exculpatory defenses (see Chapter 4).
STRIKING A BALANCE BETWEEN EXCESSIVE OPEN-MINDEDNESS AND EXCESSIVE SKEPTISM
It is critical to emphasize that at least some of the largely or entirely untested psychotherapeutic, assessment, and diagnostic methods reviewed in this volume may ultimately prove to be efficacious or valid. It would be a serious error to dismiss any untested techniques out of hand or antecedent to prior critical scrutiny. Such closed-mindedness has sometimes characterized debates concerning the efficacy of novel psychotherapies (Beutler & Harwood, 2001). Nevertheless, a basic tenet of science is that the burden of proof always falls squarely on the claimant, not the critic (see Shermer, 1997). Consequently, it is up to the proponents of these techniques to demonstrate that they work, not up to the critics of these techniques to demonstrate the converse.
As Carl Sagan (1995b) eloquently pointed out, scientific inquiry demands a unique mix of open-mindedness and penetrating skepticism (see also Shermer, 2001). We must remain open to novel and untested claims, regardless of how superficially implausible they might appear at first blush. At the same time, we must subject these claims to incisive scrutiny to ensure that they withstand the crucible of rigorous scientific testing. As space scientist James Oberg observed, keeping an open mind is a virtue but this mind cannot be so open that one's brains fall out (Sagan, 1995a; see also Chapter 9). Although the requirement to hold all claims to high levels of critical scrutiny applies to all domains of science, such scrutiny is especially crucial in applied areas, such as clinical psychology, in which erroneous claims or ineffective practices have the potential to produce harm.
WHY POTENTIALLY PSEUDOSCIENTIFIC TECHNIQUES CAN BE HARMFUL
Some might respond to our arguments by contending that although many of the techniques reviewed in this book are either untested or ineffective, most are likely to prove either efficacious or innocuous. From this perspective, our emphasis on the dangers posed by such techniques is misplaced, because unresearched mental health practices are at worst inert.
Nevertheless, this counterargument overlooks several important considerations. Specifically, there are at least three major ways in which unsubstantiated mental health techniques can be problematic (Lilienfeld, 2002; see also Beyerstein, 2001). First, some of these techniques may be harmful per se. The tragic case of Candace Newmaker, the 10-year-old Colorado girl who was smothered to death in 2000 by therapists practicing a variant of rebirthing therapy (see Chapter 7), attests to the dangers of implementing untested therapeutic techniques (see Mercer, in press). There is also increasing reason to suspect that certain suggestive techniques (e.g., hypnosis, guided imagery) for unearthing purportedly repressed memories of childhood trauma may exacerbate or even produce psychopathology by inadvertently implanting false memories of past events (see Chapters 7 and 8). Even the use of facilitated communication for infantile autism (see Chapter 13) has resulted in erroneous accusations of child abuse against family members. Moreover, there is accumulating evidence that certain widely used treatment techniques, such as critical incident stress debriefing (see Chapter 9), peer group interventions for adolescents with conduct disorders (Dishion, McCord, & Poulin, 1999), and certain self-help programs (Rosen, 1987; see Chapter 14) can be harmful. Consequently, the oft-held assumption that "doing something is always better than doing nothing" in the domain of psychotherapy is likely to be mistaken. As psychologist Richard Gist reminds us, doing something is not license to do anything.
Second, even psychotherapies that are by themselves innocuous can indirectly produce harm by depriving individuals of scarce time, financial resources, or both. Economists refer to this side effect as "opportunity cost." As a consequence of opportunity cost, individuals who would otherwise use their time and money to seek out demonstrably efficacious treatments may be left with precious little of either. Such individuals may therefore be less likely to obtain interventions that could prove beneficial.
Third, the use of unsubstantiated techniques eats away at the scientific foundations of the profession of clinical psychology (Lilienfeld, 1998; McFall, 1991). As one of us (Lilienfeld, 2002) recently observed:
Once we abdicate our responsibility to uphold high scientific standards in administering treatments, our scientific credibility and influence are badly damaged. Moreover, by continuing to ignore the imminent dangers posed by questionable mental health techniques, we send an implicit message to our students that we are not deeply committed to anchoring our discipline in scientific evidence or to combating potentially unscientific practices. Our students will most likely follow in our footsteps and continue to turn a blind eye to the widening gap between scientist and practitioner, and between research evidence and clinical work. (p. 9)
In addition, the promulgation of treatment and assessment techniques of questionable validity can undermine the general public's faith in the profession of clinical psychology, and lead citizens to place less trust in the assertions of clinical researchers and practitioners.
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