Critiques of Clinical Psychology. How Scientific is Clinical Psychology? Critiques

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1 Critiques of Clinical Psychology How Scientific is Clinical Psychology? Jim Clark Books and other works Dawes: House of Cards Lillienfield et al: Science and Pseudoscience in Clinical Psychology Wright & Cummings: Destructive Trends in Mental Health Numerous articles: see quotes on next few pages What evidence supports these criticisms? Quotes mention some things (e.g., surveys showing that clinicians rank research articles and books toward bottom of list of sources of clinical information) Critiques The gulf that divides clinical practice and clinical research is now accepted as a fact of life by many in the mental health professions and in academia.... When clinical psychologists are asked to rank the usefulness to their practice of various sources of information, research articles and books fall near the bottom of the scale. (Weisz et al., 1995) A broad-based commitment to empiricism and the scientistpractitioner model of training is seen as a viable countercontrol to the intellectual Luddites currently making their voices known in all the mental health professions, those espousing a return to phenomenology, constructivist "ways of knowing," and a repudiation of quantitative research in favor of so-called qualitative approaches to understanding. (Thyer, 1995, Promoting an Empiricist Agenda within the Human Services: An Ethical and Humanistic Imperative, p. 97) Garfield (1998, p. 1231) noted that scientistpractitioners "are no longer the majority of clinical psychologists" and that "the current conflict between scientists and practitioners, particularly private practitioners, is of real concern to many if not all scientist-practitioners." Quinsey et al. (1998) document how practices within forensic psychology related to the prediction of risk have failed to conform to sound scientific practice and have failed to weigh sufficiently the research on clinical judgment. They show that thoughtful consideration of empirical criteria and theory allow for considerable improvement in the prediction of risk. As Paul Meehl (1993) recently noted: It is absurd, as well as arrogant, to pretend that acquiring a PhD somehow immunizes me from the errors of sampling, perception, recording, retention, retrieval, and inference to which the human mind is suspect. In earlier times, all introductory psychology courses devoted a lecture or two to the classic studies in the psychology of testimony, and one mark of a psychologist was hard-nosed skepticism about folk beliefs. It seems that quite a few clinical psychologists never got exposed to this basic feature of critical thinking. My teachers at Minnesota shared what Bertrand Russell called the dominant passion of the true scientist the passion not to be fooled and not to fool anybody else all of them asked the two searching questions of positivism: What do you mean? How do you know? If we clinicians lose that passion and forget those questions, we are little more than be-doctored, well-paid soothsayers. I see disturbing signs that this is happening and I predict that, if we do not clean up our clinical act and provide our students with role models of scientific thinking, outsiders will do it for us (pp ). As clinical psychologists in turn-of-the-century America, we are confronted with the specter of pseudoscience in many guises. The past decade alone has witnessed (a) an explosion of largely unvalidated and in some cases bizarre treatments for trauma (e.g., thought field therapy, emotional freedom techniques), (b) a proliferation of demonstrably ineffective treatments for infantile autism and related disorders (e.g., facilitated communication), (c) the continued use of inadequately validated assessment instruments (e.g., human figure drawing tests and several other questionable projective techniques), (d) the widespread use of herbal remedies for depression and anxiety whose efficacy has often yet to be tested, let alone demonstrated (e.g., kava, ginkgo), (e) the marketing of subliminal self-help tapes that have repeatedly been found to be of no value in the treatment of psychopathology, (f) a burgeoning industry of self-help books, many or most of which make unsubstantiated claims, and the (g) use of highly suggestive therapeutic techniques to unearth memories of child abuse (including satanic ritual abuse) and the purported alter personalities of dissociative identity disorder (multiple personality disorder). And this, of course, is only a partial list. (Lillienfield, 1998) 1

2 Evidence Views of Clinical Psychology (Maki & Symon, 1997) Survey of clinical training programs Treatment of Facilitated Communication (%) Train No/DKDiscourage Clinical Counselling PhD PsyD Psych Dept Educ Dept Prof / Other Evidence Maki & Symon (cont d) Mean Importance Ratings on Boulder Model Science Questions (7=Very Important) Clin Couns PhD PhD PsyD Train in scientific methodology Evaluate empirical support Deal in scientific manner Faculty publication in hiring Conduct original research Require research dissertation Graduates continue to publish Evidence Performance of graduates on EPPP (Yu, Rinaldi, Templer, Colbert, Siscoe, & Van-Patten, 1997) Examination for Professional Practice in Psychology (EPPP) Numerous graduates from non-university-affiliated PsyD programs with high student-faculty ratios did not fare as well as students from more traditional PhD programs. EPPP a rather minimalist criterion for scientific psychology Evidence Many research psychologists have deserted from national organizations that increasingly focus on applied issues American Psychological Association (APA) -> American Psychological Society (APS) Canadian Psychological Association -> Canadian Society for Brain, Behaviour, and Cognitive Science Evidence? Widening Gap Between Academic and Popular Psychology (Lillienfield, 1998) Table 2 Comparisons of Web Hits and PsychLit citations for several widely researched treatment and assessment techniques (PsychLit citations in parentheses) Topic Web Hits Ratio Systematic desensitization 272 (2144).13 Token economy 182 (845).22 MMPI 1187 (7371).16 California Psych Inv/CPI 62 (847).07 Beck Depression Inventory 306 (3472).09 (compare to next table) Table 3 Comparisons of Web Hits and PsychLit citations for several treatment and assessment techniques in popular psychology (PsychLit citations in parentheses) Topic Web Hits Ratio Past life regression 1328 (6) St. John s Wort (Hypericum) 5867 (13) Kava 5844 (17) Thought field therapy 102 (3) 34.0 Rebirthing 933 (0) infinity Inner Child/Inner Child Therapy 2737 (44) 62.2 Facilitated communication 9652 (50) Subliminal self-help tapes 406 (2) Enneagrams 1408 (10)

3 Textbooks % Pages in Texts with Table / Figure of Data #Pages Table/Figure % Clinical Hecker Nietzel et al Sundberg Trull (compare to Cognitive on next slide) Cognitive Ashcraft Best Galotti Glass Howard Hunt Medin Moates Payne Reed Reisberg Sobel Solso Sternberg Recent Criticism Lillienfeld (1998): How to recognize pseudoscience Table 1 Common Characteristics of Pseudosciences (1) Overuse of ad hoc hypotheses to escape refutation (2) Emphasis on confirmation rather than refutation (3) Absence of self-correction (4) Reversed burden of proof (5) Overreliance on testimonials and anecdotal evidence (6) Use of obscurantist language (7) Absence of connectivity with other disciplines (from Bunge, 1984) Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (2003). Science and pseudoscience in clinical psychology. New York: Guilford Press. Collection of chapters documenting concerns of science-oriented practitioners and scientists with interests in 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 science-practitioner gap is being invoked with heightened frequency and concerns that the scientific foundations of clinical psychology are steadily eroding are being voiced increasingly in many quarters. (LL&R, p. 1) Reasons for concern Practices may be directly harmful: death of young girl in 2000 during rebirthing therapy, unwarranted charges of child abuse based on facilitated communication with autistic children, Consume scarce time and financial resources Ultimately erodes credibility of discipline and reduces commitment to science in future practitioners Indicators of Pseudoscience Over-use of ad hoc hypotheses to immunize hypotheses from falsification Absence of self-correction Evasion of peer review Emphasis on confirmation rather than refutation Reversed burden of proof Absence of connectivity: claims of revolutionary paradigms Over-reliance on testimonials and anecdotal evidence Use of obscurantist language Absence of boundary conditions Mantra of holism 3

4 Garb & Boyle: Understanding why some clinicians use pseudoscientific methods (ch 2) Review evidence that clinical experience may not be associated with better performance E.g., more experienced clinicians do NOT produce more valid interpretations of MMPI profiles Then explain why clinical experience a poor source of knowledge Cognitive: confirmatory bias, illusory correlation, hindsight bias, availability heuristic, Environmental: lack of feedback, Barnum effect, Hunsley, Lee, & Wood: Controversial and questionable assessment techniques (ch 3) Review basic issues in science-based assessment, especially validity Then review 5 questionable practices still in widespread use (4 are projective tests) Rorschach Thematic Apperception Test (TAT) Projective Drawings Anatomically Detailed Dolls Myers-Briggs Type Indicator Lilienfeld & Lynn: Dissociative Identity (ch 5) Describe Posttraumatic vs. Sociocognitive models of the disorder Review evidence for sociocognitive model Non-random distribution of cases: 66% cases in Switzerland diagnosed by.09% of all clinicians; 90% therapists had never seen a case, vs. 3 psychiatrists who had seen over 20 cases Cross-cultural differences in occurrence and expression of disorder Role-playing studies Question the link with child abuse e.g., problems in validating reports of abuse Singer & Nievod: New Age therapies (ch 7) Examples of New Age therapies: recovered memory therapy, rebirthing and reparenting therapy, past lives therapy, Many based on mystical views of world: past lives, magical elements, Discuss issues of accountability, both ethical and legal Lohr, Hooke, Gist, & Tolin: Novel and controversial treatments for trauma-related stress disorders (ch 9) Number of unsubstantiated practices Eye-Movement Desensitization and Reprocessing (EMDR) Thought-Field Therapy (TFT) Critical Incident Stress Debriefing (CISD) It is clear that there is insufficient evidence to support the use of EMDR, TFT, or CISD as standard treatments for PTSD or trauma sequelae. We believe that widespread application of these treatments can be partially accounted for by the pseudoscientific manner in which these treatments have been promoted to mental health professionals and the consuming public. p. 262 MacKillop, Lisman, Weinstein, & Rosenbaum: Controversial treatments for alcoholism (ch 10) Describe various common practices that lack adequate scientific support Alcoholics Anonymous: high drop out rates, studies focus on most active members, members often receive professional treatment in addition Discuss other treatment programs of questionable validity and a similarly dubious prevention program widely used in schools (DARE) Review various effective programs based on sound principles (e.g., social learning theory, operant conditioning, ) 4

5 Lilienfeld, Lynn, & Lohr: Concluding thoughts (ch 16) Prescriptions for field of clinical psychology Training programs must require formal training in critical thinking skills necessary to distinguish scientific and pseudoscientific approaches Must identify empirically-supported treatments (ESTs), AND treatments that lack empirical support APA and other organizations must play active role in ensuring that continuing education of practitioners is based on solid scientific evidence APA and other organizations must play active role in discrediting erroneous claims in press and elsewhere (e.g., www) APA and other organizations must impose sanctions on practitioners who use questionable practices What to do? My third suggestion and perhaps the one most likely to be controversial - concerns what those of us in clinical psychology programs can do to tend to the problems within our own house. Although it might be tempting to dismiss the pseudoscience problem as not of our own making, clinical psychologists have not been immune from making unsubstantiated claims. In the pages of this newsletter several years ago, Richard McFall (1991) argued that we should encourage clinical graduate programs to develop their own creative ways of meeting APA accreditation requirements. I agree. But diversity in training can go too far, and I fear that it has. In granting clinical programs considerable flexibility in finding ways to meet APA curriculum requirements, we may have neglected to ensure that certain critical issues receive the coverage they deserve. I find it disconcerting to see bright and intellectually curious students graduating with PhDs and PsyDs from APA-accredited clinical programs knowing little or nothing about the limitations of clinical judgment and clinical prediction, the effect of base rates on clinical decision- making, the fallibility of human memory, and fundamental issues in the philosophy of science. APA should encourage creativity in meeting basic curriculum requirements, while also insisting on a core set of knowledge to ensure that the clinical psychologists of the next generation emerge with a modicum of critical thinking skills. Discussion Is clinical psychology responsible for all ills in mental health professions? e.g., use of herbal remedies for psychological disorders. Are these (modest?) recommendations strong enough to promote a truly scientific clinical psychology? Perhaps need to infuse clinical psychology with well-founded, mechanistic theories (e.g., cognitive, social, ). Arbuthnott et al: The Mind in Therapy: Cognitive Science for Practice Wenzel & Rubin: Cognitive Methods and their Application to Clinical Research Numerous studies of cognitive factors involved in clinical disorders Sensory Register* Perception* Short-Term Memory* Basic Processes Cognitive Psychology Attention* Long-Term Episodic Memory* Higher Level Processes Semantic Memory* Language Problem Solving and Creativity Reasoning and Decision Making Information-Processing Model Childhood s Control Processes (Attention, Strategy Selection) Perception Pattern Recognition Sensory Register Stimulus Semantic Memory Declarative Procedural Episodic Memory Long-Term Short-Term Output System Response Mental Retardation 317 Mild Mental Retardation. (IQ to 70) Moderate Mental Retardation. (IQ to 50-55) Severe Mental Retardation. (IQ to 35-40) Profound Mental Retardation. (IQ less than 20-25) 319 Mental Retardation, Severity Unspecified. Learning s Reading Mathematics of Written Expression Learning Not Otherwise Specified (NOS) Motor Skills Developmental Coordination Figure 1. Information Processing Model of Human Cognition. 5

6 Childhood (cont d) Communication s Expressive Language Mixed Receptive-Expressive Language Phonological Stuttering Communication NOS Pervasive Developmental s Autistic Rett's Childhood Disintegrative Asperger s Pervasive Developmental NOS Childhood (cont d) Attentional and Disruptive s 314.xx Attention-Deficit Hyperactivity 312.xx Conduct Oppositional Defiant Disruptive Behavior NOS Feeding and Eating s of Childhood Pica Rumination Feeding of Infancy or Childhood Tic s Tourette's Chronic Motor or Vocal Tic Transient Tic Tic Not Otherwise Specified Childhood (cont d) Elimination s 787.6/307.7 Encopresis Enuresis (Not due to general medical condition) Other s of Childhood Separation Anxiety Selective Mutism Reactive Attachment of Infancy or Early Childhood Stereotypic Movement of Infancy, Childhood, or Adolescence NOS Cognitive s Delirium s Delirium Due to General Medical Condition 291.x, 292.8x Substance Intoxication Delirium 291.x, 292.8x Substance Withdrawal Delirium??? Delirium Due to Multiple Etiologies Delirium NOS Types of Dementia 294.xx Dementia of the Alzheimer's Type 290.4x Vascular Dementia 294.1x Dementia Due to Other General Medical Conditions (HIV, Head Trauma, Parkinsons, ) Substance-Induced Persisting Dementia?? Dementia Due to Multiple Etiologies Dementia Not Otherwise Specified Cognitive s Amnestic s Amnestic Due to General Medical Condition Substance-Induced Persisting Amnestic Amnestic NOS Cognitive Not Otherwise Specified Mental s Due to General Medical Condition Not Elsewhere Classified Catatonic Due to Personality Change Due to Mental NOS Due to 1

7 Substance-Related s Alcohol-Related s Alcohol Use s Alcohol Dependence Alcohol Abuse Alcohol-Induced s Alcohol Intoxication Alcohol Withdrawal Alcohol Intoxication/Withdrawal Delirium 291.x Alcohol-Induced Dementia/Amnesia/Psyc hotic Use/Induced s Amphetamine Caffeine (Induced only) Cannabis Cocaine Hallucinogenic Inhalant Nicotine Opioid Phencyclidine Sedative/Hypnotic/Anxiolytic Polysubstance Other or Unknown Schizophrenia and Other Psychotic s 295.xx Schizophrenia.30 Paranoid Type.10 Disorganized Type.20 Catatonic Type.90 Undifferentiated Type.60 Residual Type Schizophreniform Schizoaffective Delusional Brief Psychotic Shared Psychotic 293.xx Psychotic Due to a General Medical Condition -- Substance-Induced Psychotic Psychotic NOS Mood s Depressive s 296.xx Major Depressive Dysthymic 311 Depressive NOS Bipolar s 296.xx Bipolar I Bipolar II Cyclothymic Bipolar NOS Mood Due to General Medical Condition --- Substance-Induced Mood Mood NOS Anxiety s Panic Without Agoraphobia Anxiety Panic With Agoraphobia Anxiety Agoraphobia Without History of Panic Anxiety Specific Phobia Anxiety Social Phobia Anxiety Obsessive-Compulsive Anxiety Posttraumatic Stress Anxiety Acute Stress Anxiety Generalized Anxiety Anxiety Anxiety Due to General Medical Condition Anxiety Alcohol-Induced Anxiety Substance? Anxiety NOS Anxiety Somatoform and Factitious s Somatoform s Somatization Undifferentiated Somatoform Conversion 307.xx Pain Hypochondriasis Body Dysmorphic Somatoform NOS Factitious s 300.xx Factitious Factitious NOS Dissociative s Dissociative Amnesia Dissociative Fugue Dissociative Identity Depersonalization Dissociative NOS 2

8 Sexual and Gender Identity s Sexual Dysfunctions Hypoactive Sexual Desire Sexual Aversion Female Sexual Arousal Male Erectile Female Orgasmic Male Orgasmic Premature Ejaculation Dyspareunia Vaginismus --- Sexual Dysfunction Due to a General Medical Condition --- Substance-Induced Sexual Dysfunction Sexual Dysfunction NOS Paraphilias Exhibitionism Fetishism Frotteurism Pedophilia Sexual Masochism Sexual Sadism Transvestic Fetishism Voyeurism Paraphilia NOS Gender Identity 302.xx Gender Identity Gender Identity NOS Sexual NOS Eating s Anorexia Nervosa Bulimia Nervosa Eating NOS Primary Sleep s Dyssomnias Primary Insomnia Primary Hypersomnia 347 Narcolepsy Breathing-Related Sleep Circadian Rhythm Sleep Dyssomnia NOS Parasomnias Nightmare Sleep Terror Dis Sleepwalking Dis Parasomnia NOS Sleep s Sleep s Related to Other Mental s Insomnia Related to [Axis I or Axis II disorder] Hypersomnia Related to [Axis I or Axis II disorder] Other Sleep s 780.xx Sleep Due to a General Medical Condition --- Substance-Induced Sleep Impulse-Control s Not Elsewhere Classified Intermittent Explosive Kleptomania Pyromania Pathological Gambling Trichotillomania Impulse-Control NOS Adjustment s 309.xx Adjustment.0 With Depressed Mood.24 With Anxiety.28 With Mixed Anxiety and Depressed Mood.3 With Disturbance of Conduct.4 With Mixed Disturbance of Emotions and Conduct.9 Unspecified Personality s 301.x Personality s.0 Paranoid.20 Schizoid.22 Schizotypal.7 Antisocial.83 Borderline.50 Histrionic.81 Narcissistic.82 Avoidant.6 Dependent.4 Obsessive-Compulsive.9 NOS 3