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12/02/2009

Psychologists Reject Science? ... Oh My!

The psychotherapy community is all atwitter about an article (1) recently published in Psychological Science in the Public Interest, an article that purports to describe "psychology's failure to develop as an applied science."

The article by Baker et al  wanders across a range of topics while making a variety of assertions.  According to the authors:
  • Psychologists are "deeply ambivalent about the role of science and research." 
  • Psychologists are "not accountable to anyone and are unconstrained by procedural guidelines or practice standards (except, perhaps, for the prohibition regarding sexual relations with a patient)."
  • Rather than being licensed to practice independently,  psychologists should "have their practices monitored to ensure adherence to good standards of practice."
  • Psychologists don't know if their work is of any value to the patient.
  • Rather than listening to science,  psychologists tend instead to view experience as important and  to view "each patient as unique."
  • During training,  psychologists spend too much time on "arbitrary breadth requirements" (i.e., we're too broadly educated),  too much time actually working with clients,  and not enough time studying "molecular genetics."
  • Some of the most effective psychological treatments can be delivered "without highly trained personnel," or by health educators "with little or no prior experience" who have "received only a modest level of training" in the treatment technique.
  • "Dolphin-assisted therapy" is not likely to ever pass scientific muster.
  • Psychotherapy causes global warming
Ordinarily,  this article would have been widely ignored and roundly dismissed as the naive polemic  that it is.  But before they went to press,  the authors hooked Newsweek Science Editor Sharon Begley on the story and it became an issue.   You can't really blame Begley for buying it.  It's pretty juicy stuff for the popular press:  "psychologists reject science" and use "dolphin therapy."

Begley's assessment was that this publication signaled a "fight brewing among therapists,"  one that was "getting ugly" and where "the gloves have come off."  Her assessment was dead wrong.

The argument that Baker et al made is tired and old, and therapists did not start taking up arms.  Instead,  what I observed in a series of online discussion groups is that psychologists turned their attention to reviewing and discussing the science.  Research that might not otherwise have been carefully studied became widely discussed.  Contrary to expectations,  psychologists did not reject science.  They embraced it anew.

A consistent theme in the responses to the Newsweek article was the concern that the public might take this criticism of psychology seriously,  and that it might discourage people from seeking treatment that they need.  Historically,  only about twenty percent of individuals suffering mental or emotional distress will seek or receive help.  For those who do not obtain assistance,  the costs can be measured in many ways.  

What this is really about (3).  The Baker et al article is the latest attempt by the "empirically supported treatment (EST) movement" to plant its flag.  What this movement argues is that when it comes to psychological therapy,  the only thing that really counts are the procedures and techniques that are employed.  And in order to "earn EST status,"  a therapeutic approach must demonstrate its effectiveness via one particular research method,  the "randomized clinical trial (RCT)."  This is the method that you would use if you were studying the effectiveness of aspirin,  but it is only one of a number of scientific methods that can be used to inform practice.

The EST proponents say that RCT is the "gold standard" of research methods and are essentially saying that treatments should be designed and selected not on the basis of theory or demonstrated potential,  but instead,  on the basis of the research method used to study them.  Commenting on this,  Dr. Larry Beutler (who is extensively published on psychotherapy outcome research) said:
"the effort to identify EST or research informed psychotherapies is viewing evidence through the lens of a single or preferred research methodology,  when there are several competent methods available ... the scientist has fallen prey to worshiping the method rather than the 'truth.'"
It is in fact the case that EST research is significant and useful,  as one among a number of scientific approaches.  For example,  the finding that for the treatment of depression,  cognitive behavioral therapy (CBT) works just as well (or better) than medications has been enormously important in establishing that "talk therapy" works.  But this research method has also tended to obscure other important and significant factors that contribute to effective practice.  Yes,  the techniques work and the cookbook is handy,  but that doesn't mean that CBT is always the best treatment for depression or that everyone walks into the clinic with a specific problem that meets the "strict inclusion and exclusion criteria" demanded by the EST/RCT prescription.  In arguing that psychologists reject science,  Baker et al  chide clinicians for sometimes believing that "each patient or prediction problem is unique."

One of the things that has been obscured by the EST research is that other forms of treatment work just as well.  The randomized clinical trial method compares a treatment to "no treatment" and a placebo condition (the placebo can be something like an educational program or a waiting list).   A number of "meta-analytic" studies (a statistical technique that combines the results of hundreds of studies) have shown that in the real world,  the prescribed cognitive treatments are no better than TAU (that's "therapy as usual").  The evidence is compelling that in the real world,  outside the lab,  psychodynamic,  insight oriented,  problem focused and relationship based treatment strategies are often more effective than procedure-driven cognitive strategies. 

The reason "empirically proven" procedures are not always best is simple:  people are complex,  as are the difficulties they suffer.  People seeking care have different personalities,  different life situations, different life experiences and different coping styles.  The "fit" between the patient and the therapist makes a difference,  as does the the "fit" between the patient and the methods chosen.  Some therapists have more experience in helping people solve problems and more skill in adapting their approach to the needs of the individual.  And the "placebo" factor cannot be ignored:  it makes a difference if the client has confidence in the person providing care and if they hope and expect to obtain benefit.

The EST movement dismisses all of the above as "non-specific factors,"  elements of the treatment process that should be ignored because they cannot be randomly assigned for the purpose of an experiment.  These factors are considered to be part of the error equation.  The EST assumption is that for research purposes and for "scientific" purity,  the therapist doesn't matter and the person doesn't matter.  In their view,  all that matters to the scientist is what the therapist actually does.  That is the type of "science" that they say we have rejected.

What psychologists have not rejected (not for a moment) is the use of both theoretical and empirical science to inform practice and to provide a foundation for our work.   The research that tells us that therapy works also tells us that these "non-specific factors" are meaningful and significant and worthy of study.  In a review of the literature,  Dr. Larry Beutler had this to say about the "non-specific factors" that the "real scientists" dismiss as error:
"If,  as we have proposed,  these aspects of character,  preference,  fit,  and expectation contribute more and stronger predictive power in outcome assessments than the technical aspects of the interventions,  then they are the treatment." 
In saying that psychologists reject science,  a central datum for Baker et al  is a finding that more than half of clinical practitioners will say that their experience is more important than the research,  or that experience should be given equal weight.  These authors would perhaps be dismayed to learn that all 50 States and the Canadian Provinces have bought in to this assertion.  To practice,  they all demand that we be well trained and amply experienced.  They demand supervised experience in order to protect consumers,  rather than assuming that anyone can practice competently just by being taught a few empirically validated techniques.

The licensing boards also demand that psychologists be broadly educated in the science of psychology.
 
What's the take-away message? 
  • If you are troubled or distressed,  anxious or depressed,  it makes good sense to seek help or to talk to a psychologist.  
  • To help you decide if you are in need,  here is a brief psychological health questionnaire and a brief depression symptom inventory.   Both provide guidance as part of the results.
  • In most cases,  therapy will help.  Therapy works (that's what Consumer Reports and the U.S. Surgeon General say).
  • The therapist's experience is one of the things you should consider in choosing someone to work with.  How you get along with the person isn't the only consideration,  but it is something to consider and think about. 
  • You don't need to say "I need this specific treatment I read about in Newsweek."  What you need to do is to talk to someone to help figure out how best to proceed.  
  • There are some brands of treatment that people will say are special and unique,  miraculous and wonderful,  and guaranteed to work.  Be careful about those.  Yes,  there are some empirically validated treatments that are of proven effectiveness for certain conditions.  But there are some therapists (including some psychologists) who sell methods and models that either don't work or that can be harmful.  In most cases,  what you should be looking for is TAU (Therapy as Usual).
  • TAU might be short-term and problem focused.  Or it might need to be longer term and focused on more fundamental personality change.  An experienced therapist can help you decide on a course of action.  There are a lot of variables involved.  
  • If you are depressed,  your therapist might recommend some things that have not been the subject of rigorous scientific validation:  eat right,  get more exercise,  try some relaxation techniques,  go to yoga,  stop watching so much TV,  keep a journal,  take a vacation,  buy a dolphin ...
Final Comment:   In the days since the Newsweek article hit the stands and brought this "inside baseball" argument to the attention of the general public,  Dr. Baker has gotten an op-ed piece published in the Washington Post.  Yesterday,  his co-author Richard McFall was featured on NPR's Science Friday show.  The EST movement is on a roll.  As I said,  it's an old topic of discussion and not one that is of practical significance.  What is of practical significance is that therapy works and can be recommended.   In response to being accused of rejecting science,  psychologists are going to continue to review and discuss the science.


Copyright, Paul G. Mattiuzzi, Ph.D.

Notes:

(1)  Baker, McFall and Shoham. Current Status and Future Prospects of Clinical Psychology: Towards a Scientifically Principled Approach to Mental and Behavioral Health Care.   In: Psychological Science in the Public Interest, November 2009.  (return)

(2) Actually, I just made that up.  They didn't really say that psychotherapy causes global warming.  But you should know that psychoanalysis (that's where you lay on the couch) does have an unnecessary carbon footprint.  When you lay on the couch,  they usually put a tissue paper under your head.  All that paper,  all those trees ... it all points to global warming.  (return)

(3) For much of the discussion that follows,  I have relied on the following article:  Beutler,  Larry E.  Making Science Matter in Clinical Practice: Redefining Psychotherapy.  In:  Clinical Psychology: Science and Practice, September 2009.  (return)