As many of you have no doubt come to see over the past week or so, an extensive conversation has emerged amongst psychologists, in large part due to an article published in Newsweek by Sharon Begley. In her article, the author discussed the fact that, although there is evidence supporting the use of particular forms of therapy for particular diagnoses, many practicing clinicians choose to offer treatments with no such scientific support. In our summary of that Newsweek article, we provided some thoughts on the matter as well. The conversation did not stop there, however, as several list serves and other websites featured conversations full of strong opinions from a variety of perspectives. Late last night, I received an email from one of these list serves that provided a link to a response to the Newsweek article by Dr.Katherine Nordal, Ph.D, the American Psychological Association (APA) Director of Professional Practice. In her response - which you can read at this link - Dr.Nordal sharply criticizes Begley's piece and denies the veracity of her claims. Today, I would like to respond to Dr.Nordal's commentary, as I wholeheartedly disagree with much of what she said. To do this, I would like to respond to direct quotes from the article. In doing so, however, I would like to be clear about something: this is not a personal attack on Dr.Nordal, nor a repudiation of APA, but rather an attempt to extend the conversation further and address what I perceive to be inaccuracies in her comments. Dr.Nordal's quotes will be in bold and italics.
"But most alarming is the column’s potential to discourage the 57 million Americans with mental health disorders from seeking needed treatment or to encourage those in treatment to drop out of treatment."
Dr.Nordal asserts that Begley's decision to point out the gap between research and clinical practice will discourage individuals with mental health problems from seeking out treatment and encourage those already seeking treatment to drop out. It is unclear to me, however, how pointing out the existence but under use of empirically supported treatments would discourage people from seeking treatment. Wouldn't providing education about efficacious and effective treatments for mental illness encourage people to seek help? And, if somebody drops out from ineffective treatment in order to seek scientifically supported mental health care, wouldn't that indicate that health care consumers have become more informed in their choices and are seeking out treatments that have been systematically shown to provide strong results?
It is not clear to me how not discussing the problem somehow encourages individuals in need of help to find the care that they need. Ignorance seems to be a liability, not an asset, and the public's lack of understanding of this situation represents a particularly dangerous form of ignorance.
"In her column, Ms. Begley does admit that cognitive and cognitive-behavior therapy are effective interventions for many disorders and 'bring more durable benefits with lower relapse rates than drugs.' But she fails to acknowledge that research has also shown us that other treatment techniques also work."
I agree that Ms.Begley's column would have been enhanced had it discussed a larger proportion of the treatments that have been demonstrated to have empirical support. The following link to APA's Division 12 provides a more thorough summary of such findings. That being said, she did not deny that other approaches (e.g., dialectical behavior therapy for borderline personality disorder, interpersonal psychotherapy for depression) have empirical support. If anything, this article seems to be a good example of why many psychologists with an accurate understanding of empirical research should be disseminating information about empirically supported treatments. If that were to happen, substantially more people would know about the options that are available to them and, as such, be able to seek out treatment from clinicians who actually use scientific evidence to inform treatment decisions rather than simply going by their own intuition. Our site provides a small but growing list of such practitioners under our EST clinics link.
"Instead, she seems to endorse the positions that 'relatively few psychologists learn or practice' effective treatments and that clinical psychologists are 'deeply ambivalent about the role of science' and 'lack solid science training' (as stated by the authors of the study and journal article.) The basis for these statements—and her apparent support of them—is certainly unclear and not backed with good evidence."
I think other individuals are better suited to speak to the comment on science training in various programs. My understanding of that particular topic is limited to my training at FSU, which has been rigorous both with respect to the principles of scientific investigation and the application of empirical data to clinical work. I do, however, feel qualified to respond to the issue of ambivalence regarding the role of science in clinical psychology and the extent to which clinicians are using evidence to guide their treatment decisions. A quick and dirty way to respond to that would be to point towards the comments in the actual comment section of the Newsweek article itself. In that selection of responses, you will find many psychologists who display a disdain for empirically supported treatments and a fundamental lack of understanding of the utility of group data and the information that it provides to us. This, of course, is a rather unscientific way of responding to the issue, however, so I also call your attention to the following pieces of evidence, which are by no means entirely comprehensive:
- There is evidence that empirically supported treatments produce results in "real world" practice that is at least equivalent to the results found in controlled trials (link, link)
- Despite this, there is evidence that empirically supported treatments are not used with any regularity in "real world" practice (link)
- This is problematic because some popular treatments have been shown to be ineffective for the problems they claim to address (link, link) and worse yet, some have been shown to actually cause harm (link)
"The American Psychological Association has a code of ethics for its members that dictates psychologists must base their clinical judgments on scientific and professional knowledge."
How is this code of ethics enforced? What examples are there of clinicians who ignore empirical evidence in their clinical practice actually facing repercussions? What determines whether an individual's "professional knowledge" is accurate and based upon legitimate points that would, in fact, justify overruling empirical data rather than leading to a biased, ineffective treatment decision likely to diminish the potential impact of therapy (e.g., Meehl's "broken leg problem")?
"As psychologists, we do embrace our science and research base, but we also understand the importance of the therapeutic relationship to healing and growth. We care about helping our patients improve the overall quality of their lives, and we are not narrowly focused on eliminating one particular symptom (even though getting rid of a symptom is part of improving quality of life.) We combine our understanding of the research with how to best understand the patients who come into our offices with their complicated problems. We work collaboratively to achieve the goals that are important to them.
We have to realize the limitations of science in regard to the generalization of research results to the individual patient. Studies do not always take into account or offer a good match for the complexity of the patient’s problems or the diversity of factors in a patient such as cultural background, lifestyles choices, values, or treatment preferences.
Using our best expertise and clinical judgment, psychologists must be able to critically consider what our science tells us. And then we determine how to best include that knowledge to help our patients achieve the best results. The psychologists’ code of ethics demands that we base our clinical judgments on scientific and professional knowledge, that we practice within our areas of competency, and that we do no harm."
There are several aspects of this quote that bother me quite a bit. Let me address several of them in turn:
Therapeutic alliance, despite all of the hooplah, does not have the empirical backing as a fundamental mechanism of change that many claim it to have. In fact, we discussed this in great detail and provided substantial empirical evidence to support our points on two occasions this week (link, link). Noting the importance of alliance as justification for not embracing science simply does not make sense. Does it matter? Sure. But the degree to which it matters relative to treatment choice is an empirical question and the results thus far do not justify "considering" it or other similar factors when weighing whether or not to follow empirical principles.
The argument that science is limited because it does not tell us about each individual is frustrating for multiple reasons. First of all, nobody is saying that it does tell us about all individuals. It tells us, on average, which treatments produce the best effects for a particular diagnosis. Some individuals will fit the norm, others will not. Backers of empirically supported treatments do not argue that everyone will respond the same way to the same treatment. They instead argue that, when making a treatment decision, we should start with the treatment with the most empirical support, regularly assess progress, and adjust our treatment choice as needed if the client does not respond as expected. Certainly, people vary in their values, desired outcomes, personalities, and many other variables that could potentially influence the outcome of treatment. The problem is, we do not have any systematic way of determining who those people are ahead of time, so if we just use our judgment to determine who is unlikely to respond, we are in fact simply guessing and will, on average, provide less effective care, even if we guess correctly on a couple of occasions in which empirical data would have led us astray. Allowing judgment to overrule empirical data is likely to lead to clinicians simply overruling any data that contradict their beliefs while trumpeting data that support their cause. For a more thorough understanding of the use of group data to inform treatment for individuals, we recommend the following link, which explains our position in more detail and provides evidence to support our case.
There are, in fact, some researchers making an effort to determine moderators of treatment outcome - variables that help us predict who might respond to one treatment versus another for a particular disorder. Such research would do wonderful things to address the issue mentioned by Dr.Nordal in a systematic and valid manner (link)
Ultimately, however, the best way to address this issue would be for readers to consult the work of Paul Meehl. On numerous occasions, Meehl has provided clear evidence indicating that, when we attempt to use our judgment to overrule or compete with empirical data, our judgment falls short. No matter how much we want to believe that psychologists are blessed with insight that exceeds the power of information provided by scientific evidence, it simply is not the case. Much to my dismay, we are not wizards. Dawes, Faust, & Meehl (1989) and Grove & Meehl (1996) would be particularly useful resources for readers looking to better understand the relative value of intuition/professional knowledge and empirical data. Our "References" page provides full listings of these and other valuable resources, which are available for free through most university and library computer systems (depending upon subscriptions paid for by various institutions).
"And for someone who espouses the value of science, Ms. Begley’s column was very short on evidence for her assertions."
I find this comment somewhat puzzling, as there was not a single reference to an empirical study in Dr.Nordal's entire reply to Ms.Begley's column. In other words, Ms.Begley should be ashamed for not providing evidence to support her claims, but the APA should not be expected to supply evidence for their rebuttal? I wholeheartedly agree that the Newsweek column would have been enhanced by the inclusion of references to journal articles and discussion of precise data. That is certainly what we strive to do here (and the links to discussions of specific studies and data throughout this reply speak to this fact), but it is not the way in which the mass media tends to do things. I agree that this is not ideal; however, Ms.Begley's entire article was based upon the Baker, McFall, and Shoham (2009) article in Psychological Science in the Public Interest. In the Baker et al (2009) article, there is a wealth of evidence provided to support claims made about the utility of particular treatments and the tendency for those treatments not to be used in clinical practice. The article is long, but it seems reasonable to expect people to read it and refute specific points rather than dismissing it as full of false claims with no supporting evidence (which is not to imply that Dr.Nordal did not read the column - I simply mean that others should read the article before coming to any conclusion on its presentation of evidence). That simply is not an accurate characterization of the issue. Certainly Ms.Begley's article has some inaccuracies (e.g., her claim that medical schools provide more training in scientific investigation than other programs, such as research-based clinical psychology Ph.D. programs), but its imperfections do not negate its powerful purpose: to alert a broad audience of readers to a legitimate problem about which they likely know very little due to the dearth of discussion on the matter in resources utilized by people other than clinical psychologists.
Summary
As I said at the beginning of this reply - my comments are not intended as an attack on Dr.Nordal herself or on the APA. Instead, they are meant as an honest critique of the content of her reply to the Newsweek article, full of links to references to support my position on each point. The current state of research in clinical psychology is by no means perfect, but it is strong and getting stronger and it provides a powerful basis upon which to make informed treatment decisions. Intuition - or professional knowledge - is dangerous when used to contradict empirical evidence that does not conform to our expectations and the tendency to take such an approach in clinical practice, which has, in fact, been documented in numerous studies, is a liability that must be addressed. I look forward to hearing your thoughts.
If you would like to learn more about these or other mental health issues, we recommend consulting our online store of scientifically-based psychological resources.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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