by Michael D. Anestis, M.S.
In any health care situation, one of the most important things that providers manage is the process of informed consent. Informed consent is defined differently in different domains, but you can go to this link to read the American Psychological Association's (APA) explanation of how the process applies to psychotherapy. Generally speaking, informed consent involves providing the patient with accurate information regarding the risks and benefits associated with the proposed form of treatment and informing the patient of his or her right not to answer questions and to refuse or terminate treatment at any time. One quote that stands out to me in the APA description is:
"When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation."
There are some vague phrases there. After all, what constitutes "generally recognized techniques and procedures." How are they established? I would think that the standards established by Chambless and Ollendick (2001), which have been applied to APA Division 12's taskforce, would be the gold standard here. That might not be the case, however.
That being said, I would argue that, regardless of how strong the empirical foundation is for a particular treatment, clinicians should be required to detail that information while also providing information regarding other treatments with empirical support. Why do I say this? Quite simply, without such precautions in place, individuals can market experimental or - worse yet - iatrogenic treatments as effective solutions for mental illnesses and consumers are left to figure that out for thmeselves.
Imagine that you or somebody you love is suffering from a mental illness - perhaps an eating disorder. These conditions can wreak havoc upon an individual's life and the situation can become desperate. At some point, you or your loved one will seek treatment, but how do you know where to go? Let's say you have little or no background in clinical psychology. It might be that you're unaware that there are different forms of psychotherapy, different modes of diagnostic assessments, and a whole field of researchers devoted to determining the degree to which particular treatments work for specific populations. You might go online and search through a seemingly endless number of websites offering you treatments. Many of these individuals are doctors. Some have master's degrees and impressive websites. Their words sound compelling. They provide you with anecdotal evidence - stories of success from people whose struggles sound achingly familiar - and you start to believe that they might be the answer. How do you know if this is the case? How, in a market full of seemingly qualified individuals, are you to determine which treatment has the greatest odds of producing an optimal outcome? How comfortable would you feel questioning the claims of somebody offering to help you in your situation?
This scenario is one of the many reasons why true informed consent is necessary and that process involves disclosing to patients when a form of psychotherapy is experimental and when other treatments exist for those patients' conditions that have substantially stronger empirical foundations. If that is not done, there is simply no way for a struggling individual in need of help to know if he or she is making the right call.
All of this brings me to a situation that arose last week. I came across a new blog on the website PsychCentral devoted to equine assisted psychotherapy (EAP), a therapeutic approach we have written about on PBB before. I want to be very careful here in pointing out my goal. I do not want to launch an attack on the individual who writes this blog, nor do I want readers to go to that blog and write combative comments. My goal instead is to point out my concerns regarding the interaction I had with this individual and her blog (and website) and to hear your thoughts on the issues I raise, particularly with respect to informed consent and the ethics of marketing psychotherapy.
Anyway, as I said, last week I stumbled upon the blog Equine Therapy: Straight from the Horse's Mouth on PsychCentral. I read through a number of the articles and, in some ways, was impressed by the cautious tone taken throughout many parts of the texts. That being said, other areas left me a bit more concerned. For instance, on one post, the author wrote the following:
"Certainly this can [be] the case with both eating disorders and addictions. This is also the reason that equine therapy can be helpful for these two diagnostic categories, as developing a relationship with a horse may prove easier than with people"
Now, this statement does not promote EAP as the perfect treatment for everyone, but it does seem to indicate that there is evidence that EAP is efficacious and/or effective in the treatment of addictions and eating disorders. The thing is, as I have pointed out in my prior post about EAP on PBB, there is not a shred of empirical evidence supporting this claim. This does not mean that EAP does *not* work for these conditions. It simply means there is no evidence to support the notion that it does. What's more, there are numerous treatments that *do* have empirical support for the treatment of these conditions. For example:
- Motivational interviewing for substance use disorders
- Cognitive behavioral therapy for bulimia nervosa and binge eating disorder
- Interpersonal psychotherapy for bulimia nervosa
- Family-based (Maudsley model) treatment for adolescent anorexia nervosa
In other words, if we're thinking about this issue through the lens of informed consent, what the client is currently being presented with is incomplete (and actually inaccurate) information. They are told about the promise of one treatment with no detail regarding the manner in which that promise was determined, and no information regarding the nature of the support for other treatments. As such, individuals reading this article and pondering the potential benefit of EAP are not being provided with sufficient information to develop an informed opinion. The issue extends further though.
The author of this blog maintains her own website linked to on the PsychCentral page that promotes her business endeavors. This is, in and of itself, a good thing. It's great to use the internet to reach out to those in need. The problem is that her site includes statements like the following:
"[identity hidden by PBB] has developed an equine assisted psychotherapeutic approach that is effective in helping trauma, abuse, and eating disorder clients achieve emotional and physical balance."
This statement goes far beyond the relatively subtle comments in the EAP blog, openly declaring an EAP protocol to be effective, a term with specific meaning in the mental health care world with respect to empirical support, in producing specific effects in populations struggling with particular psychological conditions.
When I read all of this, I felt compelled to say something on the EAP blog. I did not want to be confrontational, as this seemed likely to prove counter-productive, so I left a comment that complimented the author for using caution, but indicated my concern that the article still went beyond the scope of the data (a theme in some recent PBB interactions). I reiterated the point that there is not a single randomized controlled trial examining EAP in the treatment of mental illnesses or even a study of lesser quality indicating that EAP, in fact, has a positive impact on the symptoms of any mental illnesses. I concluded by linking to the PBB article on EAP in which I discussed the evidence-base for the treatment approach and indicating that the comments included a numer of back-and-forths between different perspectives, including a healthy and friendly debate I recently had with the author of the EAP piece that I had critiqued in my text.
As is always the case with comments on PsychCentral, once I submitted, a notice appeared indicating that my comment was awaiting moderation. I waited. And waited. And waited. After a while, this notification disappeared, along with my comment. In other words, it had been deleted. I contacted the author, asking for an explanation and to see if the deletion occured by error. Later that day, I received an email indicating that the comment was awaiting moderation (this was dishonest) and expressing concern that I did not seem to think that EAP should be discussed. I found this confusing. After all, I was now having a conversation about EAP over email with the author, discussing my attempt to open a discussion about EAP on her EAP blog, and attempting to link to a prior conversation I had developed about EAP that included the perspectives of a number of EAP advocates.
I wrote back to the author, expressing these concerns and reiterating my eagerness to have a conversation about EAP while also indicating that, yes, I prefer for these conversations to take place within the context of the actual support for the treatment. Surely this would work, right?
The next night, I received another email from the author. In this note, she indicated that, because I had "repeatedly refused" to address two "well-founded" studies on EAP pointed out to me in the comment section of my original PBB article, she felt my intentions were not good. Additionally, she said EAP is quite popular and accepted and, as such, I am swimming a bit "upstream." Both of these comments baffled me. Let me explain why:
(1) Right below the comment she referenced were two replies by me. The first reply indicated that I would examine those citations as soon as I could. The second, written 25 hours after the citations were pointed out to me, directly addressed both citations, linked to the original articles (which were available online for free), and thanked the individual who had pointed them out to me. This, to me, did not seem to fit the description of "repeatedly refused," but I suppose it is possible that my understanding of that phrase is off base.
(2) Even if we accepted the notion that EAP is both highly popular and accepted - which the data would refute quite forcefully - who cares? A number of popular treatments have proven to be iatrogenic. Poplarity is not a valid metric by which to evaluate the utility of anything. If it was, boy bands would be our greatest gift to music and The Da Vinci Code would be one of the greatest literary works of the last century (I did enjoy that book, mind you...although Tom Hanks' hair in the movie freaks me out to this day).
Anyway, I made note of these points in an email to the author and noted the irony of my comment being deleted when I was accused of not wanting to engage in a conversation about EAP, but I have since heard nothing. This bring us back to the point of this article. I'm not looking to bash an individual or claim that EAP does not work. I'm looking to discuss and get your opinions on the degree to which the marketing of various forms of psychotherapy without reference to the empirical status of various treatments is ethical and within the bounds of informed consent. Is it okay to make baseless claims about a treatment and portray them as facts?
I have stated on this site before that I believe the practice of marketing experimental treatments as options without being clear about their experimental status and detailing the status of well-supported treatments to be unethical. I believe that doing this decreases the odds that individuals in need will come in contact with and seek out treatments with a greater likelihood of producing an optimal outcome. I understand that clinicians who utlize these treatments believe wholeheartedly in their approaches and are not sitting in dark rooms twisting their mustaches and hoping to steer their clients in the wrong direction, but even the best of intentions do not justify overstepping the bounds of science and even the most compelling anecdotal evidence fails to measure up to the requirements of achieving status as efficacious and/or effective. EAP may prove to be a wonderful treatment for particular individuals but, at this point, we have no scientific evidence to support this claim. In the meantime, information proclaiming otherwise is widely available and the people promoting it are intelligent individuals capable of persuasive salesmanship. This, to me, is a tremedous problem.
I do believe there should be conversations about EAP and other experimental treatments. That's why I have them on PBB all the time. I believe these conversations should be honest though, and honesty involves full disclosure of the state of treatments for the conditions being proposed as treatment targets.
What do you think? Where does scientific evidence fit into the ethics of marketing? To what extent should competing perspectives be allowed voices in forums promoting supposed health care options? I invite all perspectives here, including that of the author who denied me mine. A vigorous debate is good for everyone, as it allows them to develop their own informed opinions. In replying, however, please do your best not to launch any personal attacks.
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Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University
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