Our Raison dÊtre
Scott O. Lilienfeld, Ph.D., is Editor in Chief of the Scientific Review of Mental Health Practice. Correspondence concerning this article may be sent to email@example.com.
Portions of this article have been adapted from an invited address delivered by the author at the 1998 American Psychological Association Convention in San Francisco (see Lilienfeld, S.O., 1998, Pseudoscience in clinical psychology, The Clinical Psychologist, 51, 39). I thank Dr. Paul Rokke, editor of The Clinical Psychologist, for granting me permission to adapt some of the material from this address.
The first question many readers of this article are likely to ask is: Why another mental health journal? Indeed, this is the very question with which I struggled for quite some time before ultimately deciding that a new journal was not only warranted, but necessary. But why add yet another title to the already substantial and ever expanding list of journals in psychology, psychiatry, social work, and related disciplines? What unique contribution, if any, could another journal make to the discipline of mental health practice?
My modest goal in this article is to convince you that The Scientific Review of Mental Health Practice fills a void occupied by no other journal. In doing so, I also hope to convince youif you have not already been convincedthat the substantive issues to be addressed by this journal are of pressing and even paramount importance to the manifold fields of mental health practice.
Over the past several decades, the fields of clinical psychology, psychiatry, and social work have borne witness to a widening and deeply troubling gap between science and practice (see Lilienfeld, 1998, for a discussion). Carol Tavris (1998) has written eloquently of the increasing gulf between the academic laboratory and the couch and of the worrisome discrepancy between what we have learned about the psychology of memory; hypnosis; suggestibility; clinical judgment and assessment; and the causes, diagnosis, and treatment of mental disorders, on the one hand, and routine clinical practice, on the other. Less and less of what researchers do finds its way into the consulting room, and less and less of what practitioners do derives from scientific evidence. Researchers and practitioners often spend disconcertingly little time communicating with one another.
Bearing out Tavriss contention is the marked upsurge in the prevalence of unsubstantiated and in some cases demonstrably ineffective or harmful techniques in clinical psychology, psychiatry, and social work over the past few decades. The information explosion of the late 20th and early 21st centuries has become a misinformation explosion, and the dissemination and promotion of untested and pseudoscientific mental health techniques via the Internet, magazines, radio, and television have accelerated at an unprecedented rate. Largely as a consequence, the ratio of unscientific to scientific information in various mental health domains has been steadily but perceptibly creeping upward. Moreover, standards of research training in many disciplines, including clinical psychology, have progressively dropped, leading to a substantial increase in the proportion of individuals with inadequate grounding in the basic scientific methodology and critical thinking. Although the fields of mental health are afflicted with numerous problems, problems in four major areas appear to be particularly acute and pervasive.
A wide variety of unvalidated and sometimes harmful psychotherapeutic methods, including facilitated communication for infantile autism (see Herbert, Sharp, & Gaudiano, this issue), suggestive techniques for memory recovery (e.g., hypnotic age-regression, guided imagery, body work), energy therapies (e.g., Thought Field Therapy, Emotional Freedom Technique; see Media Watch, this issue), and New Age therapies of seemingly endless stripes (e.g., rebirthing, reparenting, past-life regression, Primal Scream therapy, neurolinguistic programming, alien abduction therapy, angel therapy) have either emerged or maintained their popularity in recent decades. Moreover, in a large-scale study published last year (Kessler et al., 2001), individuals in the general population with a recent history of anxiety attacks or severe depression were found to avail themselves of complementary and alternative mental health treatments (including energy healing and laughter therapy) more often than conventional treatments. Thus, largely untested treatments comprise a major proportionin some cases a majorityof the interventions delivered by mental health professionals.
According to one recent conservative estimate (Eisner, 2000), there are now between 400 and 500 different brands of psychotherapy, and this number is increasing on a virtually weekly basis. Even many of the most vocal critics of the present state of clinical psychology (e.g., Dawes, 1994) acknowledge that psychotherapy can be helpful in many instances. Yet because most flavors of psychotherapy have not been subjected to rigorous empirical evaluation (e.g., randomized, controlled trials), in the majority of cases we have no way of knowing whether such treatments are effective, ineffective, or harmful.
Assessment and Prediction
Many psychologists continue to use assessment techniques (e.g., the Rorschach Inkblot Test, human figure drawings, and other projective methods; the Myers-Briggs Type Indicator) of doubtful validity, and to draw inappropriate inferences on the basis of well-validated tests. Computer-based test interpretations (CBTIs) of psychological tests multiply on a yearly basis even though most CBTI programs have never been subjected to careful empirical scrutiny.
Moreover, many clinicians render highly confident clinical judgments on the basis of methods (e.g., anatomically detailed dolls for the assessment of child sexual abuse) whose validity remains highly controversial from a scientific standpoint (see Hunsley, Lee, & Wood, in press). And in many cases, clinicians proffer expert testimony on crucial questions (e.g., child custody disputes) for which mental health professionals have not been shown capable of providing valid predictions or recommendations (ODonohue & Bradley, 1999). Contributing to and perhaps compounding these problems is the general propensity of most clinicians to be overconfident in their predictions across a variety of tasks (Smith & Dumont, 1997).
Self-Help and Self-Enhancement Methods
A burgeoning industry of self-help books, manuals, programs, and tapes thrives with unabated vigor and intensity, despite the absence in most cases of compelling or even suggestive evidence for their efficacy. The most recent available estimate (Rosen, 1993) places the number of self-help books appearing each year at approximately 2,000, and there is good reason to believe that this number is rising. Although some of these books may be effective, others may be either useless or harmful (see Rosen, 1987, for evidence that certain self-help programs can produce adverse effects).
Closely allied to self-help techniques are a bewildering array of self-enhancement methods, such as speed-reading courses, sleep-assisted learning techniques, subliminal audiotapes, and hemispheric synchronization devices, most of which have not been shown to be effective. In addition, herbal remedies abound for enhancing memory or mood, even though many are of questionable or unknown efficacy. Moreover, more and more citizens look to self-proclaimed media experts or gurus for guidance concerning everyday life problems. Radio and talk show therapists increasingly dominate the airwaves and influence the publics perception of mental health practice, despite the fact that many offer advice that is not in keeping with the best available psychological science (Heaton & Wilson, 1995).
The past several decades have seen a virtual explosion in the use of controversial and poorly studied psychiatric labels, such as codependency, sexual addiction, road rage disorder, infanticide syndrome, parental alienation syndrome, premenstrual dysphoric disorder, and Munchausens syndrome (factitious disorder) by proxy (see Mart, this issue). Although some of these labels may ultimately be shown to be predictively useful, many are of undemonstrated validity (McCann, Shindler, & Hammond, in press). Nevertheless, such labels are commonly invoked by mental health professionals as scientific explanations of problematic behavior and are introduced by them into courts of law with increasing frequency. In still other cases, there are serious concerns that some psychiatric conditions (e.g., dissociative identity disorder, known formerly as multiple personality disorder) are being substantially overdiagnosed in certain settings.
As both researchers and practicing therapists, it is incumbent on us to remain open to all novel and untested claims regarding clinical practice. It would be a serious mistake to cavalierly dismiss any of these claims before adequate research is available. This holds true even for claims that are superficially implausible or even bizarre. At the same time, however, we must insist on rigorous standards of evidence before accepting these claims, as the unbridled use of unsubstantiated or even blatantly pseudoscientific techniques can cause irreparable damage to the public and to mental health professions at large.
It is essential to recall that the onus of proof for the demonstration of the validity or effectiveness of new practices falls squarely on the shoulders of the proponents of these practices. The onus does not fall on the shoulders of skeptics to demonstrate that these practices are invalid or ineffective. In plain language, it is up to the proponents of novel techniques to show that these techniques work.
WHAT HAVE WE BEEN DOING?
The field of mental health has until recently shown surprisingly little interest in doing much about the problem of questionable science and pseudoscience that has long been festering in our own backyards. Paul Meehls (1993) trenchant remarks, although directed primarily toward clinical psychologists, provide a much-needed warning for individuals in all mental health professions:
It is absurd, as well as arrogant, to pretend that acquiring a Ph.D. 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 pschology 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 [the University of] Minnesota . . . shared what Bertrand Russell called the dominant passion of the true scientistthe 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. 728729)
Nor has the American Psychological Association (APA), the worlds largest organization of social scientists and the primary home for both practicing and research psychologists, done much to combat the increasing spread of questionable or pseudoscientific mental health techniques. In fact, some critics might justifiably contend that the APA has actually nurtured or provided support for such techniques (Lilienfeld, 1998). Even a casual perusal of recent editions of the APA Monitor on Psychology, an in-house publication of the APA that is sent to all of its members, reveals that the APA has been accepting advertisements for a plethora of unvalidated psychological treatments, including Thought Field Therapy and Imago Relationship Therapy, two techniques for which essentially no published controlled research exists. Among the recent workshops for which the APA has provided continuing education (CE) credits to practicing clinicians are courses in calligraphy therapy, neurotherapy (see Kline, Brann, & Loney, this issue), Jungian sandplay therapy, and the use of psychological theatre to catalyze critical consciousness (see Lilienfeld, 1998). The APA has also recently offered CE credits for critical incident stress debriefing, a technique that has been shown to be harmful in several controlled studies (Lohr, Hooke, Gist, & Tolin, in press). Moreover, the APA has been exceedingly reluctant to impose ethical limitations or sanctions on members who engage in either unvalidated or potentially harmful mental health practices, including the use of highly suggestive therapeutic techniques to recover traumatic childhood memories.
Nevertheless, there are at last indications that things are slowly beginning to change. The 1999 Annual Convention of the American Psychological Society featured a Presidential Symposium (chaired by Dr. Elizabeth Loftus of the University of Washington) devoted exclusively to the issue of pseudoscience in psychology. This symposium, which was presented to a standing-room audience of several hundred psychologists, attests to the growing interest in the problems posed by pseudoscientific and fringe-science claims in contemporary psychology. Two years ago, a new special-interest group devoted to the study of pseudoscience within clinical psychology (called Science and Pseudoscience Review) was formed within the Association for Advancement of Behavior Therapy (see www.pseudoscience.org). Even more recently, the Committee for the Scientific Investigation of Claims of the Paranormal (the group that publishes Skeptical Inquirer magazine) established a new subcommittee dedicated to evaluating the validity of questionable or untested mental health claims.
The past several years has also witnessed a groundswell of interest among physicians, including psychiatrists, in the impartial investigation of claims in alternative and complementary medicine. Prometheus Books, which publishes this journal, founded The Scientific Review of Alternative Medicine (SRAM) to critically examine such claims and to better educate practitioners concerning the scientific status of practices on the fringes of current medical knowledge. We very much hope that our journal will make a worthy sibling to SRAM.
More broadly, the fields of clinical psychology, psychiatry, and social work have recently placed increased emphasis on evidence-based mental health practices. Much of this interest has focused on identifying psychological and pharmacological treatments that are efficacious for specific disorders. Division 12 (Society for Clinical Psychology) of the APA has generated a widely disseminated list of empirically supported treatments (ESTs) for both adult and childhood/adolescent disorders (see Chambless & Ollendick, 2001, for a recent review; see also Hunsley & Giulio, this issue), and this list has already begun to influence clinical practice, education, and training. Although vigorous and constructive debate surrounds the criteria established for identifying ESTs, as well as the current list of ESTs, there is a growing consensus among scientifically oriented psychologists that the movement toward ESTs is both healthy and essential for preserving the scientific foundations of clinical psychology and allied fields. Calls for comparable criteria and lists of empirically supported assessment techniques to guide clinical practice (e.g., see Lilienfeld, Wood, & Garb, 2000) are being heard in many quarters.
Despite the increasing interest in and awareness of the problem of pseudoscience and fringe science in the applied behavioral sciences, no academic journal is devoted to the impartial scientific investigation of novel, controversial, or untested claims in mental health. As a consequence, a major void exists among scholarly publications. Moreover, manuscripts dealing with such claims are published in a wide variety of disparate academic journals scattered across several subdisciplines, including clinical psychology, cognitive psychology, social psychology, counseling, psychiatry, psychiatric nursing, social work, law, and educational psychology. Simply put, such manuscripts have no home. Researchers and practitioners who wish to keep abreast of the status of mental health claims on the fringes of scientific knowledge are therefore severely handicapped.
OUR RAISON DÊTRE
So why should we be concerned about the widening gap between mental health science and practice? We can identify at least four major reasons, which collectively serve as the raison dêtre for this new journal.
(1) Unvalidated or scientifically unsupported mental health practices undermine the general publics confidence in our professions. Once the reputation of the mental health professions has been sullied, many individuals in the general public may understandably be reluctant or unwilling to seek psychological or psychiatric treatments, a number of which may be effective. In addition, after seeing mental health professionals make unwarranted or dubious assertions, many individuals in the general public may accord less weight to psychological advice derived from well-supported research findings.
(2) Unvalidated or scientifically unsupported mental health practices can lead individuals to forgo effective treatments. Economists refer to this unfortunate consequence as opportunity cost. Many individuals who spend large amounts of time and money on ineffective treatments may be left with precious little of either. As a result, they may forfeit the opportunity to obtain treatments that could be more helpful. Thus, even ineffective treatments that are by themselves innocuous can indirectly produce negative consequences.
(3) Unvalidated or scientifically unsupported mental health practices can be harmful. In the field of psychotherapy, the default assumption has often been that doing something is better than doing nothing. Although this assumption may well hold true in certain cases, it has been shown to be demonstrably false in others. The growing literature on deterioration effects in psychotherapy increasingly suggests that a thankfully small but nevertheless nontrivial proportion of individuals (perhaps 3 to 6%) tend to become worse following treatment (Strupp, Hadley, & Gomez-Schwartz, 1978), although the variables that account for such deterioration remain controversial. Moreover, therapists who use highly suggestive techniques, such as hypnosis, guided imagery, and sodium amytal (the so-called truth serum), to recover purported memories of satanic ritual abuse and alien abductions may be inadvertently inducing analogues or even full-blown variants of posttraumatic stress disorder in their clients (Chu, 1998). The tragic and heartbreaking case of Candace Newmaker, the 10-year-old Colorado girl who was smothered to death in 2000 by therapists practicing rebirthing therapy, an unvalidated technique for treating children with attachment problems, attests to the dangers of implementing methods that are empirically unsupported, untested, or both. Still other techniques, such as facilitated communication for infantile autism (see Herbert, Sharp, & Gaudiano, this issue), have resulted in falseand in some cases terribly destructiveaccusations of child abuse against family members.
(4) Unvalidated or scientifically unsupported mental health practices eat away at the scientific foundations of our professions. Richard McFall (1991) has argued persuasively that the scientific basis of clinical psychology is steadily eroding as a consequence of this professions collective failure to attend to the threats posed by unsubstantiated treatment and assessment methods. 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.
WHAT AND WHO WE ARE
With these four major reasons in mind, we are proud to announce the launch of a new peer-reviewed journal, The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work. The primary goal of this interdisciplinary journal is to assist researchers and practitioners across all of the major subdisciplines of mental health with the crucial task of distinguishing scientifically supported from scientifically unsupported claims. In doing so, we intend to provide professionals with a usefulif not indispensabletool for sorting out the wheat from the often considerable chaff in the mental health field. We also believe that this journal will prove to be of considerable interest to individuals in a variety of disciplines closely allied with mental health, including education, law, philosophy, and nursing, many of whom require a trustworthy source for au courant scientific information regarding mental health practices.
In evaluating mental health claims, we pledge to subject all claims to careful and searching scrutiny but not to dismiss any of them out of hand. Indeed, our hope is that at least some of the novel and largely untested techniques we place under the empirical microscope will ultimately stand the test of time. Others likely will not. In either case, we believe that the careful scientific scrutiny accorded to these techniques will prove to be beneficial to the continued health of the discipline of mental health practice.
In addition to providing a forum for presenting the best available scientific evidence on the fringes of current knowledge in mental health, we intend to enhance the overall quality of discourse regarding controversial issues in the behavioral sciences. By raising the bar for the level of scientific debate on such issues, we hope to facilitate improved research and thinking about critical questions on the fringes of present scientific knowledge concerning mental health.
The Scientific Review of Mental Health Practice has been established with the generous support and encouragement of Dr. Paul Kurtz and Steven Mitchell of Prometheus Books, both of whom have expressed an unwavering commitment to enhancing the level of critical thinking in mental health and related domains. With their help, we have assembled an outstanding and internationally recognized group of approximately 70 scholars across the worldincluding experts in psychology, psychiatry, social work, philosophy, and lawto comprise our Council for Scientific Mental Health Practice, the umbrella group that has endorsed the journal and its mission. In addition, we have formed an elite editorial board of outstanding researchers and practitioners drawn from several mental health subdisciplines. Our three associate editors, Dr. James Herbert of MCP Hahnemann University, Dr. John Kline of Florida State University, and Dr. Timothy Moore of Glendon College (York University), have distinguished themselves as both first-rate scholars and as individuals deeply committed to fostering the integration of science and clinical practice.
We very much hope that you will enjoy this first issue of The Scientific Review of Mental Health Practice and that you will provide us with your constructive feedback and suggestions as the journal continues to evolve and take shape. Indeed, we sincerely hope that you and other readers will hold us to the same high standards we hold for the field of mental health practice. We look forward to hearing from you.
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