Suggestive Techniques and Fad Therapies
To the Editor:
In the editorial that introduces the first issue of The Scientific Review of Mental Health Practice (Lilienfield, 2002), I am cited as supporting the assertion that "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." Unfortunately, this is a distorted and narrow characterization of the views expressed in my book Rebuilding Shattered Lives: The Responsible Treatment of Complex Posttraumatic and Dissociative Disorders (Chu, 1998).
I have not written on the practice of accessing purported memories of satanic ritual abuse or alien abduction. However, I have certainly urged caution in working with trauma patients, particularly concerning memory and undue suggestion: ". . . research concerning the use of suggestion and certain kinds of interrogation has shown that memory content can be affected by interactions with others, and . . . therapists must be careful not to inquire about possible abuse in a way that even subtly suggests a particular kind of response" (Chu, 1998, p. 70). I advocate phase-oriented treatment in which patients work on achieving safety and stabilization prior to attempting to access memories of traumatic experiences. Premature and aggressive attempts to access memories can indeed be harmful and retraumatizing.
I support the appropriate use of guided imagery and hypnosis. Like other modalities, these techniques can be misused, e.g., for retrieval of memories prior to stabilization. However, with proper training and practice, guided imagery and hypnosis can be of great value to relieve anxiety and provide a sense of safety early in treatment, and to facilitate safe and measured recollection and processing of traumatic memories later in the process. I do not support the contention that hypnosis often leads to so-called false memories. Improper therapy is responsible for such a result, with or without the use of hypnosis.
I have never espoused the belief that memory retrieval-whether of true or false memories-creates posttraumatic stress disorder. Nor do I believe that dissociative disorders can be created in most patients. As I have written, ". . . there is no clear evidence that [Dissociative Identity Disorder] DID can be iatrogenically created de novo in adult persons who do not have a preexisting dissociative capacity or history of trauma. However, patients with lesser degrees of dissociation can be pushed into DID-like presentations by naÔve or overzealous therapists" (Chu, 1998, p. 196).
All of the above views are expressed in the context of my advocating the use of an eclectic treatment model that includes psychodynamic perspectives, objects relations and family systems theory, and skills-based cognitive behavioral therapy. Based on the accumulated clinical experience of myself and others in the trauma field, this type of approach appears to provide effective and balanced treatment for persons with complex posttraumatic and dissociative disorders.
It is certainly reasonable to establish the empirical validity of mental health treatments. However, efforts to discredit all therapies that have not yet been subjected to in-depth empirical research are misguided. The multiple parameters and the subtleties of therapy make psychotherapy outcome research very difficult. Therapy in vivo is very different from therapy in the laboratory, and is a highly complex interaction that is not easily analyzed or tested. Rather, the experience and benefits achieved by clients over time may the best measure of the value of some forms of psychotherapy.
Fad therapies-some of which may be useless or even dangerous-continue to exist, and clients can be lulled into believing in their value. Such therapies should be exposed and discredited. However, we must be very careful not to attack the majority of mainstream mental health practitioners because of concerns about the practices of a minority group, as has occurred during the recent debate about the validity of traumatic memories. Advocates of the False Memory Syndrome (is FMS an empirically established diagnosis?) effectively used the poor clinical practices of a small number of therapists to tar the reputations and inhibit the practice of many legitimate and worthy clinicians who were wrongly accused of providing "recovered memory therapy." As a practicing psychiatrist specializing in trauma-related disorders, I personally have never heard of "recovered memory therapy," nor am I aware of any of my colleagues practicing this type of treatment.
The Scientific Review of Mental Health Practice has the potential to make a valuable contribution to mental health science. However, to be worthwhile and credible, the journal should eschew the easy road of only exposing questionable treatments, and should instead seek articles that analyze both new and established treatments for their effectiveness. Promoting effective psychotherapy in a reputable and balanced journal is important. But if a journal focuses primarily on exposing misguided efforts, it is destined to fall short of the laudable goal of promoting effective mental health care.
A. Chu, M.D.
Chief of Hospital Clinical Services, McLean Hospital
Associate Professor of Psychiatry, Harvard Medical School
Chu, J. A. (1998). Rebuilding shattered lives: The responsible treatment of complex posttraumatic and dissociative disorders. New York: Wiley.
Lilienfield, S. O. (2002). Our raison d'Ítre. The Scientific Review of Mental Health Practice, 1(1), 5-10.
Scott O. Lilienfeld replies:
I thank Dr. Chu for his comments and welcome the opportunity to respond to his constructive criticisms. I will begin with one general point of agreement with Dr. Chu, and then turn to areas of disagreement.
First, I am in full agreement with Dr. Chu that for a journal such as The Scientific Review of Mental Health Practice (SRMHP) to accomplish its goals, it must focus not only on criticizing ineffective or questionable treatments, but on promoting effective or promising treatments. Indeed, it is for this very reason that each issue of SRMHP features a regular section entitled "Focus on Empirically Supported Methods," which highlights one or more novel therapeutic or assessment methods that are either scientifically supported or highly promising. In fairness to Dr. Chu, he may not have had access to the full text of the inaugural issue of SRMHP when crafting his letter and may therefore have been unaware of this regular feature of the journal. Dr. Chu and other readers can rest assured that SRMHP is more than open to empirical investigations and reviews of novel and controversial treatments that are supported by the best available research evidence. At the same time, these treatments must withstand the same careful scientific scrutiny demanded of all techniques before they can be broadly disseminated to practitioners and the general public.
Let me now address our primary areas of disagreement. Dr. Chu makes several strong assertions that are not supported, and that are in some cases flatly contradicted, by research evidence. For example, he disputes my (Lilienfeld, 2002) contention that hypnosis often leads to false memories and he instead places the blame for false memories on "improper therapy," although he is not explicit about what differentiates proper from improper therapy. Nevertheless, Dr. Chu's claim is confuted by a large and consistent body of controlled research evidence (e.g., Lynn, Lock, Myers, & Payne, 1997) demonstrating that hypnosis tends to produce a large number of false memories, including highly implausible childhood recollections. Moreover, hypnosis tends to increase confidence in recollections while not increasing their accuracy. Such findings led Division 17 of the American Psychological Association (1995) to caution against the use of hypnosis for recovering childhood memories of abuse. Dr. Chu's endorsement of hypnosis "to facilitate safe and measured recollection and processing of traumatic memories" runs counter to scientific evidence and is, at best, ill advised.
Dr. Chu substantially understates the magnitude of the threats posed by therapists who use suggestive techniques to recover purported memories of early abuse. He maintains that critics of the recovered memory movement have used "the poor clinical practices of a small number of therapists" to sully the reputations of legitimate clinicians. Dr. Chu's claim that these practices are limited to only a small minority of therapists is erroneous. Poole, Lindsay, Memon, and Bull (1995) found that approximately 25% of U.S. and U.K. doctoral-level therapists who work with adult female patients believe that memory recovery is a significant component of treatment, believe that they can identify patients with repressed memories as early as the first session, and use two or more suggestive techniques (e.g., hypnosis, guided imagery, body work) to help recover such memories. Moreover, Poole et al. found that approximately 75% of U.S. doctoral-level therapists use at least one such technique to facilitate the recovery of childhood abuse memories. Other researchers (e.g., Polusny & Folette, 1996) have reported similar findings.
Dr. Chu contends that "efforts to discredit all of the therapies that have not yet been subjected to in-depth empirical research are misguided." Here Dr. Chu appears to confuse unvalidated therapies with invalidated therapies. In contrast to invalidated therapies, which have been demonstrated to be ineffective in well-controlled studies, unvalidated therapies have yet to be subjected to careful empirical scrutiny. We agree with Dr. Chu that it is incumbent on researchers and practitioners to keep an open mind concerning the efficacy of all untested therapies. Nevertheless, the fact that many of these therapies are difficult to study within the tightly controlled confines of the psychotherapy laboratory does not provide therapists with carte blanche to use these techniques with clients. If these treatments have not yet been shown to be effective in controlled trials, therapists must explicitly label them "experimental" and inform clients of this crucial fact.
Moreover, Dr. Chu's assertion that "the experience and benefits achieved by clients over time may be the best measure of the value of some forms of psychotherapy" comes perilously close to implying that therapists can safely dispense with the demands imposed by rigorously controlled studies in favor of their subjective clinical impressions of client improvement. A large body of research demonstrates that clinicians often misattribute naturally occurring client improvements to treatment (Beyerstein, 1997). For example, without a randomized control group, there is no way to determine whether client improvement is attributable to regression to the mean, spontaneous remission, maturation, multiple treatment interference, or a host of other factors. In addition, client improvement may be attributable to nonspecific factors that are shared by many or most other treatments, such as placebo effects or effort justification (improvement resulting from the need to legitimize the time, energy, and expense of one's treatment).
Finally, Dr. Chu takes issue with my citation of his book (Chu, 1998) as buttressing the assertion that therapists who use suggestive techniques to recover early memories can sometimes induce analogues or variants of posttraumatic stress disorder (PTSD) in clients. Nevertheless, as Dr. Chu himself notes, his book features a number of (entirely appropriate, in my view) caveats regarding the careless use of such techniques:
- ". . . caution must be exercised in inquiring about histories of child abuse." (p. 70)
- "Therapists must scrupulously avoid regressive practices. Current reality, past realities, fantasies, dreams, and fears become inextricably entangled under conditions of profound regression . . . ." (pp. 70-71)
- ". . . patients with lesser degrees of dissociation can be pushed into DID [dissociative identity disorder]-like presentation by naÔve or overzealous therapists . . . some misguided therapists seem to be fixated on finding sexual abuse and evidence of dissociation." (pp. 196-197)
- "Some patients with apparent pseudodissociation falsely embrace having been 'ritually abused.' " (p. 201)
It is therefore not entirely clear why Dr. Chu wishes to distance himself from the assertion that suggestive techniques can produce analogues or variants of PTSD in certain clients, because he clearly acknowledges that clients can sometimes come to accept the psychological reality of early traumatic events that never occurred.
Despite his justified cautions, Dr. Chu (1998) resists the conclusion that suggestive procedures by themselves can produce false abuse memories: ". . . [T]here is little evidence that direct questioning about abuse per se results in false memories of abuse" (p. 70). Moreover, Dr. Chu contends that there is no compelling evidence that DID can be created iatrogenically in individuals without a preexisting psychopathological disposition, but he acknowledges that individuals prone to dissociation can be "pushed into" variants of DID. We (Lilienfeld et al., 1999) have elsewhere put forth a very similar argument: "Given the high rates of preexisting mental conditions among DID patients . . . it seems likely that iatrogenic factors do not typically create DID in vacuo but instead operate in many cases on a preexisting substrate of psychopathology, such as BPD [borderline personality disorder]" (p. 519).
There thus appears to be at least some middle ground between Dr. Chu and ourselves. But this significant point of consensus implies that therapists who use highly suggestive techniques to recover purported early memories (or, in the case of DID, to "map" the system of purported alter personalities) can inadvertently produce DID features-and perhaps full-blown DID-in predisposed clients. Caution must therefore be the watchword in the treatment of such individuals.
American Psychological Association, Division 17 Committee on Women, Division 42 Trauma and Gender Issues Committee (1995, July 25). Psychotherapy guidelines for working with clients who may have an abuse or trauma history.
Beyerstein, B. (1997, September/October). Why bogus therapies seem to work. Skeptical Inquirer, 21, 29-34.
Chu, J. A. (1998). Rebuilding shattered lives: The responsible treatment of complex posttraumatic and dissociative disorders. New York: Wiley.
Lilienfeld, S. O. (2002). The Scientific Review of Mental Health Practice: Our raison d'Ítre. The Scientific Review of Mental Health Practice, 1, 1-10.
Lilienfeld, S. O., Lynn, S. J., Kirsch, I., Chaves, J. F., Sarbin, T. R., Ganaway, G. K., & Powell, R. A. (1999). Dissociative identity disorder and the sociocognitive model: Recalling the lessons of the past. Psychological Bulletin, 125, 507-523.
Lynn, S. J., Lock, T. G., Myers, B., & Payne, D. G. (1997). Recalling the unrecallable: Should hypnosis be used to recover memories in psychotherapy? Current Directions in Psychological Science, 6, 79-83.
Polusny, M. A., & Follette, V. M. (1996). Remembering childhood sexual abuse: A national survey of psychologists' clinical practices, beliefs, and personal experiences. Professional Psychology: Research and Practice, 27, 41-52.
Poole, D. A., Lindsay, D. S., Memon, A., & Bull, R. (1995). Psychotherapists' opinions, practices, and experiences with recovery of memories of incestuous abuse. Journal of Consulting and Clinical Psychology, 68, 426-437.