Overpromised, Underresearched

From the September/October 1994 issue

HOUSE OF CARDS: PSYCHOLOGYAND PSYCHOTHERAPY BUILTON MYTHBy Robyn M. DawesNew York: The Free Press338 pages, $22.95

WE’VE HAD A HUNDRED YEARSOF PSYCHOTHERAPY AND THEWORLD’S GETTING WORSEBY JAMES HILLMAN ANDMICHAEL VENTURASan Francisco: HarperSanFrancisco242 pages, $18.00

UNFAITHFUL ANGELS: HOWSOCIAL WORK HAS ABANDONEDITS MISSIONBY HARRY SPECHT ANDMARK E.COURTNEYNew York: The Free Press209 pages, $22.95

IN 1986, CALIFORNIA’S GOVERNOR and state assembly established a commission to study and document the proposition that improved self-esteem leads to greater success and happiness. This Task Force to Promote Self-Esteem and Personal and Social Responsibility investigated whether a statewide system of self-esteem enhancement programs would help cure various social ills such as street violence, drug abuse, teen pregnancies, school dropouts and welfare dependence. After three years (and $735,000 of taxpayers’ money), the taskforce discovered that self-esteem is not a powerful mediator of either individual mental health or community well-being. As one task force member argued, low self-esteem was almost certainly a by-product of adverse social circumstances rather than a cause of them.

There was only one small problem. Because task force members were precommitted to the original proposition (and were operating in a political climate that favored simplistic conclusions and quick fixes), they ignored their own findings and went right ahead to propose the creation of new, large, expensive and ultimately useless self-esteem programs.

All three books reviewed here, representatives of a growing literature expressing deep skepticism about the institution of psychotherapy and its impact on society, use the illustration of the California self-esteem task force to underline how plausible sounding but unsubstantiated mental health beliefs can become self-perpetuating gospels. In House of Cards, Robyn Dawes hammers away at therapists for making what he considers to be unwarranted treatment claims and for foisting pop psychology hokum on an unsuspecting public. He argues that many therapists have abandoned the one factor scientific integrity that presumably distinguishes them from the expanding cadre of self-proclaimed psychics, new-age healers, religious gurus, talk-show hosts and self-help book authors. No less stinging indictments can be found in James Hillman and Michael Ventura’s free-wheeling commentary on psychotherapy, We’ve Had a Hundred Years of Psychotherapy And the World’s Getting Worse, and Harry Specht and Mark Courtney’s study of the privitization of the social work profession, Unfaithful Angels.

Why is the field of therapy currently receiving so much criticism? Not long ago, only psychiatrists were authorized to practice psychotherapy, and only a small percentage of them actually did so. In medical settings, clinical psychologists were usually restricted to administering tests, and social workers had to content themselves with taking social histories, coordinating home visits and ferreting out community resources. At that time, the demand for psychotherapeutic services was relatively modest. Except in a few sophisticated metropolitan areas, those who sought therapy were either seriously disturbed or seriously wealthy.

Then, during the 70s and ’80s, everything shifted. Suddenly, everyone on the block was either doing therapy, going to therapy, or both. The ranks of practitioners expanded to include clinical, counseling and school psychologists; family and marriage counselors; social case workers; psychiatric nurses; clergy; adjunctive therapists; addiction workers; massage therapists; and countless others. Members of this growing ragtag therapeutic army also have been escalating their claims about what they can provide clients. In addition to curing mental illnesses, they presumably can ease separation pains and relationship woes, resolve parenting dilemmas, clarify career options, tame adolescent temper tantrums and so on. People now expect their therapists to have immediate cures for most of life’s hassles, including sleep disturbances, batting slumps, mid-life crises and writers’ blocks. As Dawes points out, most therapists, when faced with a client problem any problem seem incapable of uttering the words “I don’t know.”

Therapy has gone from being a somewhat esoteric enterprise to a national pastime and a major health care expense. In the process, there has been a loss of quality control and an expansion into realms that were never intended to be classified as “psychiatric” problems, and for which few tested treatments exist. This has prompted insurance companies to challenge the legitimacy of various conditions and procedures. It has also inspired the sort of scathing commentary exemplified by the crop of therapy critiques considered here.

IN HOUSE OF CARDS, DAWES documents the divergence between the practice of psychotherapy and the canons of good science. He tries to show how such phenomena as regression effects, base rates, selection biases and hypothetical counterfactuals are much more relevant to practice than most work-a-day clinicians assume. For instance, therapists commonly note that good sessions often are followed by slumps or setbacks. This phenomenon has spawned many fancy clinical explanations, including the notion that clients need time to “consolidate” the work they have done or that rapid change necessarily mobilizes counter-resistance. These explanations may all be superfluous. According to Dawes, the pattern clinicians observe is probably just a simple instance of the so-called “regression effect.”

Briefly, probability theory dictates that the exceptional good or bad generally reverts back to the ordinary. This is as familiar (and consternating) to gamblers and athletes as it is to therapists and clients. In all these domains gambling, sports and therapy regression effects seduce the participants into believing in spurious explanations and engaging in superstitious behaviors. The simple truth is that patterns come and go when they have not yet been reliably produced. For instance, people who have just learned to drive a shift car may think they “know” the right moves, but they still tend to stall the car about half of the time, and with mounting pressure, their shifting skill may drop to near zero. This might metaphorically be labeled an issue of “consolidation” or “resistance to change,” but practically speaking what the person needs is additional driving experience to solidify motor learning. Similarly, a client who “catches on” one week but loses it the next, probably just needs to gain more familiarity with the phenomenon at hand.

A therapist who comprehends regression effects ought to welcome with open arms clients who come for help when they are feeling at their worst. The strong likelihood is that these clients will soon feel better regardless of what the therapist does. On the other hand, clients who arrive in a particularly upbeat mood may all too soon be singing the blues. Unfortunately, they are apt to ponder whether their therapist has been missing the boat in treating them. In the first instance, the therapist gets too much credit, and, in the second, too little both courtesy of regression.

Another strong point made by Dawes is that clinicians frequently and illegitimately argue from a vacuum. When faced with experimental evidence that runs counter to clinical beliefs, they assert that the right experiments have not yet been performed. Typical are the debates that have raged for years about the validity of projective techniques such as the House-Tree-Person and the Rorschach. Clinicians have regularly dismissed massive accumulations of negative research findings about these techniques, claiming that the research was improperly conducted and irrelevant to clinical practice. They have complained about the use of individual scoring items instead of clinical profiles, the lack of qualifications of test administrators and interpreters, the inadequacy of the setting, and so on. No matter how many different research designs were tried, the outcomes were still discounted as spurious, and clinicians continued to believe and do whatever they wanted. Because they produced no systematic evidence of their own, they were, as Dawes puts it, arguing from a vacuum. As is typical in these situations, they invoked that old saw “clinical experience” to account for their position a strategy that Dawes, as we shall see, considers totally untenable.

Dawes indicates that arguing from a vacuum is not acceptable in modern medicine, and questions why it is tolerated in the mental health field. For example, it would be impossible today to urge a return to bloodletting simply by pointing out that there were gaps and weaknesses in the original investigations. To be taken seriously, a critique of past findings would have to be accompanied by new and compelling evidence of bloodletting’s effectiveness. Otherwise, no one would be the least bit interested.

Moreover, in medicine, practicing discredited or unvalidated treatments is considered quackery. Even when the need is great, medicine offers only well- substantiated treatments to the public.   Untested procedures are clearly labeled “experimental” and are used only as a last resort and only with a patient’s consent. Dawes contrasts this ethic with current practice in the mental health field, where untested and discredited methods are routinely practiced. Some are even invented on the spur of the moment but are still presented as if they were well-established procedures with good scientific backing. In fact, using the yardstick of science, Dawes considers much of what clinicians actually do to be quackery. Moreover, he finds it reprehensible that such practices are not loudly condemned by professional organizations such as the American Psychological Association and the American Psychiatric Association.

Dawes chides licensing boards for not only failing to protect the public, but for providing clinicians with a license “to use shoddy tests,” “to use techniques that don’t work,” “to make up [one’s] own psychological theories,” “to present. .. one’s [personal] fantasies in a legal setting,” and, in the case of professionals specializing in extraterrestrial abductions, “to go haywire.” By now it ought to be considered malpractice to use hypnosis to validate the accuracy of childhood memories, but this practice has not led to formal censure by professional groups nor to the revocation of anyone’s license. Similarly, as Dawes points out, no one has called a halt to psychological “experts” testifying in court using information-gathering tools and decision-making methods that have either been discredited (such as interviews with anatomically correct dolls) or that have not been subjected to scientific analysis. In fact, empirical research shows that the opinions of court “experts” are no better than the prognostications of untrained observers, and that statistical predictions based on readily available demographic data yield higher “hit rates” than most clinical profile predictions. However, the courts, basically unaware of this information, continue to privilege the testimony of mental health workers, falsely assuming that this material is scientifically justifiable. “With regard to the claim of “clinical experience,” Dawes argues that a variety of potent mechanisms, such as base rates, “availability biases,” self-fulfilling prophecies and selective memories, all conspire to give clinicians a false sense of security about their hunches, predictions and explanatory notions. Experience can, of course, be a useful teacher, but only if the conditions are right. Unfortunately, the settings in which most clinicians operate are not conducive to generating self-corrective experience. Their encounters with clients and other clinicians can actually help embed false beliefs. Feedback from clients is typically delayed, truncated or biased. Clinicians do not necessarily see a wide or representative sample of cases, and, in many instances, they never learn about the actual outcomes of their interventions. Furthermore, with so many factors occurring simultaneously, it is difficult or impossible to separate causes from effects. Under these circumstances, a few salient and possibly coincidental events can stick in a clinician’s memory and perpetuate the use of ineffective or even harmful diagnostic and therapeutic practices. At conferences, practitioners seek out “experts” who report on “clinical experience” that may not necessarily be any more valid than their own.

One of the most pervasive clinical myths that Dawes challenges is the idea that childhood events create adult psychopathology or at least strongly dictate adult patterns of personality. He labels this view “the tyranny of childhood” and, despite its current popularity, considers it pseudo-scientific hogwash, not backed by a shred of scientific evidence. He brands it a mythology as primitive as a belief in “a mountain god.”

Dawes reminds the reader that even Freud, often considered the progenitor of the therapeutic emphasis on early childhood, observed that the majority of people who experienced childhood traumas grew up without any outward manifestation of pathology. In We’ve Had a Hundred Years of Psychotherapy And the World’s Getting Worse, Hillman and Ventura join Dawes in attacking the tyranny of childhood notion, complaining that clients are more and more often being urged to convert “the present into the past.” In the process, therapeutic hours become wasteful “rituals of evoking . . . and reconstructing childhood.” Moreover, they observe that therapists routinely portray the “inner child” in a form that “represses our actual childhoods and concentrates the fear, vulnerability, failure and grief we feel as adults into an image that we can detach from our adult life an image easily marketable and played upon.” The “precious, delicate, utterly vulnerable” elements of childhood are emphasized, not other personality facets such as the obstinate, resilient, rebellious and vicious child who is on public display at any nearby shopping mall and in many of our own living rooms. Hillman and Ventura want to be sure we don’t lose sight of the fact that it was children who “invented passive resistance and civil disobedience a long time before Thoreau, Gandhi and King.”

For Hillman and Ventura, getting stuck in a romanticized image of a defenseless child (and an abused adult) handicaps our ability to empower adults to be full-bodied, potent and productive. The child archetype that is worshipped in so much of today’s mental health theory and practice perpetuates a limiting “helplessness” mythology that risks depriving adults of their political power. Hillman and Ventura are keenly aware that the metaphors therapists choose are critical to the kinds of results they produce. Therefore, they quote approvingly Confucius’s statement that “the reform of society begins in the reform of its language,” and note that “if we are getting worse, we are getting worse partly because of therapy’s linguistic callousness.” From their viewpoint, the metaphor of past helplessness is an example of a metaphor that doesn’t work well.

Similarly, the fuzzy concepts of “growth” and “development” are metaphors with which Hillman and Ventura take issue: “The very word grow is a word appropriate to children. … If you start growing after [a certain] age, it’s cancer.” Moreover, such metaphors inevitably set clients up for self-disappointment. “The fantasy of growth is a romantic, harmonious fantasy of an ever-expanding, ever-developing, ever-creating, ever-larger person. .. . And if you don’t fulfill that fantasy, you see yourself as failing.”

Some therapists will object strongly to Dawes’s and Hillman and Ventura’s negative appraisal of what seems to be a truism that the past (childhood) determines or strongly influences the present (adulthood). Having anticipated this criticism, Hillman and Ventura remind us that the myths we are in the middle of are the ones that are hardest to see.

There are, of course, plausible alternatives to the common view that the past shapes the present and the future. After all, it is only analogically that the past is a force that appears to “push” life from behind. In actuality, the past is just a summary or description drawn from a particular point of view. It is a story about where we think we have been, but a story has no actual motive power. Like a shadow, the past always sits just behind us. It follows us wherever we go. But, like a shadow, it neither determines nor limits where we can step next.

HARRY SPECHT AND MARK COURTNEY in Unfaithful Angels are less concerned with how therapists deal with issues of the past than with the myth of “inner perfectibility” that dominates therapeutic practice. In their view, the therapeutic focus on internal growth distracts attention from what Specht and Courtney consider to be social work’s primary mission the “perfectibility of society.”

Historically, in our individualistic culture, public welfare programs have been viewed with deep ambivalence. They have been perennially underfunded and understaffed. Therefore, public sector social workers have usually found themselves operating under trying circumstances buried under a mountain of paper work and forced to contend with endless bureaucratic regulations. A lack of resources and a minimum of appreciation understandably caused social workers to seek additional ways of obtaining status, recognition and autonomy. Many took a convenient escape route by emulating the theories and methods of a neighboring, higher-status profession: psychoanalytic psychiatry. As one social work professor says, it was as if the profession thought it could “find dignity, status and helpfulness only by becoming something it is not.” Although Specht and Courtney understand the frustration social workers historically experienced, they lament the solution that many in the field chose a rush to practice private psychotherapy, first with individuals and later with families and couples.

Specht and Courtney do not consider doing psychotherapy bad but, from their viewpoint, “it just isn’t social work.” Moreover, they consider that “the belief systems that underlie all forms of popular psychotherapy are fundamentally and inherently in conflict with communally based kinds of interventions.” They want social workers to return to their original focus on the infrastructure of the community rather than spending their time rendering services to middle-class clients that others are equally well-equipped to provide.

Specht and Courtney argue for the establishment of a community based system of social care. They envision well-funded, attractively furnished centers to be built in both poorer neighborhoods and also in more prosperous communities. Within these settings, a wide range of activities and services for children, parents and the elderly are to be provided, including game rooms, gymnasiums, swimming pools, classrooms, theater spaces and a “facility for serving refreshments that is a cross between a British pub and an American soda fountain.” Volunteerism would be encouraged, and an annual banquet ceremony would be held to recognize those who have served as community leaders. While all this sounds laudable, it also seems impossibly naive alongside Hillman and Ventura’s gloomier but richer image of an ecology in disrepair and a culture in which few recall what life is supposed to be about. Considering the circumstances they describe, it will take a lot more than a grant from the United Way, a soda fountain and a banquet to draw us back into some meaningful sense of community.

What may be needed is a new profession or calling that fills the void social work has left behind. It need not be connected with mental health, and its methods might have to be invented from scratch, the way Mary Richmond and Jane Addams carved out a model for social work 100 years ago. A number of years back, community psychology took a stab at such a project, but it failed miserably. This was partly due to a rapid change in the political climate, but it was also because of unclear goals, inadequate theory and divided loyalties-it tried to be an amalgam of psychology, sociology and political action, and it wasn’t very good in any of those departments. Perhaps the next social reform attempt will be more successful. However, one thing seems painfully clear: the vitality needed for such a venture will not come from recruiting contemporary social workers to return to the fold.

DAWES IS RIGHT, OF COURSE, IN calling attention to how few of our clinical practices stand up to close scientific scrutiny. It is also true that few practitioners are adequately conversant with the basic science that presumably underlies what they do. It is tough to read his examples of professional practice without wincing. On the other hand, his conception of psychotherapy as a collection of straightforward, scientifically validated and empirically based procedures is, in itself, simplistic and misleading. As even the research he reports indicates, important relationship factors in therapy are difficult to reduce to a formula. In surgery, it is the blade that cuts. In therapy, the personality of the therapist is an integral part of the “equipment,” and so is the degree of fit between client and therapist. It was perhaps a mistake to ever allow therapy to be construed as a “treatment” and to be judged as if it were a medical practice. Therapy is more akin to to education, philosophy or religion than it is to medicine. A dialogue about the meaning of life does not hinge on a specifiable set of technical maneuvers.  However, practitioners cannot have it both ways:  Philosophers rarely feel entitled to collect third-party payments.

And, of course, to play fair, Dawes ought to at least note the clay feet of the laboratory researchers he is so anxious I for us to read. In our experience, scientific I investigation is rarely a pristine, value-free enterprise, with researchers cheerfully giving up their pet theories when they see how the data comes out. Principal investigators with large egos and aggressive career goals frequently manipulate the data they produce and are selective in what gets reported and publicized. They tailor the packaging of findings to make the piddling seem important and to camouflage weaknesses of methodology and interpretation. They choose to do studies that are methodologically clean but clinically irrelevant, rather than involving themselves in messier designs that might be more useful to clinicians. In theory, the scientific method is a fine tool, but in practice it is an imperfect instrument. Perhaps Dawes will soon agree to write a sequel to his book, aimed at educating clinicians and the general public about the vagaries and illusions of science House of Cards II.

Jay S. Efran, PhD., is professor of psychology and director of psychological services at Temple University. He is author (with Michael D. Lukens and Robert J. Lukens) of Language, Structure and Change: Frameworks of Meaning in Psychotherapy.

Mitchell A. Greene is head clinic assistant of the psychological services center at Temple University, where he is also completing a doctorate in clinical psychology.