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"NONSCIENTIFIC PRACTITIONERS. It is unethical to engage in or to aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care until his or her condition becomes irreversible."
Section 3.01 AMA Code of Ethics

The Code of Ethics of the American Medical Association states clearly that professionals should use scientifically based treatments. Yet a study by W.C. Sanderson [1] shows that even though there are now many evidence-based treatments (EBT) for specific psychiatric disorders and even though these are recommended for use by professional organizations, practitioners typically do not use them. He suggests that the reasons this is the case is that (1) professionals do not have the skill to administer these treatments; (2) continuing-education programs do not require training in EBTs or (3) many clinicians have a negative bias toward them. Sanderson concludes that the failure to adopt evidence-based therapies may have a "disastrous impact on the viability of psychotherapy as the healthcare system evolves."

[1] Sanderson, W.C. "Are evidence-based psychological interventions practiced by clinicians in the field?" Medscape Mental Health, 7(1), 2002

PSYCHOTHERAPIES: VALIDATED AND NOT

By August Piper, Jr., M.D.

Reprinted from the FMSF Newsletter, Nov/Dec 1994, Vol. 3, No. 10

The False Memory Syndrome Foundation has recently begun to note that recovered-memory therapy is an unvalidated form of psychotherapy, implying that such therapy is experimental (see page one of the October Newsletter). Though the concerns leading to these criticisms are understandable, attempts to make such implications oversimplify a complicated problem.

In scientific terminology, if something is valid, it does what it is supposed to do. Thus, a validated therapy effectively treats the condition it is intended to treat. As correctly noted in the October newsletter, investigators have measured the effectiveness of various talk therapies. However, such measurement is extraordinarily difficult, for several reasons.

Psychotherapy is severely hobbled by a distressing lack of agreement among its practitioners on the answers to several critical questions. First is the question of what the goals of treatment are. Does the therapist intend simple symptom relief, recovery and reliving of past stressors, insight into the causes of the patient's problems, change in maladaptive behaviors, a thorough remaking of the personality, or what? Second, what criteria should be used to measure improvement? Measuring psychotherapy-induced change is a minefield of difficulty. Third, how much time should treatment require? Some therapists seriously recommend compressing an entire treatment course into a single session, whereas at the other extreme, treatment has endured in some cases for years. I have even heard of one patient who was in analysis for thirty (!) years.

Another difficulty is that psychotherapy has failed to adopt a uniformly-accepted method of classifying and designating the conditions it is concerned with. Such a system of classifying and arranging disorders is called a nosology. The Diagnostic and Statistical Manual, now in its fourth edition (DSM-IV), represents a good start toward such a nosology. However, it is only a start; DSM shows particular problems in classifying disorders that are treated by psychotherapeutic methods (as opposed to pharmacological ones).

In the absence of a good nosology, attempting to do psychotherapy research becomes an arduous, frustrating undertaking. This is true because the symptoms of psychological conditions overlap so much. For example, depression is a very common symptom of all psychological disorders. In some, depression is the legitimate focus of therapy: it is the problem. In others, however, the very same symptom picture results from any or all of a host of other conditions: drug or alcohol use; marital, social, or economic problems; medical conditions; other psychiatric disorders; childhood stressors; etc. Determining the "real" cause of the depression can be nearly impossible -- witness the acrimonious debate over those therapists who claim that childhood sexual abuse is the real cause of many, if not all, adult psychiatric problems, including depression. This overlap, in turn, means that researchers can never be sure that their study groups differ only in the variable under study.

With so many problems and so much disagreement within the field, and with no formal arrangements for those outside the discipline to establish standards for psychotherapy, no one should be surprised that poorly-validated treatments for psychological problems periodically, like locusts, overrun psychotherapy. Counting the protuberances of a patient's head (phrenology); believing that runaway black slaves have a disease (drapetomania); passing magnets over the body (mesmerism); spraying patients with water, or putting them in wet packs or rapidly-rotating chairs; believing that a woman can have excessive envy of the penis, or develop a wandering uterus (hysteria); surgically attacking the brain (lobotomies) -- all have had their days in the sunlight.

My purpose here is neither to make excuses for psychotherapy's problems, nor to attack the discipline, but rather to point out how difficult it is to validate therapies. The reader who recognizes this will not think an unvalidated therapy is necessarily a bad therapy: because it is so difficult to prove that a given psychological treatment is effective, many commonly-used psychotherapies are unvalidated. Nor will the reader fail to realize that saying a therapy is valid does not go far enough: the question should be, "For which conditions is it valid?"

After all the above is said, however, the essential points made in last month's newsletter article remain correct: many investigators have carefully gathered evidence documenting that one or another treatment, if performed properly, helps patients. In other words, these psychotherapies have been validated. Also, instruction manuals for several different types of psychotherapy are available to practitioners. The manuals are intended to insure that the therapy is performed properly.

Many patients, who have disorders treatable by validated psychotherapies, see recovered-memory practitioners instead. These practitioners have recently come under increasing fire because of the harm their treatments can do. Therefore, the question must indeed be asked: with so many better choices available, why would anyone see therapists who practice a form of treatment that can do such harm? People considering psychotherapy are well advised to spend a few minutes, either on the telephone or in person, to find out whether the clinician utilizes a kind of therapy that has reasonable evidence for efficacy. The list in last month's newsletter might be helpful.


August Piper Jr. M.D. is a psychiatrist in private practice in Seattle, Washington. He is a member of the FMSF Scientific and Professional Advisory Board.

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