Psychotherapy and Pseudoscience: Five Indicators of Dubious Treatments
Prior to earning my doctorate in clinical psychological, I completed a Master's degree in counseling. Living in a fairly liberal town, I was exposed to a number of different therapies by those around me. Some sounded reasonable, and some seemed a little questionable, but it was not always easy to know for certain. Earning my doctorate gave me a background in research methodology and I became a much better consumer of psychological research. Even so, with hundreds of different psychotherapies advocated by thousands of devoted clinicians, it can be difficult to distinguish therapies with a strong research base from those without such support. The distinction between the two is often blurred. Navigating this terrain can be very confusing for a trained clinician, let alone a consumer seeking out effective treatment.
Although by no means the only one, Dr. Scott Lilienfeld at Emory University is one of the most visible figures encouraging caution against embracing treatments of a dubious quality. He has devoted a large portion of his career to writing about psychotherapy treatments that are heavily promoted to clinicians but which lack a scientific evidence base to backup the claims of their adherents. He uses the word "pseudoscience" to describe these treatments.
There's not a clear cut definition for pseudoscience in the psychological literature, but a prototypical pseudoscientific treatment is one marketed as a "breakthrough" cure for a variety of psychological problems, relies on testimonials, and is based on explanations that may sound scientific but which have little to no research to back them up. For example, reparative therapy, as has been written about on this site is an example of a pseudoscientific treatment.
I'm certain the majority of therapists promoting pseudoscientific treatments are quite sincere in their beliefs about the effectiveness of these treatments. They've used them in their own practice and feel they've observed results with their own eyes. Unfortunately, research has shown again and again that we're near incapable of being unbiased observers of our own experiences. We constantly seek to confirm our expectations-especially when we've invested significant time and/or money into something. Research provides a system of checks and balances on these biases.
It's not that scientists are less biased than non-scientists. Scientists can be as prejudiced and narrow-minded as anyone. Many researchers have big money riding on the results of their research in the form of grants. However, in fidelity to the integrity of their profession, researchers actively seek to limit their bias through the use of research methods and statistical analyses. Additionally, when researchers seek to publish their results in scientific journals, anonymous reviewers who aren't invested in the studies offer a more unbiased perspective. These reviewers serve as gatekeepers for what is and is not good science. Although standards for publication vary across journals, this process is invaluable in helping to maintain the integrity of scientific research.
Consumers seeking out mental health treatments can't be expected to know how to find, read, and evaluate scientific research. It's hard enough for many therapists! The main purpose of this article is to offer some rules of thumb for evaluating whether a treatment may be pseudoscientific. Unfortunately, pseudoscience is a matter of degrees rather than an "either-or" phenomenon. Here are some of the red flags to look for.
1. If it sounds too good to be true, it probably is.
Science is a slow, multi-stepped process filled with cautious claims. Nothing emerges victoriously overnight. Even among our "gold standard" treatments there remain a significant percentage of people who don't appear to benefit. Even those who do benefit may still struggle, albeit in a mitigated form. Beware any treatment that purports to be "revolutionary" or "groundbreaking." Treatments that promise results in one or two sessions are also suspect. Except for some simple phobias (e.g., fear of spiders), our most effective treatments often take 8-12 sessions to be effective, even under the best of circumstances.
2. Pseudoscience usually relies on testimonials or anecdotal evidence.
Promoters of pseudoscientific treatments may offer glowing testimonies from people who claim to be cured by the treatment. Readers may even know someone who has raved about this or that treatment. However, expectations about a treatment can influence outcome in a big way. This is known as the "placebo effect." For over a hundred years, researchers have been using inert or sham interventions in comparisons to active treatments in order to account for psychological effects.
The placebo is extremely potent. The satirical newspaper The Onion once ran a story entitled, "FDA Approves Sale of Prescription Placebo." This isn't far off the mark. Many medical doctors admit to prescribing placebo medications. They are cheaper and don't have dangerous side effects. Recent examinations of antidepressant literature have found that the placebo effect may account for much of the improvement in all but severe depression. In psychotherapy, placebo effects are even trickier to tease out. Many people show improvement simply by meeting regularly with a compassionate and empathic individual. Consequently, a number of people will show significant improvement even with a deliberately bogus therapy.
3. Just because a treatment claims to affect the brain doesn't mean there's any evidence it does.
Many pseudoscientific treatments draw upon impressive sounding jargon such as "neural networks" or "neural integration" to describe how they impact the brain. Descriptions may even mention particular parts of the brain impacted by treatment. Usually, however, these claims are speculative, and it's doubtful there's any actual research supporting it. Research using brain scans such as an fMRI require millions of dollars to conduct. Even for scientific research using functional imaging, it's difficult to establish cause-and-effect. There's a lot of interesting neuro imaging research out there, but it's practical impact on diagnosis and treatment of mental conditions is smaller than one might imagine. Bottom line: impressive sound bites about cortical and sub-cortical brain structures don't necessarily make a treatment any more scientific. Anyone can make wild speculations about how something impacts the brain.
4. Pseudoscientific therapies may add inactive ingredients to an active treatment and claim it's something new.
In addition to the placebo effect, some pseudoscience involves adding some mumbo jumbo to an already validated treatment.
Eye Movement Desensitization and Reprocessing (EMDR) is a treatment that's been aggressively marketed for posttraumatic stress disorder (PTSD), ADHD, and a number of other conditions. Its adherents claim it affects neural processes through bilateral stimulation of the brain, such as through moving one's eyes back-and-forth, tapping on the client's hands alternately, or through alternate auditory tones. Although scientific research has supported the effectiveness of EMDR in PTSD treatment, research has not supported the use of bilateral stimulation in impacting treatment outcomes. Most researchers have concluded that EMDR is simply a form of cognitive behavioral exposure therapy. There is no strong evidence that bilateral stimulation has any affect on outcome. Despite this, proponents of EMDR continue to teach and maintain the importance of bilateral stimulation.
Scientists have compared EMDR to a hypothetical "Purple Hat Therapy." Imagine paying thousands of dollars to learn how to properly conduct therapy using a purple hat: the width of the brim, shade of purple, stitching, proper cloth-all for an accoutrement that has no impact on treatment. What sounds credible when the words "bilateral stimulation" are used sounds ridiculous when replaced with "purple hat"; however, they're functionally similar.
5. Be wary of "one size fits all."
With pseudoscientific treatments, claims are often made for the effectiveness of treatment for several very different psychological conditions. Equine-Assisted Therapy (EAP), a treatment involving riding or attending to horses is one popular example. Literature for EAP has reported effectiveness for conditions such as eating disorders, depression, anxiety, ADHD, juvenile offenders, and dementia among others, despite there being no conclusive evidence for it's use in any one of these conditions. For a great summary on the flaws of EAP literature, see Michael Anestis' Psychotherapy Brown Bag post.
To be clear, there are a several cognitive-behavioral therapies (CBT) that have been empirically validated for multiple conditions. However, CBT is an umbrella term covering a number of techniques and approaches. CBT with anxiety will likely look different from CBT with depression. Overall, be cautious of "cure alls."
Even among licensed clinicians, psychotherapists draw from a broad array of different techniques and theoretical orientations. Some are based in research but many are not. Because of placebo effects, many people benefit from less effective treatments, and many pseudoscientific treatments have components that are supported by research. Perhaps the greatest risk is wasting one's time and money on an ineffective treatment. For example, Panic Disorder can often be treated in approximately 10 sessions through cognitive behavior exposure therapies; however, it is likely to remain resistant to talk therapies with an emphasis on the in-depth exploration of one's childhood and history. Consequently, choosing the right therapist and treatment can be very important. I hope that this article provides some practical guidance in navigating an area that is extremely ambiguous for many well meaning professional therapists, let alone the treatment consumer.