Science and Pseudoscience in Clinical Psychology

This is a veritable curate's egg of a book – fascinating and enlightening in places, depressingly or infuriatingly (depending on your temperament) empiricist in others. As I will discuss below, there are a number of highly stimulating contributions; yet the underlying assumptive paradigm underpinning the highly varied contributions is that of a technological-scientific approach to psychological difficulties. By way of illustrative example, on page 146 we read that 'psychotherapy has matured considerably and progressed well beyond its origins as a healing art toward a technical psychosocial intervention' (my emphasis). I know of many a therapy practitioner (including myself) who would flatly disagree with this assertion. Certainly, the cognitive-behavioural bias in much of the book confirms that it is broadly informed by a modernist ideology which, far from being an 'objective' and validly scientific approach to emotional and mental distress, is located within an historically specific, materialistic paradigm which has come under severe epistemological challenge on a whole range of fronts (e.g. Woolfolk and Richardson, 1984; Polkinghorne, 1990), with its assumption that only the immediately observable and measurable are deemed to count as valid scientific knowledge. In the Foreword, then, the scene is set when we read that 'the cardinal rules of the scientific method [are] replicable findings, verifiable data, objective confirmation of evidence…' [whatever happened to Popper? – RH] (p. xiii). What we often end up with in this book, then, are impressively thorough and authoritative state-of-the-art commentaries on a range of themes, but cast within a narrowly empiricist world-view. The chapter on trauma-related 'disorders' is a case in point, with the authors paying no attention whatsoever to the impressive literature that incisively challenges the positivist approach to trauma and its consequences and treatment (e.g. Bracken, 2002). The book avowedly sets out to 'help professionals and students evaluate the merits of novel and controversial techniques, and differentiate between those that can stand up to scientific scrutiny and those that cannot' (publisher's blurb). And the cultural backdrop to this study is that 'unscientific and otherwise questionable techniques have increasingly come to dominate the landscape of clinical psychology and allied fields' (Preface, p. xix). A central and predictable theme is what the book's editors see as a schism between 'psychological science' and clinical practice, with 'scientifically minded clinicians… becoming a rapidly dwindling minority within their profession' (p. xi, note), and with the former 'scientist-practitioner model' having been successively replaced by a scientist/practitioner gap, and even, today, a 'war' (p. xiv). Yet there are different kinds of 'war' going on here: first, there is the one identified by the contributors to this book, raging over what they assert to be the 'unscientific' practices of many practitioners (often 'psychotherapists') and the allegedly meticulous scientific practices of the medically based clinician and the research-driven university psychology department; and then there is the kind of 'paradigm war' (which Network Review readers are probably far more interested in) between the empiricist epistemology and methodology of conventional scientific psychology, on the one hand, and on the other, 'New Science', new paradigm approaches which embrace a far broader definition of what 'science' consists in - and which distinction this book completely fails to consider. It follows that my task in reviewing this formidable book is a complex one, as I commonly found myself reading it at two different levels simultaneously and thereby having a rich diversity of responses that is difficult to summarise. But more of that later.

Following an initial contextualising chapter, the book is divided into five parts. Part I considers assessment and diagnosis, looking at research on clinical judgement, questionable assessment techniques, and the phenomena of 'expert testimony' and multiple personalities. Part II looks at some topical controversies in the psychotherapy field – namely, psychotherapy research, so-called 'New Age' therapies and memory recovery techniques. Part III moves on to look at specifically adult 'disorders' – viz. treatment for trauma-related 'disorder', alcoholism and depression. Part IV examines two culturally prevalent childhood 'disorders' – ADHD (hyperactivity) and autism. Finally, the book looks at the self-help genre and the 'commercialisation' of mental health issues. First and foremost, this is a book of considerable academic gravitas: at almost 500 pages and comprehensively referenced and glossaried throughout, its production is a formidable achievement. And with sixteen major contributions I will only have space to focus on a few of them. Chapters 1 and 2 consider the fascinating question of whether personal clinical practitioner experience is as valid a means of informing clinical and treatment practice as so-called 'objective' research evidence – a discussion which goes right to the heart of the 'paradigm war' referred to earlier. No one would surely seriously question the contention that there might well exist 'psychotherapeutic methods of unknown or doubtful validity' (p. 2); but contrary to these writers' assumption, it by no means follows from this that the embracing of the double-blind research methodology of controlled empirical research is the most appropriate response to such a possibility. First, to say the least it is somewhat rich for such criticisms to be made of the 'clinical judgement' paradigm when at least 10,000 National Health Service patients die prematurely each year due to bad reactions to conventional (and presumably 'scientifically' tested) medication (BBC News, 2004). Or put differently, the inauspicious track record of conventional medicine doesn't exactly qualify it to pronounce authoritatively upon the safety or otherwise of treatment practices that privilege clinical judgement and experience over 'objective' clinical trial methodology (CTM). Moreover, that it can be demonstrated (as the authors of Chapter 2, Garb and Boyle, convincingly do) that clinical perceptions can commonly be biased and distorted in various well documented ways by no means demonstrates (as they appear to think it necessarily does) that such procedures will commonly be more harmful to patients than treatment decisions derived from CTM-based data. Incisive writers (like John Heron in his excellent Co-operative Inquiry – reviewed in Network, 65, Dec. 1997, pp. 57-8) have convincingly demonstrated just why this is so – for, as Heron argues, CTM (in which there is random allocation of subjects to an experimental treatment group and a matched control group) is woefully inadequate from a scientific viewpoint because: (1) its statistical methodology hides, through the comparison of means, what actually happens to individuals in the trial – meaning, for example, that there may easily be some people in both groups who are worse off after treatment; (2) CTM therefore ignores the different responses of different individuals to the same treatment, so that, as Heron argues, '[CTM] cannot help with the everyday question, "What is the treatment of choice for this individual patient?"' (1996: 198); (3) CTM ignores the powerful effect of mind on body and the latent phenomenon of self-healing; (4) In true naively causal-empiricist mode, CTM assumes the validity of its mechanistic univariate approach which separates out the single treatment variable from all other influences to assess its causal impact (as if real, lived life were like that!); (5) CTM objectifies suffering as a 'thingified' process, reifying 'external' causal influence and ignoring subjective illness categories experienced and made sense of by the patient/client, and ignoring the meaning or 'tacit intentionality' (Heron) of the illness; (6) And finally, CTM ignores the possibility that its so-called 'statements of fact' (including variable specification and measurement) may inevitably be theory- and value-laden, and can only be formulated within a pre-existing (and self-fulfilling) set of theoretical assumptions (ibid.: 197). It follows from this (to my mind) devastating critique of CTM that what is urgently needed is a paradigmatic meta-view that attempts to locate and account for our historically and culturally specific methodological procedures within the context of the evolution of human consciousness (Steiner, 1966; Crook, 1980), if we are to gain a reflexive purchase on those methods and, hopefully, deepen and widen them. But alas, such an informed analysis is very far from the kind of approach pursued in this book. Readers of this Review with an interest in medicine, psychology and research methodology will be aware of manifold and successful efforts to transcend the severely limited positivism of CTM and allied procedures. It is doubly ironic, then, that in their final chapter, the editors advocate (inter alia) that all clinical psychology training programmes should require the study of 'fundamental issues in the philosophy of science, particularly the distinctions between scientific and non-scientific epistemologies…' (p. 462). Amen to that!… - though I sense that the curriculum content of such a module would vary wildly, depending upon the relationship (if any) of its authors to questions of postmodernity (Polkinghorne, 1990) and 'New Paradigm' scientific thinking more generally. Not least, the CTM researcher assumes that patients/clients are essentially the same, whereas the best of clinicians strive to be open to client uniqueness, difference, and even destiny. Of course clinicians will make all manner of human perceptual errors, misattributions and the like. (see pp. 24-30, 'Impediments to learning from experience'); but a far superior way to respond to such shortcomings is surely to strive continuously to loosen and deconstruct one's assumptions and associated practices, than it is to throw out the 'baby' of individualised treatment with the 'bathwater' of the occasional errors it makes – or far worse, replace it with the technocratic positivism of CTM-informed clinical practice. Yet despite this core shortcoming, there is also much of interest to commend this book. Not least, there are extremely interesting chapters on psychotherapy research (like the book as a whole, insightful and authoritative in places, narrowly empiricist in others – Garske and Anderson, Chapter 6); so-called 'New Age' therapies (though this is a dangerous label to invoke, with its arguably pejorative, dismissive overtones – Singer and Nievod, Chapter 7); conventional vs herbal treatments for depression (with a very interesting discussion of 'non-specific' placebo effects, and with evidence that conventional medication is far less effective in the treatment of depression than is often believed – Walach and Kirsch, Chapter 11); the self-help therapy phenomenon (Rosen et al., Chapter 14); and an excellent and enlightening discussion of the commercialisation of mental health issues (including the televisual advice industry – Oprah et al. – and advertising and entertainment; Wilson, Chapter 15). In a wide-ranging and insightful critique, Nona Wilson soberly concludes that 'the commercialised advice industry becomes a tool for discouraging real change or enhanced psychological understanding by inculcating mainstream values and perspectives … [C]ommercialised mental health products and services… actually promote conventional wisdom – only repackaged to sound new and improved' (pp. 440-1).

The book unfortunately barely touches on the question of the extent to which it is valid to criticise psychotherapy from the epistemological position of positivistic science when major swathes of the former do not even pretend or aspire to positivistic criteria of 'scientificity' (e.g. the existential therapies, and hermeneutics and meaning-making foci, as opposed to empirically controllable technocratic outcomes). This issue is touched upon in the Foreword, where Michael Nash is quoted as saying that 'therapists are right when they say that research can't help individuals learn to live with suffering, resolve moral dilemmas, or make sense of their lives' (p. xvii). In other words, (meaning-making) psychotherapy and (medical-model) clinical psychology are arguably quite different activities – and their very incommensurability surely makes it a very dubious undertaking indeed to attempt to assert the superiority of one over the other, as this book repeatedly attempts to do. The really interesting question then becomes where and how we draw the line between the two, both for practitioners themselves and for the clientele with which they work. Certainly, and as I hope to have shown, it is a highly partial (and unscientific!) standpoint to uncritically assume that adherence to the totem of empirical science and CTM methodology constitutes the most effective stance for practitioners to adopt, and to which they should all unquestioningly aspire. Certainly, the sad (some might say scandalous) litany of casualties who have suffered at the hands of the conventional ('scientific') psychiatry system, steeped as it is in the materialistic medical model (e.g. Johnstone, 1989), offers ample evidence that such uncritical adherence to empirical science is, to say the least, highly problematic. There is also, at times, ill-disguised contempt for a person-centred approach to medicine and psychological help - sacrificed again to the totem of 'objective' empirical science. Thus, we read of the desirability of 'overcom[ing] the uncritical acceptance of treatments that merely [! – RH] "feel" right or reflect little more [!] than clinical tradition' (p. 295 – as if the letter were essentially worthless in comparison with CTM); and later, that 'when people seek help they are predisposed to believe in it… - [which can] render testimonials largely useless as dispositive evidence' (p. 440). In conclusion, this is an impressive book overflowing with interesting discussions, but considerably limited by its narrow empiricist conception of what constitutes valid 'science' in clinical psychology. Not least, it implicitly assumes that the perceptual and experiential information available to the conventional senses (the data of positivism) is all there is. Yet if psychodynamic and spiritual/transpersonal factors (typically unobservable in the normal sense – and certainly unobservable in this book!) do indeed exist, possess their own efficacy, and play a significant or even decisive role in human behaviour and experience, then methodologies and practices informed by an arguably superficial positivist world-view will be wholly inadequate – with profound implications in turn for what scientifically informed clinical practices might therefore be missing (House, 2001). Notwithstanding this fundamental limitation, anyone working in the mental health field will find much in this book to inform, stimulate and provoke.