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Do therapists know what they're doing? Don't bank on it, 3 psychologists say

October 8, 2009 |  6:10 pm

When we're battling psychological problems and go see a therapist for treatment, we tend to trust that it's doing us good. But should we?

Not according to three clinical psychologists who have written a 145-page document for the November issue of the journal Psychological Science in the Public Interest. The three authors contend that far too many therapists are poorly trained and using outdated or unproven methods--while neglecting to use ones that actually work.

Timothy Baker, Richard McFall and Varda Shoham say that a lack of science-based training in many programs is the problem. They fault some PsyD programs and for-profit training centers especially. And they're calling for a reform of clinical psychology training programs and an overhauled accreditation system to deal with the issue. (Such a system is already under development.)

As an example of what they mean, Baker, McFall and Shoham note that only 30% of therapists are trained in cognitive behavioral therapy approaches for treating post traumatic stress disorder--even though this mode of treatment has been shown in studies to be the most useful treatment for such patients. And, further, only half of those who are trained in the method use it for these patients.

You can read the whole report here. And here's a Newsweek article you might want to check out, Ignoring the Evidence (by Sharon Begley).

The report--yes, it's long!--makes an interesting and not-very-flattering comparison between the state of general medicine in the early 1900s, before it began to move toward more science-based practice, and today's practice of psychology.

The authors say such reform is more important now than ever, given the increasing number of people diagnosed with mental disorders. And they say that increased health costs have both exacerbated the problem--by shunting more treatment away from trained psychologists toward general medical health settings--but also make it more important that effective treatments are chosen.

In an accompanying editorial, Columbia University psychologist Walter Mischel calls the report's analysis and call to action "long overdue" and one that "will be welcomed by those who grieve the widening gulf between clinical practice and scientific progress in psychology."

Mischel also quotes the late psychologist Paul Meehl as noting "that most clinical psychologists select their methods like kids make choices in a candy store: They look around, maybe sample a bit, and choose what they like, whatever feels good to them. For many of us who initially became clinical psychologists because we were inspired by the scientist-practitioner ideal, Meehl’s comment was as heartbreaking as it was accurate."

-- Rosie Mestel
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Comments (16)

I agree all PsyD should be trained in scientifically sound treatments. But to limit them in practice to those treatments would be disasterous. Look at the mountains of (expensive) research required to document even one form of therapy and tell me how new and innovative approaches will be implemented quickly. Talk about taking it back to the dark ages....

It is not that therapists ignore what is being called scientific evidence, but, methods like cognitive behavioral therapy are being rejected as superficial and false. Psychodyamic psychotherapy or Existential psychotherapy do not lend themselves to the so called scientific method that modern clinical psychology expounds as fool proof. However, with further research, using fMRI changes in the brain, I believe that psychoanaytic and psychodynamic methods will re emerge as the methods that bring about lasting change.

CBT is the creature of insurance companies who want short term psychotherapy because they prefer to not pay the costs of real and deep psychotherapy.

I recommend to readers most or all of the books written by Dr. Irvin Yalom, MD and psycniatrist, for his views on this issue.

In anticipation of the slew of flames soon to follow, one should concede three points in favor of the programs being criticized by the science movement, which I thoroughly support.

First, empirically supported approaches may include creatively developed treatments that are closely and rigorously monitored by therapists who are well trained to do such things. But when I say closely and rigorously, I refer to more systematic and quantitative measurement than is usually the case. Studies show that clinicians are not nearly as good as they claim to be at noticing and integrating the stream of conflicting data points coming from their clients.

Second, scientifically based programs can be fairly faulted for creating systems that have not helped people wanting purely clinical careers get into practice. In the current system, you essentially have to start graduate school wanting to be a researcher if you want to get into a top clinical psychology research oriented program. Research suggests that clients stay longer in treatment when they have more highly trained therapists (doctorally trained over Master's level), so there may be a valued place for the scientifically skillful practitioner. It is conceivable that a system whereby the general public could easily recognize the very best trained and most helpful practitioners would lead to better care for the public and better incentives for all practitioners to improve. We should not give up on a meritocracy, but this would require a training system that applauds public interest oriented clinical ambitions of skillful research students. Such is not generally the case: top programs tend to prefer that their graduates become academics. Who should the best practitioners be then?

Third, scientifically based programs, which typically fund their students through research grants, are extremely selective in admissions. By taking only those students with top honors and GRE scores, groups historically marginalized by our educational and testing system have not had adequate access to training.

The last two problems provided much of the impetus for founding the professional school movement, along with a shortage of therapists during the 1970's. We need to address the flaws that made the for-profit institute Psy.D. an attractive option initially.

Let me also say that I am appalled by the current state of the field, by the sorry state of practice (as I hear it from my patients and friends and see it on the internet), and by economic forces (a glut of practitioners) tending to distort clinical decision making out of a need to make enough money to keep the practice open. The same is true in medicine generally. For-profit healthcare may prove to be the most costly problem of all.

I applaud the authors of the articles for calling public attention to this shameful situation. Both sides need greater accountability and public scrutiny. The issue is extremely complex. But we must find ways to have a highly skilled and talented psychotherapy workforce, trusted by the general public, and meriting that trust to a greater degree than at present.


Robert Gore, Ph.D.
Los Angeles

I read the journal article. The authors conveniently ignored research supporting types of therapy they don't like. They have an ax to grind, and nothing else matters. A number of psychologists have decided that the only "evidence-based" treatments are the ones that can be done quickly and are readily publishable, thus advancing the academic careers of their authors. As a result, what appears to be an honorable attempt to stomp out unproven (in their eyes) treatments is actually a form of careerism.

As a psychologist with decades of treatment experience and a good background in research practice I know that those who are accepted into trials of any particular treatment are but a tiny percentage of patients who come in for treatment. The more complicated patients are not accepted into the trials. And science teaches us that results of a study are only correct for the same type of person who was a subject in the study and can only be generalized so far. Therefore, because of their unique humanity, most patients present with multiple problems that intertwine and invariably complicate each other in ways that make the touted evidence based protocols ineffective and therefore inappropriate.

Just as any particular FDA approved medication for a physical condition might not be right for certain patients because of complicating problems, so it is with psychological problems. The main difference between complicating physical and psychological conditions is that the physical ones are often already known. With psychological problems, complicating conditions are often hidden under the presenting problem. That is where personal experience trumps scientific evidence as "scientific" evidence is for someone who might initially present like the patient but who is really not like the patient at all. This is where the "1000s of therapies" comes from as each patient is different and therefore needs at least a little different type of treatment. Oft times the appropriate treatment is very different.

And it is here that scientists routinely fail clinicians. Research is presented as being the only way to treat while those of us in the trenches know that the vast majority of times it is an inappropriate and therefore unethical treatment for the person sitting across from us. So while researchers bask in their successful research for treating a simple condition we struggle with treating the complex human psyche.

I like how the organization is discriminating against Psy.D. programs by excluding them from the certfication process. If they were really interested in actually completing their mission instead of excluding Psy.D programs they should include them. How many PhD's actually go into any type of practice versus taking a position in academia? I am from Southern West Virginia and they have a tremendous need for doctorally trained psychologists however not one PhD is to be found because of the very low salaries. I welcome all PhD's in cyber space to come and practice down there. It is appalling to blame professional schools of psychology for something an individual does or does not do properly. Yet it is appropriate to say that we all make mistakes therefore we all share in the problem and all of us should be working together for a solution. For all those worried about professional programs pumping out gads of psychologist and supposedly "saturating" the market this is simply not the case. When soldiers start withdrawing permanetly from Iraq there will be a great and immediate need for theraputic services for years to come.

Mental illness in the 21 century is not accurately depicted by laymen who have casually continued using the term for several hundred years. We will continue to use the word "mental" indiscriminately although if you were to ask the man in the street to offer a proper definition, it would be problematic due to the metaphorical properties of "mental or maybe "mind". Accuracy to the the letter is "brain disease", obviously too difficult to wrench into the vernacular. To wit it is a convoluted or chemical imbalance within the brain that causes the garden variety diseases. We are at a point in the mental health system where talk is cheap and chemical management is the way for most patients to go. It is 2009 and a cure not semantic but actual is near.

Scientific standards - Thank god.

I just got lectured at by a "Depth Psychology" PsyD student at a party - some self-proclaimed stripe of Jungian... who was shockingly anti-science. ("you are whatever you believe you are"... dream interpretation, bla bla bla...) He seemed to forget that Jung's theories were just that - mere theories, and pre-scientific at that. We know a lot more about how the brain actually works these days than Jung (or Freud for that matter) ever did. Hormones, serotonin, etc etc ...

Of course, my own personal lecturer was going to an unaccredited school, and was quite sensitive about that. He felt he could just think whatever he liked and sit for the professional exam to practice in CA - and he can, too! I find that really shocking.

Those poor future PTSD clients of his - destined to pay $75 / hour to talk about their dreams, with no real progress on their trauma. Sad.

Allan N. Schwartz said:

"CBT is the creature of insurance companies who want short term psychotherapy because they prefer to not pay the costs of real and deep psychotherapy."

Says you?

That's ridiculous. CBT works - for what it claims to help. In case you're wondering, the studies showing this are scientifically reproducible. How many other therapies have consistently reproducible results? Not too many.

CBT is not the only therapy for every problem, but to call it "the creature of insurance companies" is really irresponsible, not to mention completely untrue and unfounded.

If anything, I have noticed a number of former CBT practitioners switching to Freudian psychotherapy - why? Because it never ends! They have that poor client forever, dissecting the minutiae of their every childhood woe, ad infinitum! Now THAT's good business!

Robert Gore said:

"... scientifically based programs, ... are extremely selective in admissions. By taking only those students with top honors and GRE scores, groups historically marginalized by our educational and testing system have not had adequate access to training.

[...supposedly accounting for a] shortage of therapists during the 1970's. We need to address the flaws that made the for-profit institute Psy.D. an attractive option initially. "

I have to say, my concern is for quality healthcare FIRST - imagine if medical schools were more concerned with providing greater access to "groups historically marginalized by our educational and testing system," than by providing the highest quality doctors?

Who needs mediocre (or worse) psychologists?

Me, I want the smartest, most perceptive professionals I can afford, whether MD or PhD. I want results as quickly as is feasibly possible, so I can get the most out of life, as positively as possible. Who wants less than that?

I personally know quite a few "graduates" of these almost self-accredited Psy schools - they are NO intellectuals, let alone health care practitioners, in my opinion. This in itself is tragic. They are not only not helping their clients - they are actually hurting them. It's the misguided leading the truly lost and floundering. Some of these Psy schools are even linked to purported cults (the "University" of Santa Monica comes to mind.)

Standards, please. Not every client knows what to look for, and they are coming in already wounded.

Granted, rigid standardized constructs advanced by Insurers and misguided administrators are a detriment to scientific method and it's advancement. The point to be stressed in this important work is that the mental processes of clinical psychologists and all competent healers should be instilled with caring rational scientific logic. The retreat to unreliable empiricism or feelgood "homecooked" psychotherapy is antiquated and dangerous. Advancement to a higher level of science based reasoning and proof is critically needed. Far too much gender bias (Ref:evolutionary psychology's critique by DJBuller), faith-based ideology and magical thinking are unhealthy and much too widespread today. The most malignant area of Psychotherapy's manipulation is in the Legal/Justice System. It would not be too great of a reach to state:
The greatest hazard to the public health of Americans is the US Legal System.
Training of Psychologists in a rigorous program of scientific logic is past due.

Why would they bother to find something that works? They can just mandate their clients convert to the 12-Step Religious Cult, and when things don't get better blame their clients for "Not following the Steps" and wipe their hands clean of any responsibility! That'll be $75 Bucks!

WOW-
I am a licensed marriage and family therapist working at a non profit with chronically mentally ill adults. I have my MS from Cal state Northridge and is was a HORRIBLE program. It needs to be completely over-hauled and science implemented.
I see so many variables in a person’s mental health it is astounding how a study of any pure diagnosis could be sampled. I rarely see it.
Example- A true Bipolar with the mania for four days and then depression that is serious for a week or so; on top of that can be Borderline or Paranoid personality disorder. If the person is not labile, is it over medication that solved for both disorders? If the person is still labile are they on the wrong medication? I see clients go through medication changes on an ongoing basis. Some are fine for years, some take months to find the right mix, and some medications stop working for some clients. If they have PTSD from a car accident they did not divulge? Has it made their Bipolar more intense?
I mostly use cognitive behavioral because it works for the hundreds of clients I have who lack insight. I try to use psychodynamic and cog/beh with my insightful clients. It is quite a dance I do in my work.
As for private practice, much depends on the report you have with the client. I have seen many, many therapists keep clients dependent for the money. Buyer beware. I have seen it in psychiatrists as well.
Therapist are people and can be as or more abusive than any lover you have. I suggest shopping around and taking breaks to reflect. If you have suspicions, talk to trusted friends. If you are personality disordered, go to someone who knows how to use dialectic. Personality disorders are at great vulnerability due to a lack of seeing the forest for the trees-so to speak. Therapists do try to avoid personality disorders as they lack insight. It is a very hard relationship, to say the least.

As a mother of 3 adopted children who has been trying and trying to get good help for them and have failed because there is no good help out there OR they want my child to help THEM get experience in the field, I agree that therapist don't know what they are doing. When an 8 year old can manipulate grown adults in this field, something is wrong. Say all you want but if some of the neglected and abuse children in this country got some actual help, we might not see as many of the pedophiles you see today. Instead you write them off and use them for your own education.

I think it's strange that the LA Times put "3 psychologists say" as part of the title to this article. Ummm....there are many more psychologists who are aware of the travesties of clinical psychology. And most of it isn't even the clinician's fault. Most of it stems from the fact that human behavior is nearly impossible to predict or diagnose. One issue is that things, such as depression, have a cyclic nature. That is, when it gets bad the client goes to see the doctor, then it gets better and would have independently of the treatment. One thing that is the clinician's fault is that they refuse to use decision aids when making diagnoses, that is a tragedy. It has been shown that they have an interater reliability and intrarater reliability at chance (50%), whereas a decision aid is 100% reliable.

I cant say I'm surprised. I've been to 5 psychologists now and they are all useless and stupid. whether its there practices or that there just stupid i don't really care.


These people are "operating" on peoples minds here, and they have no idea what there doing. they might aswell be trying to fix a broken leg with a sewing needle and a yarn of wool.

Now. i know I'm probably going to get alot of backlash, but I've done my homework, which is more then i can say for psychologists.

I could give you 100 reasons why they don't know what there doing; aka being stupid, but i doubt everyone here really cares. so ill keep it short and sweet for you.


Look at early medicine in 1900s. Look at psychology now as stated above.

If you believe that these people; that are barely more educated about the mind then children - risk it with YOUR OWN HEAD.

Long Story short:
If you where afraid of the dentist. Don't be, be afraid of psychologists =)



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