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As psychotherapy turns the corner on its first century, it's being asked to ante up in the serious game of science. After ten decades of extraordinary (and often contradictory) claims and complicated theorizing, the profession is being challenged to show its cards. And from what we've seen so far, according to this book, psychotherapists may have only been holding a pair of deuces. Some fear that we may have been bluffing all along.
Among those demanding hard, empircal evidence of effectiveness is a small but growing cadre of mental health professionals, including the author of this book. Eisner is a practicing attorney (Los Angeles) as well as a licensed psychologist.
After a brief introductory chapter on the shortcomings of behavioral research and why the scientific method is usually ignored, Eisner plows right on into a variety of psychotherapeutic theories and approaches. The Freudian school is first to be taken to task. Eisner provides a thumbnail overview of the theory and then deconstructs three of Freud's most famous cases, those of Dora, the Rat-Man, and the Wolf-Man. Although admittedly superficial, Eisner's critiques are direct and effective, and suggest just how silly a theorist can get when he or she feels relatively safe as a pioneer in a new field. However, the most telling blow that Eisner gives to the psychoanalytic world is the exposure of an almost unbelievable absence of empirically based research. Although Freud considered himself a scientist, his method was anything but scientific, Eisner claims. Because his studies were single-case and naturalistic (so to speak), they were neither replicable nor disprovable, two of the cornerstones of the scientific method. Further, according to Eisner, no psychoanalytic research since Freud has provided evidence of value or validation. He claims that psychoanalysis "may be one of the greatest scientific hoaxes of the twentieth century" (p. 40).
Next in line, because (as he states) they are direct descendants of Freudian psychoanalysis, Eisner considers the "cathartic therapies," which include primal scream therapy, est, and bioenergetics. These, of course, make easy targets both because of their problematic theoretical underpinnings and because of an absolute lack of credible evidence for their effectiveness.
Another group of treatment modalities that lacks validation are those that Eisner terms recovered memory therapies. These approaches are also considered spin-offs of Freudian theory, because they emphasize repression, the unconscious, and forgotten traumas. The therapist's uncovering methods include hypnosis, dream interpretation, and occasionally the use of hypnotic medications such as sodium amytal.
The humanistic movement, beginning in the 1950s, fares only little better in the author's estimation. On one hand, unlike most other forms of psychotherapy, Eisner reports, at least this style has made gestures toward research. But unfortunately, the research has not generally supported Carl Rogers' belief in the therapeutic effectiveness of the basic qualities of empathy, unconditional positive regard, and genuineness. In addition, there are perhaps insurmountable difficulties in even operationalizing these concepts to make them amenable to empirical research. And finally, the classic meta-analysis of Smith and Glass found, according to Eisner, no measurable difference in outcome between Rogers' person-centered therapy and placebo treatment.
In the category of behavioral and cognitive therapies Eisner includes systematic desensitization, implosion therapy and Eye Movement Desensitization Reprocessing (EMDR), as well as the more widely known cognitive behavioral therapies of Ellis and Beck. Eisner considers each approach separately, however. He notes that at least one study has found systematic desensitization to be more effective in treating social phobia (public speaking) than both psychodynamic psychotherapy and a placebo control group, although generalizations of benefits to other client groups has not yet been shown. His brief overview of EMDR references three studies, which Eisner explains are only illustrative of methodological points. (The actual points being illustrated were unclear to me.) However, he concludes that it is "abundantly clear [that] EMDR does not require eye movements in order to be effective" (p. 126). As for Ellis' Rational Emotive Therapy (now known as Rational Emotive Behavior Therapy), Beck's Cognitive Behavior Therapy (CBT), and Interpersonal Psychotherapy (IPT), Eisner concludes that treatment effectiveness has not been demonstrated. He reports on a study that compared IPT and CBT with a medication group and a placebo control group. All four groups showed client-reported improvements - - unfortunately, Eisner notes, "There appears to be little, if any, clinical significance [in outcome] between the active treatment and the so-called placebo group" (p. 138).
Somewhat curiously, paired together in one chapter are reviews of the Strategic Therapy of Jay Haley and the Neurolinguistic Programming (NLP) approach started by Bandler and Grinder. About the former Eisner writes, "the most obvious shortcoming . . . is that no scientific confirmation exists" (p. 152). To the latter Eisner gives similarly short shrift: "Virtually no clinical support has been presented for the effectiveness of NLP" (p.158).
While most psychotherapists would find them strange bedfellows indeed, Eisner includes in this book past-lives therapy, de-possession techniques, appeals to angels and spirit guides, "Buddha Psychotherapy," Thought Field Therapy, Palm Therapy, and (no kidding) Alien Abduction Therapy. It is probably unnecessary to note that these approaches have not been seriously subjected to scientific inquiry.
In his concluding chapter, Eisner restates his central thesis: "[P]sychotherapy in its present form will not survive as a viable and reliable form of assistance to people with emotional problems. . . . The most fundamental symptom [of its pending death] is the total lack of adequate scientific evidence that it is effective" (p. 205).
The strength of this book is its clear and direct assessment of the credibility of the various approaches to psychotherapy. The reader - - especially if he or she has strong theoretical affiliations - - may not agree with Eisner's assessments, but would agree at least that Eisner is a devil's advocate for thinking about how one's own approach could be justified. The reader-therapist must ask him or herself, What's the rationale for my belief X, and my use of interventions Y and Z? What's the empirical support for my theory about psychotherapy?
The major hurdle over which the reader has to jump is Eisner's relative lack of distinction between mainstream approaches and far-end-of-the-galaxy theories involving space aliens and angels. Just because various theories share the characteristic of having little (or no) empirical support, the scientist should not necessarily conclude that they are equally suspect. Even the best scientists, working in areas of "hard" science, when faced with lack of empirical data, are forced to choose for their studies the most likely from among a group of similarly unproven hypotheses. The techniques used in this selection are experience, logic, and reasoning, tempered by intuition (yes, I know) and attempts to moderate personal biases.
A second and simpler reason for skepticism about the claim that psychotherapy is dead (or at least mortally wounded) is that there is no sign that its vital energy (i.e., economic foundation) is in any way waning. Graduate schools continue to produce large numbers of new therapists, and even this number isn't enough to satisfy demand. For example, California has recently passed into law a bill requiring a study of the shortage of mental health professionals with an eye to increasing the number available for public hire. One of the nations largest HMO's, Kaiser-Permanente, has standing advertisements for positions in social work and psychology.
In any case, while its conclusion that psychotherapy is dead may be premature, this book is important as a wake-up call to the profession - - Do the research! It wasn't so long ago that the medical sciences were in the same unhappy circumstance that psychotherapy is in today. The knowledge and technologies needed to design and carry out empirical studies were extremely limited. Snake oil salespersons competed with quacks and spiritualists for the consumer's dollars. Medicine didn't give up, and psychotherapy shouldn't either.Keith Harris, PhD, is a clinical psychologist and supervisor of Victor Valley Behavioral Health Center in San Bernardino county, California. Hisinterests include clinical supervision, the empirical basis forpsychotherapy research (and its design), human decision-making processes,and the shaping of human nature by evolutionary forces.