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Science and Pseudoscience in Clinical PsychologyReview - Science and Pseudoscience in Clinical Psychology
Second Edition
by Scott O. Lilienfeld, Steven Jay Lynn, Jeffrey M. Lohr (Editors)
Guilford Press, 2014
Review by Maura Pilotti
Jul 7th 2015 (Volume 19, Issue 28)

The main purpose of Science and Pseudoscience in Clinical Psychology (second edition) is to illustrate that knowledge and use of the scientific method by practitioners in the field of mental health can be advantageous to both the recipients of services and those who deliver them.  In fact, as the editors and contributors of the book remark, the gap between research in mental health and clinical practice, which has grown to a worrisome size, not only weakens the foundation of the field of mental health, but also can harm consumers and practitioners alike.  Imagine a person who seeks relief from a specific form of distress.  A clinician's use of assessment tools that have inadequate validity and reliability and his/her administration of an ineffective treatment are likely to deprive the client/patient of the opportunity to get better and represent a superfluous use of his/her time and financial resources.  As time passes by, the clinician who relies on questionable assessment tools and ineffective treatments can be similarly damaged.  In fact, he/she is likely to be recognized by a growing number of people as unsuccessful or even as a fraud.

Although adverse consequences exist for both clinicians and patients, it is undeniable that the question of whether assessment tools indeed measure what they are purported to measure effectively and consistently has yet to be answered for a large number of tests.  It is also undeniable that the question of whether psychotherapy works is even more difficult to answer.  If the tools used for assessment are questionable, it follows that the 'data' collected and utilized to develop diagnoses cannot be trusted as 'empirical evidence'.  Yet, too often, trust in diagnoses is based on consensus of mental health professionals, and belief in the probative value of tests is based on limited and inadequate normative evidence.  Concerns regarding the scientific foundations of clinical assessment add to those pertaining to measurement of the effectiveness of psychotherapy.  For instance, can effectiveness be measured by the clinician's own opinion about the client's progress? Can it be measured by the extent to which the client's behavior and self-reported feelings and thoughts have changed? Can it be measured by the extent to which people who constitute the client's entourage (e.g., friends, family members, coworkers, etc.) report that an improvement has occurred? Albeit all questions are challenging, clinical scientists have been at work to answer them.  For instance, evidence-based guidelines, which are open to critical examination, exist regarding the effectiveness of different types of psychotherapies for specific forms of 'abnormal functioning'. 

The authors of Science and pseudoscience in clinical psychology recognize that often science remains removed from the day-to-day operations of clinical practice.  The scientific endeavor, they admit, is a lesson of humility, curiosity, and tolerance for uncertainty.  They subscribe to these basic properties of data collection and interpretation and advocate their application to clinical settings.  These properties, they note, differentiate science from pseudoscience.  The latter refers to activities that are intended to confirm existing beliefs and offer certainties.  Overall, the contributors of the book advocate a considerable reversal of the modus operandi of many clinicians and of the content of clinical training.  They envision clinicians who are educated consumers of psychological assessment and intervention tools.  The goal is to ensure that clinicians can critically and objectively evaluate the purported effectiveness of psychological tools, including their validity and reliability, and can consequently identify those that can be used to assess clients' mental status and determine suitable treatments.

Assessment based on reliable and valid tests and evidence-based selection of therapeutic interventions are reasonable aims, but often difficult to convey to and be accepted by clinicians whose training has not necessarily promoted the understanding of the scientific method and its application to clinical practice.  Currently, mental health professionals remain unfairly split into two qualitatively different groups, each representing a distinct career path: (1) clinical scientists who systematically collect information about behavior, thought, and affect with the goal of describing, predicting and explaining 'abnormal patterns of functioning'; and (2) clinical practitioners whose role is to detect, assess and treat 'abnormal patterns of functioning'.  Can the clinical practitioner integrate the role of clinical scientist in his/her practice if graduate-level training is changed to emphasize the application of scientific principles?  The scientific method endorses an empirical, evidence-based approach rather than an approach based on intuition.  As a result, measurement of behavioral and cognitive events is to be reliable and valid, assumptions are to be testable, and the attitude of the mental health professional towards data collection and interpretation is to be skeptical and focused on ensuring objectivity. 

Ultimately, the goals of scientists and practitioners converge.  For clinical scientists, explanation of mental disorders is the fundamental target as it permits the development of treatment interventions that tackle the cause(s) of a given 'abnormality'.  For clinical practitioners, knowledge of the causes of mental disorders and effective treatments makes them successful in their practice.  Yet, more ground is to be covered before the exercise of science is rightly acknowledged in everyday practice.  Current and anticipated changes to graduate-level curricula preparing students for mental health professions are encouraging steps toward making the scientific approach an integral aspect of the practitioner's training and hopefully of the exercise of the profession for years to come.  Yet, for real and substantial changes to occur, national and regional professional associations need to be heavily involved not only in promoting science (as a general ingredient of clinical practice), but also in identifying assessment tools and treatment interventions with little or no empirical support. Ultimately, the goal is to discourage practitioners from relying on such tools and interventions.  In theory, changes have already been made as illustrated by the code of ethics of the American Psychological Association, which already recognizes as misconduct practitioners' reliance on unsubstantiated diagnostic tools and interventions.  In the reality of everyday clinical practice, a matter of debate is the extent to which lack of adequate training and resistance to evidence-based practice are hindering progress.  Particularly troublesome are the results of surveys of mental health professionals which highlight doubts in evidence-based practice and beliefs in the virtues of clinical intuitions.

 Of course, it is important to remind ourselves that the guidelines used by practitioners to identify 'abnormal patterns of functioning' are also controversial and that competing guidelines exist.  For instance, the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association competes with the International Classification of Disorders (ICD) and the Research Domain Criteria (RDoC).  Although popular in North America, each edition of the DSM has been characterized by an incremental number of available diagnoses, from 128 present in the first edition of the manual (DSM-I) to 541 present in the last edition (DSM-5), thereby begging the question of whether changes reflect increased accuracy or diagnostic inflation.  As the Chair of the DSM-IV Task Force, Allen Frances, stated "the boundary of psychiatry keeps on expanding; the realm of normal is shrinking".  Not surprisingly, the increased number of diagnostic categories has not quelled questions that have plagued the identification of varied forms of abnormal functioning: What is abnormal? To what extent can diagnoses and related labels cause harm?  Although Science and pseudoscience in clinical psychology explicitly focuses on assessment and intervention practices, the underlying theme of what constitutes mental illness is palpable.

In summation, Science and pseudoscience in clinical psychology exposes the reader to key issues of an expanding mental health machinery, offering both keen critical examinations and viable solutions.  The text is a must read for students and professionals in the field of mental health and for laypersons who aspire to become educated consumers of services.  Its content is filled with data and thus represents a helpful starting point for any person who is interested in understanding the difference between mental health practices driven by science and those that rely on pseudoscience (e.g., intuition-based, uncritical, and accepting ).  The text also offers not only an illustration of pseudoscientific practices, but also advice and guidance on available remedies.  The path to follow has been drawn by the authors of this book and contributors of reputable clinical journals (see Clinical psychological science).  Will the clinicians pick up the ball and run with it?

 

© 2015 Maura Pilotti

 

Maura Pilotti, Ph.D., Ashford University

 


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