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Licensure and Legitimacy: Are They One in the Same?

December 24, 2010

The mental health profession is at a crossroads.

On one side and moving in one direction are the mental health professionals who keep up with the latest published literature in their areas and have practices that are informed by evidence. On the other side, moving in the opposite direction and doing business as usual are mental health professionals who make their decisions based, not on evidence, but rather on authority, personal/clinical experience, anecdotes, testimonials and intuition.

If a mental health professional is not keeping up with the latest evidence and is not paying attention as to whether the interventions they are choosing have evidence to support their safety and efficacy, then decisions are being based upon something else, most commonly, according to a number of published surveys of mental health professionals of all stripes,  including my own on LCSWs and others on psychologists, their clinical experience. These studies showed that clinicians tend to value personal experience over research-based evidence. Why is this unwise? The late Robyn Dawes explained this quite well in his book, House of Cards as did the late psychologist Paul Meehl in a number of his writings, including his classic, Why I do Not Attend Case Conferences. People can read detailed explanations in these works and also in Lilienfeld, Lynn & Lohr’s Science and Pseudoscience in Clinical Psychology.  What it comes down to is that human beings, including human beings who are licensed mental health professionals are subject to common human biases that cannot be avoided. Holding a license does not make one immune to such biases. Once we form a belief, we tend to engage in confirmation bias, interpreting our experience to fit those biases and explaining away any experiences that tend to contradict those. There are many other biases as well, too numerous to mention here but can be read about in the above-referenced works. Well designed studies, independently replicated by people with no vested interest in a particular treatment, while not perfect, are the antidote to such biases as they are designed to control for them.

Dawes stated “Licensing doesn’t work to protect anyone except the licensed” (p. 179, House of Cards) and makes a well-argued case for this statement in his chapter on licensing.

While there are cases where licensed mental health professionals are held accountable and disciplined by their boards, these cases appear to be the exception rather than the rule. People who have filed complaints with state licensing boards know how difficult it is to make a complaint stick. I say this because study after study of licensed mental health professionals has shown that a good percentage of them, not only undervalue research but also are using interventions that have very little research support and some that may even be classified as potentially harmful and these are all too often, licensed mental health professionals who are in good standing with their boards. It is quite possible that the people on the boards themselves may be guilty of this, which means that in some cases the proverbial fox may be guarding the chicken coop.

One recent survey of PsyD programs and Masters in Social Work (MSW) programs (Weissman et al 2006) showed that 67.3% of the PsyD programs and 61.3% of the MSW programs did not requite a didactic and a clinical supervision in any EBT (evidence-based therapy) — not even one evidence based therapy was required. This is important, especially since PsyDs graduate programs tend to have much higher acceptance rates into programs than PhD programs (which tend to be more research oriented, even the clin psych ones) and this is also the case for MSW programs. What this means is that the vast majority of clinicians who are out there in the trenches, working with clients are PsyDs, MSWs, and other masters-level licensed people such as LMFTs and many have come from programs that have left them ill-equipped to base their practices on evidence.

Can such mental health professionals who may be using unsupported and potentially harmful therapies be considered legitimate? That is highly debatable, in my opinion.  It may depend on which meaning of the term, legitimate one is intending to use. The word “legitimate” has several meanings:

1. Being in compliance with the law; lawful: a legitimate business.
2. Being in accordance with established or accepted patterns and standards: legitimate advertising practices.
3. Based on logical reasoning; reasonable: a legitimate solution to the problem.
4. Authentic; genuine: a legitimate complaint.
5. Born of legally married parents: legitimate issue.
6. Of, relating to, or ruling by hereditary right: a legitimate monarch.
7. Of or relating to drama of high professional quality that excludes burlesque, vaudeville, and some forms of musical comedy: the legitimate theater.

The first definition refers to legality, so yes, according to that definition a licensed mental health professional in good standing with his or her board is “legitimate”. However, the second and third definitions are left open to interpretation where there could be vast differences of opinion, depending upon what one considers to be established and accepted patterns. This strikes at the heart of the current ongoing controversy within the mental health profession. For some mental health professionals, established and accepted is an authority, tradition-based notion. If the practice is endorsed by enough authorities and has been around long enough, it is legitimate. Others, however, would disagree and would argue that evidence-based or evidence-informed practice, for the good of the clients, is the standard for accepted practice.

The reason for this is that, as Robyn Dawes pointed out, if we examine the history of the mental health profession, all too often so-called experts have been found to have promoted and endorsed practices that turned out to be very harmful.  One example is the use of anatomically correct dolls (dolls that have the male and female genitalia) to assess children to determine whether they have been sexually abused. The use of these dolls, by so-called “experts” who were licensed mental health professionals in good standing and considered to be experts, nonetheless, led to the false arrests and conviction of a number of people who were later shown to be innocent in the 1990s. For example (and this is just one of many illustrations), one woman, teacher Kelly Michaels, spent over 5 years in prison based on false accusations that arose from that method. She was accused of practices with the children in her care that were preposterous, as they were physically impossible. For example, one of the things she was accused of was bringing giraffes into the school to have sex with the children and yet it was physically impossible to fit a giraffe into the space they were in and she was accused of all kinds of other things she would not have been able to accomplish by herself. Yet thanks to the blind reliance on so-called experts who were preforming assessments that had no basis in evidence, great harm was done, not only to Ms. Michaels but also consider the impact this had on the children who were led into making false reports by the “experts”. This is just one of many illustrations (an illustration of evidence is not the same as an anecdote)  that shows what can happen when we put blind trust in “experts” rather than holding those so-called “experts” responsible to produce evidence for their position.

The court system has become very wise on this issue and in recent years in Federal courts and in a growing number of states, the Daubert Standard is in effect meaning that experts who testify as expert witnesses in court must be able to back their testimony up with actual evidence, not just generally accepted practices endorsed by authorities, as previous standards such as Frye required. This is definitely a step in the right direction, since Daubert, in essence, banishes authority-endorsed pseudoscience or junk science, from the courtroom in courts where it is in effect.

The results of numerous surveys of mental health professionals (I will provide some references below for those interested in looking these up) show that mental health professionals value clinical experience over research evidence and a good percentage are using practices that lack research support and in some cases are using interventions classified as potentially harmful. For example, in my own published survey of LCSWs, more than a quarter reported that they had used Critical Incident Stress Debriefing within the past year, an intervention that, according to Scott Lilienfeld, is classified as a potentially harmful therapy (PHT). Yet has a state board ever disciplined anyone for using this practice? Not as far as I know. Such mental health professionals are legitimate by the first definition, but not by the second and third definitions, in my opinion.

I wish all of you a very happy holidays and a healthy and happy new year where hopefully the mental health profession will move forward from practices based on authority to evidence, for the good of the clients, especially the ones who are not able to make decisions for themselves. Although the context is different, my philosophy in these matters can best be expressed by the following quote:

Here are some references for further study of this topic (do not be overwhelmed by the length of this list! This is only meant to give people an idea of some of the many studies and articles that exist on this topic):

Ball, S., Bachrach, K., DeCarlo, J., Farentinos, C., Keen, M., McSherry, T., et al. (2002). Characteristics, beliefs and practices of community clinicians trained to provide manual-guided therapy for substance abusers. Journal of Substance Abuse Treatment, 23, 309-318.

Bates, M. (2006). A critically reflective approach to evidence-based practice: A sample of school social workers. Canadian Social Work Review, 23, 95-109.

Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277-292.

Boisvert, C.M. & Faust, D. (2006). Practicing psychologists’ knowledge of general psychotherapy research findings: Implications for science-practice relations. Professional Psychology: Research and Practice, 37, 708-716.

Bunge, M. (1998). Philosophy of science: From problem to theory, Volume One (Revised Edition). New Brunswick, NJ: Transaction Publishers.

Cahill, S. P., Foa, E. B., Hembree, E. A., Marshall, R. D., & Nacash, N. (2006). Dissemination of exposure therapy in the treatment of posttraumatic stress disorder. Journal of Traumatic Stress, 19, 597-610.

Caldwell, K., Coleman, K., Copp, G., Bell, L., & Ghazi, F. (2007). Preparing for professional practice: How well does professional training equip health and social care practitioners to engage in evidence-based practice? Nurse Education Today, 27, 518-528.

Chambless, D. L., Baker, M.J., Baucom, D.H., Beutler, L.E., Calhoun, K.S., Crits-Christoph, P. et al. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.

Dawes, R. (1994). House of cards: Psychology and psychotherapy built on myth. New York: The Free Press.

Dawes, R. M., Faust, D. & Meehl, P. E. (1989). Clinical versus actuarial judgment. Science, 243, 1668-1674.

Gambrill, E. (1999). Evidence-based practice: An alternative to authority-based practice. Families in Society, 80, 341-350.

Gambrill, E. (2005). Critical thinking in clinical practice: Improving the quality of judgments and decisions (Second Edition). Hoboken, NJ: John Wiley & Sons.

Gambrill, E. (2006). Evidence-based practice and policy: Choices ahead. Research on Social Work Practice, 16, 338-357.

Gray, M. J., Elhai, J. D. & Schmidt, L. O. (2007). Trauma professionals’ attitudes toward and utilization of evidence-based practices. Behavior Modification, 31, 732-768.

Hartston, H. (2008). The state of psychotherapy in the United States. Journal of Psychotherapy Integration, 18, 87-102.

Hatfield, D. R., & Ogles, B. M. (2007). Why some clinicians use outcome measures and others do not. Administration and Policy in Mental Health and Mental Health Services Research, 34, 283-291.

Hays, K. A., Rardin, D. K., Jarvis, P. A., Taylor, N. M., Moorman, A. S., & Armstead, C. D. (2002). An exploratory survey on empirically supported treatments: Implications for internship training. Professional Psychology: Research and Practice, 33, 207-211.

Henderson, L. (2000). The knowledge and use of alternative therapeutic techniques by social work practitioners: A descriptive study. Social Work in Health Care, 30, 55-71.

Herbert, J. D. (2003b). The science and practice of empirically supported treatments. Behavior Modification, 27, 412-430.

Herbert, J. D. & Gaudiano, B. A. (2005). Moving from empirically supported treatment lists to practice guidelines in psychotherapy: The role of the placebo concept. Journal of Clinical Psychology, 61, 893-908.

Herbert, J. D., Lilienfeld, S. O., Lohr, J. M., Montgomery, R. W., O’Donohue, W. T., & Rosen, G. M., et al..(2000). Science and pseudoscience in the development of eye movement desensitization and reprocessing: Implications for clinical psychology. Clinical Psychology Review, 20, 945-971.

Howard, M. O., McMillen, C. J., & Pollio, D. E. (2003). Teaching evidence-based practice: Toward a new paradigm for social work education. Research on Social Work Practice, 13, 234-259.

Kazdin, A. (2008). Evidence-based treatment and practice. American Psychologist, 63, 146-159.

Klonsky, D. (2008). Website on research-supported psychological treatments. Retrieved June 14, 2008 from Society of Clinical Psychology American Association of Clinical Psychology, Division 12 site: http://www.psychology.sunysb.edu/eklonsky-/division12/ .

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.

Lilienfeld, S.O., Fowler, K.A., Lohr, J.M., & Lynn, S.J. (2005).  Pseudoscience, nonscience, and nonsense in clinical psychology: Dangers and remedies.  In R.H. Wright & N.A. Cummings (Eds.), Destructive trends in mental health: The well-intentioned path to harm (pp. 187-218). New York: Routledge.

Lilienfeld, S. O., Lohr, J. M., & Morier, D. (2001). The teaching of courses in the science and pseudoscience of psychology: Useful resources. Teaching of Psychology, 28, 182-191.

Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (2003). Science and pseudoscience in clinical psychology: Initial thoughts, reflections, and considerations. In S. O. Lilienfeld, S. J. Lynn & J. M. Lohr (Eds.), Science and pseudoscience in clinical psychology (pp. 1-14). New York: Guilford Press.

Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (2003b). Pseudoscience is alive and well. The Scientific Review of Mental Health Practice, 2, 107-110.

Meinert, R.  T. (1998). Consequences for professional social work under conditions of postmodernity. In R. G. Meinert, J. T. Pardeck, J. W. Murphy (eds.), Postmodernism, Religion and the Future of Social Work (pp. 41-54). Binghamton, NY: The Haworth Pastoral Press.

Meinert, R. T., Pardeck, J. T., & Kreuger, L. T. (2000). Social Work: Seeking relevancy in the twenty-first century. Binghamton, NY: The Haworth Press, Inc.

Norcross, J. C., Garofalo, A., & Koocher, G. P. (2006). Discredited psychological treatments and tests: A Delphi poll. Professional Psychology: Research and Practice, 37, 515-522.

Pignotti, M. & Thyer, B. A. (2009). The use of novel unsupported and empirically supported therapies by licensed clinical social workers. Social Work Research, 33, 5-17.

Sackett, D. L., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (1997). Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingstone.

Sackett, D. L., Straus, S. E., Richardson, W. C., Rosenberg, W., & Haynes, R. M. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). New York: Churchill Livingstone.

Sharp, I. R., Henriques, G. R., Chapman, J. E., Jeglic, E. L., Brown, G. K., & Beck, A. T. (2005). Strategies used in the treatment of borderline personality disorder: A survey of practicing psychologists. Journal of Contemporary Psychotherapy, 35, 359-368.

Sharp, I. R., Herbert, J. D. & Redding, R.E. (2008). The role of critical thinking in practicing psychologists’ choice of intervention techniques. The Scientific Review of Mental Health Practice.

Stewart, R. E. & Chambless, D. L. (2007). Does psychotherapy research determine treatment decisions in private practice? Journal of Clinical Psychology, 63, 267-281.

Stewart, R. E., & Chambless, D. L. (2008). Treatment failures in private practice: How do psychologists proceed? Professional Psychology: Research and Practice, 39, 176-181.

Thyer, B. A. & Pignotti, M. (in press). Science and pseudoscience in clinical assessment. In C. Jordan & C. Franklin (Eds.).  Clinical assessment for social workers:  Quantitative and qualitative approaches (third edition).  Chicago, IL:  Lyceum Press.

Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L.,  Fitterling, H., & Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63, 925–934.

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6 Comments
  1. Rhia permalink

    In this state we has this piece in our legal codes:

    All counselors, social workers and marriage and family therapists shall use techniques/ procedures/ modalities in diagnosing and treating mental and emotional disorders that are grounded in theory and/or have an empirical or scientific foundation, otherwise, they shall define the techniques/ procedures as “unproven” or “developing” and explain to their clients the potential risks and ethical considerations of using such techniques/ procedures and take steps to protect clients from possible harm.

    Those of us like myself who are in the field but believe in SBM seem to be few and far between. It seems we are taught to apply science but that is as far as it goes. Very little critical thinking and a whole lot of opposition, I would go as far as saying discrimination in some cases, against anyone who brings it up.

    Just know that there are some of us out here chipping away at the woo.

    • Thank you, Rhia for helping chip away at some of the woo that is out there. I am glad to see that your state has at least put something in place that requires informed consent. It is a start, although the wording in that legal code is interesting: “…that are grounded in theory and/or have an empirical or scientific foundation…” The “and/or” part leaves this open for theories that do not have a scientific foundation and the mental health profession is full of those. Also, it is pretty easy for people to stretch whatever they are doing to make it seem to fit an accepted theory. To give an extreme example, proponents of tapping therapies have claimed that it is grounded in quantum physics and then there are the more conventionally accepted approaches that may be “grounded” in psychoanalytic theory, a theory that lacks scientific support but is still conventionally accepted in some circles, particularly in New York City. I have been in professional organizations where those of us with a CBT orientation have been outnumbered by proponents of psychoanalysis.

      In any case, I agree with you that the battle for SBM (that’s science-based medicine for those unfamiliar with the acronym) is an uphill battle and yes, I believe I may have experienced some of that discrimination for pointing out certain inconvenient truths. In any case, this is a very important and worthy battle, so keep up the good fight.

  2. Rhia permalink

    We has? Ugh. I meant we have.

    Speaking of EFT/TFT I one of my now deceased co-workers and I would go round and round about that. Because he had trained in it and “saw it work” none of the evidence would sway him. Another one that I encounter is the therapeutic touch and reiki crowd. Seeing one of my old colleges offer TT along with how many hospitals are starting to allow TT and Reiki irritates me. I sometimes read a column/blog written by “Raven” on psychology today about reiki and her use of it (along with her praise of Dr. Oz) at Columbia Presbyterian Hospital in New York. It is really sad because she talks about being in there before, during, and after surgerical operations with cancer patients. Here is a link in case you are curious http://tinyurl.com/2vcw5ra

    Here is just a small piece of that post:

    I work with women who have cancer, providing them with hope, confidence, bravery and grace by giving them Reiki before, during and after their procedures, including surgery.

    For the past several months now, I’ve been working with Dr. Sheldon Marc Feldman, the Chief of Breast Surgery at Columbia Presbyterian Hospital in New York City. Dr. Feldman is sending his patients to me, because he has witnessed firsthand the remarkable difference in outcome when a woman facing breast cancer receives Reiki as part of her treatment…Then at Dr. Feldman’s request, I join him in the OR to administer Reiki while he performs her surgery. I give her Reiki all during her time in the OR, because it has been found that there is much less bleeding, blood pressure remains steady and healing is speedier when Reiki is added to the surgery procedures.

  3. Therapy Abuse Victim permalink

    I have a couple questions:

    Are LCSWs and MSWs equivalent in time spent in education (2 years?) and in closely supervised “practice”–and exactly how long must they remain under supervision before (a) becoming licensed and (b) being allowed to see, evaluate (which apparently means, “diagnose using the DSM”), and “treat” clients privately?

    Do you know the history of clinical social work well? WHEN and HOW did it come to pass that individuals with 2-year non-medical degrees from tremendously differing types and quality of training programs were granted the right and privilege to “diagnose” clients with ANY of “disorders” described in the controversial DSM?

    How has it come to be accepted that clinical social workers are allowed to “diagnose” and determine “treatment protocol” plans for ANYONE without involving at least one psychologist expert in administering and,more importantly, in EVALUATING diagnostic “interviews”/tests/surveys which have well-documented validity–sensitivity and specificity?

    • The time may vary from state to state but usually it is two years of supervision following graduation in order to obtain an LCSW. This is the same amount of time required in most states for supervision for someone to become a licensed psychologist, by the way. I don’t see the length of supervision to be so much the problem as the quality and lack of scientific rigor, and that goes for all the mental health professions. There is no requirement for any profession that the supervision be evidence-based. The “supervision” of the social worker, psychologist, or psychiatrist trying to get licensed only needs to be from another licensed person in that profession — that supervisor could just as easily be a DID therapist or an attachment therapist, as long as they are licensed, that’s all that counts towards the requirements.

      As for the difference between LCSWs and MSW’s, MSW is a masters degree in social work and LCSW is the license. Having an MSW is a requirement for being eligible to become an LCSW. Becoming an LCSW requires the passing of an examination, followed in most states by two years of supervision.

      I don’t really think having a medical degree is necessarily going to add to competency or even scientific practice. Psychiatrists are some of the very worst offenders, when it comes to non-evidence based practice and pseudoscience, since the nature of their training when it comes to therapy tends to be authoritarian supervision, lacking a basis in evidence (there are exceptions, of course, depending on the school, just as there are for other professions). Although they are trained, of course, in medicine, that does not mean their training in mental health is any more scientific than anyone else’s. This is a popular misconception that Carol Tavris put to rest in her book, Mistakes Were Made where she cites a study that examined their training. The profession with the best science-based training is the PhD in psychology where the person trained in what is known as a Boulder Model program, which requires a scientific approach, although not even those are equally good. However, when it comes to practicing doctoral level psychologists, many have the PsyD, which is the less research-oriented degree and their programs have been shown not to have any more evidence-based practices taught than social work programs.

      If therapists were being trained in evidence-based approaches and trained how to practice based on evidence, the two year period, plus the time spent in graduate school would be sufficient. The problem is the quality, not the quantity of the training, in my opinion. The one main difference, legally between social workers and psychologists is that psychologists can administer psychological testing that social workers cannot. Be careful, though, about over-rating the value of requiring a “psychologist expert” — their post graduate time is also only two years and again, it depends on the quality of the supervision they had. I can and have provided examples of psychologists and psychiatrists who are every bit as bad as social workers when it comes to delivering ineffective, harmful treatments. Most of psychology, as it is practiced today can hardly be considered scientific. Hours and years of being under supervision means nothing if the supervision was unscientific and consisted of questionable practices and the way the system is currently set up, this can easily occur in any of the mental health professions. That was the point of my posting.

      One salient example is that the ring leaders of DID/recovered memory therapy were psychiatrists and psychologists and very often, they were supervising the social workers, so be careful about singling out the social work profession as the main culprit in the problem — it is the entire mental health profession that is infected with pseudoscience, from the top down.

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