children's testimony, Confirmation Bias, Critical Incident Stress Debriefings, Daubert, Empirically Supported Treatments, Evidence-Based Practice, human biases, Kelly Michaels, legitimate mental health practice, Mental Health Professionals, Monica Pignotti, MSW programs, Paul Meehl, Potentially Harmful Therapies, Pseudoscience, psychologists, PsyD programs, Robyn Dawes, Scott Lilienfeld, social workers
Licensure and Legitimacy: Are They One in the Same?
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.