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Fraudulent psychological treatments
Fraudulent psychological treatments
By: Jinling Zhao
Fraudulent psychological treatments, pseudoscience in clinical psychology, are defined as the treatments or therapies which are either untested or substantiated to be ineffective by scientific methods. They have five indicators: First, if a treatment sounds too good to be true, it probably is pseudoscientific; second, pseudoscience tends to overwhelmingly rely on testimonials or anecdotal evidence; third, use of “obscurantist language” doesn’t mean there is any evidence it does have the function it states; forth, pseudoscientific therapies or treatments may add inactive ingredients to an active treatment and claim it is something new; fifth, be cautious of one treatment for all. In this chapter, five fraudulent psychological treatments, Equine-Assisted Therapy (EAT), Conversion Therapy/Reparative Therapy, Eye Movement Desensitization and Reprocessing (EMDR), Critical Incident Stress Debriefing (CISD), and Facilitated Communication treatment (FC) were reviewed in details.
Last December I went to California to participate in a clinical conference, the Evolution of Psychotherapy Conference 2009. Over 4000 therapists, would-be therapists, and psychological graduates took part in the conference. Though a few very famous psychologists were invited, such as Albert Bandura and Martin Seligman, most lecturers are therapists in practical fields. Thus, most lectures introduced a variety of psychological treatments that I never have heard of before. But anyway, I was outside of the clinical psychological field though I wanted to apply for a clinical Ph.D. program, so it was natural that I knew little about the latest psychological treatments used for various mental disorders. In this conference, I listened to Shapiro lecture on the empirical studies of EMDR (Eye Movement Desensitization and Reprocessing) because I was interested in treatments for PTSD (Post-traumatic Stress Disorder) and the introduction of the workshop mentioned EMDR was effective to treat people diagnosed with PTSD. I also listened how to use hypnotic and strategic approaches to treat depression, the exploration of the wedding of Buddhist psychology of the heart in tune with clinically sound modern society, the clinical application of focusing which refers to the physically felt body sense of a problem (e.g., the use of focusing in processing dreams), and so on.
The one-week conference was not an easy one, from seven A.M. to nine P.M. every day. Many therapists kept high spirit from one workshop to another workshop and bought a lot of books written by those presenters. When I asked some therapists about the conference, they expressed that they learned a great deal and they showed strong interest in those treatments of which I had never heard. No one questioned whether some treatments were unscientific and fraudulent.
Then, what is a fraudulent or unscientific psychological treatment? Before we know clearly about it, first we need to know what science is because a fraudulent/dubious psychological treatment always falls beyond the scope of science.
So, what is science? It seems so close to us because we begin to contact science when we were in primary school. However, it seems so far from us when we are asked which object falls faster when two objects with the same volume, one thinner object and one thicker, drop from the same height. Stanovich (2010) pointed out that “science is a way of thinking about and observing the universe that leads to a deep understanding of its workings” (p.8). Also, science can be defined as a set of methods which are designed to describe and interpret observed or inferred phenomena, past or present, and to aim at building a testable body of knowledge open to rejection or confirmation. Thus, science is a comprehensive concept including knowledge, methods, and thinking. Science has four canons. They are determinism, empiricism, parsimony, and testability (Pelham & Blanton, 2003). Determinism refers to the idea that all events have meaningful causes. Scientific studies aim at finding the underlying causal relationship. Empiricism means to make observations. It is a favorite tool for scientists to do research. All scientific studies should be empirical studies. Parsimony says that when a phenomenon or event can be explained by two theories, we keep the simpler one. That is, scientific theories should steer away from unnecessary concepts. Testability, the most important principle of science, refers to the falsifiability of scientific theories (i.e., a theory is open to disconfirmation or confirmation).
Therefore, fraudulent or unscientific psychological treatments are defined as the treatments or therapies which are either untested or substantiated to be ineffective by scientific methods (Lilienfeld, Lynn, & Lohr, 2003). They are pseudoscience in clinical psychology. Thompson (2010) summarized five indicators of fraudulent or unscientific treatments.
First, if a treatment sounds too good to be true, it probably is pseudoscientific. In the development of science, a breakthrough or the Einstein Syndrome is an exception instead of the rule (Stanovich, 2010; Thompson, 2010). Science is progressive and accumulative. The establishment of a new paradigm doesn’t mean the old paradigm is totally wrong. That is, the new paradigm explains not only phenomena which cannot be explained by the old paradigm, but also those which can be explained well by the old paradigm (Lilienfeld, Lynn, & Lohr, 2003; Shermer, 1997). Absence of connectivity with other scientific disciplines is the tendency of pseudoscientific research programs. To put it in other words, pseudoscience often purports to “create new paradigms out of whole cloth rather than to build on extant paradigms” (Lilienfeld, Lynn, Lynn, & Lohr, 2003, p. 7; Stanovich, 2010). Therefore, psychological treatments which state to be revolutionary or groundbreaking or which promise to cure some certain mental disorder in one or two sessions are suspect to be fraudulent or unscientific treatments.
Second, pseudoscience tends to overwhelmingly rely on testimonials or anecdotal evidence. Relative to science which is based on a large amount of empirical evidence, proponents of fraudulent or unscientific treatments usually offer testimonials from people who claim to be cured or who claim to know people around them to be cured by the treatment. However, controlled studies have had convergent results on the Placebo Effect that only expectations about a treatment can lead to some perceived or actual improvement (Thompson, 2010; Wikipedia, 2010). In practice, many medical doctors prescribe placebo medications to appropriate patients because placebo medicines are cheaper and have no dangerous effects. What’s more, recent antidepressant study found the placebo effect accounted for much of the improvement in all but severe depression (Thompson, 2010). Consequently, though people do experience improvement or cure from a treatment, it is hard to say if the treatment is effective and scientific. People may show significant improvement even with a purely dubious treatment.
Third, use of “obscurantist language” doesn’t mean there is any evidence it does have the function it states (Lilienfeld, Lynn, & Lohr, 2003, p. 8). Many pseudoscientific treatments resort to impressive or highly technical jargon such as “neural networks” or “synaptic potential” to provide their disciplines with a cover of science. It is possible that such language may be convincing for individuals unfamiliar with the scientific meaning of the claims. However, it is doubtful that any actual research supports it because the tools used in neuroscience study are usually very expensive, such as fMRI (Functional Magnetic Resonance Imaging), brain scans which needs millions of dollars, and the causal relationship in question is hard to be established. Therefore, the claim that a treatment has affected certain cortical activities doesn’t make a treatment scientific. People can make any wild speculation and claim, but don’t forget - extraordinary claims need extraordinary evidence (Hume, 1952; Shermer, 1997).
Fourth, pseudoscientific therapies or treatments may add inactive ingredients to an active treatment and claim it is something new. Any new development in science has specific ingredients with originality. That is why new paradigms or new theories can explain not only phenomena which old paradigms or old theories can explain, but also abnormal phenomena which old paradigms or old theories cannot explain (Lilienfeld, Lynn, & Lohr, 2003; Shermer, 1997). However, some pseudoscientific treatments claim originality and efficacy by adding some inactive ingredients to a validated treatment. For example, EMDR is a treatment that has been marketed greatly for PTSD. Eye movement is the original ingredient in this treatment. Proponents of EMDR stated that the function of eye movements or other alternative stimulation in the efficacy of EMDR was explained on the basis of “neurosis which involves a balance between excitatory and inhibitory processes” (Shapiro, 1989, p. 220). Though scientific research has supported the effectiveness of EMDR, research has also refuted the active role of eye movement or other alternative stimulation in this treatment and so-called functions of neural networks triggered by eye movement or other stimulation. Many controlled studies have made conclusions that EMDR is a cognitive behavioral exposure therapy in nature. Thus, pseudoscientific and fraudulent treatments or therapies are not substantially new. They sometimes just put on a new cover on an old book.
Fifth, be cautious of one treatment for all. Pseudoscientific or fraudulent psychological treatments often claim to be effective for several very different mental disorders. For instance, Equine-Assisted Therapy (EAT), a treatment involving riding and attending to horses, claims to be able to treat eating disorders, depression, anxiety, ADHD, juvenile offenders, dementia, and gross motor function. However, scientific research hasn’t supported the effectiveness of EAT in any one of these conditions. Therefore, be wary of panaceas.
Next, we analyze in detail why Equine-Assisted Therapy, Conversion Therapy/Reparative Therapy, Eye Movement Desensitization and Reprocessing, Critical Incident Stress Debriefing, and Facilitated Communication treatment are fraudulent or unscientific in nature.
Equine-Assisted Therapy (EAT) is a popular treatment involving riding and attending to horses. Proponents of EAT stated that this kind of treatment is able to treat eating disorders, depression, anxiety, ADHD, juvenile offenders, dementia, and gross motor function (e.g., lying and rolling, sitting, crawling and kneeling, standing, and walking, running, and jumping) (Benda, McGibbon, & Grant, 2003; Thompson, 2010; Winchester, Kendall, Peters, Sears, & Winkley, 2002).
Some experiments on the efficacy of EAT for gross motor function were conducted. Winchester et al. (2002) did a repeated-measure experiment to study the effects of a seven-week therapeutic horseback riding program and to measure if improvement was retained after the program was over. The results from this study supported a statistically significant improvement in gross motor function in post-intervention measures and there was no significant difference between improvements of posttest one and posttest two measured seven weeks after EAT had ended. The effect of EAT for gross motor function exists because “a mounted rider experiences the movements of normal gait, including hip and pelvic rotation, weight shift and proprioceptive stimulation” and “a rider’s active control of posture, balance and righting reactions is challenged by the dynamic sitting surface” (Bertoti, 1991; MacPhail et al., 1998; Winchester et al., 2002, p.38). The advantage of the study is that two posttests with a seven-week interval were measured, so it is reasonable to believe the improvement in gross motor function was not due to normal maturation, which means the experiment has internal validity. The shortcoming of the study is that sample size was too small. Only seven participants with a variety of developmental delays (e.g., Cerebral Palsy, Spina Bifida, Down Syndrome) were recruited in the experiment and data of six participants were analyzed, which makes the study short of external validity. MacKinnon et al. (1995) conducted a controlled study to evaluate the effectiveness of a 26-week EAT program, and they did not find statistically significant physical and psychological improvements for 10 participants with cerebral palsy in treatment condition, comparing with another nine in control condition who were on a waiting list for riding. The same shortcoming exists in this study as that in Winchester et al.’s. Benda et al. (2003) did an experiment on 15 children with spastic cerebral palsy to measure the improvements in muscle symmetry following an 8-minute EAT program. Data collected by remote surface electromyography (EMG) illustrated the efficacy of EAT.
As for the stated effectiveness of EAT on the previously mentioned problems, most studies have not incorporated “standardized measures and empirical examination of the improvements frequently reported” (Winchester et al., 2002, p.39). For example, Jo Ellen Christian (2005) did a case study on the efficacy of an EAT program used for treating anorexia nervosa. In this program, horses are metaphors of formidable mental disorders or problems which are hard to overcome. Usually at first, patients dislike horses. Therapists taught and urged patients to challenge their dislike or fear of horses. After patients can control horses, they will be full of confidence that they can control their own behaviors, and then solve their eating disorder. In this case study, the female patient changed her negative emotions to horses after experiencing a period of training. However, the author did not mention whether the patient solved her problem, anorexia nervosa. Obviously, this case study is inconclusive and cannot be generalized. What’s more, the EAT program in this study can be regarded as a cognitive behavioral therapy (CBT) in nature because therapists tried to change patients’ negative emotions and increase their confidence in controlling their mental problems through their successful control on horses which at first they thought they were unable to control.
Since most support on the efficacy of EAT for treating the previously mentioned problems is based on non-quantitative studies such as case studies and personal testimonials, EAT is regarded as one of the fraudulent psychological treatments. Even though there are some controlled studies on the efficacy of the EAT program for improving gross motor function, more research with larger sample size (at least 20-25 participants in one condition) needs to be conducted. In summary, from the scientific perspective, EAT is too early to be regarded as one of the evidence-based practices no matter how popularly it has been used in treating a variety of mental disorders; what’s more, because it is stated effective on treating a variety of mental disorders (i.e., one size fits all, the fifth indicator of fraudulent psychological treatments), very probably it is a dubious treatment (Thomspon, 2010, April 14).
Conversion Therapy/ Reparative Therapy
Conversion Therapy is also called sexual
orientation conversion therapy
, which refers to treatments intended to change or prevent homosexual orientation (Haldeman, 2002). It originated from the work of a British self-proclaimed psychologist, Elizabeth Moberly. She did not do any empirical research. Through reviewing an extensive outdated literature, she proposed a psychoanalytical explanation on homosexuality (Ford, 2008). According to the psychoanalytical hypothesis, homosexual men and lesbians suffer from an incomplete bond to same-sex parents or peers (e.g., boys have detached or distant fathers.), and then experience same sex ambivalence (Haldeman, 1994; 2002). The hypothesized resulting incompleteness or gender-identity ambivalence “becomes pathologically sexualized and in need of ‘repairing’”, thus conversion therapy is also termed as reparative therapy (Morrow & Beckstead, 2004, p. 642; Nicolosi, 1991).
Some studies reported the efficacy of conversion therapy. For example, Bieber et al. (1962) reported a 27% success rate in heterosexual shift after intensive, long-term therapy aimed at resolving the unconscious anxiety stemming from childhood conflicts that supposedly cause homosexuality. However, the methodology they used was criticized because the participants in their study were totally from clinical samples and the results were based on subjective therapist impressions, instead of externally validated data or even self-reports. What’s more, no empirical follow-up data were collected. In fact, of these successfully treated participants, only 18% were exclusively homosexual and 50% should be labeled bisexual (Haldeman, 1994). Similar criticism is encountered by Mayerson and Lief’s (1965) research. In their study, they indicated that 50% of 19 subjects reported that they exclusively engaged in heterosexual behavior 4.5 years after treatment, but in fact those who shifted from homosexuality to heterosexuality had heterosexual traits from the beginning of the therapy while those exclusively homosexual subjects reported little change (Haldeman, 1994).
Besides the psychoanalytical hypothesis underlying conversion therapy, the other opinion about homosexuality emphasizes that “homoerotic impulses arise from faulty learning” (Haldeman, 1994, p. 223). Thus, behavioral programs were designed to countercondition the learned homoerotic response. Behavioral therapists present aversive stimuli (e.g., electric shock or convulsion-inducing drugs) with same-sex erotic visual material, while heteroerotic visual material is presented during the cessation of the aversive stimuli. Behavioral conversion therapies are not limited to using real aversive stimuli. Cautela and Kearney (1986) focus their work on structured aversive fantasy in which “subjects are asked to visualize repulsive homoerotic encounters in stressful circumstances” (p. 223). As for the efficacy of behavioral conversion therapies, some studies suggested that though aversive interventions decrease the homosexual responses, they do not elevate heterosexual interest (Rangaswami, 1982). Some other studies stated that behavioral conditioning could not alter sexual orientation (McConaghy, 1981). However, the methodological shortcoming in these studies is near-exclusive use of self-report results, considering homosexual orientation is not a neutral issue which people can acknowledge freely (Haldeman, 1994). Lesbians and gay men were burdened with heavy psychological pressure and faced social discrimination when they publicized their sex orientation in or before 1980’s (Haldeman, 2002; Morrow & Beckstead, 2004). Therefore, the efficacy of conversion therapies cannot rely much on self-report measures.
Despite a long history when homosexuality had been viewed as pathology and mental disorder and needed to be changed, the majority of mental health professionals have accepted statements that depathologized same-sex attractions (Morrow & Beckstead, 2004). In 1975 the American Psychological Association (APA) declassified homosexuality as a mental disorder; in August, 1997, The Council of Representative of the American Psychological Association (APA) passed a resolution on conversion or reparative therapies, Resolution on Appropriate Therapeutic Responses to Sexual Orientation, reaffirming the opposition to homophobia and advocating unbiased treatments (APA, 1998). Therefore, conversion or reparative therapies aiming at changing a mental disorder on sexual orientation are no doubt fraudulent psychological treatments, even though the methodological shortcomings of the studies on the efficacy of conversion therapy are ignored.
However, APA did not deny conversion therapies on the whole. The above-mentioned resolution emphasizes unbiased treatment. According to Haldeman (2002), spiritual or religious identification and social and cultural environment may conflict against one’s homosexual orientation, which in turn urges him/her to look for help from conversion therapies. Thus, conversion therapies aiming at helping homosexual clients change their sexual orientation under their wills are not by nature fraudulent psychological treatments. Subsequently, the effectiveness of these therapies needs to be measured by controlled experiments. At present, the research supporting conversion therapy has been criticized to have a variety of conceptual and methodological flaws, such as sample bias which refers to “restricted, self-selected samples that represent a socially stigmatized population”, control groups or comparison not used, therapists’ subjective impression determining the results, and confounding factors (e.g., time, maturation, and contextual factors) not considered (Cohen & Savin-Williams, 2003; Haldeman, 1994, 2002; Morrow & Beckstead, 2004). At the same time, some researchers identified the following harms of conversion therapies: increased depression related to loss, sexual dysfunction, intimacy avoidance, demasculinization, internalized homophobia, and abandonment of spirituality and religion (Ford, 2008; Haldeman, 2001; Morrow & Beckstead, 2004; Shidlo & Schroeder, 2002). Therefore, before enough empirical studies support the effectiveness of conversion therapies, anecdotal evidence cannot push these treatments in the line of evidence-based practices, which illustrates the second indicator of fraudulent psychological treatments (i.e., pseudoscience tends to overwhelmingly rely on testimonials or anecdotal evidence.) (Thomspon, 2010, April 14).
Eye Movement Desensitization and Reprocessing (EMDR)
Eye Movement Desensitization and Reprocessing (EMDR) is a popular, controversial therapy applicable for post traumatic stress disorder but not limited to it. It is also applied to treat panic disorder, claustrophobia, blood and injection phobias, and arachnophobia (Davidson & Parker, 2001; Feske & Goldstein, 1997; Kleinknecht, 1993; Lohr, Tolin, & Kleinknecht, 1996; Muris & Merckelbach, 1997). EMDR was first developed by Francine Shapiro in 1987. Eye movements, the most salient characteristic of this method which was originally described as a crucial component, was changed to include a group of external alternative stimuli (e.g., therapist finger movements and auditory tones) to which clients’ attention is directed (Davidson & Parker, 2001; Shapiro, 1996). During a typical EMDR session, the therapist asks a client to concentrate on a traumatic event which needs to be desensitized while the client is generating rhythmic, multi-saccadic eye-movements (Shapiro, 1989). According to Shapiro (1996), the effectiveness of EMDR is based on the utilization of external stimuli and incorporation of various behavioral components such as sequential exposure, desensitization, and cognitive restructuring. The mechanism of eye movements or other alternative stimulation in the efficacy of EMDR was explained on the basis of “neurosis which involves a balance between excitatory and inhibitory processes” (Shapiro, 1989, p. 220).
Some empirical studies have supported the efficacy of EMDR. Shapiro (1989) conducted a control experiment on 22 participants who suffered from traumatic memories. She randomly assigned these participants to two conditions, a treatment group who received EMDR and a control group who received a placebo treatment. Also, follow-up tests were done one and two months after the initial session. Though participants in the control condition did not receive EMDR treatment, they were still asked to describe the traumatic memory in details which was thought by the author a modified flooding procedure (Shapiro, 1989). The purpose in using a control condition is in order to determine whether the specific components in EMDR (e.g., eye movements) would produce statistically significant changes beyond the effect from nonspecific factors of psychotherapy such as expectation of gain (Seligman, 1995). The results indicated that one session of EMDR procedure was effective in desensitizing traumatic memories and the improvement was maintained for three months after the treatment. Further, participants in the treatment condition reported that flashbacks and nightmares were eliminated and intrusive thoughts and sleep disturbances were substantially reduced (Shapiro, 1989). Scheck, Schaeffer, and Gillette (2001) studied the efficacy of EMDR by comparing with that of an active listening (AL) approach (Gordon, 1974). Sixty traumatized young women were randomly assigned to the two conditions. Follow-up data were collected about 90 days after the post-treatment evaluation. The results showed improvement for both EMDR and AL treatments, but participants in EMDR condition were significantly different from those in AL condition. Therefore, the efficacy of EMDR is from the effect of specific components instead of nonspecific factors.
Though many studies supporting the efficacy of EMDR approach adopted controlled experiments, they were still criticized heavily on methodology flaws, short of methodological rigor. Lohr, Kleinknecht, et al. (1995) pointed out that psychophysiologic and motoric indices showed little effect of treatment though EMDR treatment protocol frequently reduced obverse ratings of distress and self-report because of the limitations of procedural controls for nonspecific effects and crucial components of treatment. Lohr and Tolin (1998) indicated that the best way to control the effects of nonspecific factors is to use additive or subtractive experimental strategies to rigorously test the effectiveness of treatment components (Lohr, Hooke, Gist, & Tolin, 2003). Studies on the mechanism of eye movements or other external alternative stimuli did not show any positive results. For example, Boudewyns, Stwertka, Hyer, Albrecht, and Sperr (1993) compared the effects among EMDR, exposure control (EC), and a hospital-milieu-only control. They randomly assigned Veterans Hospital patients to the three conditions. The only difference between the EMDR group and EC group was no eye movements in the procedure of the EC condition. The results from standardized measures showed no significant differential effects of EMDR, and all three treatments did not affect scores on psychophysiological measures. A similar conclusion was made by the study of Pitman et al. (1996) contrasting EMDR treatment and a no-movement imagery analogue (fixed-eye) treatment. In this experiment, patients with combat-related PTSD were randomly assigned and the fixed-eye control procedure included all EMDR components, including movement of the therapist’s hand. However, the participants in the control group kept eye fixation and tapped one finger to respond to therapist hand movement. Treatment efficacy variables consisted of subjective distress ratings and four psychophysiological indices: HR, skin conductance, and two electromyographic measures. Analysis of results illustrated no significant difference between two treatment conditions on pyschophsiological measures, and limited change between two conditions on outcome variables. Thus, the use of the control procedure denied the effectiveness of eye movements in EMDR.
Therefore, the overall conclusions on the efficacy of EMDR treatment and the mechanism of eye movements in EMDR are that “eye movement, alternative stimulation, or cognitive reprocessing do not provide any incremental clinical efficacy” (Lohr, Hooke, Gist, & Tolin, 2003). Thus, the effectiveness showed by EMDR treatment comes from nonspecific factors, like imagery exposure, which reflects the forth indicator of fraudulent psychological treatments (i.e., pseudoscientific therapies or treatments may add inactive ingredients to an active treatment and claim it is something new.) (Thompson, 2010, April 14). Since eye movements, the original and novel part of EMDR treatment, have little use, this treatment cannot be viewed as a novel scientific psychological treatmen. Furthermore, that proponents of the treatment explained the function of eye movements from an unsubstantiated neurological perspective is consistent with the third indicator of fraudulent psychological treatments (i.e., the use of “obscurantist language” doesn’t mean there is any evidence it does have the function it states.) (Shapiro, 1996; Thompson, 2010, April 14)
Critical Incident Stress Debriefing
Comparing to EMDR which is promoted as a treatment for people with traumatic-related symptoms, the Critical Incident Stress Debriefing (CISD) approach is intended to prevent people who are exposed to traumatic events in general (e.g., people experiencing a large earthquake) and who have a high probability of exposure to such events (e.g., firefighter, police, and emergency service personnel) from developing traumatized disorders (Mitchell & Everly, 1998). There are two assumptions for CISD. First, exposure to traumatic events is sufficient to trigger the development of pathological symptoms. Second, early and proximal intervention, especially involving emotional catharsis, is necessary to prevent such pathological consequences and to ameliorate such consequences if they have occurred (Lohr, Hooke, Gist, & Tolin, 2003). CISD is also referred to as “Mitchell model”, which is a group discussion with seven steps: (1) introducing psychological debriefing, (2) stating facts about the nature of the traumatic events, (3) disclosing thoughts about the event, (4) disclosing emotional reactions, especially those with the strongest negative valence, (5) clarifying possible symptoms, (6) teaching consequences of trauma exposure, and (7) planning reentry to the social context (Campfield & Hills, 2001; Lohr, Hooke, Gist, & Tolin, 2003). It is usually provided 1 to 10 days following the traumatic events, aiming at mitigating acute symptoms, assessing the need for follow-up, and providing “a sense of post-crisis psychological closure” (Everly & Mitchell, 1997). The efficacy of CISD was asserted by Mitchell (1992) as the only way to deliver appropriate help to people exposed to traumatic events. However, not many controlled experiments supported this assertion. Though Campfield and Hills (2001) conducted a controlled experiment on the effect of timing of CISD on people with posttraumatic symptoms and concluded that immediate CISD was significantly better than delayed debriefing, several methodological limitations such as experimenter bias (all debriefings were carried out by the first author, so he might favor participants in immediate debriefing condition) and no control condition threatened the internal validity of the experiment. Everly and Mitchell (1997) emphasized many qualitative analyses supported the efficacy of CISD, but there are many quantitative studies reporting the ineffectiveness of CISD (Lohr, Hooke, Gist, & Tolin, 2003). Gist, Lubin, and Redburn (1998) studied the efficacy of CISD based on the airliner crash in Sioux City in which 112 of 296 people died. The study also included firefighters who engaged in body recovery and other related operations. The results of the study did not support the effectiveness of CISD, and even showed a slight but significantly worse condition (e.g., symptoms for PTSD worsened after debriefing) for debriefed people performed than for those who declined debriefing. What’s more, this incident didn’t produce a clinically significant impact on firefighters in two years. Besides this study, Hobbs, Mayou, Harrison, and Worlock (1996), Stephens (1997), and Mayou, Ehlers, and Hobbs (2000) also drew similar conclusions from their studies. In the most recent study conducted by Mayou et al. (2000), they continued their study on a randomized control trial which reported the ineffectiveness of psychological debriefing for four months, following a road traffic accident. They used consecutive patients admitted to hospitals to evaluate a 3-year outcome and found that the intervention group had a significant worse outcome at three years according to a variety of measures such as overall level of functioning, general psychiatric symptoms, and travel anxiety while being a passenger. Thus, the authors of the study concluded that psychological debriefing was ineffective and had some adverse effects for patients with trauma.
Therefore, CISD is not a scientific treatment for traumatic patients any longer though it is continued to be promoted, which illustrates the first indicator of fraudulent psychological treatments (i.e., if a treatment sounds too good to be true, it probably is pseudoscientific) (Lohr, Hooke, Gist, & Tolin, 2003; Thompson, 2010, April 14). According to Wessley, Rose, and Bisson (2000), the famous Cochrane Reviews made a decisive conclusion on psychological debriefing that no current evidence showed the effectiveness of psychological debriefing on PTSD and that compulsory debriefing of traumatic victims should be ceased.
Though the International Critical Incident Stress Foundation, Inc., which aims at providing leadership, education, training, consultation, and support services in comprehensive crisis intervention and disaster behavioral health services to the emergency response professions, other organizations, and communities worldwide, integrated CISD into CISM (Critical Incident Stress Management), no original effectiveness of the intervention system has been shown by empirical studies. However, the organization still promotes CISM through yearly conferences and trainings (ICISF, 2010).
Facilitated Communication Treatment
One day I talked with a friend, who is a scientist in the Computer Science field, about ABA therapy on autistic children, after I read some papers on the efficacy of Facilitated Communication (FC). I said I suddenly doubted about the effectiveness of reinforcement learning. B.F. Skinner did prove operant conditioning could let animals such as cats and pigeons learn some behaviors beyond their natural behavior repertoire, just like reinforcement learning could improve verbal-handicapped children with their oral language expression. However, what on earth do these animals and children learn? Did they really learn the meaning of those behaviors and the meaning of what they said? Or did they just memorize the conditioning between the response and the reinforcer after repeated practice? Or even did they learn the connections between some visual or auditory cues and their responses? My friend asked me how one could refuse to acknowledge the effectiveness if a nonverbal child could speak after reinforcement learning. Yes, perhaps that is why FC is popular.
It is not Oppenheim’s fault who first reported the news in 1961 that her autistic son learned to write his name and some words with minimum support and guidance from her hand (Edelson, Rimland, Berger, & Billings, 1998). This was a big surprise and hope for a mother with an autistic child, and she wanted to share with the world and even to help other similar children. She also mentioned the unsuccessful results when she used the same method with other autistic children (Edelson et al., 1998). However, after Biklen (1990) published Crossley’s work of facilitated communication on nonverbal autistic or other handicapped children, it attracted great attention in the media. Thus, FC became very popular in the United States in the 1990s before its efficacy was carefully tested by academic studies (Stanovich, 2010).
The theoretical assumption underlying FC is said that “individuals with autism have movement disorders that limit their communication abilities” (Biklen, 1990; Romanczyk, Arnstein, Soorya, & Gillis, 2003, p.365). Hudson (1995) provided a review of Crossley’s work on FC in Australia and several early experimental studies which resulted in consistent conclusions which refuted the claims made by FC proponents. In the review, he pointed out that the theoretical assumption behind FC was not held coherently in proponents’ literature.
A great deal of controlled studies indicated that the effectiveness of FC was controversial because the typed information by verbal-handicapped children represented the thoughts of the facilitator instead of their own thoughts, which Stanovich (2010) called Clever Hans (a “clever” horse which could do mathematics questions) in the 1990s. Bebko, Perry, and Bryson (1996) conducted a study by posing questions to the individual but not to the facilitator at the same time or posing different questions to the individual and the facilitator to remove potential influence from the facilitator, and they found the individual answered incorrectly consistently when facilitators were unable to hear the questions or hear conflicting information. In Regal, Rooney, and Wandas’ (1994) experiment, they presented questions to the individual in the absence of the facilitator, and later, the facilitator joined the individual to facilitate him to answer questions. The authors reported that no correct responses were made though the facilitator looked very confident on the performance of the individual. Smith and colleagues (1994) did a controlled study to investigate the effects of facilitator knowledge and level of assistance on the performance of the individual. In this study, the facilitator was able to see the stimulus that the individual had seen in half of the trials and in the other half of the trials, the facilitator was blind to the stimulus seen by the individual. Three levels of facilitator’s assistance were designed. They are no help, hand-over-hand without prevention to errors, and hand-over-hand with preventing errors. Results illustrated that the individual answered questions correctly only under the condition that the facilitator was aware of the stimulus and provided hand-over-hand with preventing errors. Edelson, Rimland, Berger, and Billings (1998) used a hand-support device to remove the possible influence from the facilitator in their experiment. Three conditions were measured: a facilitator condition, a mechanical-facilitated condition, and a non-facilitated condition (i.e., the individual typed independently without any assistance). After eight-week training, post-assessment measures did not show any evidence of independent communication with or without support. And another four-month extended training didn’t change the result.
Comparing with the visual cues used by the horse, Clever Hans, Kezuka (1997) did a study with five experiments to test the role of touch in facilitated communication. In this study, the author introduced an apparatus with a dynamic strain amplifier to detect very slight force between two people when they touch one another. The measure showed that a greater amount of force was recorded when the individual’s finger was close to the key of the correct answer. Results from these experiments indicated that it was touch cues instead of visual or auditory cues that played the significant role in FC and that the motor control hypothesis that “the receiver will not perform correctly when the sender is unable to accurately intervene in the movements of receiver” was best supported (p. 586).
Responding to the denial of proponents of FC that the empirical studies were conducted in non-normal social contexts where people with verbal handicaps usually performed FC, and then hindered their performance, Kerrin, Murdock, Sharpton, and Jones (1998) did a study in children’s typical classroom setting (Duchan, 1995; Romanczyk et al., 2003; Silliman, 1995). Both the teacher and the speech pathologist serving as the facilitators were familiar with the two autistic participants. There were two conditions in this experiment. One condition was a blind condition that the facilitator wore sunglasses with cardboard on its lenses, so she was unable to see the correct picture or word the individual should have pointed to, while the other condition is a sighted condition that the facilitator wore sunglasses without cardboard on its lenses, so she could see the correct answer. Though the facilitator in the blind condition didn’t believe she intentionally influenced the responses of the individual, the results showed that the individual in the sighted condition gave significantly more correct answers than the one in the blind condition.
Based on the converging results of so many empirical studies, facilitated communication is no doubt a fraudulent psychological treatment for people with autism or other verbal handicaps. Obviously it is corresponding to the first indicator of fraudulent psychological treatments (i.e., if a treatment sounds too good to be true, it probably is pseudoscientific.) (Thompson, 2010, April 14). The detrimental aspects are not limited to the ineffectiveness of the intervention, wasting money, and delaying access to effective treatments. One specific negative aspect is some allegations of sexual abuse from a parent or relative from facilitated autistic people (Romanczyk et al., 2003; Stanovich, 2010). Hudson, Melita, and Arnold (1993) reported a test of an allegation of sexual abuse from a 28-year-old facilitated female with severe to profound mental retardation. In the context of the legal proceedings, questions were read to the individual and to her facilitator through separate earphones. When the questions were the same for the individual and her facilitator, she answered correctly each time, while when the questions were different for the individual and her facilitator, she never answered correctly and 40% of her answers were correct for the questions listened to by her facilitator. Siegel (1995) also found that two facilitated adolescents gave random responses to questions related to their allegations of sexual molestation when the facilitators were unaware of the allegations.
In summary, fraudulent or pseudoscientific psychological treatments include treatments which have been substantiated to be ineffective by controlled studies, or those which have not been tested yet (Lilienfeld, Lynn, & Lohr, 2003). Some people might think fraudulent or pseudoscientific treatments are innocuous to patients even though they are ineffective in treating some certain mental disorders, but the fact is unsubstantiated mental health treatments or therapies are problematic in several ways (Beyerstein, 2001; Lilienfeld, Lynn, & Lohr, 2003). First, in health services, these treatments might mislead patients, for example, using scientific jargon such as EMDR, which possibly cause harmful delay to effective treating or healing. The evolutionary meaning of pseudoscience for animals or our ancient ancestors, benefiting survival and reproduction, rarely exists in modern society with current medical and health service. Second, these treatments usually are not free, so a large amount of money might be wasted. Practitioners using these treatments on certain mental disorders might have spent their time and effort in practicing other substantiated treatments. Third, believers often give personal testimonials to advertise and propagate the efficacies of pseudoscientific treatments, so they influence people around them, which is the most harmful effect of pseudoscience (Darkins, 2007).
Consequently, it is time to end the long-standing split between research and practice in clinical psychology. Evidence-based, or empirically-supported interventions are the appropriate treatments in practice. Researchers and practitioners could collaborate together to evaluate clinical practice because they share common commitments to providing the best psychological knowledge and methods to improve the quality of patient care (Kazdin, 2008). In turn, the gap between researchers and practitioners could be shortened, which is beneficial for resisting the illusion of fraudulent or pseudoscientific psychological treatments (Lilienfeld, Lynn, & Lohr, 2003).
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