Psychology and Science

In the blog and Twitter worlds this past week, there has been quite a kerfuffle over an article written by Sharon Begley in Newsweek titled "Why Psychologists Reject Science." In her editorial, described by opponents as "inflammatory," Begley writes that

many clinicians fail to "use the interventions for which there is the strongest evidence of efficacy" and "give more weight to their personal experiences than to science." As a result, patients have no assurance that their "treatment will be informed by science." Walter Mischel of Columbia University, who wrote an accompanying editorial, is even more scathing. "The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment," he told me, and there is a "widening gulf between clinical practice and science."

If that isn't the throwing of the gauntlet (or at least a few couch cushions), I don't know what is.

Dr. Katherine Nordal of the American Psychological Association responded to Ms. Begley in the a blog post titled "Taking Issue With Newsweek":

As psychologists, we do embrace our science and research base, but we also understand the importance of the therapeutic relationship to healing and growth. We care about helping our patients improve the overall quality of their lives, and we are not narrowly focused on eliminating one particular symptom (even though getting rid of a symptom is part of improving quality of life.) We combine our understanding of the research with how to best understand the patients who come into our offices with their complicated problems. We work collaboratively to achieve the goals that are important to them.

I'm guessing most of you can guess what I feel about the issue: namely, that Begley has a point, and a very good one at that. After all, by-the-book cognitive behavioral therapy can seem very sterile and clinical. What do worksheets have to do with life? Tell me why I'm like this! What about my feelings?

As one of my favorite new blogs says: F*ck Feelings.

Of course, CBT isn't necessarily sterile, nor is any other evidence-based treatment (EBT). But "evidence-based treatment" is becoming quite the buzzword, and although it's good that people are beginning to recognize the importance of using treatments that we know work, there's no guarantee that therapists who say they use EBT actually use EBT. I've met with a therapist who said she did CBT, and all too soon, it was "tell me about your mother" and "let's work on the real issues," while I continue to exercise for X hours a day and go batty. I suppose I could (and perhaps should) have reminded her that I wasn't lacking insight, I was lacking skills, but I was exhausted and I just stopped going. I'm not above or against helping educate treatment providers, but if I'm going to be doing that much work, she should be paying ME.

(I get that this sounds tremendously arrogant, but I had been desperately searching for help after I moved to DC and found no good providers that had evening/weekend hours, and therapist X was near my office, so I went. I was so beyond frustrated at this point that my patience was essentially gone.)

Dr. Nordal does have some good points, though. It's not easy to translate research into clinical practice. Research studies are very prescribed, there are typically limitations on who can participate in these studies, and adapting the therapies to best help the client is pretty much out of the question. And a good therapist should be able to tweak the evidence-based treatments to best help their clients get better.

But the touchy-feely part of being a therapist seems to be getting in the way of some therapists implementing these evidence-based approaches.

Can people get better without EBTs? Sure. People's symptoms improved when they took snake oil at the beginning of the last century, but we know now that many times, symptoms wax and wane over time. Their improvement had nothing to do with the snake oil and everything to do with the body's immune system kicking in. Is there evidence for psychotherapy? Yes. Is the evidence base as thorough as it is for other therapies? Not exactly.

The Psychotherapy Brown Bag Blog (my other new favorite blog!) had an absolutely brilliant rebuttal to Dr. Nordal that is worth reading in its entirety. This comment, however, captures the essence of the issue:

The argument that science is limited because it does not tell us about each individual is frustrating for multiple reasons. First of all, nobody is saying that it does tell us about all individuals. It tells us, on average, which treatments produce the best effects for a particular diagnosis. Some individuals will fit the norm, others will not. Backers of empirically supported treatments do not argue that everyone will respond the same way to the same treatment. They instead argue that, when making a treatment decision, we should start with the treatment with the most empirical support, regularly assess progress, and adjust our treatment choice as needed if the client does not respond as expected. Certainly, people vary in their values, desired outcomes, personalities, and many other variables that could potentially influence the outcome of treatment. The problem is, we do not have any systematic way of determining who those people are ahead of time, so if we just use our judgment to determine who is unlikely to respond, we are in fact simply guessing and will, on average, provide less effective care, even if we guess correctly on a couple of occasions in which empirical data would have led us astray. Allowing judgment to overrule empirical data is likely to lead to clinicians simply overruling any data that contradict their beliefs while trumpeting data that support their cause.

A blogger for Psychology Today wrote that

students are required to complete multiple research methods and statistics courses, conduct empirical thesis and dissertation research projects among other additional grounding courses and experiences in the science of psychology.

But knowing science isn't the same as understanding the value of science. I could teach someone how to use the biostatistics computer programs I used in grad school, and they could, in theory, "do" science. They could know what kind of tests to run, and how to enter the data, and how to devise the tests. But the numbers are largely meaningless unless you understand how to use them. I've had plenty of therapists who probably know plenty about statistics and research methods, and although that's very useful, it doesn't always translate into better clinical practice.

Ultimately, a Nature editorial summarized it beautifully:

There is a moral imperative to turn the craft of psychology — in danger of falling, Freud-like, out of fashion — into a robust and valued science informed by the best available research and economic evidence.

(I owe so many people thanks for providing these links, that I don't even know where to start. So if I interact with you on Twitter, you have my eternal gratitude!)

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8 comments:

Cathy (UK) said...

As a Biological scientist I rarely pay much attention to anything other than evidence based research in my own field of research (Physiology). However, I cannot help but feel that there is a world of difference between a more precise science (like Physiology, Biochemistry, or Physics) and Psychology. The extent of variation in individuals' processing of sensory information, their patterns of thought and their behavioural responses is huge.

On the basis that anorexia nervosa is caused by our innate biology as well as numerous, interacting life experiences (that trigger the disorder), then psychological treatment often needs to be tailored to the individual. Few people respond to re-feeding alone. Psychological therapy is nearly always necessary as an adjunct, to address the individual thought patterns/processes that drive the behaviours.

I could write an essay on this topic, but in summary, I feel that Psychology is a somewhat imprecise science, as are some of the tools (e.g. closed questionnaires - albeit 'validated') used to collect data. If one were to ask a large group of people with restricting anorexia nervosa "why do you restrict food?", there would be much inter-individual variation. Basically, the personal meaning of anorexia nervosa is highly individual.

sayhealth said...

I agree with quite a bit here! EBTs are absolutely essential, you're right. When there is so much mounting evidence that they work in a lot of cases, especially for some illnesses, like bulimia, they should often be a first line of defense. And, like you said, they should *only* be used by clinicians who are trained in and committed to using them. (And not everyone is. These articles are geared toward psychologists, and many, if not most, therapists are *not* psychologists, which means that the training is different.)

That said, EBTs don't work for everyone. I know from my own personal experience, as well as others. And the articles admit this. They are often effective, but they are not a panacea.

Additionally, I think it's difficult to compare psychology/psychotherapy with other "hard" sciences like biostatistics. We know a lot about the human body and its physical functions. Obviously we don't know it all, but we know a lot. And, though we are learning more everyday, we still actually know very little about the brain and the way that brain functions manifest can be SO drastically different in different people.

Additionally, the environment has an impact on the way brain functions (like the chemicals that affect emotions) may or may not manifest. You can walk up to me and say, "Good girls have hearts that beat at 67 bpm," but chances are, my heart is not going to suddenly start doing that. However, if as a child I have someone telling me, "Good girls don't get angry," that may very well have a strong effect on how I process, feel, and show anger. Trauma may not affect how my calf muscles work, or how my heart works, but it can affect the structure of my brain and how I move through my daily life.

There are SO many variables in the treatment and manifestation of "mental illness" that it's can be difficult to compare. Interestingly, at the same time these studies are coming out, other studies (and yes, by people with different treatment philosophies) are really stressing the evidence of the therapeutic relationship as essential to eating disorder treatment.

That said, I did cringe a bit at the comparison of psychotherapy to snake oil. And, I'm probably sensitive to this as someone who is training to be a psychotherapist! Psychotherapy works for many people. It is a science. Perhaps it's not a "hard" science, but as I stated above, there are reasons for that. There is also mounting evidence that psychotherapy ("talk" therapy) works in many cased. However, psychotherapy, unlike more "structured" therapies like CBT is hard to quantify because it works so differently depending on the clinician and the client in the room. I *needs* to work differently to be affective. I also think that psychotherapy sometimes has such a stigma attached to it - by both our culture ("you're going to see a shrink?!" and often the scientific community ("It's not a hard science." "Anyone can sit there and listen to people prattle away.") - that it is understudied and often misunderstood.

Like you, I think there needs to be a combination of factors. If treatments are shown to be effective, clinicians should either be trained in them, or be honest about the fact that they're not and be able to articulate why. Ideally, clinicians should have a range of tools and techniques to use as no therapy - whether it's based on the therapeutic bond, CBT, DBT, emdr, expressive therapies, whatever - works for everyone.

Jane said...

I appreciate that Newsweek brings the research-practice gap to the lay audience so it's not just an intra-professional discussion.

Many of the questions about using ESTs in the real world can be answered by more research. Let's take my favorite example, FBT. Beyond randomized controlled trials (the gold standard), researchers can, and already have, looked at the treatment in open trials (at Columbia and Chicago) to see how it does outside a structured RCT environment. A dissemination trial has been conducted. What about therapeutic alliance; Isn't that what matters? Well, they've looked at that, too. So, it seems to me that many of the objections to EST are being addressed, but that many people aren't fully up on the literature.

Aside from methodological concerns, there's sometimes a suggestion that researchers "think they're better" or that they are rigid or don't understand treating patients in clinical practice. Let's not forget that researchers doing treatment studies are also clinicians and, of course, they care very much about their patients. An open, curious mind is required for research. If researchers were sure they had all the answers, they wouldn't bother asking questions.

Psychotherapy Brown Bag is a really valuable site that addresses many common concerns people have about ESTs. Very worthwhile reading.

Adrianna Joanna said...

I have an autism spectrum disorder and have never had an eating disorder, so my perspective differs somewhat. But I will say this. Since anorexia/bulimia are primarily genetically and biologically based illnesses, I'm not at all surprised that talking therapy is next to useless in treating these illnesses.

Granted, talking therapy might be useful to some patients *in addition* to other treatments like CBT. Since emotional problems are hallmarks of these mental illnesses, having an unbiased person to unload with and to provide insight can be helpful. Also, no matter what type of therapy you pursue, the relationship you have with your therapist is important. For example, no eating-disordered patient wants a therapist who is judgmental of people with eating disorders and thinks they are vain. No patient wants a therapist who is abrasive or impatient. Especially where the issues at hand are so critical and personal, the "vibes" need to be right.

Talking therapy works for me because while I still have to do CBT, vocational/educational rehab, speech/language therapy, and medication, my biggest problem is that feeling of "not fitting in" that comes with being autistic. Having that safe space is very helpful. Bridging the thinking and experiential gap with someone who is nonautistic is very helpful.

But talking therapy is not a panacea and it just doesn't work with certain illnesses. Treating anorexia/bulimia with talking therapy is like treating lupus with an antipsychotic. You just don't do it.

Mike Anestis said...

First, a quick thank you for linking to our article at Psychotherapy Brown Bag and for the kind words about the site. The community of bloggers writing about science in clinical psychology are contributing to a great cause and I really admire what is going on over at this site.

I do have to disagree with a couple of things related to the comment section here.

First, with relation to the treatment of anorexia nervosa and bulimia nervosa (as well as binge eating disorder), there is, in fact, compelling evidence of successful psychosocial treatments (much more so than for pharmacological treatments). For BN, cognitive behavioral therapy, interpersonal psychotherapy, and dialectical behavior therapy have all shown very strong results in both efficacy and effectiveness studies and there is compelling evidence that CBT outperforms antidepressant medication. For AN, the results are less strong, but family-based treatment for adolescents with AN is, by far, the most effective AN treatment available. Pharmacological approaches are not more successful in any trials. I'm not sure where the previous commenter obtained that information, but I would gladly provide citations for everything I said if anyone is interested in reading about this information (I certainly do not expect anyone to take me at my word for any of this).

Also, I wonder if, when we think of science, some of us might occasionally forget the broader definition. The allegiance to the scientific method does not necessarily just involve the impressive work of neuropsychologists and biochemists (although their work is invaluable). This process involves the systematic investigation of any worldly phenomena and the analysis of empirical evidence (e.g., data analysis). In this sense, the work of clinical psychologists is no less of a hard science than is any other aspect of the field - as long as it is done correctly. Certainly, many of the variables we analyze are latent in nature, not observable to the eye, but this is true in many other sciences for which we have developed a sense that they are more "real." Think of our analyses of the smallest types of matter, or of distant places in the universe, or of the underlying processes behind diseases. Little of that, if any, is seen, but through the systematic observation and manipulation of other related variables, we are able to come to understand our targets. This is precisely what we do in clinical psychology - we simply have not be taught to think about the field in this manner or to perform this type of investigation.

Hope everyone is enjoying their weekend!

Carrie Arnold said...

Mike,

Thank you for your comments!

Your comments are very astute and well-taken. I guess I have been lazy and showing my non-expertise in the field of psychology by not distinguishing between psychodynamic psychotherapy (ie, Freudian stuff) and other forms of psychotherapy (which I generally abbreviate as "therapy").

You're definitely right in your assertions that, for EDs and AN in particular, medications aren't that effective. I do take an SSRI not to treat anorexia, but for other underlying conditions. I can (and have!) relapsed into th eating disorders while on an SSRI.

I'm a biochemist and epidemiologist by training (I became a science writer later), and I really appreciate the utility of the scientific method. It helps me do things from pick out the best shampoo (is the nice soft, shiny hair from the new shampoo, the new mousse, the combination?) to tease apart rather esoteric studies on quantum physics (for work- I'm a geek, but I haven't gotten that bad yet!).

Dr. Sarah Ravin said...

The question "tell me about your mother" is not necessarily incompatible with evidence-based treatment (though it does conjure up images of classical psychoanalysis and other out-dated and disproven treatment methods). Regardless of the therapeutic approach being used, it is important to gain background information on the patient's family relationships (family history of mental illness, family members' personalities and occupations and educational backgrounds, relationships among family members, etc.). Only the most sterile, manualized, by-the-book therapies (usually the ones used in clinical trials with "pure" uncomplicated cases without comorbidity, which we rarely see in clinical practice) would neglect to gather at least some information on family relationships.

From a CBT perspective, understanding a patient's relationship with her mother may, for example, be useful in identifying the origin of a distorted cognition, such as "I must always put others before myself." Often times our distorted cognitions originated from important figures in our lives, or at least were reinforced by them.

Interpersonal psychotherapy, which has been empirically validated in the tretment of bulimia and depression, focuses on interpersonal patterns with important figures in one's life (friends, family members, romantic partners, etc.).

I guess the key difference between these examples and the example you made, Carrie, is that it sounds as though your therapist suggested that the relationship with your mother was the CAUSE of your ED, and that exploring or correcting the relationship with your mother would in turn fix the ED. There's no evidence whatsoever to support this theory.

Jane said...
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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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