David Tolin: Pseudoscience in Mental Health Treatments

thank you very much for that introduction I appreciate it I'm very honored to be here speaking with you so I thank you for the invitation and thank you to Christian for inviting me to come and speak and when he asked me to come and speak on the topic of pseudoscience I thought well that that will be very non-controversial and I do look forward to a lively discussion around this issue it does relate to the dodo-bird verdict in Alice in Wonderland this took place after what was called the caucus race when everybody ran off in very different directions and at the end of it all when nobody had seemed to get anywhere the dodo bird who was judging the race said everybody has one and therefore all must have prizes and that has become the verdict for several people when it comes to psychotherapy and for other mental health treatments as well what we're going to talk about today is how we distinguish the scientific from the pseudo scientific processes in mental-health treatment both the psychotherapy to psycho therapeutic treatments and the somatic treatments let's begin with a quiz now you don't have to answer this but if you think about it there are a number of different psychological treatments out there and some of which you might think of as scientific some of which you might think of as pseudo scientific and similarly there are a number of different somatic treatments out there also which we might think about as being scientific or we might think about as being pseudo scientific the question is this can you look at this list and determine which of these treatments are scientific in which are pseudo scientific now I thought about this question and I stared at this slide myself for quite some time and I realized as I was preparing to come and talk to you today that there are two different paths that I could take for the next hour one path which I think would be the easy path for us all would be for me to divide the mental health world into two camps and say these are the scientific treatments and these are the pseudo scientific treatments and then I would proceed to spend the next hour giving you a list of things I don't like in the field of mental health that would be fairly easy because I can come up with a list fairly easily of what I don't like but I think that that probably would miss the mark what I'm going to suggest then is a slightly different path but a more complicated path for us to think about but I wanted to make two hypotheses to to lay two premises out for you one is that treatments are not inherently scientific or pseudo scientific what I'm suggesting to you then is there is no such thing as a pseudo scientific treatment nor is there such a thing as a scientific treatment the second is that the labels science pseudoscience apply specifically to how the proponents of any given technique or treatment deal with the evidence and in particular how they deal with the evidence that contradicts their cherished hypotheses in essence then what I'm suggesting is that science and pseudoscience are behaviors they are not products therefore what we're not going to have and this may please some and displease others we're not going to have a dirty list of bad treatments nor are we going to have a wonderful angel list of great treatments I'm going to suggest instead that science and pseudoscience are both behaviors of which we are all capable and sometimes perhaps all culpable in that essence then I am a pseudo scientist and perhaps so are you too and we try not to be but it is part of our repertoire so I'm going to talk a little bit about how science and pseudoscience can infiltrate our thinking and our processes in determining what works and what doesn't work think about it this way science and pseudoscience are not the same thing as good and bad treatment that is for any given treatment we might think of these as being two orthogonal constructs in which the evidence-based could be poor that is it clearly doesn't work could be mixed or the evidence base could be very good meaning it very clearly does work and at the same time the way that people address the evidence around that treatment might be highly pseudo scientific which we'll talk about it may be highly scientific or it might be somewhere in the middle so if you imagine the entire universe of mental health treatments be they psychotherapies pharmacotherapies other somatic treatments and so on every single treatment can be represented somewhere on this grid and what you'll see is yes there are probably some good therapies that is they have a very good evidence base and people have addressed them in a scientific way and similarly there are probably some really poor treatments out there and people are using addressing them in a suit of scientific way but there's also probably a lot of crossover it is possible therefore for us to think pseudo scientifically about a perfectly fine treatment and it is possible for us to think scientifically about a crummy treatment well if we're trying to define these and this is not a universally accepted definition of either science or pseudoscience but I think Ellen Cromer summed it up fairly well when he said that all non scientific systems of thought accept intuition or personal insight as a valid source of ultimate knowledge science on the other hand is the rejection of this belief and its replacement with the idea that knowledge of the external world can only come from objective investigation essentially he is making an argument for empiricism as the backbone of science BF Skinner said it slightly more concisely that science is a willingness to accept facts even when they are opposed to witches now in understanding what science is it's equally important for us to clarify what science is not that I don't want to equate science with cynicism it's easy I think to become nihilistic I think nobody knows anything the idea behind scientific thinking is that we're willing to entertain novel claims and we also feel the obligation to subject those claims to intense scientific scrutiny and I would also suggest that science does not or should not profess to have a monopoly on knowledge science is not the answer to everything it does not hold all the answers now I will suggest that right now it is the best way we have it arriving at those answers but it does not necessarily mean that scientists know everything or that the field of science has or ever will answer all of our questions in fact many perhaps most scientific findings will eventually be proven wrong but that's a good thing if you're a scientist now what then is pseudoscience well pseudoscience is defined as a system of theories assumptions and methods that are erroneously regarded as scientific now what I mean by that then is that pseudo scientific thinking applies a veneer of science to a logical system that is essentially non-scientific now what I don't mean is that pseudoscience me is the same thing as being wrong the reason for that is that scientists are often wrong fact they're usually wrong science is a behavior it is an approach to evidence and therefore it is not necessarily a statement that what one is saying is correct or incorrect scientists are wrong and sometimes pseudo scientists are right not necessarily for the right reason and similarly I also want to make the point that when we talk about pseudo science that I'm not referring to religion and I'm not referring to metaphysics that is there are some areas of knowledge that make no claim to be science and therefore they are not pseudoscience there are some areas of knowledge and thinking and understanding that are clearly outside the area science they make no claim to be part of science and that's perfectly fine that's oh that's not what we're talking about now if we're trying to tell the difference between pseudoscience and science we run into a problem of demarcation and this has been pointed out several times that there is no clear set of criteria that will always differentiate science and pseudoscience when you get right down to it the boundaries between these two concepts are fuzzy therefore it's very difficult for us to come up with a very clear list of if you do this it is science and if you do that it is pseudoscience that having been said others have made the argument that there's also no clear division between day and night but that doesn't mean that they're the same thing a reasonable person can tell the difference between when it is day and when it is night even if he or she cannot necessarily understand exactly where the line is so how can we start to understand pseudoscience when when we what would we see that would tell us that perhaps we're looking at pseudo scientific thinking one of the the core criteria here is what's been called an overuse of ad hoc hypotheses that are designed to immunize claims from falsification the idea is this that when some new information or data comes to light that might challenge the basic premise of a treatment the proponents of that treatment will start to come up with new hypotheses that essentially explain away what has been done so if somebody does a treatment study on a treatment that I love and it doesn't work then I will come out and say well clearly they didn't apply the treatment correctly that's an ad hoc hypothesis we also see in pseudoscience an absence of self correction that is when the model fails to develop as we get new information about a particular field that's a that's a sign that we're dealing with pseudoscience and it's not connected with the scientific world for example one could point out that the field of astrology has not changed in over a thousand years despite the fact that our understanding of the cosmos has changed dramatically as has our understanding of personality and human development the fact that the field of astrology has not kept up with those changes in our knowledge suggests that we're not dealing with a scientific process of thought we also see in pseudoscience a tendency to evade peer review a peer review of course is not a perfect system but it is one of the hallmarks of how scientists do their business they subject their ideas to scrutiny of people who perhaps don't agree with them instead when people are promoting pseudoscience what they tend to do is rely more heavily on testimonials or anecdotal evidence so this person got better this way this person got better this person got better look how dramatically this person got better without actually subjecting these to rigorous data analysis that would then be reviewed by one's peers the emphasis in pseudoscience tends to be on confirmation rather than refutation many philosophers of science have said that scientists inherently are trying to disconfirm their theories now that doesn't always play out and remember the lines of demarcation are fuzzy and none of us even those of us who think of ourselves as scientists like to have our theories disconfirm it's not fun but the process of science is designed to do just that instead what we see is that that pseudo scientific thinking is seeking out evidence specifically that affirms one's beliefs clinging to that without paying attention to evidence or without generating evidence that might disconfirm it the burden of proof is often revised in it reversed in pseudo scientific thinking typically in scientific thinking one would expect that if one has a claim to make for example this treatment is very good then the burden of proof is on the person make the claim that is it is my job to prove to you that this treatment works instead in pseudo scientific thinking the logic goes a bit like this treatment works really well and since none of you can prove otherwise I stand firm on my by my belief there also is an absence of connectivity that is a failure to account for existing paradigms from other disciplines there may be a treatment for example that's that that proposes to cure a psychiatric disorder anxiety for example post-traumatic stress depression by changing the flow of energy fields in the body without necessarily paying attention to the science of human anatomy and physiology which actually makes no particulars in some of the ways that they say they can be mastered pseudoscience is also characterized often by what has been called obscurantist language language that is essentially designed to be confusing again the but the boundaries are fuzzy and scientists will use confusing language to what we find however is that in pseudo scientific thinking this language is used specifically to make something sound more scientifically rigorous than it really is and finally in pseudo scientific thinking we see an absence of boundary conditions that is whenever one makes a claim one would also make a statement about the conditions under which a particular treatment would or would not apply but when we see a mental health treatment for example being marketed to cure not only anxiety disorders but also depression and also marital problems and also alcoholism and also cancer and it will improve world peace you have to start thinking that perhaps we have an absence of boundary conditions here now the American Psychological Association the group which with which I'm most familiar has addressed this issue in there at code of ethics they have stated first that psychologists work is based upon established scientific and professional knowledge of the discipline and when they talk about providing informed consent to the patient's they say when in obtaining informed consent for treatment in which generally recognized techniques and procedures have not been established psychologists inform their clients or patients of the developing nature of the treatment the potential risks involved alternative treatments that may be available and the voluntary nature of their participation in short then the American Psychological Association has told its practitioners you must make the use of the best science possible and if you don't have good science to guide you then you are obligated to tell the patient that that we are now operating outside the boundaries of the knowledge that has been generated by science what we are doing is experimental and to provide the person with alternatives should you not go on to go down this experimental path with me here are the other things that you could do that should solve the problem right after all the American Psychological Association has spoken and yet we have a gap what we have and this is not simply in my country but I think this is probably true worldwide is that we have two fields of mental health that have developed there is a group of scientists and perhaps scientists practitioners who believe one set of things and then we have a group of other professionals perhaps perhaps a more practitioner oriented who believe another set of things increasingly we find these two groups of people don't talk to each other very much and when they do listen to what the others have to say they tend to disparage it so the scientists all tend to say all those stupid practitioners and the practitioners all say all those stupid scientists they both have a sense that neither really understands the perspective of the other or is particularly interested in the perspective of the other and so they get angry at each other now Carol Tavor is a social psychologist took it a step further and said calling it a gap is like saying there is a israeli-arab gap in the Middle East it's a war involving deeply held beliefs political passions views of human nature and the nature of knowledge and as all wars ultimately involve money territory and livelihoods ultimately that's what this will come down to so why would clinicians do this I mean the scientists wonder this all the time we've done good research we put a whole list of treatments out in front of people and said here use these and the clinicians don't want to use them why would they do that well there's several reasons one we can think of from a cognitive perspective that we are all scientists and practitioners susceptible to cognitive biases we make errors in our judgment confirmatory bias for example is all of our tendency to see what we already think to pay more attention to things that confirm our belief yes I said science tries to disconfirm but that doesn't mean that scientists always do that scientists are prone to the same biases as everyone else and we tend to favor those data and those pieces of evidence that confirm what we already suspect we also have a tendency to be overconfident we're all very educated and that education sometimes carries risks and there's a well-documented finding that ones confidence in the truth has very little to do with the accuracy of one's knowledge in fact there have been several studies that have suggested that the relationship may be inverse the more confident you are that you're right the more likely you are to be wrong and I say this by the way knowing that this could easily be applied to myself as well we have hindsight bias we tend to pay attention to things that have already happened and interpret them in ways that confirm what we already know so when for example a treatment fails we tend to concoct hypotheses about why that occurred and those hypotheses tend to conform to our existing beliefs and we're all subject to the availability heuristic things that stand out things that are dramatic tend to hold priority in our thinking so I may treat many many patients over the course of a year and the treatment is often quite boring I do the treatment they get better or sometimes they don't and then they go away but perhaps I had one patient who got really really better in a very dramatic way and I can't quite explain it but the person was wonderfully better they were they're very very sick and now they're completely healthy and they're jumping up and down and they're happy and they're calling everybody and saying how great dr. Tolin is and I'm trying to think about why that happened what's going to end up happening is that later on when I'm trying to make decisions about what to do with my patients I'm going to start thinking back on my experiences and that patient will come up first and foremost in my memory despite the fact that he was the anomaly he did not represent the average he was the exception and yet because of the fal ability of human cognition he's the one I start thinking about and I might base my judgments on him we also find to as clinicians and I say this as somebody who treats patients as well as as conducts research but it's very difficult to get good feedback from our patients about what's working and not working not the least of which is that we tend not to have any more contact with our patients after they terminate treatment with us so the way that a treatment tends to end if we think we're doing everything right is the patient says okay doctor I'm all better and we shake hands and they go away and I probably never see them again now for all I know two days later the person had a depressive relapse and they felt awful and they weren't any better but I don't know that because clinical practice is not typically designed to allow us to collect longitudinal feedback we also find - as we're talking with with patients that we're susceptible to the Barnum effect PT Barnum who said that a great circus has a little something for everybody well a good psychotherapy probably has a little something for everybody we do all kinds of things and you know for all of us there are probably elements of this therapy and that therapy in this technique and that technique and the fact of the matter is it's very difficult for us to know at any given time which of those things is truly effective but what we will tend to do is is seize upon those things that seem to fit our thinking and our clients have a tendency to agree with us some of them don't you know we call them borderline but most of them you know have a tendency to want to please us at least somewhat and so if I start asking questions like well did that technique really help and they may say yes doctor it really did okay well why would the consumers accept this I mean after all this is a consumer driven process is it not why don't the consumers simply stand up and say no you will give me scientifically effective treatment well part of it is that the general public is not great in scientific literacy now I would say that's probably extra true in my country but I think this is also true worldwide is that the average person does not typically think in terms of science we also see that in many ways pseudo scientific explanations are are more alluring than Sciences Carl Sagan speaks about this very eloquently in his book the demon-haunted world in many cases pseudo scientific explanations are easier to get your head around you try talking with a scientist and everything is about probabilities and the scientists never will really confirm that he knows anything and he always as well we think this and we hypothesize this and there's the theory and you know it can be maddening to talk to scientists and I think I'm one of them but if you talk to somebody who's promoting pseudoscience they tend to come across much more simply yes I have an explanation that will tie it all up very neatly for you and I don't have to speak probabilistically therefore I can make stronger claims you know we don't have to be quite so tentative it's also seductive when you think about some of the claims that are being made I mean in some ways it would be really interesting and really wonderful if the Stars controlled our destiny and if we could then determine our destiny if we just knew enough about those stars wouldn't that be something wouldn't it be something if I could you know put some headphones on listen to something while I sleep and wake up feeling better that would be great I was I was working out today in the gym and I saw you have to imagine I'm on the treadmill and I'm sweating and I'm very tired and I you know I feel awful and there's a TV up and there's somebody on the TV who's selling a product where he has some massager thing have you seen this and he's rubbing it on his belly like this and it's supposed to make all of his fat go away and sure enough as a good testimonial they had a picture of him at the beginning you know and a picture of him at the end and he looked great and I'm sitting here running and sweating and I've been doing this for a long time and I find myself thinking just how seductive this all is wouldn't it be wonderful if that was really true wouldn't it be great if the solution to weight loss just involved buying this thing and rubbing it on your stomach that would be terrific and it's true in mental health as well wouldn't it be great if I could overcome my depression this way and wouldn't it be great if this would help me stop drinking or get along better with my spouse wouldn't it be great if this would help me stop hearing voices also the pseudo scientific interventions tend to be cheaper they're easier they're more accessible psychotherapy is hard to do it's hard to get into it much of the time it takes a long time it's often expensive often it's hard to find a good provider whereas many of the things that are purported to be out there I can simply order online wouldn't that be great and finally much of the information that the general population receives comes from the popular media now I don't want to knock popular media I'm on the popular media but at the same time you know it is important to recognize that the average consumer is not reading journal articles and what they're usually doing is watching television or reading a magazine or something and those kinds of media need to provide soundbite information so whenever people are watching they have to be able to put something into a message that can be consumed in 10 seconds or less and as a result it's very easy for us to learn on television for example that there are certain mega vitamins that will make you feel all better or that electroencephalography is a cure for ADHD now again those claims could be true they might not be true but the approach is essentially not a scientific one which leads me to the topic of chicken hypnosis which I'm sure is on everybody's mind I'll give you a minute just to think about chicken hypnosis are you familiar with hypnotizing chickens is this a uniquely American sport well let me tell you about chicken hypnosis if you come to America particularly the American South there is an old tradition this goes back a hundred years or more of hypnotizing chickens the idea is this you-you-you take a chicken and you do some things to it and as you'll see this is a kind of pre and post the chicken becomes completely hypnotized it's a very well replicated phenomenon something that even school kids do on the farm it turns out there are three ways that you can hypnotize a chicken this by the way comes from the US the the Farmers Almanac in the United States there are three three ways that you can hypnotize a chicken they are referred to as the sternum stroke method which you see this man doing here in which we stroke up and down the chickens sternum there's the chalk line method in which we take a piece of chalk and we draw a line starting at the beak and going out 10 to 15 feet there's also the oscillating finger method in which the farmer will wave his fingers back and forth in front of the eyes of the chicken in a way of hypnotizing him now in each of these cases you get a similar result the chicken becomes hypnotized but of course the is this question of are there really three different ways to hypnotize a chicken well it turns out that there is something that all three of these hip treatments have in common we pay lots of attention to this man's left hand what we're not really paying attention to is his right hand what is his right hand doing he's immobilizing the chicken right he's holding it down there's a well-known animal phenomenon called tonic immobility happens in humans too if you hold somebody or something down and immobilize it for a period of time it will stop moving it's evolutionarily adaptive it's playing dead the idea then is that if you want to hypnotize the chicken really all you need to do is hold it down you don't need to do all of these different things those things are superfluous and yet you ask any farmer how did you hypnotize the chicken he never talks about this he wants to talk about these in fact they even get into fights arguments about which one is better well clearly the chalk line method is superior to the sternum stroke when in fact they're all because of holding the chicken down we call that an incidental feature of the treatment it's something that is not claimed to be the effective mechanism and yet it probably is the analog to this when we start talking about humans and our work is the treatments that we have can work for reasons other than why we think the fact of the matter is in many cases we don't know why a given treatment works so we come up with hypotheses and sometimes those hypotheses are right and sometimes those hypotheses are wrong now I'm going to teach you how to sell a pseudoscience so in case you want to do this and you want to make a lot of money in selling pseudoscience here's the best way to do it and by the way it's been demonstrated that these strategies will work not only on consumers but they will work on practitioners as well so you pay attention to this because we're all going to make lots and lots of money I'll tell I'll tell you about these different steps they are and at Tony Pratt Canas who is a social psychologist has documented these I'll talk about each of these but they the steps here are to create a phantom set a rationalization trap manufacture source credibility and sincerity establish what's called a grand faloona use self generated persuasion construct vivid appeals use pre persuasion make frequent use of heuristics and common places and attack one's opponents through innuendo and character assassination let me talk to you about how to do each of these so we know how to do it the first is creative phantom creating a phantom means that we set out to promise an unavailable goal that looks real and possible that would be highly desirable if that were possible so my phantom in the gym today was this idea that I could lose all of my belly fat by rubbing this thing on myself and in 15 minutes it's at 15 minutes in 15 minutes I would look like Brad Pitt or something like that that's my phantom in this person's phantom it's a cure for autism it's an unavailable goal at least one that's not available right now that would be really wonderful if it were available set a rationalization trap setting a rationalization trap means encouraging the person to make immediate small commitments to the cause so before I even try to sell you on something suit of scientific let me first ask you to take this free personality test now what does that do what it does is it gets you to already start saying yes to me to start making small investments of your time before I will train you in this procedure I want you to sign something that agrees that this is really dangerous in the wrong hands and that you won't show it to anybody well that's setting a rationalization trap it's asking people before you've even started the persuasion process to begin to make a commitment to you and we know through social psychology that when you get somebody started making small commitments to you they're far more likely to make a big commitment to you later and they're far more likely to believe what you have to say manufacture source credibility and sincerity now if you're going to do this you must have a white-haired doctor to sell your products doesn't work unless you have oh and they it preferably they have a beard and they wear a nice suit the idea is at now different different strategies and different kinds of authority figures might appeal to different people but the idea is that you have to put somebody up front that the people and the contended and the practitioners will believe in again whether or not it's true often it comes down to how much do I trust this guy does he look like he knows what he's talking about we have to establish a grandfa loom this is a term from Kurt Vonnegut Kurt Vonnegut described a grandfa loon as a proud association of Mena proud and meaningless association of human beings in order to really sell a suit of science it's best if I make you part of a club because being part of a club makes you feel that much more allegiance to what I have to sell you so how do you create a club how do you create a grandfa loon well you put together people who share certain rituals and symbols who might use the same jargon and beliefs we start speaking a language that is different from others we share goals and feelings we share specialized information perhaps information that only we can have and importantly have to have enemies if you really want to get people to bond together you have to have a shared enemy somebody has to be the bad guy use self-generated persuasion this one is also right out of social psychology encourage your targets to persuade themselves by convincing others well known that if you are asked to convince somebody else of a fact you yourself begin believing that fact that much more so easy as I'm putting you through the persuasion process one of the things that I should ask you to do is to recruit others to the cause so this is for example some herbal supplements which again let me say might work might not work but right upfront it's asking you you know how can you help others you know we can help your friends you can have a real business opportunity what kind of business is right for your lifestyle but essentially what that is doing is bringing you more and more into the cause it's turning you into a true believer it's lowering your level of skepticism we're going to construct vivid Appeals in order to construct visible Appeals remember that availability heuristic right data are boring statistics are boring nobody listens to that what we listen to is a single case who got really really really better this is tough to read but this is somebody who attended a seminar and I went to this seminar to help myself but then it helped me so unbelievably I use it on a daily basis and and then I thought about my seven-year-old daughter and I decided I would try it on her so I began working on her energy meridians and all of a sudden her problems got better too when she went back to school and now she's a happy little girl and it becomes much easier for us to remember that man and his daughter and the testimonial than it is for us to think about the data that describes the outcome of that treatment that's human nature we use pre persuasion you have to define the situation so that you can win without much argument here's an example this is tough to read but it says these are award-winning subliminal CDs for quick change sounds legit but it asks regular subliminal CDs are fine for regular people but can mass-produce CDs from your local bookstore really improve your life can you trust the message do you know how the CD has been made was the CD even it was a CD created by a reputable DVD inspirational company right essentially what this does is it begins the discussion by setting the topic outside of the efficacy of the intervention by distracting us away from the basic question of what that sub would subliminal CDs help me it instead asks us to think about this subliminal CD company versus that subliminal CD company now all of a sudden I'm thinking about yeah those bookstores don't know me with their mass-produced CDs and all of a sudden I'm becoming less skeptical and more willing to buy what these guys are selling that now all of a sudden the idea of a tailored CD by a people who really understand me that sounds wonderful but it takes us off of a basic point again I'm making no statement here about whether subliminal CDs are or are not effective I'll let the data do the talking on that I'm simply pointing out that we can address this from a scientific perspective or we can address it from a pseudo scientific perspective we have to make frequent use of heuristics and commonplaces the heuristics come from Tversky and Kahneman and other you know behavioral economic thinkers we know for example that when you say something is scarce it's rare that it becomes more desirable not everybody can do this there's only a special group that can do this kind of treatment the bandwagon heuristic if I point out how many practitioners have signed up for this how many of these I've sold that makes you start to think that perhaps everybody knows something that I don't know the representative heuristic that is if I if I give you case examples that that will ring true in your head whether or not they're really supported by mass data you tend to believe it more the natural and the goddess within common places we have a tendency to believe that things that are natural are good we have a tendency to think that it believed that things that are spiritual are good it's actually harder to be skeptical maybe we've all seen this and maybe we've all had patients who do this who say oh I don't trust those antidepressant medications I who knows what they're going to do to me in 20 years and then they march right on down to the health food store and load up on minerals and herbal supplements that have never been tested at all it's people are simply less skeptical when something is pitched as being natural and the same thing is true of being spiritual it's tempting to think that there is a spirituality of goddess within that is being overlooked by science and that only this treatment can help us tap into and then there's the science commonplace now science gets used very interestingly in pseudo scientific thinking and in pseudo scientific sales pseudoscience has an interesting relationship to science it has to sort of have two relationships one is that it has to glorify science to a certain extent that is it has to be able to say you know millions of people have done this and we've got this evidence and you have to be able to put things out so you have to be able to create at least the veneer of science and in order to create the veneer of science you need to be able to say that what I'm purporting to be is a good thing and at the same time you also have to disparage science in order to sell pseudoscience so I'm going to give you a veneer of science which I'm going to purport is a good thing and yet at the same time my backup message is that also you should know that science doesn't have all the answers but I do so in this case for example this is you know in the scientific cosmology whatever doesn't exist obviously can't be real but the energy psychology cosmology deals with a greater reality a more inclusive reality there are numeral innumerable forms of general human experience which are not explainable by the limited cosmology of psychology but which have perfect cause and effect in the greater cosmology of energy psychology and you get a sense that there's a back-and-forth going on here between the with the relationship to science it's simultaneously saying yes yes science is wonderful and we are science but also science is highly highly flawed and we're better than that so it's an interesting dichotomy that has to be done when you're selling a pseudoscience and you also have to attack your opponents this one is critical remember you can't be part of the club unless there is a shared enemy so how do you attack your opponent's people that perhaps are skeptical about the treatment that you like or say things about a treatment that you think is really effective say things that like it's not effective or that it's you know it's no good well Cicero said it best if you don't have a good defense attack the plaintiff discover discover an incredible new learning tool the government doesn't want you to know about well who wouldn't be persuaded by that do you really want to go along with the government who doesn't want you to know the truth oh I want to go along with the people who know the truth now what when you use innuendo like this what does it do well it certainly it creates some in-group out-group thinking right by demonizing the person who is skeptical or critical it makes it that much easier for others to start to buy what you have to sell it also changes the topic of the conversation right I mean if I come out and say you know I don't I don't know you know I'm going to try not to pick on any particular one but let's say I say a vitamin so you really like vitamin E and you think vitamin E will cure everything and I come out and say I don't think vitamin E you know cures everything at all and you say well obviously you have a hidden agenda and you're a very unethical person you're probably getting money from the competitors who also don't like vitamin E you're probably being paid by you know the drug companies and so on now you see what's happened now is that we've shifted the argument now all of a sudden we're not talking about whether vitamin E is particularly good or bad now we're talking about whether or not I'm an ethical person and which is a fair thing to discuss but notice how we have shifted the discussion we also know to that using innuendo and attack has a silencing effect nobody likes being attacked me included and there is a tendency when you attack somebody for them to shut up and so when you attack your opponent's vigorously there is a tendency for them to stop being so skeptical or at least stop being so public with their skepticism they don't want to go through that again they start to ask is that really worth it do I want that kind of headache what's the harm I mean is this just all is this harmless folly or is this really something to worry about I would suggest it's something to worry about on three different fronts I think that there's reason to believe that there is direct harm to patients I'll talk about these a little bit but we know that there are treatments that harm people never mind the treatments that simply don't work there are treatments that have been demonstrated to do harm to people and yet they continue to be practiced why because they're being sold we also know there's always hysterical epidemics that sweep through the population hysterical mental health epidemics why now because we have a tendency to buy into theories that perhaps are not really solid and myths persist general public doesn't know a whole lot about real psychology they don't know a whole lot about real solid real psychiatry they have a tendency to believe certain common-sense heuristics that they think are related to what we do and these things persist essentially because of a lack of scientific skepticism we also know that treatments that are the result of pseudoscience cost people money and they cost time and one of the things that we see in economics they refer to it as opportunity cost but it's a very real phenomenon is that when somebody partakes in one particular kind of treatment they are less likely to partake in any other kind of treatment that's been demonstrated in epidemiologic research when people use for example herbal supplements they are less likely to take medications that have been approved for use for that disorder people don't just simply add on to their existing treatment they really do choose this over that and I would suggest that the persistence of pseudo scientific thinking is inherently bad for the profession in terms of litigation from patients that have been harmed in terms of our ability to collect payment for the services that we provide and in the erosion of the scientific foundations of our work talk about the harm to patients now this is not necessarily a statement about pseudoscience remember the evidence base for a treatment and the way it is promoted are to potentially different things but what I will say is that pseudo scientific thinking is probably one of the mechanisms by which some of these treatments persist we know through randomized controlled trials for example that a treatment called critical incident stress debriefing an intervention that was designed to prevent the onset of PTSD following a mass trauma can actually cause PTSD or make PTSD symptoms worsen and the average person who receives critical incident stress debriefing is worse off than the average person who did not receive it the scared-straight programs they take delinquent children and take them to prison so they can be frightened by all the scary prisoners with their big tattoos and their goatees and their piercings and I don't know what else it turns out that doesn't actually turn them away from crime it actually increases crime among those youths because the prisoners look cool facilitated communication this is a really interesting one this was designed as an intervention for autism the theory behind facilitated communication which I would add is disconnected from what's known about the the pathology and the pathophysiology of autism is that autism is primarily a language problem that the person is completely cognitively intact however they are unable to express themselves because they essentially have a language and motor problem so they came up with the idea that we get a keyboard you can see here's a person with the keyboard and a facilitator and the facilitator will hold the patient's wrist like this and help them to control their [ __ ] movements and press down on the key of a keyboard so they can type things out now one of the things that happened when facilitated communication became popular is there was a rash of accusations of sexual abuse it turned out large numbers of these autistic children reported that they had been molested by people who were entrusted with their care their parents daycare teachers their doctors many people were prosecuted at the end of it it took an elementary school girl to conduct the first randomized controlled trial of facilitated communication and she did it very simply she had the person with autism and the facilitator sitting here and she had a split screen in front of them and she simply said I want you to type what it is that you see on the picture that I'm going to show you and she would show the autistic child one picture a spoon and she would show the facilitator another picture a cat and every single time the message was see a tea leaves were not coming from the autistic child they were coming from the facilitator perhaps unconsciously an interesting phenomenon in and of itself but it taught but it speaks to the issue of how much damage can be done when we do things that really haven't been proven to work attachment therapy another very dangerous one here's a picture of a child also autistic being held down by his mother the idea is that if you hold them down long enough they will accept their love they certainly stop thrashing so do the chickens and in fact there was a very well-publicized case in Colorado in the United States where they did a variation of this where they rolled a child up in a carpet and then people adults piled on top of her to simulate being in the birth canal with the experience the idea that she would claw her way out of the birth canal and re-enter the world and love her parents again and of course she died and harm is being done and yet I would also point out these treatments are still being conducted they're being conducted in the United States are being conducted in Sweden the recovered memory techniques also leading to kind of a rash of sexual abuse allegations this idea for example that if I hypnotize you we will we will find repressed memory bad things that have happened to you in childhood the DARE program that's another really popular one and it remains very very popular in the United States they come out and they do psycho education to high school children telling them not to drink and not to use drugs seems great everybody loves it the government pours a lot of money into it when they've conducted randomized controlled trials guess what it makes alcohol and drug use go up not down that the kids who are going to drink they're going to drink anyway and the kids were kind of on the fence listen all that and go away that sounds pretty cool I talked about the hysterical epidemics maybe you remember some of these there have been these ritual sexual abuse epidemics remember there was a time when it just seemed like every daycare was a satanic cult that was engaging in ritual sexual abuse of children and many people bought that hook line & sinker there was a wave of multiple personality disorder that came through it was huge there was a point I think it was in the 80s when it just seemed like every patient had multiple personality then it sort of stopped being cool and now nobody has multiple personality disorder there was a point when everybody had alien abduction well okay not everybody but more than you would necessarily expect John Mack a very prominent Harvard psychiatrist was was largely responsible for that epidemic suggesting that lots of mental disorders were essentially the result of implanted thoughts and memories by aliens and then we also know there's this persistence of myths this is what the public generally thinks you might ask yourself true or false I'll give you a hint the answer to all of these is false but the average person when you ask them about the fields of psychology and psychiatry when you ask them about mental health they will endorse these most abused children will become abusive parents most children of alcoholics will become alcoholics childhood trauma will invariably produce emotional symptoms that carry on into adulthood most traumatic experiences are repressed and when they're repressed hypnosis can reliably uncover them and if you're angry and you don't express it the anger will like steam in a teapot resulting in an explosion none of these have any basis in fact and yet the myths persist why because we lack the scientific skepticism we haven't disseminated the truth to the consumers so if we're a practitioner and something is presented to us here go to this workshop try this treatment read this book there are some questions we could ask ourselves is this testable this relates to the issue of falsifiability is this treatment testable or is it unable to be tested or disproved can we at least hypothetically think of a research finding or a series of research findings that would tell us that this is not true turns out there are a lot of ideas out there that are simply not testable there's no way we could ever disprove them is it unchanged does that treatment remain unchanged even in the face of contradictory evidence as for example part of a treatment starts to become superfluous when it comes to the evidence as we start realizing that this part of the treatment seems to be helping in this part of the treatment doesn't seem to be helping do the proponents of that treatment then drop this that doesn't help or do they cling to it they give it an ad hoc hypothesis to explain that away is the rationale for the treatment based only on confirming evidence with disconfirming evidence being either ignored or minimized is the evidence being presented to me anecdotal does the evidence in support rely primarily on personal experience in anecdotal accounts there's one treatment that's being sold very aggressively and it is quite popular in the United States at least in which the main evidence was the results that were obtained on a daytime television talk show where this psychologist went on did his treatment the patients recruited from the audience felt better and that goes on the site this is the evidence that this treatment works are the claims of the treatment in commensurate with the level of evidence needed to support those claims there's a well as an often repeated quote that says extraordinary claims require extraordinary evidence if you're going to claim to treat anxiety and depression and alcoholism and marital discomfort and cancer and war you should be prepared to provide some rather strong evidence for those claims have the avoided peer review are the treatment claims unsupported by evidence that has undergone truly critical scrutiny for example there are a number of vanity journals that are out there that look scientific and yet they're being put out there solely by the people who benefit from this treatment being promoted who have financial stake in it it's as if you know Pfizer created at the Journal of Zoloft you know the Journal of sertraline you know and then everybody wanted to publish on certainly would publish there it's it's not exactly the same as a good peer review is the treatment disconnected from well-established scientific models or paradigms think about alien abuse just as an example right there alien abduction now if anyone here has been abducted by aliens I don't want to offend you so you don't have to listen to this part but when you think about it the notion that mental illness is caused by aliens in alien abduction for us to to by that notion would require us to rewrite the laws of physics time and space would it not that's as clear pretty clear disconnect from what the rest of science has to say about the topic is the treatment being described by fancy new terms that appear to be scientific but on further examination are not scientific at all there are treatments for example that talk about meridians neural networks other things that have kind of a science II sound to it but don't have any basis in actual scientific fact is the treatment approach based on claims that are grandiose or on outcomes that are poorly specified and is this treatment claim to make sense only within a vaguely described holistic framework this is one that you see a lot now and you see it a lot when people are talking specifically about certain assessment methods as the data come in saying look this assessment method doesn't really tell you very much the counter-argument is usually well you would never just use that you know we use a holistic approach in which we take all of the evidence into consideration in order to diagnose our patient yes well that's fine but that does sort of avoid the basic issue that the thing that you're purporting to do doesn't seem to work right that essentially the argument of holism is just another ad hoc hypothesis so what can the field do about this the field of psychology the field of psychiatry the field of Social Work the field of mental health therapy we need to do a better job of emphasizing critical thinking skills in graduate training now depending on where you are if sometimes you get all of your clinical and research training in the same place within the same degree and depending on and in other places you get your clinical training first and then you go back for a research degree I would argue that we need to emphasize critical thinking at all points along this spectrum that the critical thinking should not simply be reserved for the research programs in my country we have two different kinds of doctorate in psychology we have the PhD and the psy.d with the idea being that one had a more research flavor and one had a more practice flavor and that's fine but we need to emphasize critical thinking skills not only for those people that are going into research but also those people who are going into practice those people who will be sitting in front of the patient we need to do a better job of disseminating information about our scientific findings and the process of science to the public the public has very little understanding of what works in mental health treatment and they have very little understanding of what doesn't work in mental health treatment there's no real body that's out there talking to the public in as vital and an immanent away as say dr. Phil he reaches a lot more ears than the American Psychological Association ever has we need to ensure that the continuing education that we provide to our clinicians and to our researchers is grounded in adequate scientific evidence this is an ongoing fight by the way in the United States in which if you are a psychiatrist or you're a psychologist you can go and get continuing education credits which is mainly required to maintain your license in all kinds of things all kinds of things that lack scientific evidence you can go take a go to a shaman sweat lodge you can do Jungian sand tre therapy you can you know look at the clouds I don't know your tea leaves I don't know what you can do the idea is that that you can get credits for doing those that have nothing to do with the scientific processes of our profession this one may be a bit more controversial that the field and the governing bodies of the field need to impose sanctions on practitioners who routinely use techniques that are devoid of scientific support in my country and I think yours as well there is no requirement that practitioners use scientifically validated strategies I mean there's that APA code of ethics but you don't necessarily lose a license for that it's a guiding principle right the field needs to do a better job of identifying when somebody has stepped out of bounds we need to impart therapies and more on the empirically supported principles of change here's why I will give a bit of my own bias away I'm not a big fan of any treatment that has a name especially if the name is in all capital letters because I suspect that that's a package that's being sold and by the way I will put cognitive behavioral therapy on that list because I think that those names mostly obscure what we're doing there are over 400 different kinds of mental health therapy just psychological therapy let alone the medications and I doubt I doubt highly that there are 400 different mechanisms by which patients get better that just seems a little too complex even for the human brain we need to be paying more attention then to descent information to ourselves and to the public about what specific processes work in helping people recover from mental health problems not necessarily in which package with a little trademark or a patent sign after it helps that obscures rather than enlightens and we need to raise the bar for what is considered empirically supported now when I talk about that this is the the empirically supported therapy movement which speaks directly to to the dodo-bird verdict that we were speaking about before there is an increasing movement toward asking people to adopt treatments that are empirically supported meaning supported by evidence and the organization that for to which I was recently elected president of the Society of Clinical Psychology has been the driving force in identifying what the empirically supported psychological treatments are and I believe we got it wrong and here's why we got it wrong right now the Society of Clinical Psychology has two criteria two categories that of efficacy that they will assign to a particular treatment cognitive therapy for depression exposure therapy for PTSD you name it a treatment is determined to be possibly efficacious if it has been proven to be more effective than no treatment in a single randomized controlled trial and it is considered efficacious that is they get to drop the possibly if it's been shown to be more effective than no treatment in two randomized controlled trials problems with this aren't one nowhere in here does it make any statement about the effective mechanisms of the treatment it doesn't you don't have to understand why your treatment works you simply have to demonstrate that it works better than no treatment and there's no provision for negative findings remember if I have two positive randomized controlled trials I'm in I have an effective treatment anybody who has studied statistics knows that if your p level is set to point zero five and you study something 100 times you will probably have five false findings i'm in there is no way for example of getting off of the list because of my 95 negative findings in fact i can even have other findings that show that my patients got worse that they were harmed and yet i would still have an empirically supported treatment i would also add to not on the slide that there's no provision here for how any given treatment fares against another treatment or even against a well validated control condition compare this by the way to how drugs are approved for a drug to be approved it has to go through animal testing preclinical testing clinical testing replication of the clinical testing on a large scale safety testing by the way when it's being tested its tested not against no treatment being tested against a placebo in a double-blind trial in which the patient hopefully doesn't know whether they're receiving the placebo or not sometimes it's even tested it against an existing therapy there's no specification that we do so when it comes to psychological therapies the bar is too low theoretically then anything I come up with if I come up with shoe bashing therapy in which I'm going to cure your depression by bashing you over the head with my shoe my guess is that if I chose to conduct a randomized controlled trial of it and compared it to nothing you'd probably find a difference you maybe you're so depressed you're just happy to have me hitting you on the head with your shoe so you feel somewhat better and I'm on the list I'll tell you who talked about this in a really eloquent way were Gerry Rosen and Gerry Davison who came up with the concept of purple hat therapy one of my favorite developments in the field of clinical psychology here's what they say about purple hat therapy pathetically a doctor could ask clients with driving phobias to wear a large purple hat while applying relaxation and cognitive coping skills to in vivo practice the practitioner places a band of magnets in the purple hats claiming that particular algorithms for positioning the magnets are determined by age sex and personality structure of the client when properly placed so the practitioner claims the magnets reorient energy fields accelerate information processing improve inter hemispheric coherence and eliminate phobic avoidance the inventor might call this method purple hat therapy conduct a single randomized controlled trial against no treatment and apply for listing as an empirically supported treatment and I'm going to leave you then with a final quote from the physicist James Oberg who in looking at all of this information about scientific thinking and pseudo scientific thinking and how we should think straight about the treatments that we're applying said keeping an open mind is a virtue but not so open that your brains fall out and with that thank you very much for having me thank you you

Channel: PsychiatryLectures

Views: 36,365

Keywords: psychotherapy, david tolin, cbt, emdr, nlp, science, pseudoscience, behaviorism, lecture, karolinska institutet, Psychotherapist (Profession), David F. Tolin

Id: trt_tsTW8WY

Length: 68min 16sec (4096 seconds)

Published: Tue Jun 11 2013