"NONSCIENTIFIC PRACTITIONERS. It is unethical to engage in or to aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care until his or her condition becomes irreversible."Section 3.01 AMA Code of Ethics
The Code of Ethics of the American Medical Association states clearly that professionals should use scientifically based treatments. Yet a study by W.C. Sanderson [1] shows that even though there are now many evidence-based treatments (EBT) for specific psychiatric disorders and even though these are recommended for use by professional organizations, practitioners typically do not use them. He suggests that the reasons this is the case is that (1) professionals do not have the skill to administer these treatments; (2) continuing-education programs do not require training in EBTs or (3) many clinicians have a negative bias toward them. Sanderson concludes that the failure to adopt evidence-based therapies may have a "disastrous impact on the viability of psychotherapy as the healthcare system evolves."
1. Sanderson, W.C. "Are evidence-based psychological interventions practiced by clinicians in the field?" Medscape Mental Health, 7(1), 2002
For information about the therapies have been validated for specific disorders, the reader may go to the website of the American Psychological Association: An Update on Empirically Validated Therapies, by Dianne L. Chambless and colleagues from APA Division 12.
Readers may also find August Piper, MD's comments on this topic to be of interest:
PSYCHOTHERAPIES: VALIDATED AND UN
August Piper, M.D.
The False Memory Syndrome Foundation has recently begun to note that
recovered-memory therapy is an unvalidated form of psychotherapy,
implying that such therapy is experimental (see page one of the
October Newsletter). Though the concerns leading to these criticisms
are understandable, attempts to make such implications oversimplify a
complicated problem.
In scientific terminology, if something is valid, it does what it is
supposed to do. Thus, a validated therapy effectively treats the
condition it is intended to treat. As correctly noted in the October
newsletter, investigators have measured the effectiveness of various
talk therapies. However, such measurement is extraordinarily
difficult, for several reasons.
Psychotherapy is severely hobbled by a distressing lack of agreement
among its practitioners on the answers to several critical questions.
First is the question of what the goals of treatment are. Does the
therapist intend simple symptom relief, recovery and reliving of past
stressors, insight into the causes of the patient's problems, change
in maladaptive behaviors, a thorough remaking of the personality, or
what? Second, what criteria should be used to measure improvement?
Measuring psychotherapy-induced change is a minefield of
difficulty. Third, how much time should treatment require? Some
therapists seriously recommend compressing an entire treatment course
into a single session, whereas at the other extreme, treatment has
endured in some cases for years. I have even heard of one patient who
was in analysis for thirty (!) years.
Another difficulty is that psychotherapy has failed to adopt a
uniformly-accepted method of classifying and designating the
conditions it is concerned with. Such a system of classifying and
arranging disorders is called a nosology. The Diagnostic and
Statistical Manual, now in its fourth edition (DSM-IV), represents a
good start toward such a nosology. However, it is only a start; DSM
shows particular problems in classifying disorders that are treated by
psychotherapeutic methods (as opposed to pharmacological ones).
In the absence of a good nosology, attempting to do psychotherapy
research becomes an arduous, frustrating undertaking. This is true
because the symptoms of psychological conditions overlap so much. For
example, depression is a very common symptom of all psychological
disorders. In some, depression is the legitimate focus of therapy: it
is the problem. In others, however, the very same symptom picture
results from any or all of a host of other conditions: drug or alcohol
use; marital, social, or economic problems; medical conditions; other
psychiatric disorders; childhood stressors; etc. Determining the
"real" cause of the depression can be nearly impossible -- witness the
acrimonious debate over those therapists who claim that childhood
sexual abuse is the real cause of many, if not all, adult psychiatric
problems, including depression. This overlap, in turn, means that
researchers can never be sure that their study groups differ only in
the variable under study.
With so many problems and so much disagreement within the field, and
with no formal arrangements for those outside the discipline to
establish standards for psychotherapy, no one should be surprised that
poorly-validated treatments for psychological problems periodically,
like locusts, overrun psychotherapy. Counting the protuberances of a
patient's head (phrenology); believing that runaway black slaves have
a disease (drapetomania); passing magnets over the body (mesmerism);
spraying patients with water, or putting them in wet packs or
rapidly-rotating chairs; believing that a woman can have excessive
envy of the penis, or develop a wandering uterus (hysteria);
surgically attacking the brain (lobotomies) -- all have had their days
in the sunlight.
My purpose here is neither to make excuses for psychotherapy's
problems, nor to attack the discipline, but rather to point out how
difficult it is to validate therapies. The reader who recognizes this
will not think an unvalidated therapy is necessarily a bad therapy:
because it is so difficult to prove that a given psychological
treatment is effective, many commonly-used psychotherapies are
unvalidated. Nor will the reader fail to realize that saying a therapy
is valid does not go far enough: the question should be, "For which
conditions is it valid?"
After all the above is said, however, the essential points made in
last month's newsletter article remain correct: many investigators
have carefully gathered evidence documenting that one or another
treatment, if performed properly, helps patients. In other words,
these psychotherapies have been validated. Also, instruction manuals
for several different types of psychotherapy are available to
practitioners. The manuals are intended to insure that the therapy is
performed properly.
Many patients, who have disorders treatable by validated
psychotherapies, see recovered-memory practitioners instead. These
practitioners have recently come under increasing fire because of the
harm their treatments can do. Therefore, the question must indeed be
asked: with so many better choices available, why would anyone see
therapists who practice a form of treatment that can do such harm?
People considering psychotherapy are well advised to spend a few
minutes, either on the telephone or in person, to find out whether the
clinician utilizes a kind of therapy that has reasonable evidence for
efficacy. The list in last month's newsletter might be helpful.
August Piper Jr. M.D. is a psychiatrist in private practice in
Seattle, Washington. He is a member of the FMSF Scientific and
Professional Advisory Board.