The ISTC "Baloney Watch" Archives
If your are looking for something that once appeared on the ISTC "Baloney Watch" pages, you'll find it here!  The material is broken up into four sections based on the type of baloney being presented.  On this particular page, we review baloney associated with therapeutic technique.

Technical Baloney

A Recent Survey of Practicing Clinicians
Evidence-based practice is all the rage.  The assumption, of course, is that training therapist to practice specific models or approaches will improve treatment outcome.  Momentarily setting aside volumes of research showing little difference in outcome between competing treatment approaches, another way of approaching the issue of evidence-based practice is by surveying what average clinicians believe and do in their daily clinical work.  For years, the data has shown that therapists become less committed to particular treatment approaches with time and experience.  And now, a recent study shows that little has change in 15 years.  In spite of being "official policy" of professional organizations and training, the dominant theoretical orientation of practicing clinicians is...you guessed it: Eclectic!  More than double the number of those claiming to be cognitive in orientation.  What's more, consistent with previous research, the number of those claiming to be eclectic grows even larger the longer one is in practice.  The reason?  Well, consider another study by Najavits and colleagues at Harvard Medical School.  Briefly, the researchers examined therapist satisfcation and competence with four manual-based treatments–the sine qua non of evidence-based practice.  On average, it took therapists 8 months to become "comfortable" with the treatment approach.  More to the point, however, "few" indicated that they would be willing to use the treatment without modifications following the study.  Treatment, in their opinion, needed to fit the client, rather than the client being made to fit the treatment.  Well, duh.  Rather than mandating that therapists learn and practice a specific model, perhaps graduate programs and professional organizations could promote strategies for tailoring work to the individual client!

Najavits, L. et al. (2003.  Therapist satisfaction with four manual based treatments.  Psychotherapy, 41(1), 13-25.
Norcross, J. et al. (2002).  Psychologists conducting psychotherapy in 2001.  Psychotherapy, 39(1), 97-102.

Practice-based Evidence versus Evidence-based Practice
Therapists are being told by the powers that be that they must become more "evidence-based" in their clinical work. This strategy, they are told, not only means better treatment but also better public relations for the field. Long given to fads and fashions that have wreaked havoc on public and payor confidence, the idea is that therapists using approaches that research has shown to be effective will increase the prestige and forestall their fall from grace.

Research showing the problems with evidence based practice has been reviewed numerous times this website. You can learn more about this by clicking on "what works in therapy." The question that often arises is, "what should we do instead. We say, "practice-based evidence." That is, find out if this therapy provided by this clinician is making a difference for this client at this time in their life. It's not hard to do and several studies are providing evidence of how well this approach works:

	Putting to rest the old notion of symptom substitution and "flight into health," Hass et al. found that early treatment gains were associated with better maintenance of treatment gains over time. Strategy? Measure such gains, use them to identify clients who are not making expected progress, modify the treatment to increase benefits.
	Of those clients who are making progress, the data clearly indicates that more treatment is better than less treatment. The problem is that therapists often push successful clients out of care earlier and focus more intensely on clients not making progress. A recent review of the literature found that 57.6% of people in a bonafide treatment achieve clinically significant improvement. Strategy? Measure improvement, use that data to extend the treatment of those benefiting from a particular pairing of client and therapist, identify clients not making expected progress so that the treatment can be adjusted or they can see a different therapist.
	Early change in treatment appears to predict eventual success of a particular pairing between client and therapist regardless of the problem. In a recent study of Bulimia Nervosa, clients who did not stop purging at least 70% after 6 visits, we unlikely to respond to completed treatment. Strategy? Look for change early, and then change or modify treatment or therapist when clients are unsuccessful in the initial stages.

Hass, E. et al. (2002). Do early responders to psychotherapy maintain treament gains? Journal of Clinical Psychology, 58, 1157-72

Hansen, N. et al. (2002). The psychotherapy dose-effect...Clinical Psychology, 9, 329-343.

Agras, W. (2000). Outcome predictors for the CBT of BN. American Journal of Psychiatry, 157, 1302-8.

We told you so...more on EMDR
As the old EST saying goes, "I used to think I was different, now I'm the same."  EMDR, like every other model of therapy to come along in the last 40 years, burst on the scene with dramatic claims (and studies) regarding effectiveness and efficiency.  Clinicians signed up in droves to learn the process, hoping–like their clients–that the new methodology would lead to speedier recovery from traumatic events and, of course, happier lives.  Evidence regarding the approach has been reviewed previously on the site questioning claims regarding the supposed "specific ingredients" in the method and differential efficacy.  And now another study.  Researchers in this well controlled study, randomized 60 people diagnosed with PTSD into either exposure-based treatment, EMDR, or relaxation training.  Blind evaluators assessed outcome directly following treatment and at 3 month follow up.  Importantly, outcomes from EMDR and relaxation training were not significantly different.  Furthermore, compared with relaxation training and EMDR, exposure was associated with signficant improvement in re-experiencing and avoidance.  Finally, EMDR showed no evidence of effecting more rapid improvement.

Taylor, S et al. (2003).  Comparitive efficacy, speed, and adverse effects of three PTSD treatments.  Journal of Consulting and Clinical Psychology, 71, 330-338.

Cognitive Behavioral Therapy is the Best, Better, Pretty Good, exactly the same as other treatments in terms of outcome!
Oh, the American Psychological Association is going to be upset now. Ignoring the verdict of 40 years of outcome research, they've been telling everyone that Cognitive-Behavioral Therapy is the best treatment for an ever widening range of problems. Now, a new study shows what experienced therapists have known all along: it works with some and not with others. How do we know this? Well, because group comparisons usually find little difference in efficacy between two competing treatments. Rhyming with history, a recent meta-analytic study in Professional Psychology found that regular exercise worked as well as cognitive therapy in the treatment of depression! Indeed, so effective is exercise that merely a few visits with an exercise trainer provided significant relief. Moreover, those engaged in a regular routine of exercise maintained their gains over a year. Will the APA now seek to have all psychologists certified as exercise physiologists?!

Tkachuk, Gregg A.; Martin, Garry L. (1999). Exercise therapy for patients with psychiatric disorders: Research and clinical implications. Professional Psychology: Research & Practice, 30(3) 275-282

Now read this one . . .
Researchers in the psychology department at Duke University compared the efficacy of Zoloft (an anti-depressant) to an exercise program or combination of the two and found that 60-70% of participants recovered from symptoms of depression within 3 to 4 months in all three treatments. In other words, no difference between the various treatment approaches. Most important, however, the research found that members of the exercise-only group were significantly less likely to have relapse back into depression at 6 month follow up than either the drug or drug plus exercise group. When the only difference between treatment conditions is the drug, one has to wonder when some smart person might suggest that drug treatment actually increases relapse as data from other studies convincingly shows!

Segall, R. (2001). Work it out. Psychology Today, 34(1), 26.

Prayer and Healing: Fad, Fashion, or Therapeutic Fact?
The field of mental health has suddenly re-discovered religion and spirituality. Never mind that this is the very field that charismatically claimed religion and spirituality were the cause of neurosis. Now mental health professionals of all sorts are extolling the virtues of some form of daily religious practice--chanting, crystals, zazen, yoga, or plain old-fashion church attendance. Prayer has been getting a lot of press lately. Usually, some workshop guru claims that "research has established that prayer enhances/speeds/improves healing" from a variety of physical and mental ailments. Giving the tendency toward the strategic use of imaginary studies by such guru-types, however, the question remains, "What does the data really say?

Here's the skinny. There have been 8 empirical studies of intercessory prayer (that is, prayer by someone on behalf of another) since the original study by Sir Francis Galton in 1872 (which, by the way, found no effect of prayer on recovery). Six studies examined the effect of prayer on various medical conditions in children and adults and found no statistically significant effects. One study found an effect but only if accompanied by the recipients positive expectation in the effectiveness of prayer. The most frequently cited study by those praying that prayer proves efficacious was published by Byrd in 1988 in the Southern Medical Journal. In this study, the patients who were prayed for showed significantly less congestive heart failure, cardiopulmonary arrest, pneumonia, and required fewer antibiotics and ventilation. Now, before shouting "Hosanna to the Highest," think about a couple of things: (1) this is one study out of 10, nine of which showed no effects; (2) the latter study did not control for intervening variables already shown to impact recovery (e.g., positive expectancy, age, sex, SES, marital status); and (3) the latter study involved multiple comparisons which increases the chances of finding some statistically spurious significant correlations.

The bottom line when translating this research into clinical practice: Remember, prayer was more likely to work if the people believed it would. Perhaps therapists should stop selling techniques to people (e.g., EMDR, the "Miracle Question," or Intercessory prayer) and instead support the beliefs of the people they work with that contribute to healing and use approaches which are congruent with those beliefs.

Group or Individual therapy?

In these lean economic times, consumers and payers are looking for more cost effective treatment methods. Many have turned to group therapy. After all, you can see multiple clients an hour--like a real doctor (ha ha)--and the clients can, in essence--share the expense. But what does the data say?

A recent meta-analysis of 48 studies on group therapy for depression finds that:

	Group therapy is superior to no treatment.
	The average person treated in a group was better of than 85% of the untreated sample in most studies.
	No difference in outcome between group and individual treatment.
	No difference in outcome between studies conducted in a lab versus those in real world clinical settings.

The study did find a slight advantage ("barely significant") of CBT of psychodynamic therapy. Given previous research finding no such advantage or that such differences are due to researcher allegiance and measure reactivity, however, it's not much to write home about. The good news? Groups work!

McDermut, W. (2001). The efficacy of group psychotherapy...Clinical Psychology, 8, 98-116.

On a related note...when therapy hurts the hurting.
Grief therapy. We've reviewed the research a number of times on the website (see archives). But some ideas...well, for lack of a better expression, just seem to take for ever to die off. Research indicates that those who lose a loved one (not through unnatural or traumatic circumstances) may be depressed for up to three years. More than half may show no obvious signs of grief, however. While judged by some as dysfunctional, the research clearly indicates that those who focus less on the loss and grief, end up healthier over time. What's more, forcing these folks to dwell on the loss may actually retard the grieving process.

Campbell, S. (2002). Does therapy prolong the agony. Psychology Today, 35(4), 28.

Where o' where are the specific ingredients in psychotherapy?
OK. First the good news. And it is good and deserves repeating. Therapy works. Over the last 40 years, study after study finds that the average treated client is better off than 80% of the untreated sample in those studies. Now for the bad news. In spite of years of careful research, the same data has not found any one model, method or approach that results in reliably better outcomes for specific diagnoses.

Despite such findings, legions of folks have continued to argue that certain models are more effective than others and gone in search of the specific ingredients said to be contained in those approaches in order to prove their point. It's a bit reminiscent of the old story about a child who opens his first birthday present only to find it full of poop. Not discouraged, he rips into the next one. And though full of hope, he finds that it and the next one--as well as all his gifts--are full of poop. At that point, he jumps up and begins running through the house. He opens closets, looks under furniture, scans the backyard, etc. When his parents ask him what he is doing, he replies, "with all this poop, I know there must be a pony around here somewhere."

One of the ways that proponents of specific approaches have suggested to assess the importance of technique in outcome is through the development and use of treatment manuals. Indeed, it is virtually impossible to get a study published nowadays unless it includes a treatment manual. The assumption, of course, is that therapists who follow the recipe--that is, do the therapy as prescribed--should get better results. Not so says, most recently, Miller & Binder (2002). In their review of the literature, these authors conclude, "researchers have been unable to draw strong links between treatment fidelity and strong outcomes."

As if that weren't enough, then consider the recent meta-analysis of Ahn and Wampold (2001). These researchers looked specifically at studies designed to tease out specific ingredients said, by the proponents of various models, to account for change in treatment. And what did they find? Well, that there was no difference in outcome when an approach contained the supposed effective ingredients and when it did not! So...put that in your model and make it work.

Miller, S., & Binder, J. (2002). The effects of manual based training on treatment fidelity and outcome. Psychotherapy, 39(2), 184-198.

Ahn, H., & Wampold, B. (2001). Where oh where are the specific ingredients? Journal of Counseling Psychology, 48(3), 251-257.

Whose the most Effective? Therapists or Paraprofessionals?
First, if you're a therapist, be sure you're sitting down before you read this next bit of research...OK, you ready? They're both effective; that is, equally effective. Atkins and Christensen (2001) reviewed the latest data in a special issue on training in The Australian Psychologist, and while bemoaning the inadequacy of many of the studies that exist, the conclude in the end, "the existing evidence supports the efficacy of paraprofessionals." Indeed, after a simple six week course in counseling skills, paraprofessionals achieve roughly equivalent results as professionals.

OK, it's time to admit it: we've been duped. It's also time to do something about the situation. The problem is not that therapists are no more effective than others able to establish helpful relationships, the problem is that the paradigm governing professional practice suggests that we should be more effective. The real difference between professional helpers and any other helpful person rests in the ethical promises professionals therapists make to those they service (e.g., they will not hurt or harm, they will work for the good and not exploit, they will keep a confidence, etc.).

Atkins, D. & Christensen, A. (2001). Is professional training worth the bother. Australian Psychologist, 36(2), 122-130

Should Therapists Self-disclose? No Wonder Therapists are confused!
It's a debate as old as the field itself: should therapist use self-disclosure in therapy? Well, the answer is, "it depends." According to Bryant Welch, a Washington, DC based psychologist and attorney, "self-disclosure of the therapists own feelings and life experiences...(along with touching of the patient and extra-therapeutic contact) would be formally frowned upon by licensing boards." He then continues, "There is no clear research data to support either conclusion...but the clinician...should beware. Coming before a rigid licensing board can be very problematic."

At the same time, several studies have now been published showing the "positive effects of therapists' self-disclosure." In a recent study, for example, Barrett and Berman found that clients reported significantly less symptom distress and liked their therapists more when the therapist disclosed personal information. In addition, they found that experienced therapists were better at it than inexperienced ones.

So what's a therapist to do?

Insight (2001). Keeping up: The need for continuation education (Interview with Bryant Welch). New York: American Professional Agency. .

Barrett, M.S., & Berman, J.S. Is the psychotherapy more effective when therapists disclose information about themselves. Journal of Consulting and Clinical Psychology, 69, 597-603.

Is EMDR Effective?
Sounds like a straightforward question, eh? Well, the answer is, "Yes, it's effective." Now, wait, wait, a minute before you run off to learn the technique. Yes, it is effective, the latest review of the research indicates, but no more so than other established approaches (e.g., exposure, CBT). Additionally--and here's the real zinger, the fly in the ointment so to speak--analyses of the method shows that it works with or without the eye movements. Now think on that one for a minute. It works but no more so than other approaches and any effectiveness has nothing to do with the chief ingredient of the approach. By the way, there's no evidence that the approach is more effective for specific diagnostic groups either (e.g., PTSD).

Whither EMDR in light of this data? Well, if this technique follows historical precedent in the field of therapy, then the proponents of the approach will eventually move away from earlier claims regarding the effective ingredients of the approach, then small groups emphasizing one aspect or another will splinter off and create rival groups, each of these in turn will attract therapists and lead to a waning of interest in the method. In the process, few will recognize the pattern as "more of the same" stuff that has haunted the field since the beginning, nor suggest that such findings are evidence of the operation of common factors in therapy.

Now, of course, this doesn't mean you shouldn't go ahead and take a course in EMDR. For the last 40 years, the data has simply indicated that other less compelling factors are likely responsible for any change that happens in treatment. New approaches may give therapists new and novel ways of operationalizing these factors. Were the field focused on the common factors, however, the list of such techniques would be as many and varied as clients themselves.

Davidson, P. et al. (2001). Eye movement desensitization and reprocessing: A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-316.

Crisis Intervention and Critical Incident Stress Debriefing: Royal Road to Recovery or Iatrogenic Illness?
The arrival of therapists at the scene of tragic events has become routine. Leaders from the professional organizations seek and receive funds for "treating" the traumatized and the efficacy of the treatment is assumed by professionals, the public, and the media. And yet, what do the data say? According to researchers, Gist and Lubin, "The jury is no longer out in deliberation on this matter. . . it is clear that debriefing interventions have no preventive efficacy and hold, at least for some, demonstrable iatrogenic potential.

The intriguing question is, of course, "Why?" It would seem, given the field's time-honored axioms regarding the value of emotive catharsis, the relationship between proximity of intervention and severity of impact, and such that these exercises should--at the very least--be mildly beneficial. Any yet, the the data indicate that they're benign at best and reliably harmful to at least some recipients. Even more troubling, there are reliable data that tell us the intervention is subjectively appreciated by most recipients--indeed, there are suggestions that those who "like" it best may include those for whom paradoxical impacts may be stronger!

So, what does this mean for the field? Some say the field should look for "empirically valid" approaches to the treatment of trauma? We say, trauma is no different than any other problem that brings people into therapy and, therefore, no special approach is needed. Rather, therapists can apply what research conducted over the last 40 years indicates works across models, approaches, and diagnostic classifications.

For more information, check out these references and URL: National Center for PTSD

Gist, R., & Lubin, B. (1999). Response to Disaster. Philadelphia: Brunner/Mazel.

Gist, R., Lubin, B., & Redburn, B.G. (1998). Psychosocial, ecological, and community perspectives on disaster response. Journal of Personal and Interpersonal Loss, 3, 25-51.

Mayou, R.A., Ehlers, A., & Hobbs, M. (2000). Psychological debriefing for road traffic accident victims. British Journal of Psychiatry, 176, 589-593.

And Finally...The Grief about "Grief Work"
"You got to let it out," "stop bottling it up," "get in touch with your emotions." At least that's the common clinical belief when it comes to bereavement and grief. The idea can be traced (at least in modern terms) to Freud's notions regarding melancholy and the idea that healthy resolution involved a period of inward analysis leading to a gradual disconnection from the "lost object." And yet, the empirical data suggest exactly the opposite. In a review of this data, researcher Bonanno actually found that the suppression of sadness and anger and the expression of positive emotions associated with loss are associated with the best outcome (i.e., fewer grief symptoms) at follow up periods ranging from 6 to 25 months. Such data indicate that clinical lore may actually lead to therapies that prolong rather than help people resolve the grief that brings them into treatment.

Bonanno, G. (1999). Toward an integrative perspective on bereavement. Psychological Bulletin, 125, 760-776.

On a related note...What about Suicide Contracting?
More bad news, were afraid. In spite of the fact that "contracting for safety" is standard practice with suicidal people, no studies have examined whether the activity actually works! That's right! The reason for this may be that case law has been more influential than research in establishing standards of clinical practice.

What does the data say? In a mail survey, researcher Kroll examined the rate of successful and attempted suicides following contracting and found that 41% of respondents had people commit or make a serious attempt after entering into a no-suicide contract. While this data tells us nothing of the efficacy of contracting relative to no contracting, it does indicate that no clinician should take excessive comfort from the fact that a suicidal person agrees to contract for safety.

Kroll, J. (2000). Use of no-suicide contracts by psychiatrists in Minnesota. American Journal of Psychiatry, 157, 1684-6.

Eye Movement, Thought Fields, and now Ear Tapping Densensitization?
By now you've heard the miraculous claims being made about EMDR and Thought Field Therapy. Just when you thought nothing more effective would ever be developed, now comes talk of Ear Tapping Desensitization and Remobilization (ETDR). According to some, this new procedure builds on the success of EMDR and TFT by adding taps on the acupressure points on the ear. The only problem with the procedure? It was a joke--a hoax! Yup, a parody of EMDR and TFT suggested "tongue-in cheek" by Gerald Rosen in an article that appeared in Behavior Therapy following his experience in an EMDR workshop. Apparently ready to believe anything, however, therapists began using the technique and writers began extolling it's virtues. You can read about the whole issue at: http://www.ozemail.com.au/~jsjp/etd.htm.

Rosen, G. (2000). Ear today, gone tomorrow. Skeptic, 8(1), 24-25.

More on Thought Field Therapy . . .
In the last update of the ISTC website, information was posted about a review of TFT published in Skeptic magazine. The developer of the approach, Roger Callahan, Ph.D., responded in that same issue about statements made about the approach. The authors of one of the pieces respond to a letter of complaint that Callahan sent to the magazine in which he claimed that the approach and claims made about it were mis-represented. Again, the authors point out that TFT has no empirical support, that the concepts of "thought fields," and "perturbations" are at odds with knowledge about how the body and brain work, that efforts to explain failures are mere post hoc attempts to maintain belief in the approach, and that calls for Callahan to provide evidence of effectiveness have gone unanswered. As the authors point out, "a treatment that is [claimed to be] so vastly superior to any other existing method should be quite easy to verify." The question is, therefore, why--other than enthusiastic testimonials--is there no credible evidence?

Gaudiano, B. et al. (2000). Letter. Skeptic, 24(6), 62.

Searching for the "Quick Fix": EMDR and Thought Field Therapy
Unless you've been asleep or haven't attended a continuing education conference recently, you've probably heard about or been exposed to two therapies heralded as extremely effective for the treatment of trauma; namely, E.M.D.R., and Thought Field Therapy (TFT). The testimonials from clients and therapists claim that both approaches are more effective than "traditional" approaches--the developer of the latter claims the method words with 80-98% of the time! Of course, the success of the methods have led to a variety of "copy cat" approaches including: Tapas Acupressure Technique, Ear Tapping Desensitization and Remobilization, and Emotional Freedom Technique. Claims have even been made that these approaches might cure cancer! What does the evidence say? The answer is, "What Evidence?" In the case of EMDR, for example, the most recent controlled studies have consistently failed to find that the method is faster or superior and that the supposed active ingredient (eye movements) have no therapeutic power whatsoever. This leaves the American Psychological Association in a bit of a bind given that the organization recently designated EMDR an "Empirically Validated Treatment." Oh yeah, the developer of the approach was also awarded the 1994 Distinguished Scientific Achievement Award for discovering the method. How quick we forget. The award should have gone to Franz Anton Mesmer whose work and development, researcher R.J. McNally (1999) argues, closely parallels the development of EMDR.

So, if you'd like to evaluate whether a "new" approach is credible simply ask whether the approach is similar to other "miracle methods" to have appeared throughout the history of the field.

Characteristics of "Miracle Cures"

	The approach is discovered through a personal epiphany.
	The approach is proclaimed useful for a large range of ailments.
	The developers establish lucrative training institutes and insist on trainee secrecy.
	The developers inspire the founding of professional societies to promote the approach.
	The developer offers pro bono therapy in the face of criticism.
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