ASSOCIATION for BEHAVIORAL and ISSN 0278-8403 ABCT COGNITIVE THERAPIES

▲ VOLUME 41, NO. 1•JANUARY 2018 the Behavior Therapist

SPECIAL ISSUE PSEUDOSCIENCE Introduction to the Special Issue in Mental Health Tr eatment Pseudoscience in Mental Special Issue Editor: R. Trent Codd, III Health Treatment: What Remedies Are Available? R. Trent Codd, III Introduction to the Special Issue: Pseudoscience in Mental R. Trent Codd, III, Cognitive-Behav- Health Treatment: What Remedies Are Available ● 1 ioral Therapy Center of WNC, P.A. David N. Rapp and Amalia M. Donovan The Challenge of Overcoming Pseudoscientific Ideas ● 4 MANY MENTAL HEALTH professionals deliver David Trafimow interventions that are unsupported by science. The Scientist-Practitioner Gap in Clinical Psychology: These interventions range from inert to harm- ful. In addition, many consumers of psycholog- A Social Psychology Perspective ● 12 ical services espouse confidence in scientifically William O’Donohue unsound theories and their associated interven- Science and Epistemic Vice: The Manufacture and Marketing tions. The behavioral consequences of such of Problematic Evidence ● 19 confidence is frequently consumer pursuit of unhelpful treatment, often to the exclusion of William C. Follette treatments with empirical support. Clinician Pseudoscience Persists Until Clinical Science and consumer allegiance to unsubstantiated Raises the Bar ● 24 treatments is a major barrier to the optimal care of persons with psychological difficulties. Clara Johnson, Shannon Wiltsey-Stirman, and Heidi La Bash An example of how pseudoscience has inter- De-implementation of Harmful, Pseudoscientific Practices: fered in my own clinical practice is instructive. An Underutilized Step in Implementation Research ● 32 There is widespread agreement in the scientific Stuart Vyse community that exposure and response preven- What’s a Therapist to Do When Clients Have Pseudoscientific tion (ERP), which has been available for Beliefs? ● 36 decades, is the gold-standard treatment for obsessive-compulsive disorder (OCD). Yet, it is Dean McKay unclear whether most persons with OCD The Seductive Allure of Pseudoscience in Clinical Practice ● 39 receive ERP rather than treatments not indi- cated or even contraindicated in the treatment Scott O. Lilienfeld, Steven Jay Lynn, and Stephen C. Bowden of OCD. Many anecdotes illustrative of this Why Evidence-Based Practice Isn’t Enough: problem are available for sharing. Also available A Call for Science-Based Practice ● 42 are examples of patients involved in ERP who simultaneously received competing advice that Lisa A. Napolitano undermined their treatment and did not com- Pseudotherapies in Clinical Psychology: port with the scientific database pertaining to What Legal Recourse Do We Have? ● 47 OCD. One salient anecdote involves a former patient of mine with particularly severe OCD Monica Pignotti symptoms. During my attempt to deliver ERP Exposing Pseudoscientific Practices: Benefits and Hazards ● 51 to him, this patient was variously advised to

[Contents continued on p. 2] [continued on p. 3]

January • 2018 1 the Behavior Therapist Contents, continued Published by the Association for Behavioral and Cognitive Therapies 305 Seventh Avenue - 16th Floor New York, NY 10001 | www.abct.org At ABCT (212) 647-1890 | Fax: (212) 647-1865 Classified ● 54

Call for Nominations for ABCT Officers ● 55 Editor: Kate Wolitzky-Taylor Awards & Recognition Ceremony, 2017 ● 56 Editorial Assistant: Bita Mesri Call for Award Nominations, 2018 ● 58 Associate Editors RaeAnn Anderson 52nd ANNUAL CONVENTION

Katherine Baucom Preparing to Submit an Abstract ● 60

Sarah Kate Bearman Understanding the ABCT Convention ● 61 Shannon Blakey Call for Continuing Education Sessions ● 62 Angela Cathey Call for Papers (General Sessions) ● 63 Trent Codd David DiLillo ABCT and Continuing Education ● 64 Lisa Elwood Clark Goldstein David Hansen Katharina Kircanski Richard LeBeau Angela Moreland Stephanie Mullins-Sweatt Amy Murell Alyssa Ward Tony Wells Steven Whiteside Monnica Williams INSTRUCTIONS Ñçê AUTHORS ABCT President: Sabine Wilhelm Executive Director: Mary Jane Eimer The Association for Behavioral and Cog- Submissions must be accompanied by a Director of Communications: David Teisler nitive Therapies publishes the Behavior Copyright Transfer Form (which can be Therapist as a service to its membership. downloaded on our website: http://www. Director of Outreach & Partnerships: Eight issues are published annually. 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Please also All items published in the Behavior Therapist, includ- ited to approximately 3 double-spaced include, as an attachment, the completed ing advertisements, are for the information of our read- manuscript pages. copyright transfer document. ers, and publication does not imply endorsement by the Association. 2 INTRODUCTION TO THE SPECIAL ISSUE: PSEUDOSCIENCE seek chiropractic care, neurofeedback, and tific treatments seem to propagate, the to pseudoscientific psychotherapy and even allergy shots! For clarity, those inter- debunking model can only result in an offers some recommendations for remedi- ventions were all recommended specifi- endless game of whack-a-mole. Other ation. Lilienfeld, Lynn, and Bowden (this cally for his OCD. Sadly, I was not particu- strategies have been tried too, of course, issue) then note that evidence-based prac- larly persuasive and, despite my including various forms of advocacy, edu- tice (EBP) has not been particularly suc- recommendation not to do so, this individ- cation campaigns, and legislative efforts. cessful in impeding the spread of pseudo- ual pursued each of these interventions, Yet, the problem remains. science in psychotherapy. Consequently, one after the other, as each failed in turn. The primary objective of this special they introduce and argue for science-based Notably, the patient neglected ERP as he issue is to explore alternatives to the pure practice as an alternative to EBP. worked through this sequence of treat- debunking model. The contributors' acad- Then, Napolitano (this issue), trained in ments. Also notable is that this patient’s emic disciplines differ, affording fresh per- both clinical psychology and law, OCD symptoms were so impairing that he spectives stemming from their unique and approaches the problem from a legal per- was unable to maintain employment and varied vantage points. Experimental psy- spective. She makes the case that profes- thus he struggled financially. He was not chologists Rapp and Donovan (this issue) sional associations and government agen- able to compensate with monetary assis- open the issue with a presentation of an cies have been ineffective in protecting tance from his family because they did not experimental literature that can inform the consumers and the mental health profes- possess robust financial resources. How- construction of interventions targeted at sions from the negative impact of ever, his financial obstacles did not impede the remediation of pseudoscientific beliefs. pseudotherapies. Consequently, she his pursuit of the recommended interven- Next, Trafimow (this issue) provides a emphasizes the value of exploring legal tions. Although all of these interventions social psychological perspective and options and suggests a specific legal strat- were expensive, the allergy shots were par- addresses two main areas. First, he suggests egy. ticularly costly because they entailed travel improvements in the science of clinical Finally, Pignotti (this issue) provides us costs (e.g., airfare, accommodations) as the psychology, an area also emphasized by with an account of her efforts in exposing provider of this intervention resided out of other contributors to this special issue. harmful practices and the high personal state. This patient never returned to me for Second, he recommends a line of research and professional costs of her having done treatment, so his terminal outcome is focused on practitioner behavior change so. There’s much to be learned, as well as unknown. However, my belief, based on using the Reasoned Action Approach admired, from a reading of this history. She the science, is that the odds of treatment (Fishbein & Ajzen, 2010). concludes by providing her reflections of success with ERP at my office were favor- O’Donohue (this issue) and Follette what might be learned from her experi- able. (this issue) focus on research methods in ence. The problem of pseudoscience in clinical psychology. More specifically, The problem of pseudoscience in mental health treatment is not new, unfor- O’Donohue introduces the concept of epis- mental health treatment is significant. tunately. Scientifically minded practition- temic virtue and suggests that it has not Please do not read these articles and then ers have directed their attention to this received adequate attention in CBT fall into inaction. Allow these articles to problem. One of the primary approaches to research. He then underscores its impor- stimulate action: Share them widely, exe- addressing this problem involves the appli- tance and provides recommendations for cute the actionable items they suggest, cation of critical analyses to various pseu- improving its presence in CBT science. and/or initiate a new line of empirical work doscientific methods followed by the dis- Follette (this issue) argues that the histori- based on their content. Numerous suffer- semination of these analyses to consumers cal emphasis on efficacy studies in clinical ing human beings are counting on you. and professionals. The hope, of course, is psychology to the exclusion of tests of that these analyses will impact the behavior mechanisms of change has allowed pseu- Reference of practitioners and their clientele. doscientific interventions to persist by Fishbein, M., & Ajzen, I. (2010). Predicting Whether this approach is effective is dubi- claims of effectiveness. and changing behavior: The reasoned ous, yet it seems to be the dominant strat- Johnson, Wiltsey-Stirman, and La Bash action approach. New York, NY: Psy- egy pursued historically. For example, (this issue), coming from the vantage point chology Press (Taylor & Francis). when soliciting manuscripts for this special of dissemination and implementation issue, even a well-known pseudoscientific researchers, discuss de-implementation or ... treatment debunker had difficulty imagin- the discontinuation of previously imple- ing how he could contribute without mented practices. They consider the gener- “taking down certain approaches” specifi- alization of de-implementation models for The author has no funding or conflicts of cally by name. This seems to be the addressing the problem of pseudoscientific interest to disclose. common way of approaching this problem practices. Correspondence to R.Trent Codd, III, among well-intentioned scientists. Next, behavior analyst Stuart Vyse (this Ed.S., LPC, BCBA, Cognitive-Behavioral My objection to the debunking model is issue) addresses the problem of clients who Therapy Center of WNC, P.A., 1085 Tunnel not a moral one. Rather, given the abun- are committed to non-evidence-based Road, 7A, Asheville, NC 28805; dance of pseudoscience, it seems safe to therapies. He offers several strategies for [email protected] conclude that a debunking model isn’t par- reasoning with these types of clients based ticularly effective. Even if it were successful, on recent research on effective discrediting it’s not a practical solution because there of misinformation. are simply too many pseudoscientific inter- This is followed by McKay (this issue), ventions to address one-by-one. If one con- who contemplates why mental health pro- siders the rate at which new pseudoscien- fessionals may be particularly susceptible

January • 2018 3 The Challenge of Overcoming Pseudoscientific sure to this pseudoscientific claim can have problematic consequences. Our discussion Ideas then focuses on processes of memory and learning that should, under most circum- stances, support successful comprehen- David N. Rapp and Amalia M. Donovan, Northwestern University sion, but that can also result in uptake and reliance on inaccurate information. Articu- lating the contributions of these processes PEOPLE HOLD MANY different kinds of also often reject wholesale the need for sci- for comprehension helps identify condi- beliefs. Some are rooted in direct experi- ence by disregarding consideration of tions and activities that may help reduce ences, such as that at the end of the day the experimental controls, the importance of reliance on inaccuracies (Rapp, 2016). We sun will set, and in the morning the sun will accumulated evidence, and the theoretical conclude by outlining other factors that, in rise in the sky. Others are derived from supports underlying empirically based concert with these processes, contribute to explanations and evidence communicated claims. In efforts to reject scientific consen- the pervasive effects of pseudoscience. Our by outside sources, such as learning in sus and to promote their beliefs as valid work attempts to identify these contribu- school that the world is round. The hope is alternatives, these advocates often contend tions so as to inform theoretical accounts of that our direct experiences with the world, that nobody can actually know the truth, pseudoscientific thinking, and to support and the knowledge provided by others, will that evidence and experiments can be the design of interventions intended to converge and be accurate, such that we can biased (sometimes invoking conspiratorial combat the acquisition and persistence of use what we have learned to make deci- stances), and that school-supplied under- inaccurate beliefs. sions and solve problems successfully in standings of the world are derived from the future. The problem, unfortunately, is book claims rather than from what experi- Consequences of Exposure to that our direct experiences can encourage ence tells us (Lewandowsky, Gignac, & Inaccurate Information beliefs that are incorrect (diSessa, 1993; Oberauer, 2013; Lewandowsky, Oberauer, Vosniadou & Brewer, 1994), and informa- & Gignac, 2013). Contemporary concerns To begin, consider the following tion provided by others can be wrong (Gar- about the growth of pseudoscience are excerpt from a story in which a conversa- rett, Weeks, & Neo, 2016; Rapp & Braasch, becoming increasingly worrisome, linked tion between two characters, Dane and 2014). to recent sociopolitical events, the ease of Brad, turns to the topic of mental illness: For example, consider standing on the publishing information through online edge of a beach, peering out at the water. In sources, and concerns about journalistic As quickly as Brad had become the distance you can see the horizon. This investments and integrity (Kahne & excited, he calmed down …"Well," he perceptual experience can suggest that the Bowyer, 2017; Lewandowsky, Ecker, said, "if I'm crazy, it's only because world just ends; it isn’t curved, but rather Seifert, Schwarz, & Cook, 2012). you were crazy first and you keep seems to drop off at some distance far Pseudoscientific beliefs can have impor- breathing on me all the time —I away. What we are seeing does not accu- tant consequences for everyday behaviors caught it from you." rately inform us as to the actual shape of the and decisions, including our health and Dane laughed and said, "I bet you Earth. Also consider that there are groups well-being. Consider one particular pseu- think you're being funny." that subscribe to the incorrect idea of a flat doscientific belief—the notion that mental Earth, presenting the view with anecdotes illnesses are contagious maladies that you "Right now, I'm just being brain- and personal tests intended to raise skepti- can catch from another person, similar to dead." cism that we do not live on a spherical the cold or the flu. We highlight this partic- planet (e.g., the Flat Earth Society). Our ular belief for three reasons. First, the topic Dane forged ahead: "No, really, direct experiences, and the information connects with the theme of this special there's now evidence that you can supplied by other people, as exemplified in issue as considered in other articles in this catch some forms of mental illness this case, can inform inaccurate beliefs volume. Second, this belief has received from your friends and loved ones. . .. about the world. extended examination in the psychological I was really amazed when I read this This case also provides an illustrative literature, as accounts attempt to highlight stuff. . . . They now have shown that example of pseudoscience, which we can factors associated with possessing it, as well there are some mental troubles that define as a set of claims, beliefs, and prac- as potential outcomes associated with such are passed through the air." tices that invoke notions of scientific inves- thinking (Marsh & Shanks, 2014). Third, "Mental troubles?" tigation but that are actually based on mis- this belief is one of a series of incorrect understandings and misapplications assertions that we have explicitly tested in "Sure — paranoia, hallucinations, (sometimes intended and sometimes not) our own research focused on the conse- fits. All the good stuff. You never of the scientific method. Pseudoscientific quences of exposure to inaccurate informa- know what you'll breath in nowadays. conjectures lack and often run counter to tion. Focusing on this belief helps highlight You could catch almost anything just scientific claims derived from accumulated the broader consequences of learning by being breathed on by the wrong and generally accepted evidence (Lobato, about false information as identified in person. It's amazing that more people Mendoza, Sims, & Chin, 2014). Some pseu- empirical projects (e.g., Marsh, Meade, & aren't aware that mental illness can be doscientific beliefs have their bases in naïve Roediger, 2003; Rapp & Braasch, 2014), highly contagious." preconceptions about biology, physics, and and is situated with awareness of and chemistry (e.g., Vosniadou & Brewer, respect for work on mental health treat- In a series of experiments (Rapp, Hinze, 1992). Advocates of pseudoscientific beliefs ment. In our analysis, we show how expo- Kohlhepp, & Ryskin, 2014), participants

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ISBN: 978-1626259430 | US $16.95 Re sources Edition New RAPP & DONOVAN were asked to read a 19-page story, almost contagious,” as compared to participants features of routine cognition that con- 8,000 words in length, that potentially con- who read a version of the story in which the tribute to these effects. tained this excerpt, as well as other conver- assertion about mental illness being conta- Fluency sations between characters, none of which gious was discussed by the characters as were integral to the plot. Some of the con- being obviously wrong. What is notewor- Our judgments about what we know, versations contained inaccurate assertions thy about this finding is that the assertions and the degree to which what we know is about the world, as in this example, while used in these experiments had been previ- accurate or requires additional contempla- other conversations offered more valid ously normed with members of the popula- tion and consideration, is influenced by a assertions. Two versions of the story were tion from which participants were sampled host of factors. One factor that has received constructed, with participants assigned to (i.e., undergraduate psychology students at substantial empirical investigation is the read one or the other, to counterbalance Northwestern University), which indicated ease with which people feel they can access the 16 presented assertions for accuracy they should have been familiar with and information from memory. This is defined (i.e., 8 of the assertions in each version were known which version of the claim was as fluency, and our feelings as to how flu- presented in an inaccurate form, with the accurate. Yet despite their accurate prior ently we can retrieve our existing under- remaining 8 presented in an accurate knowledge concerning the potential trans- standings and recall what we have experi- form). After reading one version of the mission of mental illness, participants’ enced also informs expectations as to how story, participants completed a distractor decisions were contaminated by what they valid we consider that information (Op- task to discourage rehearsal and reflection read. penheimer, 2008). Feelings of fluency are on the story contents. Finally, participants These results have been replicated a often useful as information that we are were presented with a series of statements variety of times and emerge across the dif- more familiar with and have thought more and asked to indicate whether each state- ferent assertions used in the texts (e.g., Seat about is often information we should ment was true or false. This validity judg- belts do/do not save lives; Brushing your indeed feel confident in accepting and ment task included statements that refer- teeth can lead to/prevent gum disease; Aer- reporting. Information that is easily enced ideas offered in the 16 critical obic exercise strengthens/weakens your retrieved from memory is often considered assertions, and was administered as a mean heart and lungs; e.g., Gerrig & Prentice, to be more true than is information for of assessing whether the story content 1991; Prentice, Gerrig, & Bailis, 1997). which we have to exert effort and delibera- influenced participants’ postreading con- Besides assertions, similar problematic tively search memory to consult (Fazio, siderations of assertion content. Two ver- effects emerge when participants are pre- Brashier, Payne, & Marsh, 2015). Accurate sions of the validity judgment task were sented with inaccurate declarative state- information should be more easily avail- created such that half of the statements ments (e.g., The Pilgrims sailed to America able than inaccurate, inappropriate infor- were presented as true and the remaining on the Mayflower/Godspeed; The scientist mation; it should be the information we half were presented as false. who discovered radium was Curie/Pasteur; can quickly deliver and apply when we With respect to our example, half of the Abraham Lincoln was assassinated by need it. participants read the story, including the Booth/Oswald), which can subsequently be The challenge is that a variety of cues above excerpt (as well as 15 other asser- used to answer related questions (e.g., can confer feelings of fluency that inappro- tions), while the other half read a version Hinze, Slaten, Horton, Jenkins, & Rapp, priately invoke such confidence (Reber & that rejected the notion of mental illness as 2014; Marsh 2004). The accumulated Schwarz, 1999; Unkelbach, 2007). As such, being contagious with similar linguist con- results indicate being exposed to inaccurate information that is retrievable can be mis- tent (and again, along with 15 other asser- information negatively impacts people’s takenly believed to also be true, or more tions). During the judgment task, for half attempts to make decisions and answer modestly, is less likely to be submitted to of the participants one of the test items queries involving that same information, careful evaluation and rejection. Consider, asked them to determine whether the state- even when they should know better. for example, having recently read a text ment, “Most forms of mental illness are promoting the claim that mental illness is contagious” was true or not, while the other Mechanisms That Influence Reliance contagious. Memory traces for that half of the participants were asked to judge on Inaccurate Information recently encoded information are now the statement, “Most forms of mental ill- more available for retrieval than other, less ness are not contagious.” Again, this is only Recent work has articulated underlying recently experienced ideas and events. one of a range of test statements included cognitive processes associated with People can misattribute the phenomeno- for all participants in the task. memory, language, and comprehension logical feeling that the information is easily The results indicated that participants that contribute to people’s reliance on available as an indicator that the informa- who previously read inaccurate assertions patently inaccurate information (Marsh, tion is valid. This misattribution process is were more than twice as likely to make Cantor, & Brashier, 2016; Rapp & Braasch, thus a potential contributor to people’s use incorrect validity judgments, regardless of 2014; Rapp & Donovan, in press; Rapp, of inaccurate information, as well as a rou- the kind of test statement they were asked 2016). To be clear, these processes support tine consequence of the normal operation to evaluate (i.e., true or false), as compared the development of accurate understand- of memory. to participants who previously read accu- ings, as they facilitate the encoding and We might expect that fluency effects rate assertions. Specifically, if participants retrieval of correct information people based on the recency with which we have read the earlier excerpt, they showed have experienced. The challenge is that experienced information would fade, as greater difficulty rejecting the claim, “Most these processes operate generally, with encoded information, when unrehearsed, forms of mental illness are contagious,” as problematic consequences when people are becomes more difficult to retrieve after well as greater difficulty accepting the state- exposed to inaccurate information. To going unconsidered for some time. While ment, “Most forms of mental illness are not exemplify this issue, we discuss here two this is a reasonable inference, it would

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January • 2018 7 RAPP & DONOVAN necessitate individuals never being exposed should carefully evaluate information, sitates overcoming the routine, heuristic to the inaccurate information again so as to skeptically contemplate what they read, processing we engage in and that is often allow those earlier acquired memory traces see, or hear, and recruit relevant knowledge effective and efficient for everyday reason- to decay or at least be less accessible given to reject information that is incorrect. Out- ing (McNeil, personal communication, less attention. This may never actually side of the issue that people often do not September 1, 2017). happen in the real world, though, despite have the appropriate knowledge to conduct Added to this issue, information in being a condition that could be usefully set such evaluations, they also do not routinely memory is, at least initially, reactivated up and studied in a lab setting. In the real engage in careful appraisals of information through a process some researchers have world, people are often exposed and reex- content or of the sources providing that identified as automatic and unguided posed to inaccurate information. For content even when they should. And if they (Cook, Halleran, & O’Brien, 1998; O’Brien, example, imagine reading a post on social do engage in such activity, the products of 1995), meaning without being strategically media presenting a pseudoscientific argu- their evaluations are not guaranteed to lead retrieved. When a particular cue provokes ment for mental illness being contagious. to careful encodings of credibility or accu- retrieval in memory, concepts broadly Such information is often repeatedly racy (Isberner & Richter, 2014). associated with that information becomes reposted by others, making it more likely For example, when participants are pre- activated, with some of those concepts that it will not just be seen once but several sented with information from a source that rising above threshold to be brought into times. Repeated exposure to inaccuracies should not be considered reliable, unless conscious awareness. The challenge is that can bring with it increased feelings of valid- they receive instructions, repeated concepts broadly associated with a retrieval ity in at least two ways. First, repetition reminders, and guidance to reflect upon cue can become activated, including closely helps ensure the information remains and base decisions on source credibility, related and indirectly related information. recently experienced. Second, repeated their subsequent understandings do not Given that activated memories are likely exposures can make the information feel seem to include an acknowledgement of a not effectively tagged, a routine conse- more familiar, with ready familiarity also lack of credibility (Sparks & Rapp, 2011). quence of retrieval is that inaccurate infor- conferring feelings of fluency (McGlone & Several studies have shown that readers do mation might become available for use. Tofighbakhsh, 2000). The consequence is not outright reject information from unre- In sum, comprehension involves that repeated experience with an inaccu- liable sources, unless the credibility of those encoding information into memory for racy can be misattributed as meaning the sources is explicitly identified and associ- subsequent retrieval. Because people may information is more true, or that it should ated with performance concerns or not routinely add tags to those encodings be relied upon, or that it might be recruited repeated reminders (Andrews & Rapp, that reflect the credibility or validity of in future considerations about the same 2014). Source monitoring, the process by what has been experienced, retrieval can topic. which individuals encode information involve reactivating inappropriate, inaccu- To summarize, feelings of fluency can about the person or group providing infor- rate concepts. Activated inaccurate infor- convey information about the validity of mation, does not seem to be a routine activ- mation in memory, including pseudoscien- information in ways that are inappropriate. ity during comprehension (Johnson, tific claims, even after they have been Those feelings can be driven by the recency Hashtroudi, & Lindsay, 1993). Tagging debunked, can thus have effects on subse- with which we have experienced informa- information as credible or unreliable quent comprehension and decision tion, and the degree to which we have been would be useful for guiding subsequent making. repeatedly exposed to that information. judgments that invoke retrieval of that Political groups and news agencies often information. But lacking such tags, infor- Discouraging the Use take advantage of these feelings, sometimes mation that was encoded as false can still be of Inaccurate Information intentionally and sometimes without retrieved for subsequent use. awareness of the consequences. These cues The seeming negligence to engage in Given these processes are routinely are also often explicitly associated with such tagging can emerge for a variety of recruited in the service of comprehension, techniques that advertisers, lawyers, and reasons, but one important explanation and when enacted on accurate information authors, among other groups, rely upon to relates to the allocation of people’s limited are supportive and necessary for building convince, persuade, and entice their audi- cognitive resources. In our efforts to com- effective understandings, determining ences (Johar & Roggeveen, 2007; Sundar, prehend information, we apply mental ways of “correcting them” when informa- Kardes, & Wright, 2015). All of these cases resources to determine meaning, build tion is faulty is both challenging and poten- could involve pseudoscientific claims. inferences, rehearse content, and derive tially misguided. Much of the information These cues are often useful for informing interpretations (along with a host of other we routinely encounter is, after all, worth feelings as to whether information should processes). This leaves fewer resources relying upon. With this in mind, a variety be trusted and whether it might be true, of available for other processes that are not of recent experimental findings from our course. However, in many circumstances, necessarily critical to building meaning in lab have revealed situations in which those cues are at best uninformative and at the here-and-now, such as source monitor- people are more effective at rejecting inac- worst misleading. ing. As a consequence, information curate information. These findings high- encoded into memory can be jumbled light important features of memory and Source Monitoring together without an effective indexing of language processing that delineate the Another issue relevant to people’s expe- which information is accurate and reliable, allure and influence of pseudoscientific riences with information is that they do not and which information is inaccurate and claims. seem to be particularly adept or systematic should be discounted for further use When confronted with information at tagging information as accurate or inac- (Schwarz, Sanna, Skurnik, & Yoon, 2007). that is patently inaccurate, people may nev- curate. In the best of situations, people Engaging in more careful evaluation neces- ertheless encode the information into

8the Behavior Therapist OVERCOMING PSEUDOSCIENTIFIC IDEAS memory, despite being aware it is wrong. genic spirits and demons), the likelihood are involved in developing and testing And once that information is encoded, it they might consider that idea later is greatly ideas. Increased awareness and familiarity can potentially be reactivated later to influ- reduced, in contrast to when the account is with applying a scientifically based per- ence comprehension. To combat this, we more plausibly motivated (e.g., other spective should help readers call into ques- have instructed participants to carefully people’s behaviors might inform how we tion the kinds of unsubstantiated claims edit what they are reading as a text unfolds should behave). Some individuals might and false information commonly presented (Rapp, Hinze, Kohlhepp, et al., 2014). For still endorse even implausible ideas in in pseudoscientific discourse. example, when a participant encounters efforts to support their existing world- pseudoscience that sounds dubious, they views, but implausible information often Concluding Thoughts might note skepticism about that informa- calls attention to explicit inconsistencies, tion, or annotate correct ideas that are not discrepancies, and logical leaps that mark The cognitive factors discussed above being reported. These kinds of edits are information as inappropriate. These quali- that support attention to and reliance on likely effective because they encourage an ties can encourage careful evaluation and inaccuracies are one set of contributors to encoding of the accurate information that tagging of that information as wrong. people’s use of pseudoscientific claims such is already known, rehearsing that knowl- In both of the above cases, individuals as a flat earth and mental illness as being edge as participants retrieve it and write it must be given the motivation to carefully contagious. But these are far from the only down as they edit. This helps ensure the consider the validity and plausibility of contributors to such problematic acquisi- accurate information will be available later, what they read, as well as the appropriate tion and reliance. There are a host of other and discourages encoding the inaccurate tools for engaging in evaluation. These are considerations that, in concert with the information into memory. skills that people differentially possess, and routine operations of human memory and Sometimes text content itself can that they opt to apply in different contexts language, can lead to surprising and prob- reduce reliance and enhance evaluation, as to varying degrees (Gottlieb & Wineburg, lematic endorsements. People’s naïve the- has been shown when participants 2012). The upshot is that explicit training ories as to how the world works often encounter false information that is implau- on evaluation and media literacy may be invoke simple, intuitively appealing expla- sible (Rapp, Hinze, Slaten & Horton, 2014). beneficial in helping people overcome the nations that can connect to claims associ- For example, if people read an account allure of inaccurate information. This ated with pseudoscience (Vosniadou & contending that mental illness is conta- training could, for example, and as relevant Brewer, 1992). A lack of familiarity with gious associated with a particularly out- to pseudoscience, involve exposure to the scientific investigations, including the tools landish set of claims (e.g., involving patho- scientific methodologies and practices that and practices of scientists, can lead to dis-

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January • 2018 9 RAPP & DONOVAN trust and confusion that may make other Del Vicario, M., Bessi, A., Zollo, F., and Action. Cambridge, MA: Harvard seeming explanations appealing and viable Petroni, F., Scala, A., Caldarelli, G., Stan- Kennedy School. (Miller, 2004). The filter bubbles that ley, H. E., & Quattrociocchi, W. (2015). Lewandowksy, S., Ecker, U. K. H., & Cook, people routinely place themselves in, The spreading of misinformation online. J. (in press). Beyond misinformation; exposing themselves to and accessing Proceedings of the National Academy of Understanding and coping with the post- information that aligns with their beliefs Sciences, 113, 554-559. truth era. Journal of Applied Research in without considering alternative perspec- diSessa, A. A. (1993). Toward an episte- Memory and Cognition. tives and contradictory evidence, can help mology of physics. Cognition and Lewandowsky, S., Ecker, U. K. H., Seifert, Instruction, 10, 105-225. drive pseudoscientific thinking (Lewan- C., Schwarz, N., & Cook, J. (2012). Misin- dowsky, Ecker, & Cook, in press; Fazio, L. K., Brashier, N. M., Payne, B. K., formation and its correction: Continued & Marsh, E. J. (2015). Knowledge does Lewandowsky & Oberauer, 2016). The influence and successful debiasing. Psy- not protect against illusory truth. Journal unmoderated content available through chological Science in the Public Interest, of Experimental Psychology: General, 144, 13, 106–131. social media, blog postings, and Internet 993-1002. Lewandowsky, S., Gignac, G. E., & Ober- articles can make false ideas and claims Garrett, R. K., Weeks, B. E., & Neo, R. L. available to audiences that may not have auer, K. (2013). The role of conspiracist (2016). Driving a wedge between evi- ideation and worldviews in predicting the time, energy, or inclination to evaluate dence and beliefs: How online ideological rejection of science. PLoS One, 8, e75637. that content carefully (Del Vicario et al., news exposure promotes political mis- Lewandowsky, S., & Oberauer, K. (2016). 2015; Kumar & Geethakumari, 2014). perceptions. Journal of Computer-Medi- Motivated rejection of science. Current Contemporary concerns about “fake news” ated Communication, 21, 331–348. Directions in Psychological Science, 25, make this last notion even more worri- Gerrig, R. J., & Prentice, D. A. (1991). The 217–222. some, as individuals who promote pseudo- representation of fictional information. Lewandowsky, S., Oberauer, K., & Gignac, Psychological Science, 2, 336–340. scientific claims often like to call into ques- G. (2013). NASA faked the moon landing tion whether we can truly know anything, Gottlieb, E., & Wineburg, S. (2012). — therefore (climate) science is a hoax: to support arguments that their view, lack- Between “veritas” and “communitas”: An anatomy of the motivated rejection of ing evidence, is just as reasonable as any Epistemic switching in the reading of science. Psychological Science, 24, 622– other (Lazer et al., 2017). Even the routine academic sacred history. Journal of the 633. Learning Sciences, 21, 2012. use of terms like “theory” and “hypothe- Lobato, E., Mendoza, J., Sims, V., & Chin, Hinze, S. R., Slaten, D. G., Horton, W. S., ses,” detached from their more rigorous M. (2014). Examining the relationship Jenkins, R., & Rapp, D. N. (2014). Pil- implementations to instead be synony- between conspiracy theories, paranormal grims sailing the Titanic: Plausibility mous with the terms “opinion” and “view- beliefs, and pseudoscience acceptance effects on memory for misinformation. point,” have consequences for how people among a university population. Applied Memory & Cognition, 42, 1-20. might opt to think about the claims that Cognitive Psychology, 28, 617-625. Isberner, M., & Richter, T. (2014). Com- underlie pseudoscientific conjectures. Marsh, E. J. (2004). Story stimuli for creat- prehension and validation: Separable ing false beliefs about the world. Behavior Understanding and combatting the stages of information processing? A case influence of “fake news,” inaccurate infor- for epistemic monitoring in language Research Methods, Instruments, & Com- mation, and pseudoscience requires a con- comprehension. In D. N. Rapp & J. L. G. puters, 36, 650–655. certed, interdisciplinary effort. This will Braasch (Eds.), Processing inaccurate Marsh, E. J., Cantor, A. D., & Brashier, N. require leveraging theoretical understand- information: Theoretical and applied per- M. (2016). Believing that humans swal- ings of cognition and behavior, as derived spectives from cognitive science and the low spiders in their sleep: False beliefs as from the social and medical sciences, with educational sciences (pp. 353–379). Cam- side effects of the processes that support applied understandings derived from prac- bridge, MA: MIT Press. accurate knowledge. Psychology of Learn- tices including journalism and educational Johar, G. V., & Roggeveen, A. L. (2007). ing and Motivation: Advances in Research and Theory, 64, 93-132. design, as well as from domains studying Changing false beliefs from repeated topics such as persuasion, media literacy, advertising: The role of claim-refutation Marsh, E. J., Meade, M. L., & Roediger, H. and critical evaluation (to name a few rele- alignment. Journal of Consumer Psychol- L. (2003). Learning facts from fiction. Journal of Memory and Language, 49, vant fields and topic areas). The goal is to ogy, 17, 118 –127. 519–536. encourage more careful evaluation on the Johnson, M.K., Hashtroudi, S., & Lindsay, part of readers, which hopefully will bene- S.D. (1993). Source monitoring. Psycho- Marsh, J. K., & Shanks, L. L. (2014). logical Bulletin, 114, 3-28. Thinking you can catch mental illness: ficially lead to a reduction in the promotion How beliefs about membership attain- of and reliance on pseudoscientific dis- Kahne, J., & Bowyer, B. (2017). Educating for democracy in a partisan age: Con- ment and category structure influence course. fronting the challenges of motivated rea- interactions with mental health category soning and misinformation. American members. Memory & Cognition, 42, References Educational Research Journal, 54, 3-34. 1011-1025. Andrews, J., & Rapp, D. N. (2014). Partner Kumar, K. P. K., & Geethakumari, G. McGlone, M. S., & Tofighbakhsh, J. characteristics and social contagion: (2014). Detecting misinformation in (2000). Birds of a feather flock conjointly Does group composition matter? Applied online social networks using cognitive (?): Rhyme as reason in aphorisms. Psy- Cognitive Psychology, 28, 505-517. psychology. Human-centric Computing chological Science, 11, 424–428. Cook, A. E., Halleran, J. G. & O’Brien, E. J. and Information Sciences, 4, 1-22. Miller, J. D. (2004). Public understanding (1998). What is readily available during Lazer, D., Baum, M., Grinberg, N., Fried- of, and attitudes toward, scientific reading? A memory-based view of text land, L., Joseph, K., Hobbs, W., & Matts- research: What we know and what we processing. Discourse Processes, 26, 109- son, C. (2017). Final report from Combat- need to know. Public Understanding of 129. ing Fake News: An Agenda for Research Science, 13, 273-294.

10 the Behavior Therapist OVERCOMING PSEUDOSCIENTIFIC IDEAS

O’Brien, E. J. (1995). Automatic compo- on inaccurate information. Memory & Unkelbach, C. (2007). Reversing the truth nent of discourse comprehension. In R. Cognition, 42, 11-26. effect: Learning the interpretation of pro- F. Lorch & E. J. Obrien (Eds.), Sources of Rapp, D. N., Hinze, S. R., Slaten, D. G.,& cessing fluency in judgments of truth. coherence in reading (pp. 159-176). Hills- Horton, W. S. (2014). Amazing stories: Journal of Experimental Psychology: dale, NJ: Erlbaum. Acquiring and avoiding inaccurate infor- Learning, Memory, and Cognition, 33, Oppenheimer, D. M. (2008). The secret mation from fiction. Discourse Processes, life of fluency. Trends in Cognitive Sci- 51, 50-74. 219 –230. ence, 12, 237-241. Reber, R., & Schwarz, N. (1999). Effects of Vosniadou, S., & Brewer, W. F. (1992). Prentice, D. A., Gerrig, R. J., & Bailis, D. S. perceptual fluency on judgments of Mental models of the earth: A study of (1997). What readers bring to the pro- truth. Consciousness and Cognition, 8, conceptual change in childhood. Cogni- cessing of fictional texts. Psychonomic 338 –342. tive Psychology, 24, 535-585. Bulletin & Review, 4, 416-420. Schwarz, N., Sanna, L. J., Skurnik, I., & Vosniadou, S., & Brewer, W. F. (1994). Rapp, D. N. (2016). The consequences of Yoon, C. (2007). Metacognitive experi- reading inaccurate information. Current ences and the intricacies of setting people Mental models of the day/night cycle. Directions in Psychological Science, 25, straight: Implications for debiasing and Cognitive Science, 18, 123-183. 281-285. public information campaigns. Advances Rapp, D. N., & Braasch, J. L. G. (Eds.). in Experimental Social Psychology, 39, (2014). Processing inaccurate informa- 2007. ... tion: Theoretical and applied perspectives Sparks, J. R., & Rapp, D. N. (2011). Read- from cognitive science and the educational ers' reliance on source credibility in the The authors have no funding or conflicts of sciences. Cambridge, MA: MIT Press. service of comprehension. Journal of interest to disclose. Rapp, D. N., & Donovan, A. M. (in press). Experimental Psychology: Learning, Routine processes of cognition result in Memory, & Cognition, 37, 230-247. Correspondence to David N. Rapp, Ph.D., routine influences of inaccurate content. Sundar, A., Kardes, F. R., & Wright, S. A. 2120 Campus Drive, Northwestern Univer- Journal of Applied Research in Memory (2015). The influence of repetitive health sity, Evanston, IL 60208; and Cognition. messages and sensitivity to fluency on the Rapp, D. N., Hinze, S. R., Kohlhepp, K., & truth effect in advertising. Journal of [email protected] Ryskin, R. A. (2014). Reducing reliance Advertising, 44, 375-387.

January • 2018 11 The Scientist-Practitioner Gap in Clinical ence that the null hypothesis is unlikely given the finding. The editors of Basic and Psychology: A Social Psychology Perspective Applied Social Psychology (Trafimow & Marks, 2015) banned the NHSTP for the simple reason that low p-values (less than David Trafimow, New Mexico State University .05) fail to provide a logically defensible justification for rejecting null hypotheses and accepting alternative ones. The Amer- ican Statistical Association (Wasserstein & MUCH LITERATUREATTESTS to the exis- ing and predicting behavior is the reasoned tence of a large gap between the science of action approach (see Fishbein & Ajzen, Lazar, 2016), though stopping short of sup- clinical psychology and how it is practiced 2010, for a comprehensive review). As will porting the ban, admitted that the NHSTP (Garb & Boyle, 2015; Gaudiano, Dalrym- be explained at some length, there are dif- fails to provide a sufficient reason for ple, Weinstock, & Lohr, 2015; Katz, 2001; ferent routes to behavior, and these differ- rejecting null hypotheses or drawing any conclusions whatsoever other than the tau- Lilienfeld, Lynn, & Lohr, 2015; McFall, ent routes might imply quite different tological one that if p is a low value, the 1991; Nunez, Poole, & Memon, 2003; interventions to induce practitioners to probability of the finding is low given the Poole, Lindsay, Memon, & Bull, 1995; change their behaviors. null hypothesis. As the primary “evidence” Polusny & Follette, 1996; Tavris, 2015). To There are three main sections. The first for the efficacy of treatments comes from gain an idea of some researchers’ percep- section includes a brief discussion of two statistically significant p-values, a skeptic tions of the gap, consider that Tavris flaws in the actual science. I wish to make has clear grounds for his or her skepticism. likened it to that which separates the clear that although I support practitioners Researchers should consider alternatives Israelis and the Arabs. Assuming the desir- using the science of clinical psychology (e.g., Trafimow, 2017; Trafimow & Mac- ability of bridging the gap, we might (indeed, this is the point of the present arti- Donald, 2017). inquire as to the reasons for its existence to cle), there can be little doubt that there is much wrong with the science itself that Another problem concerns the failure gain clues about what to do about it. One of researchers to distinguish cleanly possibility is that practitioners believe the researchers should fix. The argument that practitioners should attend to the science between theoretical assumptions and science of clinical psychology is so badly assumptions that are auxiliary to the main flawed or irrelevant that there is no point in of clinical psychology would be augmented by improvements in that science. The theory (hereafter, auxiliary assumptions), basing their clinical practices on it. Alter- but are nevertheless necessary to derive natively, practitioners might believe that second section explains the reasoned action approach and what it implies about treatments. The importance of auxiliary the science is neither badly flawed nor irrel- assumptions comes from a more general evant, but that they are not capable of possible reasons for the science-practi- tioner gap in clinical psychology. The third concern in science than clinical psychol- learning it or applying it to their practices. ogy, or even psychology more generally. Of course, there are many other possibili- section discusses implications for how to design research to investigate behaviors Philosophers of science long have recog- ties too. nized that theories contain nonobserva- In the present article, I use the literature relevant to reducing the science-practi- tioner gap. tional terms (e.g., Duhem, 1954; Lakatos, cited above as providing two starting 1978). In clinical psychology, “anxiety” points. First, there is a large science-practi- The Science of Clinical Psychology might be considered a nonobservational tioner gap. Second, it is important to bridge term. But every science uses nonobserva- the gap. These starting points suggest at Because the science of clinical psychol- tional terms. In fact, the Nobel Laureate least two possibilities: the gap can be ogy is a subset of the larger field of psychol- Leon Lederman (1993) pointed out that bridged by inducing clinical scientists to ogy, it is plagued with some of the prob- Newton used mass as a nonobservational move in the direction of practitioners or by lems that plague psychology more term that even lacks an independent defin- inducing practitioners to move in the generally. For example, clinical psychology ition!1 Despite this lack, Newton’s equa- direction of clinical scientists. From the depends on the null hypothesis significance tion, force = mass x acceleration, is possibly point of view of evidence-based practice, it testing procedure (NHSTP). But the proce- the most important equation in the history is more desirable for practice to move in dure has come under much fire for being of physics. Because theories contain the direction of clinical science than for logically invalid (e.g., Bakan, 1966; Carver, nonobservational terms, there is no way to clinical science to move in the direction of 1978, 1993; Cohen, 1994; Grice, Cohn, derive empirical predictions from them practice. There doubtless are institutional Ramsey, & Chaney, 2015; Kass & Raftery, except by using auxiliary assumptions that changes that could aid in moving practi- 1995; Kline, 2015; Meehl, 1967, 1978, 1990, link the nonobservational terms in theories tioners in the direction of clinical science, 1997; Rozeboom, 1969, 1997; Schmidt, to the observational terms in empirical but these will not be discussed here. 1996; Schmidt & Hunter, 1997; Trafimow, hypotheses. Haley used Newton’s theory to Instead, consistent with a social psychology 2003, 2006 Trafimow & Marks, 2015, 2016; predict the reappearance of the comet that focus, I take the goal as that of inducing Valentine, Aloe, & Lau 2015). In short, the now bears his name, in conjunction with practitioners to change their behaviors to fact that a finding is unlikely given the null auxiliary assumptions about the present be more in line with clinical science. An hypothesis fails to justify an inverse infer- position of the comet, gravitational influ- important step in changing such behaviors is to diagnose the reasons why practition- ers perform them or fail to perform desir- 1The nonobservational term “mass” should not be confused with the observational term able behaviors. The most widely researched “weight.” That these are different can be seen easily merely by considering that an object of the social psychology program for understand- same mass would weigh different amounts on different planets.

12 the Behavior Therapist SCIENTIST- PRACTITIONER GAP ences, and so on. In clinical psychology, index. And let us even suppose that the Kranz, Luce, & Tversky, 1989), researchers there is no way to derive treatments from effect size is reasonably large, there was a in clinical science have not taken the trou- theories, except in conjunction with auxil- sufficient sample size, and so on. Can we ble to test whether their indexes, such as iary assumptions. A theory may lead to an conclude that practitioners should use the that which measures depression, actually excellent treatment when used in conjunc- touted treatment? It depends, in part, on are at the interval level or ratio level of mea- tion with one set of auxiliary assumptions whether one believes that the depression surement. Ironically, just as clinical scien- and a failing treatment when used in con- index is at least at the interval level of mea- tists accuse practitioners of failing to attend junction with another set of auxiliary surement (Stevens, 1946). Without an to the relevant literature in clinical science, assumptions. Thus, the success or failure of assumption of at least an interval level of it is possible to accuse clinical scientists of a treatment need not provide a strong case measurement (a ratio level would be even failing to attend to the basic mathematics for the worth or lack of worth of the theory. better), the effect size calculation is mean- underlying the assumed quantitative Unfortunately, researchers in clinical psy- ingless. In fact, several researchers have nature (or lack thereof) of their indexes. chology have not been careful about questioned whether typical indexes in psy- Despite the foregoing criticisms of the spelling out the auxiliary assumptions that chology really are at the interval level or science of clinical psychology, there is no lead from theory to treatment. This is a ratio level of measurement to justify the intent to declare the science to be worth- major strike against the science of clinical usual calculations upon which researchers less. There have been gains, too, and the psychology and researchers should remedy base their conclusions (e.g., Barrett, 2003; fact of shortcomings provides a poor justi- it if they wish practitioners to take the sci- Michell, 1997, 2000, 2008a, 2008b; Morris, fication for practitioners being unaware of ence more seriously. Grice, & Cox, 2017). Unfortunately, the science of clinical psychology. A third issue concerns level of measure- although the mathematical basis for Although the present section can be con- ment. Suppose that a proper experiment is making this determination was worked out sidered a slight indictment against how the conducted that shows that a particular in the 1970s (Kranz, Luce, Suppes, & Tver- science of clinical psychology has been treatment group does better than the con- sky, 1971; also see Luce, Krantz, Suppes, & conducted, the remainder of this article trol group with respect to, say, a depression Tversky, 1990; Roberts, 1979; Suppes, assumes that practitioners nonetheless

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January • 2018 13 TRAFIMOW should attend to it and be influenced in the belief-motivation to comply products, strated to be an imprecise concept of per- conduct of their clinical practices. summed across all products: ceived behavioral control, it is possible to (SN=∑_(i=1)^ substitute the more precise concepts of per- The Reasoned Action Approach k"n_i m_i !). ceived control and perceived difficulty. There is also a measurement model that And to go with perceived control and per- The major goal of the reasoned action accompanies the substantive theory. The ceived difficulty, there also are beliefs about approach (Ajzen, 1988, 1991; Ajzen & Fish- basic principle, sometimes called the “prin- the factors that render a behavior under bein, 1980; Ajzen & Fishbein, 2005; Fish- ciple of correspondence” or the “principle one’s control or not (control beliefs) and bein, 1963; Fishbein, 1967, 1980; Fishbein of compatibility,” is that all behaviors have about the factors that render a behavior & Ajzen, 1975; Fishbein & Ajzen, 2010) is four elements and these elements must cor- easy or difficulty to perform (difficulty to understand and predict behavior. Con- respond across all reasoned action con- beliefs). sequently, the easiest way to comprehend structs. That is, each behavior has a target, Finally, Fishbein (1980) argued strongly the theory is to work backwards from action, time, and context. For example, the that attitude only consists of a cognitive behavior to its determinants. The immedi- behavior of “eating a chocolate bar at 3:00 evaluation, and also criticized the factor ate determinant of behavior is behavioral on Friday in my office” has the following analytic approaches that indicated an affec- intention; people do what they intend to do elements: target (chocolate bar), action tive component too. While agreeing with and not what they intend not to do. There (eating), time (3:00 on Friday), and context Fishbein’s criticisms of the factor analytic are complications to be discussed later, but (in my office). To perform well at predict- work up to that time, Trafimow and these can be ignored for now. ing behaviors; measures of behavioral Sheeran (1998) performed a set of experi- In turn, behavioral intentions are deter- intentions, attitudes, subjective norms, ments that demonstrated that affect and mined by attitudes and subjective norms. behavioral beliefs, evaluations, normative cognition nevertheless need to be sepa- Attitudes are people’s evaluations of the beliefs, and motivations to comply; all rated. They also showed that “affective” behavior (how much they like or dislike to should mention the same four elements of beliefs can be distinguished from “cogni- perform it) and subjective norms are target, action, time, and context. Research tive” beliefs. Thus, the reasoned action tra- people’s opinions about what most others performed in the 1970s (e.g., Davidson & dition is much richer in the 21st century who are important to them think they Jaccard, 1975, 1979), specifically on the than it was in the 1970s. On the negative should do or not do. Because a person measurement principle, supports that side, this increased richness comes at a cannot know for sure what others think, excellent prediction is obtained when it is price in parsimony. this is the subjective part of subjective complied with fully, but that a mismatch norms. Any particular behavioral intention on even one of the four elements is prob- Defining the Behavior might be influenced more by attitudes or lematic. The long description of the theory was more by subjective norms: that is, a behav- Thus far, we have the received view necessary so that the reader could appreci- ior might be more under attitudinal control from the 1970s (e.g., Ajzen & Fishbein, ate some important ambiguities. One of or more under normative control. In addi- 1980; Fishbein, 1980; Fishbein & Ajzen, these concerns the behavior of interest. To tion, Trafimow and Finlay (1996) showed 1975), but Ajzen (1988) added the notion reiterate, the presenting problem is that that people also can be more under attitu- of perceived behavioral control. The origi- clinical practitioners fail to consider the dinal or more under normative control, nal theory only was meant to apply to scientific evidence that is relevant to their across a wide range of behaviors. behaviors that people are capable of per- practices. But it is not clear what we mean Suppose that a behavior is more under forming, but Ajzen wanted to extend the by this. Do we mean that practitioners attitudinal than normative control. To theory to behaviors that people might not should read the scientific literature? If so, intervene, it is desirable to know the deter- be capable of performing. Although there how often should they read it, when should minants of attitudes, which are behavioral is no way to measure actual control over a they read it, and in what context should beliefs and evaluations of those beliefs. behavior, it is possible to measure people’s they read it? Behavioral beliefs are judgments about the perceptions of their degree of control; Or do we mean that clinical practition- likelihood of the consequences that might hence, the notion of perceived behavioral ers should apply the scientific literature to arise from performing a behavior whereas control came into being. Usually the con- their own practices? If so, when should evaluations are judgments about how good cept is measured by having participants they do it, to what extent should they do it, or bad each of the consequences would be respond to items referring to how much and in what context should they do it? if they were to happen. In the reasoned control they have over the behavior and What we might mean is that we wish for action tradition, attitudes are a function of how easy or difficult the behavior would be practitioners to perform a set of behaviors each behavioral belief-evaluation product, for them to perform. But Trafimow et al. that will result in evidence-based practice. summed across all products (2002) argued that “control” and “diffi- This is fine, but we need to specify the set of Analogously, subjective norms are deter- culty” are different concepts that should be behaviors we wish to change in a precise mined by normative beliefs and motiva- kept distinct for the sake of precision. To manner. tions to comply with normative referents. back up this claim, Trafimow et al. showed A normative belief is a judgment about the that it is possible to perform manipulations Multiple Pathways to Behavior likelihood with which a specific normative that influence perceptions of control with- Another ambiguity pertains to how to referent believes one should or should not out influencing perceptions of difficulty, get to behavior. In the original version of perform the behavior, and these are paired and to perform manipulations that influ- the theory, there was an attitudinal and with how much one is motivated to comply ence perceptions of difficulty without normative pathway. To that, researchers with what that person thinks. Thus, subjec- influencing perceptions of control. Thus, have added perceived control and per- tive norms are a function of normative rather than use what has been demon- ceived difficulty. We might even consider

14 the Behavior Therapist SCIENTIST- PRACTITIONER GAP affect to be a fifth pathway, though some reminded of unpleasant aspects of grad- mentioned earlier, it is necessary to specify would argue that it is part of the attitude uate school (affective belief). the behavior or set of behaviors of interest. construct. Before any sort of intervention is Once a behavior of interest is chosen, likely to work, it is necessary to figure out To change the behaviors of practition- the researcher can conduct a two-part which pathway predominates for most ers towards reading relevant clinical sci- study. In the first part, the researcher can practitioners, assuming, of course, that one ence, changing their own practices in measure behavioral intentions (and actual has specified a behavior or set of behaviors accordance with relevant clinical science, behaviors, too, if that is feasible), attitudes, of interest. For example, there is no point and so on, it is necessary to know which of subjective norms, perceived control, and in intervening at the normative level if the the foregoing beliefs, or other beliefs not perceived difficulty. It is important to keep behavior is mostly under attitudinal con- mentioned in the bullet list, determine the the principle of correspondence in mind trol. behavior or behaviors of interest. For for all measures. By determining which of The usual method for determining con- example, if the main obstacle for practi- the four precursor constructs (attitudes, trol is to use multiple regression with tioners is a belief that their learning the rel- subjective norms, perceived control, or behavior or behavioral intention regressed evant clinical science will not result in pos- perceived difficulty) are good predictors of onto the other variables. In the traditional itive consequences for their patients, then behavioral intentions (or better yet, behav- version of the theory, a large attitude and an intervention designed to educate them iors), and which precursor constructs are small subjective norm beta-weight is taken to see how relevant clinical science can not, it may be possible to narrow matters as indicating that the behavior is more result in positive consequences for their down substantially. For example, suppose under attitudinal control than normative patients is likely to be effective. However, if that attitudes do an excellent job of pre- control whereas the reverse pattern of beta- the problem is at the level of a control or dicting behavioral intentions (or behav- weights is taken as indicating that the difficulty belief, such education likely will iors) but that subjective norms, perceived behavior is primarily under normative be ineffective. And to make the problem control, and perceived difficulty do not. In control. To make use of the more recent lit- more complex, I stress that the bullet-listed that case, the researcher would not have to erature, it is desirable to measure perceived beliefs compose only a small set of the deal with the latter three precursors in the control and perceived difficulty too. potentially relevant ones. subsequent study, and also would not have Although strong beta-weights and correla- to deal with normative beliefs (or motiva- tion coefficients do not prove causation Zeroing in on an Intervention tions to comply), control beliefs, or diffi- culty beliefs. from a precursor construct to behavior, There are at least three stages to zeroing Measurement reliability and validity are they support that some precursor con- in on an intervention. First, there are two extremely important. For well over a cen- structs are better candidates than others for preliminary studies that the researcher tury (Spearman, 1904), it has been known intervention. must complete. Second, the researcher that reliability sets an upper limit on valid- should use the data to find out which The Belief Level ity. If one imagines two variables, X and Y, beliefs are good candidates for interven- We have seen that the constructs that that have “true scores” according to classi- tion, and design the intervention. Third, it are precursors to behavioral intentions and cal true score or classical test theory (Gul- is desirable to perform a third study to eval- behaviors have, in turn, their own precur- liksen, 1987; Lord & Novick, 1968; Spear- uate the effectiveness of the intervention. sors. And these precursors are beliefs of man, 1904), the following equation shows I’ll present more details of the two prelimi- various types, augmented by evaluations or how the correlation one might expect to nary studies as clinical psychologists are motivations to comply. But remaining with observe (ρ ) is decreased from the true less likely to know these. And I will say very XY beliefs, we have behavioral beliefs, norma- correlation (ρ ), depending on the relia- little about evaluating the effectiveness of TXTY tive beliefs, control beliefs, difficulty beliefs, bilities of the measures of X(ρ ) and Y the intervention because readers of this XX' and affective beliefs. Which of these are rel- (ρ ): journal are likely to know this already. YY' evant to the scientist-practitioner gap? Consider some plausible possibilities. How to Conduct Two Preliminary Studies • It could be that practitioners believe that Although there are many candidates for As an example, suppose that the true using clinical science will not actually relevant beliefs, they fall into four cate- correlation is .7 and that the reliabilities of have positive consequences (behavioral gories.2 These are beliefs about conse- the two measures are .7 and .7, respectively. belief); quences that determine attitudes, norma- In that case, the observed correlation can • Practitioners may believe their col- tive beliefs that determine subjective be expected to come out at .49 rather than leagues think they should not use clini- norms, control beliefs that determine per- at the true level of .7. cal science (normative belief); ceived control, and difficulty beliefs that Fortunately, because all of the reasoned • Practitioners may believe they do not determine perceived difficulty. I recom- action variables are very precisely defined, have the ability to learn the clinical sci- mend that researchers conduct two studies it is possible to capture most of the mean- ence (control belief); to zero in on an intervention, but first, as I ing with very precise items. In fact, Trafi- • Practitioners may believe that it would mow and Finlay (1996) showed that—in be difficult for them to learn the clinical science, or might take too much time and effort (difficulty belief); • Practitioners may simply have negative 2 For the sake of brevity, I am skipping a possible fifth category, pertaining to affective reactions affective reactions to the clinical sci- to learning or using the science of clinical psychology. However, researchers who seriously wa nt ence, possibly because of being to pursu e this issue might wish to consider this as a possibility too, that should be investigated.

January • 2018 15 TRAFIMOW violation of a standard rule of scale con- that indicates participants’ perceptions of be used to predict attitudes. If the struction—even single item measures do the likelihood of the consequence if they researcher can find a small number (hope- well if designed with care, both with respect were to perform the behavior. An evalua- fully one or two) of belief-evaluation prod- to test-retest reliability and predictive tion item can be paired with it, asking to ucts that account for almost all of the vari- validity. Nevertheless, I recommend using what extent it would be “extremely good” ance in attitudes that the sum of the three to five items to measure each con- to “extremely bad” if the consequence were products accounts for, those are excellent struct, remembering, of course, to obey the to happen. At the risk of sounding like a candidates for intervention, especially if principle of correspondence, without broken record, I reiterate that the principle they do a good job of predicting behavioral which there will be a lack of validity. Ajzen of correspondence must be followed even intentions (or behaviors) too. Alterna- and Fishbein (1980, Appendix A) contain at this level. For example, if the behavior is tively, it might be that a different construct example items and demonstrate how to “to read an average of three clinical science matters. My preliminary bet would be on create items that obey the principle of cor- papers per week for the next year,” and a perceived difficulty as an important con- respondence. consequence is that “I will get bored,” then struct. That is, beliefs having to do with But it also is necessary to obtain relevant the behavioral belief item might be as fol- time, effort, and so on devoted to learning beliefs, which leads us to the second part of lows: “How likely or unlikely would you be relevant clinical science literature might be the first study, which depends on open- to get bored if you read an average of three likely to perform well as predictors of, say, ended questions. Specifically, the clinical science papers per week for the next learning the clinical science literature. researcher should obtain behavioral beliefs year?” Designing the Intervention by asking participants to list the advantages Although attitudes tend to be the most Designing the intervention is the most and disadvantages of performing the important construct for predicting most difficult part. The foregoing two prelimi- behavior. Again, the principle of corre- behavioral intentions or behaviors, this is nary studies can be performed in a rather spondence needs to be obeyed even at the not always so. It may turn out that subjec- “automatic” way, following the principle of level of beliefs. Moving to normative tive norms, perceived control, or perceived beliefs, the researcher should ask partici- correspondence, and it is practically a cer- difficulty also are important, and may even tainty that the result will be a few, or sev- pants to list the people whose opinions are be more important than attitudes for pre- relevant to their performing the behavior. eral, beliefs that are good candidates for dicting a particular behavior. In that case, intervention. Based on both an extensive The researcher can obtain control beliefs normative beliefs, control beliefs, or diffi- by asking participants to list specific rea- literature (see Fishbein & Ajzen, 2010, for a culty beliefs might be important too, and sons why the behavior might be under their review) and my own experiences, I can say should be included in Study 2. As always, control or might not be under their con- with confidence that, up to this point, fail- the principle of correspondence should be trol. Finally, the researcher can obtain diffi- ure is extremely unlikely provided that the obeyed. culty beliefs by asking participants to list researcher complies carefully with the It also might be useful to replicate the specific reasons why the behavior might be principle of correspondence. But from first part of Study 1, concerning behavioral easy or difficulty for them to perform. here, matters are no longer straightfor- intentions (or behaviors), attitudes, subjec- The design of the second study depends ward. The theory does not tell the tive norms, perceived control, and per- on the results obtained in the first study. If researcher how to intervene, only how to ceived difficulty. A benefit of the replica- luck is with the researcher, all but one of find the beliefs that matter most for the the precursor constructs can be eliminated, tion is that the researcher can be more behavior. which implies that only one category of certain about which precursor constructs As an example, suppose that as a result beliefs is relevant. With less luck, the matter and which do not. of the two preliminary studies, the behav- researcher might find that two or three cat- In the end, though, interventions will be ioral belief pertaining to “being bored if I egories are relevant. Suppose, for example, at the level of beliefs, and so it is important read an average of three clinical science that only attitudes do a good job of predict- to find the ones that matter. This can be papers per week for the next year” turns out ing behavioral intentions (or behaviors). In done with simple correlations. Remaining to be critical. At one level, the solution is that case, it is important to find out the rel- with attitudes as the most important con- obvious: change that belief! But at another evant behavioral beliefs. Happily, these can struct, for example, how well do each of the level, it is far from obvious how to inter- be obtained from the open-ended list of behavioral beliefs correlate with attitudes? vene to change the belief. How do you con- advantages and disadvantages of the As a complication, recall that it is the sum vince someone that an activity they con- behavior obtained in Study 1. Assuming a of belief-evaluation pairs that determine sider to be boring is not boring? Or, failing reasonable sample size in Study 1, many attitudes. Consequently, it also might be that, how do you convince someone not to behavioral beliefs may be listed, and it may worth computing each belief-evaluation evaluate being bored so poorly? Perhaps a take some judgment to decide how many product separately, to investigate which solution might be to introduce a journal people need to have listed a particular product terms best predict attitudes.3 with the goal of filtering and translating behavioral belief for it to deserve to be used These will be excellent candidates for inter- important advances in clinical science so in Study 2. Ajzen and Fishbein (1980) sug- vention. As a more general check, the sum that useful information is provided with a gested a 70% rule (item listed by 70% of the of the belief-evaluation products also can minimum of boring statistical detail (espe- participants), but this is arbitrary and may not fit any particular case at hand. Once the researcher decides to include a particular 3According to traditional reasoned action thinking, belief-evaluation products should be behavioral belief, participants can be asked used. Arguably, belief measures or evaluation measures are not at a ratio level, in which case to respond on a scale ranging from it might be best not to use products after all. This would constitute an argument that beliefs “extremely likely” to “extremely unlikely” should be correlated directly with attitudes and intentions, directly.

16 the Behavior Therapist SCIENTIST- PRACTITIONER GAP cially t-tests, F-tests, and resulting p-values have to be at some distance from how it But although I obviously believe in the that are invalid anyhow). actually would be implemented on a large direction advocated in the foregoing com- On the other hand, there are other sorts scale. As an example, suppose that ments, it is important to be up front about of beliefs that might pose less of a problem researchers find that to handle the most the difficulties. The first difficulty, as I for intervention. For example, suppose that predictive beliefs, it is necessary to do emphasized earlier, is to figure out pre- an important belief is as follows: “There something at an organizational level, such cisely what the behaviors of concern should would be no benefit to my clients if I were as founding a journal whose purpose is to be. This includes specifying the target, to read an average of three clinical science translate important clinical science papers action, time, and context of each behavior papers per week for the next year.” It may from journalese into language that is inter- but it also includes specifying correspond- be possible to cite data showing that their esting and easy to understand. Short of ing target, action, time and context for all patients likely would benefit after all, espe- actually founding the journal and evaluat- precursor variables. Although the two pre- cially if reading the literature results in ing its effects, a preliminary intervention liminary studies are reasonably straightfor- actual change in practices to more effective study necessarily will be somewhat differ- ward, and are practically guaranteed to ones. ent. For example, practitioners might be provide useful information, there also are The problem can be considered more randomly assigned to read specific articles complications with respect to performing abstractly. Whenever a theory is applied to tailored in this direction in the experimen- and evaluating intervention studies. For make an empirical prediction or an appli- tal condition, but not in the control condi- example, what are the auxiliary assump- cation, it is necessary to make auxiliary tion, to determine whether the behavior of tions that allow the researcher to traverse assumptions, as I explained in the first sec- concern is influenced, and by how much. the distance from the nonobservational tion of the present article. With respect to To what extent the findings from such a terms in the theory to the observational the preliminary studies described in the preliminary intervention study will sup- terms used in the experimental hypothesis? foregoing subsection, the requisite auxil- port broader conclusions about the likely Another problem is that the researcher iary assumptions have been worked out in effect of founding a journal may depend on needs to figure out which type of effect size great detail, thereby reducing the creative a variety of factors, such as how close the to use to index the size of the effect of the load on the researcher. In contrast, when it tailored articles in the experiment would be intervention. Although researchers may be comes to interventions, relevant auxiliary to the real articles in the founded journal, in the habit of using a particular sort of assumptions have not been worked out, the extent to which it would be easy for effect size for a particular experimental and so the researcher is thrown on his or practitioners to access the founded journal, paradigm, the issue is not automatic, and her own ingenuity and creativity. and many others. My point is not that researchers should consider it carefully Evaluating the Intervention researchers should not conduct such research, only that they should be aware before coming to any conclusions. Finally, Because readers of this journal are that a single study is unlikely to be defini- even if an intervention is quite successful in already knowledgeable about evaluating tive. an experiment, there might be quite a dis- interventions, this section can be kept brief. tance between the laboratory context and But it seems useful to make the following how the intervention actually would be points. First, it is important to evaluate Conclusion implemented with real practitioners in real intervention effects with means other than practice sorts of contexts. p-values. As I pointed out earlier, not only There has been much complaining on Although I have attempted to be up have these come under much criticism, but the part of those knowledgeable about the front about the ambiguities that face the even aficionados of p-values admit that science of clinical psychology about the fact researcher to whom change in practition- they fail to indicate how well an interven- that practitioners mostly are uninfluenced ers’ behaviors is an important concern, this tion works. Most statistical authorities rec- by that science. Certainly, from the point of focus should not be taken too pessimisti- ommend effect sizes. For example, Cohen’s view that therapy should be based on evi- cally. I am not arguing that the effort is not d gives the distance between means of two dence, this is a deplorable state of affairs. worthwhile. Nor am I arguing that the evi- conditions, in standard deviation units. But what has been lacking from the scien- dence has to come from a single, definitive, However, it is possible to argue that even tists themselves is (a) an admission that study. What I am saying, however, is that Cohen’s d is problematic because it con- there is much wrong, as well as much that is changing practitioner behavior is likely to founds variation due to randomness and right, with the science of clinical psychol- prove extremely difficult, with an enor- ogy; (b) strong efforts to fix what is wrong systematicity. Provided that the researcher mous amount of psychological inertia to to provide a better case that practitioners has obtained good reliability estimates of overcome. If the reader nevertheless would the dependent variables, Trafimow (in ought to be influenced; and (c) effort like to move in this direction, the fight will press) demonstrated that it is possible to devoted to finding out why practitioners be difficult and protracted. Still, very little distinguish the variance due to random- fail to do what scientists think they should that is worthwhile is obtained without a ness, the independent variable, and system- do. Let me emphasize this last point. If fight, and so I hope and anticipate that sci- atic effects due to variables not considered. researchers do not know what determines entific clinical psychology researchers will Using this tripartite distinction, it also is the behaviors that practitioners perform or not allow themselves to feel too discom- possible to obtain more focused effect sizes fail to perform, efforts to change practi- that control for either randomness or for tioners’ behaviors are likely to fail. The moded. systematic effects that are not of interest point of the present article is to focus on (due to variables not considered). how to find out that which is relevant and References A second consideration is that the inter- that which is irrelevant, to provide a start- Ajzen, I. 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Science and Epistemic Vice: The Manufacture Herbert et al. [2000], on EMDR, and O’Donohue, Snipes, & Soto [2016a & b] on and Marketing of Problematic Evidence Acceptance and Commitment Therapy— but also see Gregg & Hayes [2016] for a rejoinder); (5) there are unresolved issues William O’Donohue, University of Nevada, Reno regarding how disparate individual studies can be properly and fairly aggregated and summarized to accurately produce certain McFall (1991) in his classic “Manifesto for 2013); (2) the social sciences, including useful summary statements such as a Science of Clinical Psychology,” sug- clinical psychology, have seemed to enjoy “empirically supported treatments” (e.g., gested that science is the only warrant for much less scientific progress (e.g., discov- see Chambless & Hollon, 1998); and (6) evaluating knowledge claims in clinical ery of scientific laws) than the natural sci- there are longstanding concerns about psychology. Certainly science has given rise ences (Meehl, 1978); (3) not all of science whether scientific epistemology is com- to both an unprecedented growth in has produced beneficial results—for exam- plete or whether other ways of knowing are knowledge as well as powerful technologies ple, certain technologies have had harmful also needed to complete our knowledge that allow humans to apply this knowledge effects on the environment and weapons of (see, for example, Hempel, 1965, on ethics for their desired ends. In addition, profes- mass destruction have been produced; (4) and Houts, 2009, on religious beliefs). sional expertise is founded on epistemic there has been a grab bag of vexing and These are all important problems and duties—a duty to know. embarrassing problems in psychology, concerns relevant to the work of the cogni- However, there are at least six problems such as replicability failures, fraudulent tive behavior therapist. However, this in this otherwise generally rosy picture data, concerns that business interests such paper will focus on several key issues regarding science: (1) philosophers of sci- as those of Big Pharma add considerable described in point 4 above, which may be ence and others engaging in the study of noise to the literature (see for example, summarized by the problem of pseudo- science do not agree on how to define sci- Antonuccio et al., 1999), such that at times science. The basic notion is it is possible for ence or even if there is a single scientific what may appear to be proper science is research to be conducted in a way that method (Feyerabend, 1975; O’Donohue, actually pseudoscience (see, for example, appears to be scientifically sound but actu-

January • 2018 19 O ’ DONOHUE ally misses some essential characteristic of and from her teaching Sunday school and ative results were file drawered; multiple science, so that one must conclude that so on. One could then examine these sam- outcome measures were used but only the proper science actually has not been con- ples to see if these refute the proposition outcome variables that failed to reach sig- ducted but rather what has occurred is “My minister never swears” by finding an nificance failed to be reported; side effects pseudoscience—literally false science. The instance or instances of swearing. This were not fully reported; safety concerns Nobel Laurette Richard Feynman (1974) would be a test of the proposition—even an such as increased suicidality were not expli- picturesquely called this cargo cult science: empirical one—but not a severe one. cated; multiple statistical analysis were Alternatively, the researcher could conducted until supportive results were In the South Seas there is a cargo cult sample from the minister’s golf games, found; statistical significance was conflated of people. During the war they saw air- after she stubs her toe, when she is intoxi- with clinical significance; process variables planes land with lots of good materials, cated, when someone cuts her off in traffic, were not directly measured or properly and they want the same thing to or when she is in a heated argument. Both reported, and so on. In addition, it is happen now. So they've arranged to studies could count as a test of the belief: important to note that most of these prob- imitate things like runways, to put fires but it is only the latter that counts as a lems were not immediately apparent— along the sides of the runways, to make severe test; it is simply much more likely to these were hidden by researchers and a wooden hut for a man to sit in, with expose the potential falseness of belief uncovered only after often arduous inde- two wooden pieces on his head like under test. It is a more risky test. The ques- pendent investigation. Moreover, the drug headphones and bars of bamboo stick- tion then becomes, How severe have tests researchers themselves also had various ing out like antennas—he's the con- such as random clinical trials been in cog- personal motivations that were often troller—and they wait for the airplanes nitive behavior therapy? To what extent hidden: they were financially incented in to land. They're doing everything are behavior therapists designing and con- various ways by Big Pharma to find and right. The form is perfect. It looks ducting tests that actually place their cher- report positive results; they were offered exactly the way it looked before. But it ished beliefs at risk—or to what extent are other inducements such as expense paid doesn't work. No airplanes land. So I they practicing “cargo cult”—science in trips to present results in luxurious confer- call these things cargo cult science, which there are “tests” but there is very ences; and the allure of publishing in high- because they follow all the apparent little risk of their cherished belief being impact journals was also present among precepts and forms of scientific inves- shown as false? Are they looking at ser- other inducements. tigation, but they're missing some- mons for swearing or after toe stubbing? It Other critics have also pointed out addi- thing essential, because the planes will be argued that the general answer is tional problems with research involving don't land. (p. 7) twofold: first, research in cognitive behav- other medications—e.g., that there were ior therapy generally has not been properly often deviations in the analysis plan A key underlying problem is that if evaluated on this key dimension—which between protocols and published papers, philosophers of science have not produced will be argued is quite problematic; second, and, interestingly, that the effect sizes of a consensual characterization of what sci- there are exemplars where at least some drug interventions are larger in the pub- ence is, it can be somewhat difficult to appear to be quite lacking on this dimen- lished literature compared with the corre- identify some missing essential property of sion. sponding data from the same trials submit- epistemically sound science (O’Donohue, ted to FDA (Ioannidis, Munafo, Fusar-Poli, 2013). For example, a popular candidate The Case of “Scientific Research” Nosek, & David, 2014). Ioanndis et al. for an essential feature of science is the and Big Pharma: Lessons Learned? (2014) nicely summarized other problems maximization of criticism (Bartley, 1962). with other drug studies: In this view good scientific research is an One of the best known recent examples For example, in a review of all random- attempt to expose cherished beliefs to of such problematic science and the lack of ized controlled trials of nicotine replace- severe criticism in order to efficiently iden- severe testing is research that has been con- ment therapy (NRT) for smoking cessa- tify errors in one's web of belief. Genuine ducted by Big Pharma, particularly numer- tion, more industry-supported trials (51%) science is not a craving to be correct, but ous for clinical trials of antidepressants reported statistically significant results rather a craving to efficiently learn where (Antonuccio et al., 1999). Speaking gener- than nonindustry trials (22%); this differ- our beliefs are wrong so that our errors can ally, this research used apparently sound ence was unexplained by trial characteris- be eliminated. The prominent philosopher methodologies such as random clinical tics. Moreover, industry-supported trials of science Sir Karl Popper (1959), for trials, decent sample sizes, double blinds, indicated a larger effect of NRT (summary example, suggested that it is only through statistical analysis, and usually was pub- odds ratio 1.90, 95% CI 1.67 to 2.16) than such error elimination that knowledge lished in high-impact peer-reviewed stud- nonindustry trials (summary odds ratio grows. ies—that is, with many of the apparent 1.61, 95% CI 1.43 to 1.80). Evidence of Thus, the best and most efficient way of characteristics of sound science and indeed excess significance has also been docu- rooting out error in our beliefs is to expose even exceptional quality/high-prestige sci- mented in trials of neuroleptics. Compar- these to severe criticism through empirical ence. However, numerous critics have isons of published results against FDA tests that can efficiently uncover error. To astutely pointed out many methodological records shows that, while almost half of the give a general picture of the distinction problems with this research and thus ques- trials on antidepressants for depression between severe vs. nonsevere tests, suppose tioned the intellectual virtue of this have negative results in the FDA records, one wanted to test the belief, “My minister research (e.g., Antonuccio et al.; Greenberg these negative results either remain unpub- never swears.” The researcher could collect & Fisher, 1994, Kirsch et al., 2008; Klein, lished or are published with distorted verbal samples from her sermons, from her 2006). These problems occurred at a reporting that shows them as positive; thus, speeches in front of community groups, number of levels: blinds were violated; neg- the published literature shows larger esti-

20 the Behavior Therapist SCIENCE AND EPISTEMIC VICE mates of treatment effects for antidepres- quent publications exaggerating the posi- decision making than statements about an sants than the FDA data. A similar pattern tive findings in the dissertation; (c) the individual study. has been recorded also for trials on antipsy- development of a bibliotherapeutic inter- There have been longstanding ques- chotics. vention explicitly marketed to people with tions about the epistemic virtue of other This is a serious concern for obvious diabetes (claiming to be “a proven pro- research in psychotherapy—for example, reasons—the pollution of the scientific lit- gram”) in which the reader is led to believe with the refusal of proponents of facilitated erature which can affect clinical decision the bibliotherapy intervention they were to communication to accept evidence that fal- making and thus client welfare—but it also use had been shown to be effective and safe sified the notions that facilitated was effec- is a parochial concern for cognitive behav- in past research, when the bibliotherapy tive or that its hypothesized process vari- ior therapists because in many cases these intervention had not even been studied at ables were operative (Lilienfeld et al., 2014): psychotropic medications were often seen all; (d) the failure to accurately describe in the refusals of proponents of EMDR to as in direct competition with cognitive subsequent publications, particularly in the adequately test simple exposure can behavior therapies. The general scientific peer-reviewed journal publication, what explain positive results instead of finger question could be phrased, “Which is more are at best equivocal findings regarding the waiving (Herbert et al., 2000), or whether efficacious, this medication, some CBT, or role of putative ACT processes as mediat- claims for the efficacy of positive psychol- both?” Any jimmying of results toward the ing these results. Instead, the opposite is ogy have vastly outstripped the data (Eidel- medication not only distorted information found: clear, but inaccurate, statements son & Soldz, 2012). In all these cases, and placed patient welfare at risk but it also about ACT processes producing clinically adherents are not disinterested—there are had direct implications for the rational significant changes in diabetes self-man- numerous payoffs for ignoring reasonable appraisal of the efficacy of CBT. Obviously, agement when the original data simply do criticisms, data that is falsifying, and con- something is seriously amiss here—many not warrant this; and (e) a lack of appropri- ducting research so that only weak tests are of the characteristics of science seem to be ate caution and qualification in interpret- employed that will produce “positive” in place but yet all these efforts seem to be ing the data relating to the effectiveness of results. However, like Big Pharma’s distort- violating what Meehl (1993) once attrib- ACT for diabetes self-management despite ing research, there are serious conse- uted to Bertrand Russell as the fundamen- numerous methodological shortcomings, quences to clients and to the scientific liter- tal orientation of an intellectually virtuous including, but not limited to: therapist alle- ature from such problematic studies. scientist— “the passion not to be fooled giance effects, dependent measures with and not to fool anybody else.” unknown psychometrics, no blinds, mini- Science and Virtue Epistemology These criticisms of Big Pharma seem mal follow-up, no safety measures, signifi- reasonable, fair, and important—but this If there is such scrutiny of epistemic cant attrition, problems with alpha rate kind of scrutiny to date also seems to be virtue of scientific practices, how ought this inflation, no comparison to key treatments somewhat one sided. Few are asking the to be understood? One such viable candi- as usual, and no replications. All of these extent to which CBT’s research house is in date is virtue epistemology (Sosa, 2009). are serious problems and problems that order with regard to such epistemic vice. At Virtue epistemology is a growing approach seem to be similar to those found in Big first blush, one would have to admit that to understanding rational agency and the Pharma’s problematic pseudo-scientific some of the same personal incentives could way knowledge can be legitimately gained. be present in CBT research (although per- research. Interestingly, the existence of Kidd (2016) provides a useful summary: haps a bit less flush). CBT researchers can these problems sometimes occurred in a have a financial interest to produce positive context in which the authors were explic- The core conviction of virtue episte- results—from paid trainings, from book itly reassuring readers that they would mology is that enquiry is an active sales, from academic promotions, and refrain from excessive claims and would process that can go better or worse, from additional salaries from grants, and point out unresolved empirical issues, thus and that central among the factors that so on. CBT researchers can also be inter- providing readers with a false assurance determine how it goes are the charac- ested in other inducements such as fame, that good scientific practices were being ters of the enquirers who perform it. awards, professional offices, increased cita- followed. This certainly raises clear issues Since enquiry is initiated and per- tions, and publications in high-prestige about bias, pseudoscience, and intellectual formed by epistemic agents, such as journals. The question becomes ought vice scientists or scholars, the stable cogni- behavior therapy research and behavior It is also important to note that there is tive and behavioural dispositions of therapists also be scrutinized for their epis- an important second-order concern that those agents are surely crucial to the temic virtue along lines similar to the also needs to be mentioned: Bias can occur success of that enquiry. (p. 10) scrutiny received by Big Pharma? not only in the design and reporting of a For example, a case study (see O’Dono- particular study, but it also can occur in the The list of possible epistemic virtues is hue et al., 2016a, 2016b; and for a rejoinder, way studies are aggregated or how that lenghty as rational belief formation can be see Gregg & Hayes, 2016) of a series of pub- study is spoken about subsequently. Utter- evaluated on multiple dimensions: consci- lications related to Acceptance and Com- ances like, “This and other studies show entiousness, transparency, discernment, mitment Therapy and diabetes self-man- that this treatment is scientifically proven”; intellectual honesty, and intellectual agement found several similar problems, “There are 200 RCTs proving the efficacy humility, for example. For our purposes including: (a) a failure to report several key of X therapy” and so on each can also be here critical epistemic virtues in research negative results from the dissertation in a examined for bias and epistemic virtue. It are to honestly and transparently conduct subsequent peer-reviewed journal publica- may be particularly important to examine and report severe tests instead of gaming of tion; (b) a series of overstatements and mis- these statements as these summary state- methodology and scientific reporting to statements by the researchers in subse- ments may be more influential in practical produce weak or pseudo-tests to manufac-

January • 2018 21 O ’ DONOHUE ture in an effort to report only “confirm- 8. Use multiple outcome variables but 16. Do not attempt to search for any ing” results. in any discussion prioritize only those negative side effects. There is a growing recognition that that show statistically significant 17. Do not conduct a failure analysis such biases occur in scientific research and results. Interpret the nonsignificant and do not report the percentage of these epistemic problems need to be both results as “minor” instead of falsifica- patients that did not change or identified and prevented. However, it tions of any beliefs or hypotheses. Or, became worse in the experimental seems that the field of clinical science and alternatively, completely fail to men- condition. CBT generally has been somewhat of a lag- tion these in subsequent publications. 18. Be unclear in what exactly the key gard in this movement. For example, there 9. Have a weak control condition—do is no recognition of this in most concepts processes are, e.g., “acceptance” and not test for equivalence in initial cred- “commitment,” and how these were of empirically supported treatments, such ibility; do not test for the presence of instantiated in the research. as the well-known Chambless report any other key psychotherapeutic (Chambless & Hollon, 1998). Instead, any processes in the experimental condi- 19. Have a vague, elastic model of randomly controlled trial with positive tion such as the nonspecifics. Espe- therapy process in which “accep- results seems to be taken without scrutiny cially avoid a control that is evidence- tance,” “emotional avoidance, “mind- for bias or interest and is taken as sound based treatment as usual as this is a fulness,” “valued action,” “deliteral- evidence to gain the mantle of “empirically harder hurdle to beat. Ignore the ization,” “psychological flexibility,” supported treatment.” iatrogenic effects that may realize if “recontextualization skills,” “cogni- This has perhaps led to a problematic any real patients are switched from a tive entanglement,” “loss of core enterprise associated with research in cog- more robustly tested treatment as values,” “cognitive fusion,” “domina- nitive behavior therapy: “If I can manufac- usual due to one’s weak test and exag- tion of conceptualized self over ‘self as ture randomly controlled studies in sup- gerated results. context,’” “relational frames” and so port of my therapy, I can gain the rewards 10. Do not analyze for clinical signifi- on are all intermixed so that it is associated with this.” Of course, the easiest cance. This is a tougher hurdle, so in unclear exactly what actually ought to way to do this is to avoid severe testing, as discussions conflate statistical signifi- occur in treatment. Do not acknowl- discussed above—one would report data cance with clinical meaningfulness. edge that many of these allegedly key from the sermon not from the golf game. constructs were not actually tested in 11. If the experimental therapy condi- To be more precise, O’Donohue et al. the study. (2016b, p. 40) suggested that these method- tion fails to reach statistical signifi- 20. Do not provide an assessment ological moves would make the manufac- cance on any outcome measure but ture of such positive RCTS possible and the means are in the favored direc- plan for each of these many con- would all be problematic from the view tion—report these positively as structs in the study but still use these point of epistemic virtue: trends. This still gives a more favor- concepts in theoretical talk. able impression to the original belief 21. Do not report any problems in the 1. Ensure that therapy allegiance system. theoretical background of the ther- effects are operative in favor of the 12. Do not run many or any follow- apy—e.g., problems in the conceptu- experimental treatment; for example, ups after therapy is completed even alization or replication of relational by having one therapist strongly though one may be treating a chronic frame theory (see e.g., Roche, 2010). aligned with a therapy orientation condition like diabetes. Relapse is a 22. Use measures of unknown or and the other not aligned with the common problem so the absence of problematic validity. control condition. long-term follow-ups avoids the 23. Run analyses on a variety of out- 2. Do not use blind data collectors, detection of relapse which would be a come measures such as change scores, therapists, or subjects. Give every less favorable study. and absolute differences at the end of chance that biases and expectations 13. If statistical tests show nonsignifi- can be communicated. therapy and report those that show cance find another statistical test that more significant results. 3. Once these biases and expectations shows a significant confirmatory 24. Do not conduct analyses on both have been instantiated, rely on self- result. Do not report in the publica- therapy completers and intent to report as a key outcome measure. tion that a previous statistical test was treat. Generally, ignore attrition; 4. Use a small convenience sample of run that showed nonsignificant especially do not interpret attrition as clients who only have relatively low results. a problem for the experimental treat- levels of the clinical problem. 14. Use a small unrepresentative ment condition. 5. In single subject experimental sample—which increases the odds of designs run more than three subjects a false positive result. However, make 25. Make claims that one modality of but report only the three that provide claims that the therapy works for a therapy (bibliotherapy) works even confirming results. broad class of patients—seemingly all though another modality (a work- 6. Stop collecting data once p < .05 is diabetics, for example. shop) was tested. reached. 15. Ignore initial differences if 26. In reporting results, simply do not 7. Do not randomly assign or sample random assignment fails to produce report some hypotheses that were not therapists: use the more advanced, equivalent groups, particularly if confirmed. more talented, therapist in the experi- these are in favor of the experimental 27. If all outcome measures are nega- mental condition. treatment condition. tive, then use the file drawer.

22 the Behavior Therapist SCIENCE AND EPISTEMIC VICE

28. In publications, make exagger- 6. No research such as an RCT ated summary statements of the state should count as support for an hon- of the science such as “scientifically orific such as an “empirically sup- proven” that ignore any design limita- ported treatment” if the test is a tions, any outcome variables that fail suitably severe test. to reach significance, any failures, any 7. Summary statements about a analysis of relapse, etc. body of research are also scruti- 29. Make misleading statements nized for their epistemic virtue. towards the positive, e.g., the ACT bib- liotherapy for diabetes has been stud- Conclusions ied when it simply hasn’t. One can also state that ACT has shown its useful- It is important that science be con- Figure 1. Common practices and possible ducted with an integrity where its essential ness in integrated care settings for dia- solutions (retrieved from https://www.ncbi. betes when there have been no studies functions of error detection operates nlm.nih.gov/pmc/articles/PMC4078993/ instead of in a manner in which only the of this. figure/F2/) 30. Use honorific and obscurantist lan- topography of science is present (“cargo guage to describe one’s approach to cult” science). Big Pharma provides an important object lesson and more CBT science, e.g., “reticulated.” Specific Recommendations 31. Keep a scorecard regarding research needs to be scrutinized for its epis- number of RCTs supporting one’s pre- for Controlling Bias in More temic virtue. Perhaps this can result in the ferred position but an incomplete one. Epistemically Virtuous Research increased growth of knowledge and over- Do not report the scorecard of the come what Meehl (1978) has called “the One seems to be confronted with the slow growth of soft psychology” by a more competition such as standard cogni- fact that the epistemically virtuous scientist tive behavior therapy. thoroughgoing commitment to Bertrand might be rare or one should at least not Russell’s recommended orientation for the 32. Do not mention that the results assume that research being produced is have not been replicated in an inde- virtuous scientist, “the passion not to be based on epistemic virtue. Instead, one fooled and not to fool anybody else.” pendent laboratory. ought to conduct, publish, and appraise all 33. When asked for therapy manuals research. The following steps are recom- References to attempt to replicate, indicate that mended: these are not available. Antonuccio, D. O., Danton, W. G., DeNel- 34. Indicate that one is open to criti- 1. Epistemic vice and virtue are sky, G. Y., Greenberg, R., & Gordon, J. S. cism but ignore this criticism. taught as part of research methods (1999). Raising questions about antide- (O’Donohue et al., 2016b, p. 40) and ethics courses. pressants. Psychotherapy and Psychoso- matics, 68(1), 3-14. 2. All clinical trials are preregis- Perhaps there has been too much emphasis Bartley, W. W. (1962). The retreat to com- tered. This can allow a better assess- mitment. New York: Knopf. on cognitive biases such as heuristical errors ment of the use of file drawer, p- Chambless, D. L., & Hollon, S. D. (1998). as affecting judgment of scientists and clini- hacking, as well as problematic cians (e.g., see Garb, 1989). The biases dis- Defining empirically supported thera- deviations from protocols and post pies. Journal of Consulting and Clinical cussed here provide a more comprehensive hoc analyses. and thus accurate view of the biases that can Psychology, 66(1), 7. 3. Part of peer review for journals affect science. Bertrand Russell (1950) in his Eidelson, R., & Soldz, S. (2012). Does com- and grants is evaluating the extent Nobel Prize acceptance speech suggested prehensive soldier fitness work: CSF to which methodological decisions research fails the test. Coalition for an four main desires that motivate much were made to construct a severe test Ethical Psychology Working Paper, 1(5), behavior, including scholarship: acquisitive- vs. to manufacture a positive result. 1-13. ness (“the wish to possess as much as possi- The steps described above as allow- Feyerabend, P. (1975). Against method. ble”); rivalry (“a much stronger motive”); ing weaker tests are made more New York: Verso. vanity (“a motive of immense potency”); transparent and scrutinized and are Feynman, R. (1974). Cargo cult science. and love of power (“which outweighs them generally reasons for rejection. Engineering and Science, 37(7), 10-13. all”). We may note the tremendous degree Garb, H. N. (1989). Clinical judgment, to which all four desires seem actively at 4. Method sections are written to increase transparency by including clinical training, and professional experi- work in shaping science, including research ence. Psychological Bulletin, 105, 387– in cognitive behavior therapy. According to a subsection in which the study’s methodological decisions are eluci- 396. Russell, it is important to be clear-sighted on Greenberg, R. P., & Fisher, S. (1994). Sus- this matter. dated in more detail and sufficient information is provided to evaluate pended judgement seeing through the double-masked design: A commentary. for bias and severe testing. Recommendations to Identify Bias Controlled Clinical Trials, 15(4), 244-246. and Promote Intellectual Virtue 5. Replications are seen as having Gregg, J. A., & Hayes, S. C. (2016). The increased value and an important progression of programmatic research in Figure 1 illustrates common practices part of science. This would need contextual behavioral science: Response and possible solutions across the workflow buy-in from journal editors and to O’Donohue, Snipes, and Soto. Journal for addressing multiple biases (from Ioan- promotion committees. of Contemporary Psychotherapy, 46(1), nidis et al., 2014). 27-35.

January • 2018 23 FOLLETTE

Hempel, C. (1965). Aspects of scientific submitted to the Food and Drug Admin- chotherapy: An ACT intervention for explanation. New York: The Free Press. istration. PLOS Medicine, 5(2), e45. diabetes management. Journal of Con- Herbert, J. D., Lilienfeld, S. O., Lohr, J. M., Klein, D. F. (2006). The flawed basis for temporary Psychotherapy, 46(1), 15-25. Montgomery, R. W., T O'Donohue, W., FDA post-marketing safety decisions: O’Donohue, W., Snipes, C., & Soto, C. Rosen, G. M., & Tolin, D. F. (2000). Sci- The example of anti-depressants and (2016b). The design, manufacture, and ence and pseudoscience in the develop- children. Neuropsychopharmacology, reporting of weak and pseudo-tests: The ment of eye movement desensitization 31(4), 689. case of ACT. Journal of Contemporary and reprocessing: Implications for clini- Lilienfeld, S. O., Marshall, J., Todd, J. T., & Psychotherapy, 46(1), 37-40. cal psychology. Clinical Psychology Shane, H. C. (2014). The persistence of Popper, K.R. (1959). The logic of scientific Review, 20(8), 945-971. fad interventions in the face of negative discovery. London: Hutchinson. Houts, A.C. (2009). Reformed theology is scientific evidence: Facilitated communi- Russell, B. (1950). What desires are politi- a resource in conflicts between psychol- cation for autism as a case example. Evi- cally important. Retrieved from Nobel- ogy and religious faith. In N. Cummings, dence-Based Communication Assessment prize.org. W. O’Donohue, & J. Cummings (Eds.), and Intervention, 8(2), 62-101. Sosa, E. (2009). A virtue epistemology. Psychology’s war on religion. Phoenix, Meehl, P. E. (1978). Theoretical risks and Oxford: Oxford University Press. AZ: Zeig, Tucker, Thiesen. tabular asterisks: Sir Karl, Sir Ronald, and Ioannidis, J. P., Munafo, M. R., Fusar-Poli, the slow progress of soft psychology. ... P., Nosek, B. A., & David, S. P. (2014). Journal of Consulting and Clinical Psy- Publication and other reporting biases in chology, 46(4), 806. The author has no funding or conflicts of cognitive sciences: Detection, prevalence, Meehl, P. E. (1993). Philosophy of science: interest to disclose. Help or hindrance? Psychological and prevention. Trends in Cognitive Sci- Correspondence to William O'Donohue, ences, 18(5), 235-241. Reports, 72(3), 707-733. Ph.D., Director, Victims of Crime Treat- Kidd, I. J. (2016). Why did Feyerabend McFall, R. M. (1991). Manifesto for a sci- ment Center, Department of Psychology, ence of clinical psychology. The Clinical defend astrology? Integrity, virtue, and University of Nevada, Reno, Reno, NV Psychologist, 44(6), 75-88. the authority of science. Social Episte- 89557; [email protected] mology, 30(4), 464-482. O’Donohue, W (2013). Clinical psychology Kirsch, I., Deacon, B. J., Huedo-Medina, T. and the philosophy of science. New York: B., Scoboria, A., Moore, T. J., & Johnson, Springer. B. T. (2008). Initial severity and antide- O’Donohue, W., Snipes, C., & Soto, C. pressant benefits: A meta-analysis of data (2016a). A case study of overselling psy-

cinations based on false information link- Pseudoscience Persists Until Clinical Science ing vaccinations to the development of Raises the Bar autism (see Rao & Andrade, 2011, for a synopsis and timeline of Wakefield's retracted report; Wakefield et al., 1998). William C. Follette, University of Nevada, Reno This report fed into personal beliefs and heuristic errors of parents that place at risk not only their children, but other children TO MANY OF US it is perplexing as to why Our interest in this issue gets rekindled who cannot be immunized. At a larger level providers or utilizers of interventions when a practice that represents a signifi- of analysis, climate change deniers place intended to help people in distress ignore cant cost to society uses the trappings of multiple species at risk of extinction. One research findings that document effica- science to establish credibility and attract thing we know is that once misinformation cious interventions in favor of unsup- disciples. At some point our scientific is received, it is extremely hard to correct ported pseudoscientific therapies. Clinical values are sufficiently offended to cause us (Chan, Jones, Jamieson, & Albarracín, science programs certainly present the to decry pseudoscientific practices, non- reports on empirically supported treat- science, or antiscience. Examples have been 2017). ments (Chambless, 2015; Chambless et al., identified for decades (e.g., Beyerstein, If we emphasize science in the training 1998; Chambless & Hollon, 1998; Chamb- 2001). Researchers have proposed methods of our students and make available lists of less & Ollendick, 2001). In research meth- for identifying harmful practices (Dimid- empirically supported treatments, why do ods or philosophy of science courses, the jian & Hollon, 2010). There may be debate people make use of alternative treatments? demarcation criteria for differentiating sci- about what is meant by harm. Tragically, It might be useful to ask the question of ence from pseudoscience are often taught there are some cases where harm is indis- why people are not persuaded by science (Lilienfeld, Lynn, & Lohr, 2015a; Schermer, putable, therapy is abusive, and deaths and go on to create and consume such ther- 2002). Some classes will offer classic occur (e.g., Advocates for Children in apies. Paraphrasing Skinner, it behooves us debates about whether this distinction Therapy, 2017; Chaffin et al., 2006; Mercer, to study the behavior of the person, between the two can be reliably made (cf. 2014; Singer & Lalich, 1996). because the person is always right. Let us Laudan, 1983; Mahner, 2013; Pigliucci, Outside of therapeutic interventions, leave aside such factors as greed, gullibility, 2013). Even without philosophical tutor- fraudulent science poses threats to the col- lack of training, motivated reasoning, ing, at some point it is clear that one has lective well-being of larger groups of indi- naiveté, hopelessness, etc. Let us ask the departed from science into pseudoscience viduals. Recent examples of people being question of why our appeal to scientific evi- (Lilienfeld, 2011, p. 109). misled by fraud are those who oppose vac- dence is not sufficiently convincing to keep

24 the Behavior Therapist PSEUDOSCIENCE PERSISTS the audience for pseudoscience sufficiently either our understanding of the treatments achieve is no symptoms of a disorder. For- small. for the “disorders” or the validity of the mally, this is an instrumentation threat to underlying nosology itself. internal validity due to a floor effect. If the Context One effect of adopting an atheoretical goal of an intervention is “cure” a disorder, nosology seemed to be a reluctance to then the best one can do is have zero So why do pseudoscientific practices develop and test theories of mechanisms of amount of the disorder. Others have persist? It is not because the issue has not etiology or change. Yet specifying testable argued that psychology could offer a more been well articulated. For many years mechanisms of change is a hallmark of sci- robust model of psychological health that Lilienfeld and colleagues and many others ence that distinguishes it from pseudo- would conceptually allow for a richer mea- have provided thoughtful critiques of pseu- science. Treatments often did have theories surement model of outcome (Bonow & doscience in clinical psychology (Lilienfeld, of etiology or change, but theory testing Follette, 2009; Follette, Bach, & Follette, Lynn, & Lohr, 2003, 2015b). Yet practition- was not the focus of treatment studies. 1993). Unfortunately, for a long time out- ers, some psychologists and some not, Instead, studies were often of the “horse come assessment did not differentiate invent and practice dubious interventions race” variety where the winner was what- between an instance where depressive even though other therapies may have doc- ever treatment produced significantly symptoms were gone and a second umented efficacy. Perhaps there are other more reduction in symptoms. The general instance where depressive symptoms were sufficiently potent contextual features that conclusion has been that the races often gone and the patient was more involved make the science less clearly persuasive ended in ties where many treatments were with family, enjoyed an engaging social thus allowing the production and con- better than a waitlist control, and most network, experienced more control over sumption of pseudoscientific practice were equivalent to each other. These types life, or worked and played with greater sat- instead. Let’s consider some reasons why of studies are still done and mostly produce isfaction. clinical science has not preempted alterna- similar results. The question of interest in If an alternative treatment offers an out- tive practices. clinical trials was usually whether one got come that is more than misery manage- The Choice of the Medical Model to the finish line but not how. Since scien- ment but also includes a richer life experi- Perhaps one reason the quality of our tific programs receiving significant funding ence, one can appreciate the appeal of science is not sufficiently convincing is were being judged by whether they pro- improvement claims beyond “diseased or because the field took a wrong turn in 1980. duced improvement, pseudoscientific not” as an outcome. There is no assertion Psychology misestimated the effects of gen- treatments can often show some amount of here that the claims offered by alternative erally acquiescing to an implicit medical self-reported improvement as well. treatments were valid, only that the scope model when accepting DSM-III as the Because randomized controlled trials were of outcomes addressed by alternative treat- dominant nosology to organize research not judged by the evidence testing the the- ments can be more appealing. More and practice in clinical psychology (see ories on which treatments were designed, recently, there have been thoughtful con- Kirk & Kutchins, 1992, for a discussion). pseudoscientific theories have not suc- tributions on the treatment quality and Several negative effects ensued (see Follette cumbed to the criticism that the theories outcome assessment measurement & Houts, 1996, for a critique and alterna- behind them are invalid or untestable. domains (e.g., Lambert, 2017; Thornicroft tive; Follette, Houts, & Hayes, 1992). Instead, pseudoscientific interventions are & Slade, 2014), but these additions are late identified by the apparent absurdity of the to the game. In the meantime, interven- • The research strategy. One ill-effect of rationale. We will discuss falsifiability later. tions that made claims to improve the qual- this decision was that DSM influenced ity of life or enhance control had an oppor- researchers to construe distressing behav- • Inclusion and outcome measures. To tunity to proliferate. ior as one of hundreds of disorders rather receive treatment clients had to have a than different topographies of a much diagnosable disorder. Without a diagnosis, • Dissemination. If there were a reduced smaller number of functional classes of people who were unhappy with life cir- audience for pseudoscientific interven- behavior that rested on common psycho- cumstances, relationships, prejudice, or tions, the problem would fade to a manage- logical principles. DSM-III claimed to be didn’t understand the relationship between able level. Lilienfeld and colleagues have atheoretical (American Psychiatric Associ- the environment (writ large) with how suc- discussed sources of resistance to evidence- ation, 1980, p. 7). With the exception of cessfully they achieved valued goals were based practice by psychotherapists (Lilien- PTSD, there were almost no statements of never the focus of study. By focusing on feld, Ritschel, Lynn, Cautin, & Latzman, etiology of clinical problems. The result disorders rather than including well-being 2013). Beyond the difficulties with psy- was that treatments were developed to treat as part of the assessment of outcomes, clin- chotherapists being convinced by data, disorders with little regard to commonali- ical researchers largely ceded these latter others struggle with how to translate scien- ties that produced or maintained distress. issues to others. tific information to a variety of audiences What emerged was treatment X for depres- Accepting the presence or absence of a (Kaslow, 2015). However, the way clinical sion. The same basic treatment X was later disorder as an outcome measure produces scientists disseminate information cannot developed for (applied to) anxiety, and a methodological problem. Effect sizes are possibly be as influential on consumer then other disorders. Less attention was generally reported with respect to some behavior as how purveyors of pseudo- paid to common processes for the develop- measure of change in the degree of distress science approach the task. One of the crite- ment of these disorders from a psychologi- (e.g., reduction in depression or anxiety ria used to identify pseudoscience is the use cal science perspective. The fact that the scores or no longer meeting criteria for a of testimonials, a practice that is prohibited same basic treatments worked across sev- diagnosis). This choice of dependent mea- by the APA in Standard 5 of the Ethical eral diagnostic categories should have been sures creates problems for arguing for very Principle of Psychologists and Code of taken as an occasion for us to question large effects. First, the best result one could Conduct because of concerns about vul-

January • 2018 25 FOLLETTE nerability to undue influence (American tices. I raise the issue that psychology per- the EST list. Let us consider the roads taken Psychological Association, 2017). Practi- suasion science would predict that the dis- by two therapies, now both with some level tioners outside the purview of APA are not semination practices of pseudoscience of empirical support but dubious theoreti- always so constrained. would be more effective than those used by cal underpinnings. The first example is of a Social psychologists and persuasion psychology clinical scientists. This state of therapy that ultimately produced evidence experts have long identified the potency of affairs is especially ironic given that social of efficacy but initially was wrapped in personal narratives compared to how sci- psychology provides some of the foremost obscurant language and contained unnec- entific information is usually conveyed to experts in persuasion and influence (e.g., essary treatment elements. The second the public or policy makers. Almost every Pratkanis, 1995, 2007). example is of a treatment with an initially presidential State of the Union address well-received theoretical foundation and now includes a policy initiative bolstered • Summary. The initial acceptance of a evidence of efficacy, but eventually has by a vivid story that refers to a specific indi- medical model and the emphasis on effi- maintained evidence of efficacy but its pro- vidual who embodies the need for the cacy rather than the testing of psychologi- posed mechanism of change has been sub- policy or policy change. Ronald Reagan’s cal theory placed clinical science at a disad- stantially challenged. Both are on the list of vivid description of a “welfare queen” vantage. By failing to make model testing a ESTs. during the 1976 presidential campaign is primary focus of study, clinical trials did Eye Movement Desensitization and one such example used to illustrate the can- not follow its own methodology for distin- Reprocessing therapy for the treatment for didate’s assertion that reform was needed guishing science from pseudoscience. The trauma and anxiety (EMDR; Shapiro, to protect against wanton abuse. In 2009 model did not include measures of well- 1998) garnered considerable criticism, in President Obama made references to three being and improved adaptability but rather part, because, among other issues, one of specific instance of individuals who were or only reducing a limited set of symptoms. the initially identified treatment compo- would be impacted by policy changes This constrained the ability to show larger nents included having clients track the during his State of the Union address. treatment effects and a richer domain of therapist’s finger movements that were When discussing the improved state of the treatment benefits. Though there have learned by participating in training and economy in his 2015 State of the Union been efforts to disseminate findings to certification programs. However, data address, then President Obama detailed a practitioners and the public, the methods accumulated that the eye-movement com- story of the Erler family, who fell on hard of doing so are less effective than those who ponent of the intervention was not neces- times and recovered in parallel with the propose and advocate alternative treat- sary (Hyer & Brandsma, 1997). To many economy. When the need for change is ments. researchers, the important element of the advocated or accomplishments touted, the therapy was exposure and habituation. Empirically Supported Treatments president names such a person or family Many considered the initial explanation to who is often in the audience who stands (ESTs) use obscurant language, invoke untestable and receives an ovation. Certainly, the Following the evidence-based medicine mechanisms, and resulted in monetary subtle but powerful influence of social movement in England, in 1995 APA estab- gain for the developer. These and other fea- media on public attitudes has been the lished the Task Force on Promotion and tures of the therapy satisfied some that focus of much attention since the last elec- Dissemination of Psychological Proce- EMDR passed the demarcation criteria for tion, attesting to the power of repetition dures with the laudable goal of identifying pseudoscience. and volume over facts. and disseminating treatments with known Over time an EMDR journal has Thus far, clinical scientists have not efficacy (Chambless & Ollendick, 2001). formed, and studies of EMDR were con- identified the optimal, ethical ways to How does this decision by APA, and Divi- ducted that met criteria for inclusion as an better disseminate scientifically grounded sion 12, contribute to the context that EST. The rationale for how EMDR worked practices. Pseudoscience practitioners or might paradoxically lead to the discounting has also changed (see references in Perkins complementary alternative medicine of scientifically supported therapies? The & Rouanzoin, 2002, for some of the argu- providers operate under a different dissem- enormity of the task of sifting through the ments about mechanisms). It is now ination model. While scientists might literature and reliably identifying ESTs argued that the intervention results in argue that the use of testimonials is a way required a focus on evidence that a therapy changes in adaptive information process- to identify pseudoscience, the public views worked. Treatments were not evaluated on ing (Oren & Solomon, 2012). The mecha- such testimonials as influential, credible how they worked, whether one worked sig- nism of action still may seem to rely on sources of information. The issues related nificantly better than other ESTs, how clin- technical, obscurant language (Oren & to pharmaceutical “direct to consumer” ically meaningful the observed changes Solomon, 2012, pp. 200-201), but in a advertising is more complex than can be were, or what, if anything, differentiated recent report EMDR does not appear to be addressed here, but it is easy to observe the one therapy from another and contributed an outlier in terms of clinical efficacy when correlation between advertising and sales to a better outcome (Follette, 1995; Follette compared to several other therapies for of a drug. Even not considering pharma- & Beitz, 2003; Follette & Houts, 1996; Fol- PTSD (Cusack et al., 2016). ceutical marketing, woe to anyone watch- lette et al., 1992; Jacobson, Follette, & The point of presenting EMDR is not to ing late-night television who fails to have Revenstorf, 1984; Kazdin, 2007, 2014). say whether it was or is pseudoscience, or is the correct pillow, doesn’t hang by their now more normal psychological science. feet, or does not partake of the cornucopia • Mechanisms. Because mechanisms of The point is that many treatments for of dietary and vitamin supplements to an intervention were not the primary focus PTSD make use of in vivo or imaginal improve, well, just about everything. I am of study, it was and is possible for the exposure, and many refer to changes in unequivocally not advocating for the aban- “same” therapy to be reinvented under information processing that results from donment of ethical dissemination prac- another name and subsequently appear on the exposure component. Because empiri-

26 the Behavior Therapist PSEUDOSCIENCE PERSISTS cally supported treatments are not required little to do with the direct correction of cog- resource . . .” (p. 596). In an article pub- to demonstrate mechanisms of change nor nitive distortions. In 2006 another study lished in the APS Observer, the authors are define ways to identify its essential treat- demonstrated that behavioral activation quoted as saying, “Our model suggests that ment components, nor describe ways in performed better than CT (Dimidjian et al., any intervention that targets key predis- which a therapy is essentially different for 2006). posing, precipitating, or resilience factors another therapy, nor the conditions under In 2001, a study was published that can reduce risk or alleviate symptoms” which the treatment and its underlying examined the relationship between depres- [Italics in original] (Observer, 2016, April). theory could be fundamentally challenged, sion, anxiety, and dysfunctional attitudes One can take these statements to allow for the list of therapies continues to grow. (DAs) in 521 patients receiving a 12-week a variety of interventions to claim to influ- More important, until such requirements course of CBT (Burns & Spangler, 2001). ence the system Beck and Bredemeier are established, there is nothing to keep Using structural equation modeling, the describe. pseudoscientific treatments from compet- study examined four hypotheses: The point of describing these lines of ing. The effort to identify ESTs was laud- theory and treatment development is that able. Now a more refined strategy is (1) changes in DAs lead to changes in the route from theory to treatment or treat- required beyond just showing that a partic- depression and anxiety during treat- ment to theory unfolds over time. Compo- ular treatment produces change (e.g., ment (the cognitive mediation nents were shown to be misunderstood or David & Montgomery, 2011; Follette & hypothesis); (2) changes in depression superfluous in both cases. Both interven- Beitz, 2003; Lilienfeld, 2011; Tolin, McKay, and/or anxiety lead to changes in DAs tions appeal to some combination of prac- Forman, Klonsky, & Thombs, 2015). Until (the mood activation hypothesis); (3) titioners and patients. Neither are effective these features of treatments are defined, DAs and negative emotions have reci- in all cases. Beck’s and Bredemeier’s for- there is little to dissuade treatment devel- procal causal effects on each other (the mulation is accepting of a vast number of opers from adding superfluous but mar- circular causality hypothesis); and (4) interventions. Therapy designers can con- ketable components to principle-based there are no causal links between DAs struct (fabricate) all kinds of explanations treatment elements and creating a “new” and emotions—instead, a third vari- for how an intervention targets resilience therapy where the purported mechanism is able simultaneously activates DAs, or any other component. The reference in completely unrelated to how an interven- depression and anxiety (the “common the theory to conserving energy almost tion actually works.1 cause” hypothesis) . . . This common invites “energy therapies” to justify the Now turning to cognitive therapy (CT) cause accounted for all the correlations intervention in spite of the underlying for depression: Beck, in his classic publica- between the attitude and mood vari- explanation for energy therapies being tions (Beck, 1967; Beck, Rush, Shaw, & ables, and also appeared to mediate the considered as classic pseudoscience by Emery, 1979), highlighted the role of dys- effects of psychotherapy and medica- many. functional cognitions in depression. The tion on dysfunctional attitudes, Both EMDR and CBT have empirical theory highlighted the importance of the depression, and anxiety. (p. 337) support. But what is the basis for the sup- cognitive triad of a negative view of the self, port? It cannot be that the theoretical basis the world, and the future as well as dys- This study was particularly interesting was always (or ever was) correct. In the case functional attributional styles in depres- because the first author, having written a of EMDR, the treatment charitably had an sion. Notions of core self-schemas evolved successful self-help book making use of improbable theoretical basis. The treat- and CT evolved into an intervention with CBT principles (Burns, 1980), had a strong ment had a component, the finger move- an articulated mechanism for the treat- allegiance to CBT. The findings were ments, that seems superfluous. Yet because ment of depression that was plausible and clearly reported and cast doubt about the eventually there was evidence of efficacy, was efficacious. However, there have been mechanism of change for CBT. the treatment persisted while the theoreti- some important studies along the way that What were the consequences of these cal explanation morphed. Over time, data have challenged the purported mecha- findings? Certainly cognitive behavior were accumulated to qualify EMDR as an nisms underlying CT. therapy was not deleted from the EST list, EST. In the other instance, a treatment with In 1996 Jacobson and colleagues con- but our understanding of how it works is an initially plausible theoretical basis and ducted a component analysis of CT com- now known to be wrong or incomplete at good initial support was later shown to be paring the behavioral activation compo- best. Beck’s most recent theoretic model of effective but for reasons not entirely under- stood from an initial examination of how nent of CT, CT with behavioral activation depression has changed considerably (Beck that intervention was thought to achieve its and skills to modify automatic thoughts, & Bredemeier, 2016). It is now a multicom- effect. and the full version of CT including behav- ponent model featuring several interacting At some point both treatments made ioral activation, skills to modify automatic systems at different levels of analysis. It is their way onto the EST list. At some point thoughts, plus the addition of focus on core an elaborated diathesis-stress model that the theoretical rationales for both failed. In schemas. That study, involving 150 outpa- seems difficult to falsify. The language now both cases the treatments remain on the tients, showed that the complete version of states that “depression can be viewed as an EST list. CT did no better than its components adaptation to conserve energy after the including behavioral activation, which had perceived loss of an investment in a vital The Practice of Clinical Science Research One of the features of a psychotherapy 1 Space constrains don’t allow for discussions of placebo effects (Kirsch, 2008; Stewart-Williams, that gets labeled as pseudoscience is that it 2004), common factors, or the Dodo bird arguments (cf. Honyashiki, et al., 2014; Rosenzweig, is, in principle, not subject to falsification. 1936; Wampold, 2015). In an oft-cited paper Platt (1964) argued

January • 2018 27 FOLLETTE that for the social sciences to advance at a if they met the diagnostic criteria for one Criteria, for better or worse, now seeks to more rapid rate, it needed to utilize strong selected disorder but showed no other clin- identify mechanisms of change or influ- inference tests, similar to those in physics. ical problem. Such studies have been used ence (Cuthbert & Insel, 2013; Insel, 2014; Such tests pit competing theories against in RCTs to identify efficacious treatments. National Institute on Mental Health, 2011). each other. Ideally, one would identify two The logic is that if the treatment does not How progressive have our treatment theories that would make opposite predic- work on a “pure” sample for which it was development programs actually been? tions in a particular experimental condi- designed, it is probably not likely to pro- Lakatos (1974) recognized that research is tion, run the experiment, and the result duce an effect large enough to pursue in typically programmatic. Research pro- should be that one hypothesis is falsified more complicated cases. In many such grams do not initially start with fully devel- and eliminated from further consideration. studies the comparison is made between oped theories and therefore may not ini- Such experiments are actually difficult the active treatment and a no treatment tially be experimentally supported. He to conduct because in order to test a pri- control and then to another active treat- allows for modifications to either the core mary hypothesis, all related assumptions or ment or treatment as usual. theory or the auxiliary hypotheses to auxiliary hypotheses must be valid. If an While this strategy has identified many account for contrary findings. Lakatos sug- experiment (or clinical trial) does not per- empirically supported therapies for specific gested that as long as modifications to the form as predicted, it may not be that the disorders, the scientific evidence has not theory (a) account for findings that pro- therapy or theory is incorrect, but that been sufficient to persuade the majority of vided counter-evidence to the theory, and there may have been a problem with the practitioners to use ESTs. As in evidence- (b) provide for novel predictions not measurement instruments, training, based medicine, the adoption of ESTs by entailed in the prior version of the theory, fidelity, adherence, etc., that could account primary practitioners has been limited such theory revisions are permissible and for the outcome rather than a problem with because practitioners do not treat highly indicative of a progressive research pro- the underlying theory or therapy design selected samples without other complicat- gram. Modifications to the theory that did (see Curd & Cover, 1998, for a discussion ing factors. Explaining with precision and not accomplish both goals and were not of the Duhem Quine thesis that raises this scope, how to apply the science purported supported by empirical research were ad issue). to underlie the treatment when applied to hoc modifications and indicative of a Consider an elementary school science more complicated cases has not been per- degenerating program of research. teacher who intends to show her class that suasive (see Lilienfeld, et al., 2013, for an In clinical science it seems rare that a water boils at 100° C. During the demon- elaborated discussion of resistance to adopt theory is refuted, though it is easy to find stration water boils at some other tempera- evidence-based practices). individual articles attempting to do so (see ture. Rather than concluding to the class above discussion of EMDR and CT). It is that known gas laws have been falsified, she • Has the EST effort been progressive? difficult to identify the process where a would have to determine that all the neces- Recently, NIMH has recognized that a therapy is falsified and discarded. Hosts of sary auxiliary assumptions were met, i.e., reliance on the medical model, and DSM in auxiliary hypotheses are invoked to explain that the thermometer was accurate, that the particular, has not served the research apparent deficiencies in the theory. Modifi- water was free of impurities, and the exper- agenda well. Noting that perhaps the focus cations are offered but rarely evaluated as iment was conducted at 1 standard atmos- on efficacy research may have been a mis- to whether they are ad hoc or progressive phere of pressure. If any of those assump- take, now effectiveness research is favored, (consider the history of modifications to tions were shown to be false, the claim that where it is hoped that less restricted criteria the learned helpless model of depression). water boils at 100° C is never directly for inclusion might lead to larger, more Perhaps this is one reason why pseudosci- tested, and the theory could not be falsified. general principles of intervention and entific therapies persist—there is no good In clinical psychology the problem is results that will have more reported applic- model for discarding a practice or defining considerably more difficult because the ability to practitioners. the acceptability of a modification to a auxiliary hypotheses usually involve hypo- Additionally, NIMH is now interested theory or practice. As Paul Meehl once thetical constructs of cause and hypotheti- in identifying mechanisms of change, not stated of theories, “Most of them suffer the cal constructs of effects that are not directly just evidence that change occurs, but how it fate that General MacArthur ascribed to measured. Depression, adherence, compe- occurs. These changes, for better and for old generals—They never die, they just tence, alliance or outcomes do not have the worse, recognize that the earlier strategy slowly fade away” (Meehl, 1978, p. 807). same potential to be directly assessed (or for advancing science has not yielded the Tools for the evaluation of mediators and even have a consensus definition) that tem- results one might anticipate given the time moderators have been developed and perature, water purity, or the atmospheric and money invested (Cuthbert & Insel, refined (MacKinnon, 2008), but no con- pressure at the time of the experiment do. 2013; Insel, 2014; Insel & Gogtay, 2014). sensus exists about how to conceptually Without statements of mechanisms of compare the results of such analyses with • Programmatic research. For several change that are falsifiable, judgment about respect to how comparably sized mediation decades the gold standard for program- one of the central issues in the demarcation effects advance our understanding of how matic research has been the randomized problem are almost impossible to adjudi- one theory prevails over another or controlled trial (RCT). The RCT usually cate. whether the magnitude of a mediator is follows earlier phases of research to That NIMH has abandoned the sufficient in size to be conceptually mean- demonstrate feasibility and gather the data research strategy used from the 1980s to ingful. necessary to plan the larger-scale RCT. One the beginning of this decade suggests that of the decisions researchers have made was the clinical research strategy has not deliv- • Summary. Clinical science has to use highly selected participants where ered a convincing, progressive science. The focused on efficacy studies that have not the participants were eligible for inclusion change described in the Research Domain been convincing to practitioners. The strat-

28 the Behavior Therapist PSEUDOSCIENCE PERSISTS egy has been replaced by a call for more for these services establishes an expectation on the basis of whether the respondent also meaningful effects and an understanding that they will be beneficial. used conventional therapy” (p. 291). of mechanisms. As of yet, there is no agree- Reports on the efficacy of treatment for • Reasons for seeking alternative care. ment about how to identify when a theory both depression and anxiety in the psy- There have been attempts to identify rea- has been refuted. Without being able to chotherapy literature are variable, but a sons why patients seek CAM treatments. In define the criteria for discarding a theory reasonable estimate is that about half the on the basis of evidence, it makes it difficult 1994, a small sample of physicians were surveyed in Washington, New Mexico, and people respond significantly and half do to argue that scientific and pseudoscientific not. Clinical science cannot yet provide practices actually meet different standards. Israel. That study reported that in the last outcome data so convincing as to negate Currently the difference between a theory year, 60% of physicians made referral to the demand for alternatives. It does not being not falsifiable versus not knowing alternative providers. The referrals for seem likely that thoughtful instruction to when or how to falsify theories that rest on alternative care included spinal manipula- hypothetical constructs may be a distinc- tion, naturopathy, spiritual healing, and the public will help them discern the tion without a difference. movement therapy, among other forms of threats to validity and heuristic errors that interventions. The rationale for referrals even clinicians make when assessing actual Social Factors included patient requests, cultural beliefs, versus spurious therapeutic effectiveness So far commentary on our failure to failure of conventional treatment, and (Lilienfeld, Ritschel, Lynn, Cautin, & Latz- mount a powerful methodological attack physician beliefs that patients had nonor- man, 2014). on pseudoscience has focused on our ganic disease (Borkan, Neher, Anson, & research and analytic shortcomings. How- Smoker, 1994). In a 1996 study that utilized • Summary. In addition to problems in ever, there are social influences that under- phone interviews, a sample of CAM utiliz- being able to mount a strong theory-based mine the perceived value of making use of ers were characterized as unconventional argument against the use of alternative evidence-based practices. and reported a lack of confidence in con- treatments, there are social and cultural ventional medical treatment (McGregor & factors that support the continued use of • Financial support. Many products and Peay, 1996). such interventions. Social policy makes practices that are considered to be exam- The CDC National Health Interview many practices seem equivalent; profes- ples of pseudoscience fall under the rubric Survey interviewed over 30,000 U.S. adults sionals may actually refer to alternative of complementary alternative medicine and examined the utilization of 27 CAM (CAM). There is considerable variability in treatments (Barnes, Powell-Griner, practitioners; there is distrust of conven- costs of complementary alternative treat- McFann, & Nahin, 2004). The study tional treatments; combined treatments ments. The Affordable Care Act does not reported that 36% of adults used some may be presumed to offer the best of both allow insurance companies to discriminate form of CAM treatment in the last 12 worlds; alternative treatments may address against health providers with a recognized months (62% when prayer was included). important issues consumers believe are not state license. If an insurance policy pro- Mind-body interventions were among the addressed by more conventional treat- vides for mental health services, then a con- 10 most common CAM therapies utilized ments. sumer has the possibility of finding a within the last 12 months of the data col- licensed practitioner to deliver nontradi- lection. Respondents with anxiety or Conclusion tional therapy and get reimbursed. Reim- depression were the most frequently iden- bursement varies by state. Even where tified users of CAM for those who self- The application of criteria to identify insurance may cover some licensed service, identified as having a mental disorder. the differences between clinical science and it does not allow for reimbursement for CAM users reported a variety of reason for pseudoscience have been noted. One of nonlicensed treatments such as aromather- using CAM treatments including belief those important features is the ability to fal- apy, Ayurveda, cryotherapy, reflexology, that a combined approach would be useful, sify the theoretical basis for an interven- vibroacoustic therapy, crystal therapy, and conventional medical professionals sug- tion. There is nothing in this paper that the like. However, lax restrictions imply gested it, belief that it would be interesting, prevents one from identifying absurd prac- that all permitted choices share the same cost, and believing conventional treatment tices. In clinical psychology the predomi- evidence for efficacy. Of course, they do would not be helpful. nant research strategy has focused on effi- not. There are no data on exactly how Another study by Kessler and col- cacy and not tests of the underlying theory much money people spend on pseudosci- leagues utilized a nationally representative upon which the intervention is based. Even entific alternatives to psychotherapy or for phone sample with over 2,000 respondents if we can describe a method for rejecting a what problems people seek such services (Kessler et al., 2001). Two findings were clinical theory, with few exceptions, we that may be out of the purview of ESTs. For particularly interesting. First, a majority of have not done so. That means that con- complementary or alternative medicine, those with “anxiety attacks” and “severe sumers look for perceived benefits and not data do indicate that consumer out-of- depression” reported the use of CAM treat- for scientific justification when choosing a pocket spending is about $34B or 1.5% of ments. Second, the proportion of anxious total health care expenditures in the U.S. and depressed respondents who reported treatment. Social influences support the Approximately 2/3 of those expenses were CAM treatments “very helpful” was com- notion that treatments are equivalent. for self-care purchases (NIH National parable to those who rated conventional Until we take on the task of defining Center for Complementary and Integrative treatment the same. The authors state that, whether a research program is progressive Health, 2007). In addition to public policy “No evidence was found for significant or not, we will be lacking the strongest making it appear that all reimbursed ser- variation in the perceived helpfulness of argument against consumers using pseu- vices are equal, the fact that consumers pay complementary and alternative therapies doscientific interventions.

January • 2018 29 FOLLETTE

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January • 2018 31 De-implementation of Harmful, Pseudo- A Potential Solution: De-Implementation of Harmful, Scientific Practices: An Underutilized Step Pseudoscientific Practices in Implementation Research Although de-implementation is most commonly studied within the realm of low- value medical treatments, the existing de- Clara Johnson, National Center for PTSD implementation frameworks can be used to guide de-implementation within mental Shannon Wiltsey-Stirman, National Center for PTSD and Stanford health (e.g., Elshaug, et al., 2009; Henshall, University Schuller, & Mardhani-Bayne 2012; Ibar- goyen-Roteta, Gutiérrez-Ibarluzea, & Heidi La Bash, National Center for PTSD Asua, 2010; Montini & Graham, 2015; Niven et al., 2015; Polisena et al., 2013; Prasad & Ioannidis, 2014). Although we IN CLINICALPSYCHOLOGY, implementa- burden of proof… 6. Absence of connectiv- focus in this article on harmful, pseudosci- tion research has focused on sustained use ity… 7. Overreliance on testimonial and entific practices, the guidelines below can of evidence-based psychosocial treatments anecdotal evidence… 8. Use of obscuran- be used for de-implementation of ineffec- (EBPT) by testing different implementa- tist language… 9. Absence of boundary tive practices that are not necessarily pseu- tion strategies and models to improve conditions… [and/or] 10. The mantra of doscientific or harmful. treatment delivery and patient outcomes. holism” (pp. 7-10). This article focuses on Guideline 1: Identify and Prioritize the However, an integral and foundational step pseudoscientific practices that include one of implementation has been understudied Harmful, Pseudoscientific Practice or more of the above tendencies. More and frequently overlooked until recently: Before implementation leaders can specifically, we define a harmful, pseudo- the de-implementation of less effective begin to de-implement a harmful, pseudo- scientific practice as one that has empirical practices. De-implementation is defined as scientific practice, they need to identify ceasing the use of previously implemented evidence of long-term physical or emo- which practice(s) to target. A high-level practices (Niven et al., 2015). Fortunately, tional harm on patients or other individu- analysis should initially take place where strategies for de-implementation are als in the patients’ lives (Lilienfeld, 2007). implementation leaders conduct a meta- emerging, which pave the way for imple- Conversion therapy, a treatment used analysis of existing data on therapeutic out- mentation of EBPTs. We suggest that this to change sexual orientation in the mid- comes with a focus on articles that provide recent work can be extended to the chal- 1900s, is a common example of a harmful, evidence of a harmful treatment (i.e., lenge of reducing harmful, pseudoscientific pseudoscientific practice. The American declining patient outcomes, increase of practices. In this article, we will address the Psychological Association (APA) and the symptoms after treatment, etc.; Lilienfeld, danger of harmful, pseudoscientific prac- National Association of Social Workers, 2007). After an exhaustive list of harmful, tice and how it can inhibit the implementa- among other associations, deemed conver- pseudoscientific practices is created, the tion of EBPTs. Using de-implementation sion therapy to do more harm than good to practices should be reviewed to determine models from the medical sector and clinical patients (APA, 2009; Jenkins & Johnston, which to target first. The following are psychology implementation research, we 2004). For example, conversion therapy is aspects to consider when deciding which harmful, pseudoscientific practice to de- will also briefly outline the steps required to unsuccessful 70% of the time and fre- de-implementing harmful practice in the implement first: quently leads to depression, avoidance of mental health sector (e.g., Elshaug, Watt, intimacy, de-masculinization, and loss of Moss & Hiller, 2009; Niven et al.). • Evidence base. Priority should be given religion. Implementing evidence-based to a harmful practice with the most data The Problem: Harmful, psychosocial treatments can serve as a solu- documenting patient harm (Elshaug et al., 2009; Henshall et al., 2012; Ibargoyen- Pseudoscientific Practices tion to stop the use of harmful, pseudosci- entific practice like conversion therapy Roteta et al., 2010). In the case of psy- Before embarking on the process of de- (Hansson, 2013). However, to forego the chotherapeutic practices, harm can include implementing harmful, pseudoscientific de-implementation of the harmful practice worsened patient outcomes, and/or emo- psychotherapies, it is critical to define before implementing a new EBPT may tional and physical harm to a patient’s pseudoscience. A pseudoscientific practice result in unsuccessful implementation family or friends. Moreover, it is integral to is one that uses vague and broad scientific (Niven et al., 2015). For example, if a clini- the prioritization of de-implementation to language yet falsely promotes the reliabil- consider the populations in which the cian’s case conceptualization or selection of ity, efficacy, or effectiveness of the practice harm is documented, while focusing on interventions remained more consistent (Hansson, 2013). Lilienfeld and his col- research evidence that includes partici- leagues (2015) go further to point out spe- with the theory and practices of conversion pants with demographics most related to cific tendencies of pseudoscience: “1. An therapy, while attempting to deliver an the system’s specific patient population. overuse of ad hoc hypotheses designed to EBPT, the EBPT would be unlikely to Prioritization based on the existing evi- immunize claims from falsification… 2. achieve the desired results, and their confi- dence and highest impact changes is key to Absence of self-correction… 3. Evasion of dence in the EBPT would remain low. successful de-implementation of harmful, peer review… 4. Emphasis on confirma- pseudoscientific practice, as it is important tion rather than refutation… 5. Reversed to be realistic about the amount of change

32 the Behavior Therapist DEIMPLEMENTATION OF PSEUDOSCIENTIFIC PRACTICES that is feasible in the short term within an • Existing alternatives. As we will dis- the desired effects, and can facilitate sup- organization, particularly if multiple new cuss later, presenting an alternative EBPT port for de-implementing the practice and interventions will need to be introduced to is one of the most useful tools in increasing a willingness to try something new. replace existing practices. proponent buy-in and sustaining the de- Guideline 3: Identify Barriers and Facil- implementation of a harmful, pseudoscien- • Severity of functional impairment. tific practice. itators to De-implementation Implementation leaders and other stake- Another guideline to consider is identi- holders must consider the degree to which Guideline 2: Increase Proponent Buy-in fying barriers and facilitators to the de- the functional impairment of the patients After leaders identify the harmful, pseu- implementation of the harmful practice engaged in the harmful, pseudoscientific doscientific practice to de-implement, they within a specific clinic to help inform de- practice interferes with daily life (Elshaug should begin to increase provider buy-in implementation efforts. We suggest incor- et al., 2009; Ibargoyen-Roteta et al., 2010; for the change. As described by Niven and porating all types of stakeholders in this Polisena et al., 2013). Leaders should focus colleagues (2015), the engagement of stake- step to gather facilitators and barriers spe- de-implementation efforts on the practices holders is a critical step in the de-imple- cific to different levels (e.g., patient level, delivered to patients who experience the mentation process. First, implementation clinician level, facility level, etc.). Bringing lowest quality of life. leaders must ascertain what pressures and in the perspective of each stakeholder will barriers exist for proponents of the pseudo- achieve two goals: (a) to increase support • Financial burden and resource alloca- scientific practice before intervening. Even and understanding of the change early on tion. Priority should be given to harmful, if some clinics and systems mandate a and (b) to measure feasibility across differ- pseudoscientific practices that pose an policy change, it is important to engage ent levels. For example, patients can best extreme financial burden on patients, clin- individual clinicians. We suggest first explain their needs within a therapeutic icians, clinics, and/or insurance companies learning about the core values of clinicians context, while clinicians can express their compared to an alternative EBPT (Elshaug who provide the identified harmful, pseu- goals and concerns, and clinic leaders can et al., 2009; Henshall et al., 2012; Polisena doscientific practice. These values are typi- bring up structural issues within the clinic et al., 2013). Generally speaking, it is more cally related to providing patients with the that may interfere with de-implementa- likely that stakeholders will support de- best possible care to increase the likelihood tion. Looping individual stakeholders in at implementation efforts if implementation of recovery. Once those leading the imple- this point can be extremely helpful in leaders can report on expected savings. If mentation effort identify the core values, building support for change throughout the alternative EBPT costs clinicians less they can frame the need to de-implement the entire de-implementation and imple- money to train, patients less money to the therapy in terms that reflect those mentation process. Frameworks and mea- complete, and clinics less money to pro- values. sures exist to guide this assessment (cf. vide, the successful de-implementation of To further increase clinician buy-in, Aarons et al., 2011; Rabin et al., 2016). the old, harmful, pseudoscientific practice Lilienfeld and colleagues (2013) recom- Once the stakeholders identify a compre- will be more likely. While there are costs mend involving clinicians in the dissemi- hensive understanding of barriers and associated with all treatments, some thera- nation of information regarding the pseu- facilitators to de-implement, the imple- pies make more sense to de-implement doscientific nature of the targeted practice mentation leaders then need to select, because of the extent of the costs. For a and to present the alternative EBPT. tailor, and implement the de-implementa- medical example, the radical mastectomy Researchers can involve clinicians in tion intervention depending directly on the was a popular yet expensive surgery for reviewing research and evaluation data (on stakeholders, facility, clinicians, and breast cancer in the late 1800s to early both pseudoscientific and evidence-based patient-level needs within a specific clinic 1900s (Montini & Graham, 2015). treatments) to increase the clinician’s basic (Powell et al., 2017). Researchers later discovered other safer understanding of the effectiveness of the and lower cost methods of removing such current practice. Moreover, researchers Guideline 4: Develop a Sustaining De- tumors. Hospitals and facilities were able to need to present research findings that point Implementation Strategy successfully de-implement radical mastec- to a practice’s lack of evidence in an easy- The next step is to determine a de- tomies because they recognized financial to-understand manner. Often clinicians implementation strategy or, more likely, a incentives of the change (Montini & resist de-implementing pseudoscientific set of strategies. Below we provide possible Graham). practice or implementing an EBPT because strategies to develop and sustain the de- of the complexity in which a researcher implementation of a harmful, pseudoscien- • Policy mandates. All individuals presents the findings (Lilienfeld et al.). tific practice. involved in the de-implementation process Developing a system of patient outcome should consider harmful practices that run measurement that feels relevant to the clin- • Strategy 1: Implement an alternative counter to policy, mandates or clinical icians and their patients may increase clin- EBPT. Part of the de-implementation practice guidelines a priority to increase ician support to de-implement certain process is to give hope to clinicians that a patient, clinician, and clinic buy-in for harmful practices. Clinicians can use this better alternative exists. If implementation change (Elshaug et al., 2009; Polisena et al., system to see firsthand whether the prac- leaders do not present a new practice with 2013). While external motivation may not tice is working. In the case of harmful, evidence, clinicians will likely feel no need always be the best way to promote change, pseudoscientific practice, the clinician will to stop the old practice, and may in fact feel mandating change can still help persuade notice that the patient is not improving pressure to offer something else, defaulting clinicians to de-implement the practices based on measured outcomes. Systematic to the practices they know best. The that cause harm to patients. measurements can help clinicians recog- options for new practices should be pre- nize their current strategies are not yielding sented in an easy-to-understand manner,

January • 2018 33 JOHNSON ET AL. and then compared with the old practice in in control, in that they could change the de-implementation efforts. Overviews and terms of the clinic's goals and mission. If an treatment plan if the measures revealed frameworks for implementation and sus- evidence-based alternative does not exist patient improvement, worsening, or no tainability will provide a richer under- for the specific clinic-level needs, it may be change. standing of the process of implementation wise to collect practice-level data or partner Clinic-wide outcome monitoring will (Aarons et al., 2011; Damschroder et al., on research to test and refine practices that likely help all stakeholders see the improve- 2009; Kilbourne, Nuemann, Puncus, Bauer are identified as the best available alterna- ment in patient outcome before and after & Stall, 2007; Stirman, Gutner, Langdon, & tives, perhaps benchmarking against previ- the de-implementation of the pseudoscien- Graham, 2016). ous program evaluation data on the pseu- tific practice. This will also let clinicians see doscientific practice (see Strategy 3). that the clinic leadership is observing the Conclusion degree of patient improvement and the Although relatively understudied • Strategy 2: Provide consultation. clinician’s role in achieving the improve- within the mental health sector, de-imple- Implementation leaders should provide a ment. By collecting and presenting the pre- mentation of harmful, pseudoscientific space in which clinicians can give feedback post comparison data, clinics can further practice is a critical initial step in a success- and ask questions about the de-implemen- evaluate the extent to which of the de- ful implementation process of an EBPT. tation process. By creating this space, clin- implementation improves patient out- Failing to attend to harmful, pseudoscien- icians will feel involved in the process and comes. If the results show little improve- tific practice within a clinic or system can ideally will align with the need to de-imple- ment or an increase in patient symptoms lead to an eventual return to the harmful ment the harmful, pseudoscientific prac- and other valued outcomes, clinics can use practice. Clinicians should therefore work tice. Those tasked with implementation of the data to rethink and reevaluate the to cease the use of harmful, pseudoscien- effective practices should also provide con- implementation strategies or the new prac- tific practices to achieve the overarching sultation on how to de-implement the ther- tices that have been identified. apy and replace it with the new alternative. goal of therapy: improve patient outcomes. For example, clinicians could meet once a • Strategy 4: Incent the delivery of effec- The present article highlights guidelines week and present their cases to understand tive alternatives. Emerging evidence sug- and frameworks based from medical what to do in place of the old pseudoscien- gests that clinicians and clinics are more research that may guide the de-implemen- tific practice. Consultation is often studied likely to implement EBPTs when they tation of pseudoscientific practice: (a) iden- under the context of training clinicians in receive external rewards for doing so tify and prioritize the harmful, pseudosci- EBPTs (Beidas, Edmunds, Marcus, & (Andrzejewski, Kirby, Morral, & Iguchi, entific practice; (b) increase proponent Kendall, 2012; Nadeem, Gleacher, & 2001; Carise, Cornely, & Gurel, 2002). At a buy-in; (c) identify barriers and facilitators Beidas, 2013). Nonetheless, implementa- policy level, possible strategies to facilitate of the de-implementation; (d) develop a tion researchers should incorporate con- de-implementation include incentives such sustaining de-implementation strategy; sultation in the earlier phases of de-imple- as preferential contracting with agencies and (e) sustain the implemented effective mentation to enhance the implementation that use EBPTs (McLellan, Kemp, Brooks, treatment. These guidelines can also be process. Ongoing consultation and sup- & Carise, 2008), block grants to fund initial used to support de-implementation of port, or the development of internal EBPT implementation, and enhanced those practices that are not pseudoscien- resources to support evidence-based prac- reimbursement rates for EBPTs (Magna- tific or harmful, but less effective than tice, is likely to be necessary to ensure that bosco, 2006). These incentives might established EBPTs. We advise that any time the practice changes are sustained. increase an organization leader’s support EBPTs are to be implemented, that both for discontinuation of pseudoscientific the less effective, and the potentially harm- • Strategy 3: Evaluate patient outcomes. practices and a transition to EBPTs. ful existing practices be identified, and that Comparing pre- and postpatient outcomes Research also suggests that incenting clini- implementation efforts focus on strategies may help clinicians see the benefits first- cians to deliver EBPTs can lead to for de-implementation of these practices as hand of de-implementing the harmful, improved adherence and intention to well as implementation of new practices. pseudoscientific practice. Before doing deliver EBPTs (Garner et al., 2012). Such A major limitation of the present article this, researchers may need to develop rewards could be contingent on demon- is the lack of research specific to de-imple- better methods of outcome measurement. strating that EBPTs have in fact replaced mentation of harmful, pseudoscientific This should take place in two ways: at the harmful practices. practice within the field of clinical psychol- clinician level and at the clinic or system ogy. We recognize the need to study such level. For example, clinicians who see Guideline 5: Sustain the Implemented guidelines and frameworks within the patients with anxiety disorders could use Effective Treatment mental health context. We encourage fur- the Beck Anxiety Inventory (BAI) or Gen- To ensure the permanent de-imple- ther attention to de-implementation in eral Anxiety Disorder 7-item (GAD-7) to mentation of a harmful, pseudoscientific both research and practice contexts, as it compare patient outcome before and after practice, implementation leaders need to may be necessary to ensure the delivery of changing from a pseudoscientific practice focus their efforts on sustaining the imple- effective care. to an EBPT. Measures of quality of life and mentation of the alternative EBPT. If clini- functioning and client satisfaction are also cians begin to drift from the EBPT that References important to examine. Using outcome replaced the de-implemented practice, they Aarons, G. A., Hurlburt, M., & Horwitz, S. tracking to evaluate patient outcomes gives may fall back on old harmful practices. M. (2011). Advancing a conceptual clinicians an empirical way to see positive Ongoing support and the use of implemen- model of evidence-based practice imple- change among patients. Measurement- tation strategies to promote and sustain mentation in public service sectors. based care may also allow clinicians to feel new and effective practices are essential to Administration and Policy in Mental

34 the Behavior Therapist DEIMPLEMENTATION OF PSEUDOSCIENTIFIC PRACTICES

Health and Mental Health Services of health technology disinvestment. Powell, B. J., Beidas, R. S., Lewis, C. C., Research, 38(1), 4-23. Health Policy, 98(2), 218-226. Aarons, G. A., McMillen, J. C., Proctor, American Psychological Association. Jenkins, D., & Johnston, L. (2004). Unethi- E. K., & Mandell, D. S. (2017). Methods (2009). Report of the American Psycholog- cal treatment of gay and lesbian people to improve the selection and tailoring of ical Association’s Task Force on Appropri- with conversion therapy. Families in implementation strategies. The Journal of ate Therapeutic Responses to Sexual Ori- Society, 85(4), 557-561. Behavioral Health Services & Research, 44(2), 177-194. entation. Washington, DC: American Kilbourne, A. M., Neumann, M. S., Pincus, Psychological Association. Retrieved H. A., Bauer, M. S., & Stall, R. (2007). Prasad, V., & Ioannidis, J. P. (2014). Evi- from http://www.apa.org/pi/lgbt/ Implementing evidence-based interven- dence-based de-implementation for con- resources/therapeutic-response.pdf. tions in health care: application of the tradicted, unproven, and aspiring health- Andrzejewski, M. E., Kirby, K. C., Morral, replicating effective programs frame- care practices. Implementation Science, A. R., & Iguchi, M. Y. (2001). Technology work. Implementation Science, 2(1), 42. 9(1), 1. transfer through performance manage- Lilienfeld, S. O. (2007). Psychological Rabin, B. A., Lewis, C. C., Norton, W. E., ment: The effects of graphical feedback treatments that cause harm. Perspectives Neta, G., Chambers, D., Tobin, J. N., and positive reinforcement on drug on Psychological Science, 2(1), 53-70. Brownson, R.C., & Glasgow, R. E. (2016). Measurement resources for dissemina- treatment counselors’ behavior. Drug Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. and Alcohol Dependence, 63, 179–186. tion and implementation research in (2015). Science and pseudoscience in health. Implementation Science, 11(1), 42. Beidas, R. S., Edmunds, J. M., Marcus, S. clinical psychology: Initial thoughts, Stirman, S. W., Gutner, C. A., Langdon, C., & Kendall, P. C. (2012). Training and reflections, and considerations. Science K., & Graham, J. R. (2016). Bridging the consultation to promote implementation and Pseudoscience in Clinical Psychology gap between research and practice in of an empirically supported treatment: A (2nd ed., pp. 1-16). New York: Guilford mental health service settings: An randomized trial. Psychiatric Services, Press. 63(7), 660-665. overview of developments in Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., implementation theory and research. Carise, D., Cornely, W., & Gurel, O. Cautin, R. L., & Latzman, R. D. (2013). Behavior Therapy, 47(6), 920-936. (2002). A successful researcher– practi- Why many clinical psychologists are tioner collaboration in substance abuse resistant to evidence-based practice: Root treatment. Journal of Substance Abuse causes and constructive remedies. Clini- ... Treatment, 23, 157–162. cal Psychology Review, 33(7), 883-900. Damschroder, L. J., Aron, D. C., Keith, R. Magnabosco, J. (2006). Innovations in This project was supported by E., Kirsh, S. R., Alexander, J. A., & mental health services implementation: 1R01MH106506-01A1. Lowery, J. C. (2009). Fostering imple- A report on state-level data from the U.S. Correspondence to Clara Johnson, mentation of health services research evidence-based practices project. Imple- National Center for PTSD, 795 Willow findings into practice: A consolidated mentation Science, 1, 1–11. Road, Bldg. 334, Rm. C119, Menlo Park, CA framework for advancing implementa- McLellan, A. T., Kemp, J., Brooks, A., & 94025; [email protected] tion science. Implementation Science, Carise, D. 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Consultation as an implementa- Archives of Pediatrics & Adolescent Medi- tion strategy for evidence-based practices cine, 166(10), 938–944. across multiple contexts: Unpacking the Haldeman, D. (2002). Therapeutic anti- black box. Administration and Policy in dotes: Helping gay and bisexual men Mental Health and Mental Health Ser- recover from conversion therapies. Jour- vices Research, 40(6), 439-450. nal of Gay and Lesbian Psychotherapy, 5, Niven, D. J., Mrklas, K. J., Holodinsky, J. 119–132. K., Straus, S. E., Hemmelgarn, B. R., Jeffs, Hansson, S. O. (2013). Defining pseudo- L. P., & Stelfox, H. T. (2015). Towards science and science. The Philosophy of understanding the de-adoption of low- Pseudoscience, 61-77. value clinical practices: a scoping review. Henshall, C., Schuller, T., & Mardhani- BMC Medicine, 13(1), 255. Bayne, L. (2012). Using health technol- Polisena, J., Clifford, T., Elshaug, A. 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January • 2018 35 cation in science and critical thinking. In What’s a Therapist to Do When Clients Have addition, Lilienfeld, Lynn, and Lohr (2014) Pseudoscientific Beliefs? offered a number of suggestions for reforming the standards and training of clinical psychologists. But these societal Stuart Vyse, Stonington, Connecticut and professional reforms will not come in time for therapists who have credulous clients in their offices today. Understand- MENTALHEALTH PRACTITIONERS have against the “elites,” repeatedly asserting, “I ing this, I will discuss four possible strate- long struggled to assert their authority on alone can fix it” (Jackson, 2016). gies for dealing with unscientific client matters psychological. Even now that So how should we respond to these beliefs: adopting, avoiding, reasoning, and mental health services have become more challenges? Michael Bowen (2017), writing collaborating. widely available than they once were, prac- for the World Economic Forum’s Young titioners suffer by comparison to the med- Scientists Community, asserts that we are Adopting ical profession. Seeking psychological ser- confronted with “a populist backlash Although it may seem odd to consider vices is often stigmatized in a way that against scientific consensus and expert adopting the unscientific ideas of your medical treatment is not (Sartorius, 2007; opinion” and urges scientists to strengthen clients, it is not without precedent. Con- Schulze, 2007). In addition, physicians gain their resolve and fight back with facts. But fronted with a client who has a particular an air of authority from their highly techni- it seems like scientists have been fighting worldview, therapists have been known to cal subject matter. In contrast, everyone back with facts and evidence for a while incorporate client beliefs into the treatment witnesses human behavior every day. What now, with minimal results. It has been 19 years since Andrew Wakefield published plan. Sweat lodge ceremonies have been could be so difficult about knowing why recommended as part of treatment for people act the way they do? his infamous study in The Lancet, purport- ing to show a relationship between the posttraumatic stress disorder in Native Indeed, the problem is much larger than Americans, and other practitioners have just mental health professions. Today, the MMR vaccine and the incidence of autism. Many failures to replicate Wakefield’s suggested praying with or for clients during denial of authority extends to almost therapy (Meichenbaum, n.d.; Silver & anyone claiming to be an expert. Scien- results followed, and 7 years ago, the British General Medical Council revoked Wilson, 1988). Therapists who adopt these tists—who should be afforded some credit methods may have the admirable goals of in return for their extensive training and Wakefield’s medical license and The Lancet withdrew his 1998 article (Offit, 2010). acknowledging cultural or religious differ- the quality of their data—are often at odds ences or wanting to make clients feel more with the views of the general public. A Much ink has been spilled and words spoken in an effort to use facts to convince at home, but the ABCT is an organization recent Pew Research Center poll found an parents that vaccination is safe and impor- committed to EBPs (ABCT, 2017). With- astonishing 51-point gap between the tant, but a 2015 poll found that only 84% of out convincing empirical support, these views of U.S. adults and members of the Americans thought vaccination of young practices represent an ethical dilemma for American Association for the Advance- children was very or extremely important, the therapist. Furthermore, if therapists ment of Science (AAAS) on the safety of down from 93% fourteen years earlier hope to project a consistently evidence- genetically modified foods (GMOs; Funk & (Newport, 2015). In 2014 the Centers for based image to the public, adopting non- Rainie, 2015). Eighty-nine percent of Disease Control reported a record 663 scientific methods will only muddy the AAAS members said GMOs were safe. cases of measles, the “greatest number of waters and make it harder to distinguish the profession from other non-evidence- (They can’t all work for Monsanto!) Simi- cases since measles elimination was docu- based practitioners. Finally, in the case of larly, the Pew study found that 87% of sci- mented in the U.S. in 2000” (Centers for sweat lodge ceremonies and a number of entists agreed with the statement, “Climate Disease Control, 2017). other nontraditional methods, there may change is mostly due to human activity,” Lest hubris begin to set in, it should be be substantial safety concerns (Dougherty, compared with only 50% of U.S. adults. acknowledged that therapists are far from 2009). As a result, adopting nonscientific A recent book decries the “death of immune to nonscientific practices. Recent client beliefs as part of therapy is not a rec- expertise” (Nichols, 2017b), and there is no evidence shows that many practicing psy- ommended strategy. shortage of anecdotal evidence to certify chologists and social workers are using the death. The United States recently techniques that are unsupported by scien- elected a real estate developer with no prior tific evidence (Barnett & Shale, 2012; Pig- Avoiding government experience to be president, notti & Thyer, 2009; Stapleton et al., 2015). From a utilitarian viewpoint it might be and he went on to appoint a number of As a result, considerable effort needs to be reasonable to say nothing. As long as the people to high-level positions who were aimed at healing ourselves (Lilienfeld et al., client is faithfully following through with similarly lacking in expertise relevant to 2013). But putting that issue aside, let’s your treatment recommendations and their assignments. As just one example, the assume you are a behavior therapist com- making progress, a pragmatic strategy new administration appointed a former mitted to evidence-based practice (EBP) might be to avoid confronting the client’s conservative radio talk-show host to the who is confronted with a client who is misconceptions and say as little as possible highest science position in the Department equally committed to Reiki, chelation ther- about the pseudoscientific methods being of Agriculture—a man whose only science apy, or homeopathic medicines. What is a used or advocated by the client. When degree was a B.A. in political science (Geil- therapist to do? therapists are directly asked about non- ing, 2017; Nichols, 2017a). The new presi- In the long term, the solution to these EBP treatments, they are under an ethical dent came into power by campaigning conflicts may come from better public edu- obligation to provide accurate information,

36 the Behavior Therapist WHEN CLIENTS HAVE PSEUDOSCIENTIFIC BELIEFS but given that the primary goal is improv- interest of fairness, a therapist might cially and on free websites (e.g., ing client well-being, saying nothing may admit that homeopathic medicines have YouTube.com), it is likely that therapists sometimes be an option. an intuitive appeal and that many effec- can find useful material to present to However, biting one’s tongue will rarely tive medicines were similarly derived clients. be a comfortable choice because the thera- from naturally occurring herbs and com- pist risks appearing to give credence to an pounds, but this would be a mistake. The Collaborating unsupported treatment, and just as in the research on debunking suggests that any If the rational approach does not case of the “adopting” strategy, it is impor- recounting of arguments in support of quickly move the client in a constructive tant to present the profession as consis- misinformation tends to solidify a mental direction, a more empirical strategy can tently guided by evidence. But, in the inter- model, making it more difficult to quash sometimes work. The therapist and client est of keeping positive momentum going, with new information. have an important common goal, helping individual therapists may choose to avoid the client. If sharing accurate information unnecessary battles. Unfortunately, some- • Don’t just say the misinformation is does not shake the client from unsupported times the client’s unsupported remedies wrong; provide an alternative formula- or pseudoscientific beliefs, then offering to obstruct the implementation of evidence- tion. The debunking of misinformation collaborate on an empirical test can be based interventions and/or are potentially leaves a void that is an obstacle to a lasting helpful. Rather than continuing to argue harmful. In these cases, avoidance is not an effect. As time passes, the client is likely to with the client—or sending the client option. refill the hole with the same old myth. As a result, it is important to supply the client away—the therapist can offer to join forces Reasoning with information about EBPs that is in an evaluation of the treatment options. explained in some detail, along with the In brief, the therapist might simply say, In addition to a rejection of experts, the available evidence to back it up. As a “OK, I can see you’re not convinced. Let’s current era has seen a decline in the value result, when debunking homeopathy, the perform a test with the understanding that of rational argument. Indeed, sophistry therapist should point out that the active whatever method works best will be the appears to be enjoying a period of growth. ingredients are far too diluted to be effec- one we choose.” During the 2016 U.S. presidential cam- tive, but it is also important to create a This strategy has been successfully paign the eventual winner was greatly new theory of the client’s problem employed by Shannon Kay (2015), a tal- rewarded for his use of derogatory nick- through the lens of a sound empirical ented behavior analyst who has worked names for his political rivals, a practice that research. Be prepared to report what sci- with many parents of children with has continued during his presidency ence has to say about the client’s concern. autism.1 Autism continues to be a “fad (Estepa, 2017), and formerly trusted news magnet” (Metz, Mulick, & Butter, 2015), sources are now routinely labeled “fake • Try to keep the explanation of EBPs attracting a seemingly endless stream of news.” simple and clear. Somewhat paradoxi- pseudoscientific treatments. As a result, As difficult as the current environment cally, as important as it is to create a new Kay reported that, by the time she arrived appears to be, a discussion with clients evidence-based theory of the problem, on the scene of a newly diagnosed case, the about basic research methods and levels of debunking research suggests that an child’s parents were often already using evidence—or lack of evidence—supporting overly elaborate explanation can backfire. prism glasses or sensory integration ther- various methods is worth trying. It would If the misinformation is simpler and apy. In those cases where she was unable to be impractical to administer a full course in clearer than the more valid alternative, win parents over by sharing information critical thinking; however, some therapists the myth may survive. Unfortunately, it and readings, she offered to conduct a have had success giving clients reading can be difficult to keep the description of single-participant study testing an applied material about both EBPs and non-EBPs an EBP simple. For example, when a ther- ABA approach against the methods being (Kay, 2015). But what if those early conver- apist is confronted with a parent who is used by the parents. And, of course, the sations don’t go smoothly? What’s a thera- committed to the use of facilitated com- subject of the research was the most impor- pist to do? munication in the treatment of a child tant person of all, the child everyone was If there is a benefit of the current cli- with autism, the elaborateness of an trying to help. mate of rampant credulity it is the emer- applied behavior analysis (ABA) protocol Kay described her experiences and pro- gence of a growing literature on the best is going to come up short in relation to the vided data from three case studies in a methods for debunking misinformation. In far simpler explanation, “Jenny has a chapter for the book Controversial Thera- 2012, Lewandowsky and colleagues pub- motor problem. She needs help steadying pies for Autism and Intellectual Disabilities lished a very useful qualitative review, and her hand on the keyboard.” (Foxx & Mulick, 2015). In each of the three recently Chan, Jones, Jamieson, and Albar- cases, she used an alternating treatments racin (2017) published a meta-analysis of • If there is a choice between giving infor- design and trained the parents in data col- the effectiveness of various debunking mation in printed or video form, choose lection. In all three instances, the unsup- methods. These studies point to a number video. A recent study showed that when ported therapy being used at the time was of recommendations about how to success- fact-checking information was presented shown to have a negative effect on the fully counter misinformation, and several in either long-form written format or in a child’s behavior, rather than a positive one, of these may be useful to the clinician who video, the video presentation was more and the parents and educational team hopes to steer a client towards EBPs: effective in debunking misinformation (Young, Jamieson, Poulsen, & Goldring, • Avoid reviewing any evidence in sup- 2017). Given the number of professional port of unsupported treatments. In the videos that are available both commer- 1Shannon Kay is a former student of mine.

January • 2018 37 VYSE members quickly reversed their positions media, or write for the general public can science in professional practice (2nd ed.). and endorsed a plan based on ABA. help to counter the misinformation in their New York: Routledge. When working with adults on issues communities. Although many profession- Funk, C., & Rainie, L. (2015, January 29). other than autism treatment, it may be als feel most comfortable speaking about Public and scientists' views on science and impractical to implement a test of compet- the EBPs they have been trained to use, society. Pew Research Center. ing therapies, and when a test is possible, a reducing the level of psychological snake http://www.pewinternet.org/2015/01/29/p reversal design (e.g., ABAC) may be more oil in the marketplace will take additional ublic-and-scientists-views-on-science- appropriate than the alternating treatment efforts. According to research cited above, and-society/ design employed by Kay (2015). But intro- effective debunking will require therapists Geiling, N. (2017, July 20). Trump officially ducing the client to some of the basics of to inform people about the current scien- nominates climate-denying conservative research design and objective data collec- tific understanding of the disorders they talk radio host as USDA's top scientist. Retrieved from tion can be very useful. Furthermore, it treat and to call out the unsubstantiated https://thinkprogress.org/sam-clovis-offi- appears that one of the important features treatments that are sometimes used. cially-nominated-still-not-a-scientist- of Kay’s approach is putting aside the Taking these extra steps may eventually d47be4ffb1a8/ struggle to assert one’s authority as a thera- reduce the number of clients who come to Jackson, D. (2016, July 22). Donald Trump pist and offering to solve the dispute in a you under the influence of pseudoscientific accepts GOP nomination, says 'I alone can collaborative fashion. Understandably, theories and will have the added benefit of fix' system. Retrieved from some therapists may find it objectionable publicly reinforcing the point that, in con- https://www.usatoday.com/story/news/ to agree to test a previously unsupported trast to other approaches, behavior therapy politics/elections/2016/07/21/donald- therapy. Furthermore, the empirical test is a rigorous evidence-based discipline. trump-republican-convention-accep- approach is not without risks. Clients can tance-speech/87385658/ rarely be blinded to the experimental con- References Kay, S. (2015). Helping parents separate the ditions, and client expectations about pseu- wheat from the chaff: Putting autism ABCT. (2017). About psychological treat- treatments to the test. In R. M. Foxx & J. doscientific therapies can lead to measur- ment. Retrieved September 28, 2017, from A. Mulick (Eds.), Controversial therapies able placebo effects. In the unlikely event of http://www.abct.org/Help/ for autism and intellectual disabilities: Fad, a positive outcome for a non-EBP, the ther- ?m=mFindHelp&fa=WhatIsEBPpublic apist would be confronted with a thorny fashion, and science in professional practice Barnett, J.E., & Shale, A. J. (2012). The inte- (pp. 196-208). New York: Routledge. dilemma. It is best not to gamble if the out- gration of complementary and alternative come is in doubt. But in those cases where medicine (CAM) into the practice of psy- Kruger, J., & Dunning, D. (1999). Unskilled a collaboratively designed test seems both chology: A vision for the future. Profes- and unaware of it: how difficulties in rec- feasible and potentially effective, it may be sional Psychology: Research and Practice, ognizing one's own incompetence lead to inflated self-assessments. Journal of Per- more convincing than talk. 43(6), 576–585. sonality and Social Psychology, 77(6), Bowen, M. (2017, June 22). As scientists, we It is difficult to be optimistic about the 1121-1134. prospect of a near future free of supersti- must fight fake news with truth. Retrieved from https://www.weforum.org/agenda/ Lewandowsky, S., Ecker, U. K., Seifert, C. tion and pseudoscience. In recent decades M., Schwarz, N., & Cook, J. (2012). Misin- we have experienced an explosion in access 2017/06/as-scientists-we-must-fight-fake- news-with-truth/ formation and its correction: Continued to information; however, much of the easi- influence and successful debiasing. Psy- Centers for Disease Control. (2017, August est information to find is false. The Pew chological Science in the Public Interest, studies cited above suggest that many 23). Measles Cases and Outbreaks. https://www.cdc.gov/measles/cases-out- 13(3), 106-131. people are unable to judge the quality of breaks.html Lilienfeld, S. O., Lynn, S. J., Lohr, J. M. information and, as a result, are unpre- Chan, M. P. S., Jones, C. R., Hall Jamieson, (2014). Science and pseudoscience in clin- pared to separate out the misinformation. K., & Albarracín, D. (2017). Debunking: A ical practice: Concluding thoughts and Furthermore, as the Dunning-Kruger meta-analysis of the psychological efficacy constructive remedies. In S. O. Lilienfeld, effect suggests, it is often the least informed of messages countering misinformation. S. J. Lynn, & J. M. Lohr (Eds.), Science and people who are the most convinced they Psychological Science, 28, 1531-1546. pseudoscience in clinical psychology (pp. are right (Kruger & Dunning, 1999). As a https://doi.org/10.1177/ 527-532). New York: Guilford. result, further research on debunking 0956797617714579. Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., strategies will be needed, and for the fore- Dougherty, J. (2009, October 11). Deaths at Cautin, R. L., & Latzman, R. D. (2013). seeable future, therapists will continue to sweat lodge bring soul-searching. New Why many clinical psychologists are resis- come across clients who espouse unscien- York Times. Retrieved September 28, tant to evidence-based practice: Root causes and constructive remedies. Clinical tific therapies. 2017, from http://www.nytimes.com/ Psychology Review, 33(7), 883-900. A final thought. Fad therapies appear to 2009/10/12/us/12lodge.html reproduce at alarming rates and, in some Estepa, J. (2017, September 21). It's not just Meichenbaum, D. (N.D). Trauma, spiritu- ality and recovery: Toward a spiritually- cases, are all but impervious to rational 'Rocket Man.' Trump has long history of integrated psychotherapy. Unpublished attack. Despite the recent blows to the nicknaming his foes. Retrieved September 21, 2017, from https://www.usatoday. manuscript. Retrieved from http:// authority of experts of all kinds, behavior com/story/news/politics/onpoli- melissainstitute.com/documents/ therapists are in an excellent position to tics/2017/09/21/its-not-just-rocket-man- spirituality_psychotherapy.pdf speak publicly on these topics. It is unlikely trump-has-long-history-nicknaming-his- Metz, B., Mulick, J. A., & Butter, E. M. that pseudoscience and superstition will foes/688552001/ (2015). Autism: A Twenty-First Century ever be permanently vanquished, but Foxx, R. M. & Mulick , J. A. (2015). (Eds.). fad magnet. In R. M. Foxx & J. A. Mulick behavior therapists who seek out public Controversial therapies for autism and (Eds.), Controversial therapies for autism speaking opportunities, comment in the intellectual disabilities: Fad, fashion, and and intellectual disabilities: Fad, fashion,

38 the Behavior Therapist and science in professional practice (pp. 169-194). New York: Routledge. The Seductive Allure of Pseudoscience in Newport, F. (2015, March 06). In U.S., Per- Clinical Practice centage Saying Vaccines Are Vital Dips Slightly. Retrieved from http://www.gallup.com/poll/181844/ Dean McKay, Fordham University percentage-saying-vaccines-vital-dips- slightly.aspx Nichols, T. (2017a, September/October). , AMAJOR PROFESSIONAL orga- phers of science have struggled with the How We Killed Expertise. Poltico Maga- RECENTLY zine. http://www.politico.com/magazine/ nization sponsored a webinar whereby the problem of pseudoscience, citing a demar- story/2017/09/05/how-we-killed-exper- attendees would learn about the underly- cation problem suggesting a continuum of tise-215531 ing mechanisms and procedures for Emo- sorts from that which can be definitively Nichols, T. (2017b). The death of expertise: tional Freedom Techniques (EFT; see termed science to that which is squarely The campaign against established knowl- Moran & Keynes, 2012, for overview). pseudoscience (Popper, 1957). edge and why it matters. New York, NY: What was notable about this webinar offer- While all sciences seem to be suscepti- Oxford University Press. ing was not so much the topic as the fact ble to pseudoscience, psychotherapy Offit, P. A. (2010). Deadly choices: How the that the sponsoring organization indicates approaches may be at particular risk. The anti-vaccine movement threatens us all. a commitment to promoting scientific aim of this paper is to suggest some expla- New York: Basic Books. foundations of assessment and treatment. nations for this problem, and some modest Pignotti, M., & Thyer, B. A. (2009). Use of One might even make a case for the scien- recommendations for remediation. novel unsupported and empirically sup- tific basis of EFT, given that there are ported therapies by licensed clinical social claims in the literature of efficacious out- Therapy Allegiance: A Special workers: An exploratory study. Social come with the method (Clond, 2016). Problem in Mental Health Delivery Work Research, 33(1), 5-17. However, most readers of this journal Sartorius, N. (2007). Stigma and mental know what’s coming next: namely, that Since you are reading this article, you health. The Lancet, 370(9590), 810-811. EFT, as a member of the broader class of are most likely an adherent to the theories Schulze, B. (2007). Stigma and mental energy therapies, lacks (a) an underlying that underlie cognitive and behavioral health professionals: A review of the evi- theoretical basis for different psychopatho- therapies. Asked to describe the approach dence on an intricate relationship. Inter- logical states and (b) an empirical basis for to a friend or colleague in another profes- national Review of Psychiatry, 19(2), 137- sion, you might offer a detailed litany of 155. the mechanisms of treatment efficacy. And yet, offerings like the aforementioned justifications for the approaches based on Silver, S. M., & Wilson, J. P. (1988). Native your intimate knowledge of the theory and American healing and purification rituals webinar proliferate, available through a for war stress. In J. P. Wilson, Z. Harel, & wide range of organizations that are other- its accumulated empirical support. If asked B. Kahana (Eds.), Human adaptation to wise solidly science-minded. on follow-up why this approach to treat- extreme stress: From the Holocaust to Viet Energy therapies are hardly the only ment is so special and different from tradi- Nam (pp. 337-355). New York: Plenum example of treatment methods that lack tional psychotherapy, you might go so far Press. any scientifically compelling underlying as to explicate paradigmatic differences Stapleton, P. H., Chatwin, E., Boucher, E., mechanisms of psychopathology or around the degree that each therapeutic Crebbin, S., Scott, S., Smith, D., & Purkis, explanatory structures for the intervention approach values data (discussed by a psy- G. (2015). Use of complementary thera- methods. Indeed, there are far too many to chodynamic theorist; Bornstein, 2005). But pies by registered psychologists: An inter- enumerate here. Those who practice what happens should this same person ask national study. Professional Psychology: approaches that the scientific community what made you choose this therapeutic Research and Practice, 46(3), 190–196. have declared science-based smugly1 deni- approach over all the others that are out Young, D. G., Jamieson, K. H., Poulsen, S., grate these other approaches as nonscien- there? You might very well offer an expla- & Goldring, A. (2017). Fact-checking nation that sounds like cold hard rational- effectiveness as a function of format and tific or, worse, pseudoscientific. Despite tone: Evaluating FactCheck.org and this divide, these approaches proliferate, ity—the data made you do it! The approach FlackCheck.org. Journalism & Mass Com- and many practitioners offer treatments is evidence-based, and I’m an evidence- munication Quarterly. https://doi.org/ that lack qualities that we might call scien- based person! But the research suggests 10.1177/1077699017710453. tific. that these explanations are as likely ex post Further, mental health practitioners are facto explanations as they may be a priori ... not the only professional group to fall prey decisions. to pseudoscientific theories. One famous Research has suggested that the deci- The author has no funding or conflicts of example is the pursuit of achieving cold sion to align with CBT comes more from interest to disclose. fusion in the lab, with the most recent personal factors, whereas traditional psy- unsubstantiated claim coming in 1989, chotherapy approaches come more from Correspondence should be addressed to despite the lack of a compelling theoretical training experiences (Buckman & Barker, the author at [email protected] basis for predicting the phenomenon could 2010). That is, if you have a particularly be produced (Beaudette, 2002). Philoso- compelling personal training experience,

1I count myself among the smug.

January • 2018 39 MCKAY you may be more likely to adopt a psycho- pseudoscientific methods is called out for be a sizeable market for New Age dynamic approach to treatment, whereas if proffering a nonscientific approach? approaches, look no further than the con- you possess specific personality character- Douglas (1966) described a robust siderable sales of the book The Secret istics (low Openness to Experience, high social process, evident in religion, group (Byrne, 2006), a bestseller with a central Conscientiousness), you are more likely to dynamics, and close-knit tribal communi- thesis that the way to a better life is that choose CBT. Notice that neither justifica- ties, whereby external threats are identified simply thinking positive thoughts will in tion is derived from such factors as “find and specific remedies are developed and and of itself change oneself and the world. data compelling” or “possess skeptical sanctioned by the group. Practitioners of Imagine for a moment now that, as a CBT ideas about therapy research methods.” all stripes are members of "tribes," and will practitioner, you include in your treatment Digging a bit deeper into this single inves- seek out assistance from the tribe when plan an effort to directly challenge thought- tigation, we find that a vast swath of practi- threatened. Accordingly, the purveyor of action fusion (Shafran & Rachman, 2004), tioners who adhere to psychodynamic pseudoscientific methods will find support the specific cognitive distortion that think- approaches are self-described as being par- from their "tribe" of like-minded providers ing something bad increases its likelihood, ticularly attuned to inner experiences and when attacked for their practices. The sci- and you learn your client subscribes to the to find meaning in symbolic processes. entific community is not a part of this model described in The Secret. At the very This suggests that the factors that lead equation since that is not the tribe that will least the discussion that will follow will be to self-identification with one or another be available to them. And without external awkward. therapeutic approach is less about com- structures that might restrict their practice, We can then conclude that practitioners pelling data and more about a feeling state, pseudoscientific approaches will likely con- who offer pseudoscientific approaches may tinue and even thrive. The methods of an irrational basis unmoored from any sci- do so as a consequence of true identifica- assistance vary widely based on group- tion with a group that endorses these meth- entific findings.2 Long before survey data specific customs that develop to create a ods (tribalism), and that it is perpetuated identified variables that explained the sense of group purity and cohesion. through a market that supports it. Attacks routes for how therapists sorted themselves on these approaches are met with credulity, into different theoretic camps, it was recog- Market Forces Support counter-attacks, and retrenchment. How nized that the therapy approach one prac- often have you heard some variation on the ticed strongly influenced outcomes in oth- Different Tribes following counter-argument: “I’m not erwise controlled research (see Leykin & Travel to areas of the desert southwest going to worry about which theory or DeRubeis, 2009, for detailed discussion). in the United States and one finds a wide mechanism is at work, I just do what I This means that should you have a good range of New Age practices. For example, know is effective.” This ultimate tribal training experience, and are the kind of Sedona, AZ has numerous practitioners of retreat allows for retention of the approach person who ascribes strong meaning to physical and mental healing that relies on without concern for science, and retains inner experiences, and receives training in the local “crystal vortex” (Dannelly, 1995). the claim that what they do works. You a pseudoscientific method, you may be a This specific region is said to possess spe- might even be on the receiving end of a new adherent to that approach. And once cial qualities, and the crystals in the red counter-accusation that because of a slav- that happens, adherence to that method is rock formations distinctive to the town ish reliance on science, you are lacking in difficult to shake. converge with mystic energies that pro- compassion (discussed in McKay, 2017). mote a healing process. Aside from the Tribalism in Therapeutic Approaches stunning beauty of the place, there is little Making Pseudoscience to support the idea that the local vortex The factors that go into group affiliation possesses special healing properties. Unappealing to the Masses are complex and wide ranging, certainly far Nonetheless, people suffering from all This has not been an exhaustive consid- beyond the scope of this article. However, types of maladies seek “treatment” from eration of all the ways pseudoscience is in the self-sorting process that takes place what are effectively faith healers. appealing to clinicians and consumers. But following the determination of therapeutic These approaches persist for a variety of some of the factors that make it appealing, orientation, it can be expected that we reasons, one of which involves strong and difficult to dislodge, come more from choose groups with whom to affiliate that market forces that support their demand. personal preferences and sociological we anticipate having similar values The various pseudoscientific practices forces than from cold hard facts. Among (Wagner, 1995). These values can be fur- roughly correspond to so-called New Age the challenges are: demarcation; illusory ther crystallized as we further identify with practices. Research suggests that segments effectiveness in psychotherapy; and public the group. So what happens when the of the population find these practices com- education in science. broad outlines of the values of the group pelling and includes endorsement of magi- are threatened? In the case of our discus- cal ideation (Farias, Claridge, & Lalljee, The Demarcation Problem sion, what happens when the purveyor of 2005). As further evidence that there would It was noted earlier that the demarca- tion problem in science has been a persis- tent challenge in rooting out pseudoscience from science. Indeed, some philosophers of 2Self-disclosure moment: During my undergraduate years I self-identified as psychodynamic in science declared it hopeless to pursue any orientation. It was only in graduate school that I found I had a talent for exposure, discovered longer (Lauden, 1983). Since that time, a accidentally over a dinner outing, and later crystallized during a training experience. So it seems healthy reemergence of interest in estab- that reinforcement and determinism shaped my professional trajectory rather than some clear- lishing a specific boundary between what eyed and deliberate planning. constitutes science and what belongs in the

40 the Behavior Therapist PSEUDOSCIENCE IN CLINICAL PRACTICE category of pseudoscience has sprouted fidelity of treatment delivery. This is that public science education is more (Pigliucci & Boudry, 2013). In assessing the important to the dissemination effort. essential than ever if consumers are going importance of this approach, it has been Namely, the public has to trust that treat- to be able to parse fraud from fact in the suggested that pseudoscience is actually ments delivered in everyday practice will pursuit of good treatment. essential for understanding science itself mimic the scientific findings of efficacy for Understanding is the first step in devel- since it permits a clarification of definition CBT from carefully controlled investiga- oping an action plan. At this point there is for what counts as evidence (Ladyman, tions, or come as close as reasonably possi- still an inadequate understanding of what 2013). ble. Otherwise, how can we disseminate compels well-intentioned clinicians to In some ways, psychotherapy research that this is evidence-based if clients cannot adopt practices that have dubious efficacy, is ahead on this matter. We have begun to readily access genuine CBT? questionable scientific foundations, and reckon with this problem by directly and simply lack clear and compelling mecha- Public Education in Science unambiguously identifying practices that nisms for actions. There are some promis- are pseudoscientific (such as the aforemen- An old commercial for Syms clothing ing options for consideration here that tioned energy therapies) by specifying the store intoned, “An educated consumer is include individual preferences, group characteristics of questionable practices our best customer.” In a similar vein, edu- processes, and market forces. Hopefully, by (see Lilienfeld, Lynn, & Lohr, 2014). Of cated consumers will be the best customers clarifying the role each of these play, poli- course, this optimism is tempered by the for CBT as well as for the future of scientif- cymakers will design methods to combat mere fact that pseudoscientific approaches ically informed psychotherapy. However, pseudoscientific practices as a means to are not only still practiced, but that train- unlike in clothing, this will mean that con- protect an unsuspecting public. ing in these approaches continues to prolif- sumers will need to be better educated erate. about the science of treatment, and what References counts as evidence. This requires that the public have some Beaudette, C.G. (2002). Excess heat and Illusory Effectiveness and the Public layman’s understanding of causation in why cold fusion research prevailed. South Pseudoscientific therapy approaches treatment. On this we might be a bit less Bristol, ME: Oak Grove Press. can retreat into pure empiricism to support optimistic. First, the problem of different Bleske-Rechek, A., Morrison, K.M., & Hei- the claims of efficacy. A long-standing and levels of analysis germane to psychopathol- dtke, L.D. (2015). Causal inference from descriptions of experimental and non- well-known problem in psychotherapy is ogy remains elusive to practitioners of the experimental research: Public under- that virtually any treatment performs various mental health disciplines. For standing of correlation-versus-causation. better than waitlist (Eysenck, 1952). Early example, Kendler (2012) made a persuasive Journal of General Psychology, 142, 48-70. compilations of the outcomes of treatment case that there are numerous levels of Bornstein, R.F. (2005). Connecting psy- suggested that all interventions had com- analysis appropriate for consideration in choanalysis to mainstream psychology: parable efficacy (Smith & Glass, 1977). This treatment, ranging from genetics up Challenges and opportunities. Psychoan- led to a defense of common factors and a through and including culture. However, alytic Psychology, 3, 323-340. broad therapeutic relationship as central from the policy side, recent research fund- Buckman, J.R., & Barker, C. (2010). Thera- mechanisms in efficacy since it appeared ing priorities such as the Research Domain peutic orientation preferences in trainee that all treatment were on comparable Criteria favor biological mechanism expla- clinical psychologists: Personality or footing, an argument that continues to nations over other levels of analysis (Insel training? Psychotherapy Research, 20, attract supporters (Shedler, 2010). et al., 2010). By favoring single levels of 247-258. The practice community engages in a analysis over multifaceted contributions to Byrne, R. (2006). The secret. New York: wide range of errors in reasoning that can psychopathology, the public is less likely to Simon & Schuster. lead to the development and adoption of appreciate putative causes and correlates Clond, M. (2016). Emotional freedom practices that lack scientific merit. Lilien- since the assumption across all mental techniques for anxiety: A systematic feld, Ritschel, Lynn, Cautin, and Latzman health problems is that biological factors review with meta-analysis. Journal of (2014) described a taxonomy of these prob- are causative, even if the evidence is not Nervous and Mental Disease, 204, 388- lems, termed causes of spurious therapeu- demonstrated. 395. tic effectiveness. This taxonomy has three Second, the public is not in an advan- Dannelly, R.D. (1995). Sedona: Beyond the broad categories: perception of client taged position to recognize the difference vortex. Flagstaff, AZ: Light Technology. change in its actual absence; misinterpreta- between a hierarchical view of causes of Douglas, M. (1966). Purity and danger. tions of actual client change derived from psychopathology and resultant treatment London: Routledge. extratherapeutic factors; and misinterpre- compared to a more situational-con- Eysenck, H.J. (1952). The effects of psy- tation of client change resulting from non- strained perspective. This is largely because chotherapy: An evaluation. Journal of Consulting Psychology, 16, 319-324. specific factors. some concepts persistently escape under- However, the public has begun to iden- standing by the general public. For exam- Farias, M., Claridge, G., & Lalljee, M. (2005). Personality and cognitive predic- tify problematic therapeutic approaches for ple, in a series of experiments it was shown tors of New Age practices and beliefs. themselves. It has been suggested for sev- that participants were equally likely to Personality and Individual Differences, eral years now that more and more clini- draw causal inferences from experimental 39, 979-989. cians recognize that clients request evi- data as from nonexperimental data. Fur- Insel, T., Cuthbert, B., Garvey, M., dence-based treatment, and cognitive- ther, causal inferences were more frequent Heinssen, R., Pine, D.S., Quinn, K., behavior therapy in particular (McKay, when it conformed to intuitively held Wang, P., (2010). Research domain crite- 2014). The stated adoption of CBT means notions (Bleske-Rechek, Morrison, & Hei- ria (RDoC): Toward a new classification that increased attention must be paid to dtke, 2015). This difficult situation means framework for research on mental disor-

January • 2018 41 LILIENFELD ET AL.

ders. American Journal of Psychiatry, 167, Lilienfeld, S.O., Ritschel, L.A., Lynn, S.J., 155-191). New South Wales: Allen & 748–751. Cautin, R.L., & Latzman, R.D. (2014). Unwin. Kendler, K.S. (2012). The dappled nature of Why ineffective psychotherapies appear Shafran, R., & Rachman, S. (2004). causes of psychiatric illness: Replacing the to work: A taxonomy of causes of spuri- Thought-action fusion: A review. Journal organic-functional/hardware-software ous therapeutic effectiveness. Perspectives of Behavior Therapy and Experimental dichotomy with empirically based plural- on Psychological Science, 9, 355-387. Psychiatry, 35, 87-107. ism. Molecular Psychiatry, 17, 377-388. McKay, D. (2014). “So you say you are an Shedler, J. (2010). The efficacy of psycho- Ladyman, J. (2013). Toward a demarcation expert”: False CBT identity harms our dynamic psychotherapy. American Psy- of science from pseudoscience. In M. hard earned gains. the Behavior Thera- chologist, 65, 98-109. Pigliucci & M. Boudry (Eds.), Philosophy pist, 37, 213-216 of pseudoscience: Reconsidering the Smith, M.L., & Glass, G.V. (1977). Meta- McKay, D. (2017). Presidential Address: analysis of psychotherapy outcome stud- demarcation problem (pp. 45-59). Embracing the repulsive: The case for Chicago: University of Chicago Press. ies. American Psychologist, 32, 752-760. disgust as a functionally central emo- Wagner, W. (1995). Social representations, Lauden, L. (1983). The demise of the tional state in the theory, practice, and group affiliation, and projection: Know- demarcation problem. In R.S. Cohen & dissemination of cognitive-behavior L. Lauden (Eds.), Physics, philosophy, and therapy. Behavior Therapy, 48, 731-738. ing the limits of validity. European Jour- psychoanalysis (pp. 111-127). New York: nal of Social Psychology, 25, 125-139. Springer. Moran, C., & Keynes, M. (2012). Introduc- ing emotional freedom techniques. Leykin, Y., & DeRubeis, R.J. (2009). Alle- ... London: Speechmark Publishing. giance in psychotherapy outcome research: Separating association from Pigliucci, M., & Boudry, M. (2013). Philos- The author has no funding or conflicts of ophy of pseudoscience: Reconsidering the bias. Clinical Psychology: Science & Prac- interest to disclose. tice, 16, 54-65. demarcation problem. Chicago: Univer- Correspondence to Dean McKay, Ph.D., Lilienfeld, S.O., Lynn, S.J., & Lohr, J.M. sity of Chicago Press. (2014). Science and pseudoscience in clini- Popper, K. (1957). Philosophy of science: Department of Psychology, 441 East Ford- cal psychology (2nd ed). New York: Guil- A personal report. In C.A. Mace (Ed.), ham Road, Bronx, NY 10458; ford. British Philosophy in Mid-Century (pp. [email protected]

Why Evidence-Based Practice Isn’t Enough: such as cognitive restructuring or stimulus control methods (von Ranson et al., 2013). A Call for Science-Based Practice Other survey data indicate that up to half of people who meet diagnostic criteria for major depression receive no formal psy- Scott O. Lilienfeld, Emory University, University of Melbourne chological treatment, and fewer than 10% of those who do receive interventions con- Steven Jay Lynn, Binghamton University sistent with scientific evidence (Layard & Clark, 2014). Stephen C. Bowden, University of Melbourne Over the past decade or so, the standard remedy for bridging the science-practice AS CLINICAL PSYCHOLOGISTS and other tered exposure and response prevention gap has been evidence-based practice mental health professionals, our priority (ERP) for obsessive-compulsive disorder (EBP), which is an overarching approach should be crystal clear: to ensure that indi- (OCD), even though ERP is the clear-cut to clinical decision-making (Straus, viduals suffering from mental illness scientific intervention of choice for OCD. Glasziou, Richardson, & Haynes, 2010). receive the highest quality psychological Many of these therapists availed them- EBP integrates three legs within a “three- legged stool”: (a) the best available data on care. Nevertheless, survey data on thera- selves of treatments boasting minimal sci- psychotherapy outcome (and to a lesser pists’ treatment selection make abundantly entific support for OCD, such as psychody- extent, process), (b) client preferences and evident that we are falling woefully short in namic therapy, art therapy, and Thought values, and (c) clinical expertise (Ander- this regard (Lilienfeld, Ritschel, Lynn, Field Therapy, the latter being one of sev- son, 2006; Spring, 2007). EBP emanated Cautin, & Latzman, 2013). Our discipline eral energy therapies (more on that soon). from the evidence-based medicine move- has long been marked by a science-practice In a survey of 130 Canadian therapists who ment, which was launched in McMaster gap, a wide schism between the best avail- treat patients with eating disorders (von University in Canada in the late 1980s and able research evidence bearing on the effi- Ransom, Wallace, & Stevenson, 2013), only early 1990s (Guyatt et al., 1992). Later, this cacy and validity of psychological tech- 23% reported using cognitive-behavioral movement emigrated to the U.K. (Sackett, niques, on the one hand, and their routine techniques, even though these methods are Rosenberg, Gray, Haynes, & Richardson, use in clinical practice, on the other (Lilien- among the few empirically supported ther- 1996), American medicine, and, belatedly, feld, Lynn, Ritschel, Cautin, & Latzman, apies (ESTs) for eating disorders. More- American psychology. Although the 2013; Tavris, 2014). over, even among therapists who claimed American Psychological Association To take merely a handful of salient to administer cognitive-behavioral meth- (APA, 2006) has declined to adopt a stance examples, a survey of 51 licensed therapists ods for eating disorders, sizeable pluralities on which, if any, of the three legs of the EBP in Wyoming (Hipol & Deacon, 2013) or minorities did not make regular use of stool should be accorded highest priority in revealed that fewer than one third adminis- standard cognitive-behavioral techniques, treatment selection, the Canadian Psycho-

42 the Behavior Therapist CALL FOR SCIENCE- BASED PRACTICE logical Association (2012) has advocated opposed to psychology, an independent chological conditions (Satel & Lilienfeld, that the first leg—research evidence— analysis of SBP as opposed to SBM is war- 2016). The rationale for the inclusion of should take precedence above the others, a ranted. Thought Field Therapy is that this tech- position that we strongly endorse. Some nique has been demonstrated in multiple authors have extended this three-legged The Recent Impetus for controlled studies to be efficacious for stool from psychological interventions to Science-Based Practice enhancing resilience and self-concept, evidence-based assessment (Bowden, 2017; and for diminishing trauma- and anxiety- Hunsley & Mash, 2007), an issue to which The awareness that EBP has its note- related symptoms, depressive symptoms, we briefly return (see “Concluding worthy shortcomings is similarly not new. and so on, when compared to wait-list Thoughts”). For example, some authors have observed control conditions (http://nrepp. Ideally, the research leg of EBP should that the APA task force on EBP was con- samhsa.gov/ProgramProfile.aspx?id=60). enhance the quality of mental health care spicuously vague when it came to opera- by aligning clinical practice more closely tionalizing the meaning of “evidence” • A growing number of practitioners of with scientific evidence (Kazdin, 2008; (Stuart & Lilienfeld, 2007). Nevertheless, highly dubious interventions are now Lilienfeld et al., 2013). As a consequence, if the limitations of EBP have become eagerly claiming the “evidence-based” EBP is functioning as intended, it should increasingly evident in the last few years. mantle and advertising themselves using help to stem the tide of pseudoscientific Indeed, this article was precipitated largely this moniker (Mercer & Pignotti, 2007). and otherwise questionable intervention by a series of relatively recent events that For example, websites for, and articles on, and assessment techniques (see Lilienfeld, have raised troubling questions regarding the following interventions describe these Lynn, & Lohr, 2014, and Thyer & Pignotti, the capacity of EBP to curtail the continued treatments explicitly as “evidence-based”: 2016, for reviews). spread of pseudoscience in mental health therapeutic drumming (https://wakeup- In this commentary, we contend that practice. We highlight three developments world.com/2015/04/07/6-evidence- although EBP has been a laudable and nec- in particular. based-ways-drumming-heals-body- essary first step toward ensuring high-qual- mind-and-soul/); animal-assisted therapy ity mental health care, it is not sufficient. • The APA and several other national psy- for eating disorders (https://www.remu- More provocatively, we maintain that in chological associations continue to daranch.com/index.php); Thought Field some noteworthy respects, EBP has failed accredit sponsors for continuing educa- Therapy (https://www.thoughtfieldther- and will continue to do so. Hence, the tion (CE) courses and workshops on apy.net/tft-recognized-by-nrepp/); Emo- mental health disciplines need to adopt an intervention techniques that are premised tional Freedom Techniques (Church, approach that is at once considerably on dubious or blatantly implausible theo- 2013); Imago Relationship Therapy broader and more rigorous than EBP, retical rationales, such as energy therapies (https://www.newharbinger.com/evi- namely, science-based practice (SBP). As we (e.g., Thought Field Therapy and Emo- dence-based-therapies); Jungian sandplay will demonstrate, SBP incorporates all the tional Freedom Techniques; e.g., see therapy (http://sandplayassociation.com/ fundamental elements of EBP but goes well http://www.eftuniverse.com/certifica- faqs/); primal therapy (http://primalther- beyond it in one significant respect—which tion/accreditation-information). Energy apy.com.au/frequently-asked-ques- we soon discuss. therapies are based on the highly suspect tions/); dance movement therapy Our call is not entirely novel, as similar and probably unfalsifiable suppositions (https://www.hochschule- arguments have been advanced in medi- that (a) humans are surrounded by invis- heidelberg.de/en/academics/masters- cine. For example, Gorski and Novella ible and unmeasurable energy fields, and degree/dance-movement-therapy/), abre- (2014) advocated for science-based medi- (b) blockages or other disturbances in active hypnosis for PTSD (Barabasz, cine (SBM) as a more stringent and all- these fields produce anxiety disorders and 2013); acupuncture for clinical depression encompassing alternative to evidence- other psychiatric conditions. Similar (https://www.alternativementalhealth. based medicine. We gratefully acknowl- problems extend to social work, where com/evidence-based-uses-of-chinese- edge the influence of their thinking on our licensed practitioners can obtain CE cred- medical-therapies-in-the-treatment-of- analysis and adapt their terminology to its for a host of energy therapies, primal depressed-mood/); and neurolinguistic mental health practice (see also Hall, 2011; therapy (colloquially termed primal programming (NLP; Zaharia, Reiner, & Sampson & Atwood, 2005). Furthermore, scream therapy), and internal family sys- Schütz, 2015). Furthermore, recent as we note in a later section (“The Remedy: tems therapy (Thyer & Pignotti, 2016), unpublished survey data suggest that Science-Based Practice”), a few authors in the latter of which posits that the human large majorities of practitioners who the psychotherapy literature have antici- mind comprises largely distinct subper- administer non-evidence-based interven- pated our core arguments (e.g., David & sonalities, each with its distinctive way of tions for anxiety disorders nevertheless Montgomery, 2011; see also Lilienfeld, viewing oneself and the world. describe themselves as offering “evi- 2011). dence-based” services (Deacon, personal Nevertheless, to our knowledge, we are • In 2014, the Substance Abuse and communication). the first to call explicitly for a wholesale Mental Health Services Administration transition from EBP to SBP in clinical psy- (SAMHSA), an agency within the U.S. Superficially, it might seem straightfor- chology and allied mental health domains, government, added Thought Field Ther- ward to address all three of the aforemen- such as psychiatry, counseling, social work, apy to its list of National Registry of Evi- tioned trends by means of logic alone. After and psychiatric nursing. Moreover, dence-based Programs and Practices. all, one might presume, energy therapies— because several of the substantive issues This registry is intended to educate the to take merely one example—cannot pos- and details of this approach’s pragmatic public regarding efficacious interventions sibly be evidence-based given that their implementation differ in medicine as for substance use disorders and other psy- theoretical foundation is exceedingly

January • 2018 43 LILIENFELD ET AL. implausible scientifically. Almost surely, it psychopathology, and NLP may also clear and Atwood (2005), among others, advo- is not true that humans are surrounded by the evidence-based research bar. cated for a Bayesian approach, in which invisible and unmeasurable energy fields, When it comes to proponents of these treatment outcome data are integrated let alone that blockages or disruptions in treatments claiming evidence-based status, with the a priori likelihood of the treat- these fields are the central causes of psy- some readers might reasonably contend ment’s efficacy (“Bayesian prior probabil- chological distress. Hence, this reasoning that it is unfair to lay the blame on EBP. All ity”; see also Lilienfeld, 2011) in ascertain- continues, energy therapies cannot possi- concepts can be misused, as the principle of ing an intervention’s scientific status. bly satisfy the research leg of EBP. abusus non tollit usum (the abuse of a Further, in a useful analysis, David and Nevertheless, given how this leg of EBP claim does not invalidate its proper use) Montgomery (2011) proposed that the EST is presently operationalized in American reminds us. Neverthleless, in many cases criteria be expanded to incorporate evi- clinical psychology, proponents of energy these proponents can legitimately lay claim dence for a given psychotherapy’s theoret- therapies are equipped with an effective to fulfilling the research leg of the EBP stool ical rationale. Specifically, they suggested rebuttal: If one relies exclusively on con- given the current EST criteria, which focus that parallel criteria be employed to evalu- trolled outcome data on energy therapies, exclusively on outcome data. Hence, EBP ate the plausibility of a treatment’s theoret- one can make a reasonable case that these leaves the door wide open for precisely ical rationale as that currently employed to interventions are in fact supported by such misuse. evaluate its empirical status, namely, two research evidence. Why? Because con- well-conducted supportive studies. Yet trolled studies reveal that energy therapies The Remedy: Science-Based Practice because theories are underdetermined by typically outperform wait-list control con- scientific evidence (Laudan, 1990), two ditions (Feinstein, 2008, 2012). Indeed, Fortunately, there is at least a partial supportive studies are almost always insuf- when the first author, among others, has solution to the aforementioned problems: ficient to provide compelling evidence for a asked members of the APA Education science-based practice (SBP). In SBP, as in treatment’s theoretical rationale. Another Directorate why sponsors who offered science-based medicine (SBM; Gorski & limitation of David and Montgomery’s courses on energy therapies were approved Novella, 2014), treatment outcome data are framework is its invocation of a categorical for CE credit, they referred in part to the not the only source of data bearing on the cutoff for theoretical support (two studies), published research support for these inter- research evidence for interventions. which does not necessitate consideration of ventions. Instead, in SBP, treatment outcome data the full body of high-quality scientific evi- Of course, energy therapy critics could are considered along with broader research dence bearing on the evidence for and respond with considerable justification evidence bearing on the plausibility of the against a treatment’s rationale (Lilienfeld, that this apparent efficacy almost certainly treatment’s theoretical rationale when eval- 2011). derives from nonspecific influences, such uating an intervention’s scientific status. To be sure, the second limitation as placebo effects, regression effects, spon- That is, in SBP, all forms of research evi- applies to the Division 12 criteria for ESTs taneous remission, and perhaps most dence are relevant when evaluating the sci- as well. In this respect, we side with Tolin, important, the incidental repeated expo- entific status of an intervention. If the treat- McKay, Forman, Klonsky, and Thombs sure that accompanies the intervention ment is based on a grossly implausible (2015), who maintained that the current (Bakker, 2013; Pignotti & Thyer, 2009). theoretical rationale, one that runs counter EST criteria should be superseded by a Nevertheless, the APA Division 12 (Society to what research has consistently demon- much more comprehensive approach to of Clinical Psychology) criteria for ESTs, strated about how the natural world works, psychotherapy and assessment methods which constitutes by far the most influen- it should not be regarded as fully evidence- evaluation that includes all relevant data on tial instantiation of the research prong of based, even if supported by promising out- treatment outcomes, along with a careful EBP, require only that a treatment must come data. analysis of the methodological rigor of the outperform a no-treatment control condi- By the workings of the “natural world,” relevant studies (see also Miller & tion in two or more randomized controlled we include the laws of physics in addition Wilbourne's 2002 “mesa grande” approach trials or systematic within-subject designs to well-established principles regarding the to evaluating the strength of evidence for (Chambless & Hollon, 1998; http://www. functioning of the human mind. As noted alcohol use disorder treatments; and the div12.org/psychological-treatments/ earlier, energy therapies conflict sharply theoretically motivated approach to cogni- frequently-asked-questions/). Energy ther- with research evidence derived from tive ability assessment of Riley, Combs, apies may very well meet this lax criterion. physics. Or, to take an example from the Davis & Smith, 2017). In SBP, the same Hence, the APA Education Directorate, more psychological realm, primal therapy principle should hold for the evaluation of which approves CE sponsors, may have its rests on the supposition that mental research evidence for the treatment ratio- hands tied when it comes to approving anguish in adulthood results from the nale, namely, a comprehensive analysis of such interventions. The same problem repression of unbearable psychological all relevant high-quality data. arises for a number of the other interven- pain emanating from traumatic experi- In an important but largely neglected tions listed three paragraphs earlier. Using ences in infancy or early childhood, in article, entitled “Psychotherapy Is the Prac- the current EST criteria, a host of other some cases the trauma of birth. Such pain tice of Psychology,” Sechrest and Smith pseudoscientific and otherwise question- can purportedly be released and expunged (1994) argued that the practice of psy- able interventions, such as animal-assisted by repeated screaming. There is no com- chotherapy, as well as psychotherapy therapies of many stripes (e.g., dolphin- pelling or even suggestive evidence for any research, must be informed by broader assisted therapy and equine-assisted thera- of these assertions (Singer & Lalich, 1996). knowledge of psychology, including pies; see Anestis, Anestis, Zawilinski, Hop- As noted earlier, some authors have research in neuroscience, affect, cognition, kins, & Lilienfeld, 2014; Marino & anticipated our arguments. In medicine, learning, social psychology, personality, Lilienfeld, 2007), dance therapies for severe Gorski and Novella (2014) and Sampson culture, development, and other subfields.

44 the Behavior Therapist CALL FOR SCIENCE- BASED PRACTICE

Their article is worth quoting from at whether the outcome evidence for energy details of a proposed SBP operationaliza- length: therapies is as persuasive as its advocates tion for mental health care, however, have contend, which is doubtful (see Pignotti & yet to be fleshed out. A psychologically integrated psy- Thyer, 2009), this argument neglects the A fourth objection is that the theoretical chotherapy will not be merely eclectic, crucial point that interventions with bla- rationale for many well-established or for it will be guided by both the scien- tantly implausible theoretical rationales are promising psychological treatments, tific theory and evidence available at unlikely to be both “efficacious and spe- including exposure treatments, remain in any one time. . . . In our view . . . psy- cific” (Chambless & Hollon, 1998).That is, dispute or are incompletely understood chology is making great strides in they are unlikely to display efficacy above (Lilienfeld, 2011). Nevertheless, our goal in knowledge about many aspects of and beyond nonspecific ingredients, such this brief communication is modest: behavior, e.g., in the workings of the as placebo effects, effort justification, or the namely, to present SBP as an overarching brain, in the genetic bases for behavior, generalized effects of attention and inter- framework that can serve as a partial safe- in cognitive functions, in the course of personal support (Lilienfeld et al., 2014). guard against interventions whose theoret- human development over the life span, As a consequence, they are far less likely to ical rationales are markedly at variance and so on. These gains in knowledge be deserving of further research investiga- with well-replicated scientific evidence. We provide a large, sound data base rich tion compared with other interventions, are far less concerned about interventions with implications for psychotherapy. not to mention more efficacious than stan- whose rationales are inadequately under- It will be a shame if psychotherapy dard interventions. stood than those whose rationales are continues as a fragmented enterprise A second objection is that scientists are exceedingly implausible from a scientific on the borders of psychology, limited sometimes mistaken about how the natural standpoint. In this respect, SBP should be both conceptually and scientifically by world works, so it is illegitimate to consider able to function as a partial bulwark against self-imposed insulation from what by research evidence bearing on a treatment’s the ongoing intrusion of pseudoscience its origins is its birthright. (p. 27) theoretical rationale when evaluating its into clinical work, evidence-based practice scientific status. Scientific knowledge guidelines, graduate education and train- Similar considerations apply to SBP. changes, in some cases radically. As one ing, and continuing education courses. To properly appraise psychotherapies, we familiar example, German geophysicist need to consider not merely how well they Alfred Wegener was dismissed by some Concluding Thoughts work when compared against wait-list con- scientists as a crackpot after introducing EBP has been an essential step toward trol conditions, but also whether they are his theory of continental drift in 1912, as grounding the field of clinical psychology grounded in adequate scientific founda- the idea that the continents move struck more firmly in science. Nevertheless, it has tions, including basic psychological sci- them as preposterous. As we know, how- not gone far enough, as it has failed to oper- ence. ever, Wegener was later vindicated by stud- ate as an effective safeguard against the SBP should help to solve several press- ies in plate tectonics, paleontology, and penetration of pseudoscience into myriad ing problems. First, SBP should begin to other disciplines (McComas, 1995). But for domains, including continuing education curb the continued infiltration of pseudo- every Wegener, there are at least a thou- courses, clinical practice guidelines, and science into clinical practice, as many and sand inventors of would-be perpetual the marketing and promotion of interven- arguably most poorly supported interven- motion devices and mind-reading tions. SBP, although not a panacea, should tions rest on highly questionable theoreti- machines (Sagan, 1995). More important, nudge the field in the direction of a cal premises. Second, SBP offers a cogent SBP, like EBP (see Gibbs & Gambrill, 2002; stronger scientific foundation. By incorpo- counterargument to assertions that scien- Lilienfeld et al., 2013), is not ossified, as it rating evidence from all relevant science, tifically dubious interventions that outper- evolves in accord with new evidence. If including the natural sciences (e.g., physics, form wait-list control conditions should physicists were to uncover compelling evi- chemistry), rather than merely treatment qualify for CE credits or clinical practice dence for the existence of energy fields sur- outcome evidence, SBP should help to pre- guidelines. Third, SBP renders it difficult rounding the human body, or if psycholo- vent advocates of treatments based on for advocates of energy therapies and other gists were to uncover compelling evidence grossly implausible theoretical rationales highly dubious interventions to dub them- for the existence of internal subpersonali- from laying claim to the coveted evidence- selves “evidence-based,” which they can ties, then energy therapies and internal based mantle. often do now with some justification given family systems therapy, respectively, might Although we have focused our analysis current EBP standards. warrant consideration as meeting SBP cri- teria. on psychological treatment, many or most Potential Objections A third objection is that we have not of the same considerations we have raised offered explicit criteria for SBP status akin (e.g., Sechrest & Smith, 1994) apply in We can envision several potential objec- to those for ESTs. To this objection, we equal force to psychological assessment tions to SBP; we briefly address four here. plead guilty, as we do not intend to propose (see Bowden, 2017). For example, in neu- First, critics of SBP might contend that “if a a specific operationalization of SBP here, ropsychological assessment, good scientific treatment works, it works.” So, if we wish although we hope to do so in a future com- theory plays a critical role in test score to be blindly empirical, we should regard munication. At this juncture, we will say interpretation. Neuropsychological assess- energy therapies as roughly equivalent to only that to meet full SBP status, the two ments rooted in stronger theory are not well-established ESTs in evidentiary prongs of (a) controlled research outcome only likely lead to more interpretable strength, as the controlled outcome data evidence and (b) evidence for the scientific assessments, but are also likely to reduce for the former interventions are also sup- rationale are both necessary, though nei- decision errors, because the assessment is portive. Setting aside the question of ther in isolation is sufficient. The full motivated by a theory that will have under-

January • 2018 45 LILIENFELD ET AL. gone more rigorous evaluation and replica- Barabasz, A. (2013). Evidence based abre- Hunsley, J., & Mash, E. J. (2007). Evi- tion (Riley et al., 2017). One theory that active ego state therapy for PTSD. Ameri- dence-based assessment. Annual Review accounts for a vast array of neuropsycho- can Journal of Clinical Hypnosis, 56, 54- of Clinical Psychology, 3, 29-51. logical data is the Cattell-Horn-Carroll 65. Jewsbury, P. A., & Bowden, S. C. (2017). (CHC) model, an integration of the empir- Bowden, S. C. (Ed.). (2017). Neuropsycho- Construct validity has a critical role in ical work of the three eponymous authors logical assessment in the age of evidence- evidence-based neuropsychological over many decades (McGrew, 2009) that based practice: Diagnostic and treatment assessment. In S. C. Bowden (Ed.), Neu- evaluations. New York, NY: Oxford Uni- ropsychological assessment in the age of has been validated across diverse popula- versity Press. evidence-based practice: Diagnostic and tions and clinical conditions (Jewsbury, Canadian Psychological Association. treatment evaluations (pp. 33-63). New Bowden, & Duff, 2016; Jewsbury, Bowden, (2012). Evidence-based practice of psycho- York: Oxford University Press. & Strauss, 2016). This model articulates logical treatments: A Canadian perspec- Jewsbury, P. A., Bowden, S. C., & Duff, K. several different cognitive ability con- tive (Report of the CPA Task Force on (2016). The Cattell–Horn–Carroll model structs that have historically been grouped Evidence-Based Practice of Psychological of cognition for clinical assessment. Jour- under the broad rubric of “executive func- Treatments). Ottawa, Ontario: Author. nal of Psychoeducational Assessment, 35, tion.” The latter atheoretical grouping is http://www.cpa.ca/docs/File/Practice/ 1-21. illustrated by the cognitive ability taxon- Report_of_the_EBP_Task_Force_ Jewsbury, P. A., Bowden, S. C., & Strauss, omy of DSM-5 (American Psychiatric FINAL_Board_Approved_2012.pdf M. E. (2016). Integrating the switching, Association, 2013). Nevertheless, if multi- Chambless, D. L., & Hollon, S. D. (1998). inhibition, and updating model of execu- ple constructs are assessed and interpreted Defining empirically supported thera- tive function with the Cattell-Horn-Car- together exclusively as a global construct, pies. Journal of Consulting and Clinical roll model. Journal of Experimental Psy- Psychology, 66, 7-18. chology: General, 145, 220-245. the risks of confounded assessments and Church, D. (2013). Clinical EFT as an evi- clinical decision errors are exacerbated Kazdin, A. E. (2008). Evidence-based dence-based practice for the treatment of treatment and practice: Newopportuni- (Jewsbury & Bowden, 2017). psychological and physiological condi- ties to bridgeclinical research and prac- In closing, we encourage more explicit tions. Psychology, 4, 645-654. tice, enhance the knowledge base, and integration of SBP into CE courses as well David, D., & Montgomery, G. H. (2011). improve patient care. American Psycholo- as into graduate training and education, The scientific status of psychotherapies: gist, 63, 146–159. including clinical supervision and formal A new evaluative framework for evi- Larrabee, G. J. (2000). Association coursework. Current and would-be mental dence-based psychosocial interventions. between IQ and neuropsychological test health professionals need to conceptualize Clinical Psychology: Science and Practice, performance: Commentary on Tremont, and evaluate clinical practice, including 18, 89–99. Hoffman, Scott, and Adams (1998). 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46 the Behavior Therapist LEGAL RECOURSE

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Pseudotherapies in Clinical Psychology: Therapy to its National Registry of Evi- dence-Based Programs and Practices as an What Legal Recourse Do We Have? effective treatment for trauma and other conditions (Lilienfeld & Satel, 2016). The fact that we cannot rely on profes- Lisa A. Napolitano, CBT/DBT Associates, New York sional associations and national agencies to protect us from ineffective and harmful pseudotherapies underscores the impor- SINCETHE EARLY 90s, the field of psy- have been allocated to other efficacious and tance of legal recourse for the consumer chotherapy has witnessed a proliferation of effective treatments (Lilienfeld et al., and the concerned professional. pseudotherapies—seemingly scientific 2015b). But what legal recourse do psycholo- treatments that are not actually based on The current measures in place to pro- gists and consumers have? The answer scientific principles (Lilienfeld, Lynn, & tect the field of clinical psychology and the varies by jurisdiction. Lohr, 2015b). As a result, consumers and public from pseudotherapies are inade- This article examines the legal strategies mental health professionals are increas- quate. Rather than issuing practice guide- that have been used to curtail the practice ingly vulnerable to pseudoscientific pro- lines and sanctioning the practitioners of of pseudoscientific therapies. In particular, motions. Pseudotherapies have infiltrated these treatments, the American Psycholog- it examines two legal approaches that have popular psychological discourse and ical Association (APA) and various gov- been used to curtail the practice of sexual threaten to erode the scientific foundations ernmental organizations have arguably orientation change efforts (SOCE), a cate- of clinical psychology. They also pose contributed to their proliferation. For gory of pseudoscientific therapies designed potential harms to the public. The majority instance, the APA offers continuing educa- change a person’s sexual orientation from of pseudotherapies are ineffective rather tion credits for Jungian sandtray therapy lesbian, gay, or bisexual (LGB) to hetero- than iatrogenic (Lilienfeld, 2007). How- and psychological theater (Lilienfeld, Lynn, sexual. ever, even when not overtly harmful, they & Lohr, 2015a). Recently, the Substance The first strategy is the enactment of may inflict indirect harm by depriving Abuse and Mental Health Services Admin- targeted legislation by states to prohibit the individuals of time and money that could istration (SAMHSA) added Thought Field practice of SOCE. The second is the use of

January • 2018 47 NAPOLITANO the state’s consumer fraud laws to sue ulation into one of speech (Victor, 2014). increased anxiety, depression, suicidality, SOCE practitioners. These approaches are As such, it is outside the scope of First and loss of sexual functioning (APA, 2009). compared and evaluated as potential Amendment protection. However, the risks of SOCE methods models for legal approaches that can be that exclusively involve talk therapy and Infringement on Parental Rights used to curtail the practice of SOCE and exclude physical techniques are less clearly other pseudotherapies. The California legislation was also chal- documented. For these forms of SOCE, the lenged as an infringement of parents’ rights APA report concluded there is only anec- Legislative Bans Targeting SOCE to control their children’s upbringing and dotal evidence of harmful outcomes and it and the California Model make important medical decisions for could not definitively state how likely it is them. In other words, parents should have that harm would occur from them (APA, In 2012, California enacted legislation the right to choose SOCE for their children 2009). For this reason, the California legis- making it illegal for a mental health (Pickup v. Brown, 2014). lature included the second type of harm. provider to practice SOCE with a minor The court acknowledged that although Reasoning that because SOCE is premised under the age of 18. SB 1172 was landmark parents have a constitutionally protected on the notion that LGB status is pathologi- legislation, making California the first state right to make decisions regarding the care, cal, the legislature concluded that SOCE in the nation to restrict the practice of custody, and control of their children, this impedes the development of a healthy self- SOCE. Under SB 1172, the practice of right is not without limitations. If the concept and self-acceptance, and con- SOCE is considered unprofessional con- child’s mental health is jeopardized, the tributes to the internalization of stigma. duct and provides grounds for the therapist state has the right to intervene to protect to lose his or her license. this child. Other States Adopt the California The basis for California’s legislation was For this challenge, the central issue Model to Target SOCE the state’s “compelling interest in protect- before the court was whether parents’ fun- Several states have adopted the Califor- ing the physical and psychological well- damental rights include the right to choose nia model to target SOCE. However, the being of minors . . . and in protecting its a therapy for their children that the state need to produce clinical evidence of minors against exposure to serious harms has deemed harmful. The court stated that SOCE’s harmfulness has limited the scope caused by sexual orientation change parents could not compel the state to of these legislative bans to conversion ther- efforts” (S.B. 1172, § 1 (n), 2011-2012, S. permit licensed mental health profession- apy because there is less evidence for the Reg. Sess. (Cal. 2012)). als to engage in unsafe practices and cannot harms caused by noninvasive forms. Addi- dictate standard of care in California based tionally, these bans tend to be limited to the First Amendment Challenges on their own views. It concluded that the practice of conversion therapy with minors Immediately after it was enacted, the fundamental rights of parents do not who are generally viewed as in greater need legislation was challenged by mental health include the right to choose a specific med- of the state’s protection than adults. practitioners on First Amendment ical or mental health treatment that the To date, eight states and the District of grounds as an infringement of protected state has reasonably deemed harmful Columbia have enacted legislation that speech (Pickup v. Brown, 2014). (Pickup v. Brown, 2014). narrowly prohibits the practice of conver- The primary issue raised by this First California Legislation as a Model for sion therapy with minors, rather than Amendment challenge was whether the SOCE more broadly and with all ages. They Other States California legislation regulated a therapist’s include Illinois, Nevada, New Mexico, New professional conduct or whether it inhib- Although SB 1172 passed constitutional Jersey, Oregon, Rhode Island, and Ver- ited constitutionally protected speech. muster, similarly crafted legislation would mont. New York is considering similar leg- The regulation of professional speech is be vulnerable to constitutional challenges. islation. not a well-defined area of First Amend- One of the reasons for this vulnerability Connecticut has enacted the broadest ment law. The court acknowledged that is that the state may not be able to meet its legislation against conversion therapy, mental health professionals have a First burden in showing that SOCE or another banning the practice with adults, as well as Amendment right to express their opinions pseudotherapy causes harm that the state children. It has also banned the expendi- in public. However, this protection dimin- has a compelling interest to protect against. ture of public funds on this pseudotherapy. ishes for speech uttered in the context of California increased the likelihood of meet- As in California, legislation in New the therapist-client relationship. Further, it ing this burden by recognizing two cate- Jersey was challenged on First Amendment “ultimately ceases when it is uttered in a gories of harm: (a) the cause or exacerba- grounds by practitioners. The court ruled context exclusively regulated by the tion of psychiatric disorders such as that the state’s interest in protecting the accepted standards of professional con- anxiety, depression, and suicidal behavior; public from harm outweighed the thera- duct” (Victor, 2014, p. 1555). and (b) the internalization of stigma and pists’ free speech interests (King v. Gover- The court ultimately decided the legis- impeded development of a positive LGB nor of New Jersey, 2014). lation was a regulation of conduct that only identity. incidentally regulates speech. The rationale To establish the first type of harm, the Limitations of California Model for this decision was twofold. First, the Legislature relied heavily on a report by a Although California’s legislation seems court noted that California has the author- Task Force of the APA that surveyed all like a promising model for other states to ity to prohibit licensed mental health pro- existing literature on SOCE. The report curtail the practice of SOCE and other fessionals from providing therapies that the found compelling evidence that physically pseudotherapies, it has significant limita- legislature has deemed harmful. Second, invasive forms of SOCE, such as aversion tions. the fact that speech is used to carry out therapy or conversion therapy, cause First, adults tend not to be protected those therapies does not transform the reg- harmful mental health effects such as from the harms of pseudotherapies by leg-

48 the Behavior Therapist LEGAL RECOURSE islative bans. Even in states with legislative tionally, it is less vulnerable to constitu- The court found JONAH’s expert testi- bans, SOCE may be offered by any mental tional challenge. mony inadmissible. New Jersey, like many health practitioner to an adult with the other states, has adopted the Frye test to Ferguson v. Jonah exception of Connecticut. Second, this reg- determine the admissibility of expert testi- ulatory scheme does not prevent unli- The same year the California legislation mony (United States v. Frye, 1923). Under censed providers, such as religious leaders, was enacted to restrict SOCE, another this test, the reliability of expert testimony from administering SOCE or other approach was being taken in New Jersey depends on whether it has general accep- pseudotherapies. Nor does it prevent against this pseudotherapy. tance in its field. The court found that “the licensed mental health practitioners from In November 2012, a lawsuit was filed overwhelming weight of scientific author- referring children and adults to unlicensed against a SOCE practitioner group called ity concludes that homosexuality is not a practitioners of SOCE and other pseudo- Jews Offering New Alternatives for Healing disorder” (Ferguson v. Jonah, 2015, p. 19). therapies. (JONAH) by a group of former patients. It also noted that a “group of a few closely From a legal perspective, California’s The patients alleged that JONAH’s associated experts cannot incestuously val- legislation and similarly modeled legisla- promise to cure them of their homosexual- idate one another in order to establish the tion are particularly vulnerable to First ity was fraudulent and deceptive in viola- reliability of their shared theories” (Fergu- Amendment challenges because it pro- tion of New Jersey’s Consumer Fraud Act son v. Jonah, p. 26). hibits a type of speech partly on ideological (CFA). Ferguson v. JONAH (2015) is a The New Jersey court ruled that grounds. landmark case—the first consumer fraud JONAH had violated the consumer fraud To withstand constitutional challenge, claim filed against conversion therapists in act by stating that homosexuality is not a legislation enacted by the states must show the nation (Dubrowski, 2015). normal variant of sexuality. After only 3 the state has a compelling interest to pro- The bases for the fraud claim were three hours of deliberation, the jury found the tect the public from harm. Accordingly, in key misrepresentations made by JONAH: defendants were guilty of unconscionable the absence of clear evidence of harm, the first, homosexuality is a mental disorder; consumer fraud. legislative approach to curtail the practice second, sexual orientation can be changed; In addition to attorneys' fees and dam- of therapies is not effective. Because the and third, that JONAH’s practices were ages, the plaintiffs were granted injunctive vast majority of pseudotherapies are well grounded in science and that there was relief and the JONAH clinic was perma- merely ineffective rather than harmful, this “empirical evidence” supporting their effi- nently closed (Dubrowski, 2015). approach is not optimal. cacy. Other misrepresentations included The verdict in JONAH has been that the program’s success rate was 66% described as a potential “coup de grace to Consumer Fraud Acts and and that it worked on a specified time the remaining providers of conversion the New Jersey Model frame (Dubrowski, 2015). therapy in the United States” (Dubrowski, In addition to advertisements for indi- p. 79). Given the limitations inherent in a leg- vidual and group therapy, the main evi- The case provides a powerful model for islative approach, a more promising strat- dence of fraud came from JONAH’s list lawsuits in other states that can be used to egy for the restriction of SOCE and other serve and emails to potential clients. The curtail the practice of conversion therapy, pseudotherapies may be the use of the plaintiffs also testified that they had been and potentially other pseudotherapies. states’ Consumer Fraud Acts. personally assured they had a two out of Pseudotherapies lack scientific evidence three chance of changing their sexual ori- Implementing Ferguson to Target SOCE of efficacy and effectiveness. Yet, most entation. Every state has a consumer protection practitioners of these treatments make mis- Bolstering the plaintiffs’ case for fraud law that grants private citizens the right to leading claims to the public about their was the 2009 APA report discrediting any enforce it through civil causes of action. success for treating problems. For exam- treatment model that purports to change Accordingly, implementation of the Fergu- ple, SOCE practitioners misleadingly hold sexual orientation. After a systematic son model means that individual victims of themselves out as being able to “convert” review of the research on the efficacy of SOCE would bring lawsuits against SOCE patients from LGB to heterosexual. Roger sexual change efforts, the APA’s report practitioners for deceptiveness-based pro- Callahan and other practitioners of Voice concluded that claims of the effectiveness fessional conduct. Therapy, a variant of Thought Field Ther- of SOCE for changing sexual orientation This antideception approach to SOCE is apy, have claimed 97% to 98% cure rates for are not supported. consistent with the ways in which many all emotional disorders (Callahan & Calla- The APA also filed an amicus brief for states currently regulate the advertising of han, 2000). the plaintiffs stating that the consensus of licensed therapists. For example, California These misleading claims by therapists mental health professionals and research- has a provision that prohibits public com- arguably fall under a broader existing legal ers is that homosexuality is a normal munications by psychologists that contain regime that defines them as fraud (Victor, expression of sexuality (Dubrowski, 2015). false, fraudulent, or misleading statements. 2014). An antifraud approach casts a wider To counter the claims of fraud, JONAH This includes any claims intended to net than targeted legislation and could be submitted reports from six experts includ- induce or likely to induce services that used to address pseudotherapies that are ing four conversion therapists, one medical cannot be substantiated by reliable, peer- merely ineffective rather than harmful. It doctor, and one rabbi. They all testified that reviewed, and published scientific studies. also closes many of the loopholes that exist homosexuality is not universally accepted Under these provisions, an offending prac- under legislative bans. This approach can as normal. Rather, they asserted that titioner can be de-licensed (Victor, 2014). be used to restrict the practice of pseudo- homosexuality is a learned response to This strategy has been used successfully therapies by unlicensed practitioners and childhood “wounds” and is addressable in Arizona to limit the practice of Voice practitioners who work with adults. Addi- through therapy. Technology (VT), a variant of Thought

January • 2018 49 NAPOLITANO

Field Therapy (TFT). In 1999, the Arizona Second, this approach is less vulnerable ments are false would suffice (Dubrowski, Board of Psychologists sanctioned a psy- to First Amendment challenges. Fraudu- 2015). chologist for making false advertising lent or deceptive advertising is widely con- The intent requirement poses a poten- claims of a 95% success rate for VT and sidered to be outside the scope of the First tial obstacle for those seeking to pursue a forbid him from practicing both VT and Amendment and the government may ban pseudotherapy fraud action. While con- TFT (Pignotti, 2007). it. For this reason, there is a general sensus within the psychological commu- An antideception approach can be used assumption that states may prohibit mis- nity certainly exists for conversion and to expand the protection of legislative bans leading advertising. States also have the rebirthing therapies, it does not for many against SOCE. For example, adult citizens authority to regulate the conduct of psy- other pseudotherapies. The APA, for of California who are currently not pro- chologists and other licensed mental health example, offers continuing education cred- tected by the legislative ban can sue SOCE professionals. Restricting speech that is its for attachment therapy and EMDR. practitioners for fraud. incidental to the regulation of professional Similarly, in states with narrower leg- conduct is not considered a free speech Conclusion islative bans against conversion therapy restriction at all. Consequently, prohibiting only, the antideception approach expands a psychologist from making deceptive The proliferation of pseudotherapies protection against SOCE broadly for adults promises about a treatment’s efficacy poses harm to consumers of therapy and and children. would likely survive First Amendment clinical psychologists. The inadequate pro- Under some state antideception laws, challenges (Dubrowksi, 2015; Victor, tection by professional associations and it’s not necessary that the individual have 2014). governmental agencies underscores the received the services to file the complaint. Third, unlike a legislative ban, there is importance of exploring legal remedies. For example, California law provides that no need to show that the pseudotherapy is A review of the two primary legal strate- “anyone who thinks that a psychologist has harmful and the state has a compelling gies that have been used to curtail the prac- acted illegally or irresponsibly can file a interest to protect against it. Because the tice of SOCE suggests that pseudotherapies complaint” (Victor, 2014, p. 1574). majority of pseudotherapies are merely could be effectively targeted through the The primary disadvantage to the use of ineffective rather than harmful, a larger state’s antideception laws. This strategy the consumer fraud acts to curtail the prac- number can be targeted with this approach. seems to be an effective alternative to leg- tice of SOCE is its slow pace. Cases must be Fourth, every state’s consumer fraud islative bans and is relatively impervious to brought on an individual basis. However, if law provides a plaintiff who wins their case challenge on constitutional grounds. The a sufficient number of individual com- equitable relief. This means the court can use of the states’ consumer fraud acts also plaints are brought, the state board of psy- enjoin or stop the offending therapist from obviates the need to establish the treatment chology could adopt a regulation that clar- continuing to perpetrate the fraud on the is harmful. Without the burden of showing ifies that SOCE advertising and SOCE public. In JONAH, a permanent injunction harm, this strategy casts a wider net than efforts within a doctor-patient relationship was issued closing the clinic and prohibit- targeted legislation and can be used to are covered under the state’s definition of ing the JONAH therapists from ever prac- target a broader number of pseudothera- unprofessional conduct. ticing conversion therapy again (Dubrow- pies. ski, 2015). The Comparative Benefits of an Fifth, many states’ consumer fraud laws References do not require that the practitioner of a Antifraud Approach for Targeting American Psychological Association, Task SOCE and Other Pseudotherapies pseudotherapy knew or intended his actions to be fraudulent. Consequently, Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Because there is consensus within the actions brought under the Consumer Report of the APA Task Force on Appro- mental health establishment that homosex- Fraud Acts could target pseudotherapy priate Therapeutic Responses to Sexual uality is not a disorder and that SOCE practitioners who seem to believe firmly in Orientation, 22-25. http://www.apa.org/ cannot change sexual orientation, SOCE their treatments and the pseudoscientific pi/lgbt/resources/sexual- falls squarely within the ambit of an antide- basis for them rather than seek to defraud orientation.aspx. ception regime (Victor, 2014). However, the public (Dubrowksi, 2015). For exam- Callahan, R.J., & Callahan, J. (2000). Stop for other pseudotherapies that lack this ple, Roger Callahan is the creator of TFT the nightmares of trauma. Chapel Hill, consensus (e.g., TFT, past life regression and frequently described as a “true NC: Professional Press. therapy), an anti-deceptive approach may believer” in the effectiveness of his treat- Dubrowski, P. (2015). The Ferguson v. be more challenging. ment, despite a lack of any scientific evi- Jonah verdict and a path towards Nevertheless, in comparison to targeted dence to support it (Pignotti, 2007). Simi- national cessation of gay-to-straight legislation, the use of state consumer fraud larly, the SOCE practitioners at JONAH “conversion therapy.” Northwestern Uni- laws to target pseudotherapies has several may have genuinely believed in the effec- versity Law School, 110, 77-99. advantages. tiveness of their treatment. Ferguson v. JONAH, No. L-5473-12 (N.J. First, logistically it’s easier to use exist- For states that do require a showing of Sup. Ct. Law Div. 2015). ing laws rather than have new laws passed. intent, the burden can be met with expert King v. Governor of the State of New Jersey, If a state doesn’t have a consumer fraud testimony that there is no science to sup- 767 F. 3d 216 (3d Cir. 2014). law, it’s likely easier to convince legislators port the efficacy of the pseudotherapy. Lilienfeld, S. O. (1998). Pseudoscience in to pass general antideception statutes than Alternatively, expert testimony that there is contemporary clinical psychology: What a targeted ban against a particular pseudo- a general consensus in the psychological it is and what we can do about it. The therapy. community that the practitioner’s state- Clinical Psychologist, 51(4), 3-9.

50 the Behavior Therapist Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspective Exposing Pseudoscientific Practices: on Psychological Science, 2, 53-56. Benefits and Hazards Lilienfeld, S. O., Lynn, S.J., & Lohr, J. (2015a). Science and pseudoscience in clinical psychology: Initial thoughts, Monica Pignotti, Independent Scholar reflections, and considerations. In S.O. Lilienfeld, S.J. Lynn, & J.M. Lohr (Eds.), Science and Pseudoscience in Clinical Psychology (pp., 1-16). New York: Guil- EXPOSING PSEUDOSCIENTIFIC practices The report also noted that not all ford. comes with a price. Although I knew this attachment-based interventions were dan- Lilienfeld, S. O., Lynn, S.J., & Lohr, J. when I began exposing such practices, I gerous, and that some of the more focused (2015b). Science and pseudoscience in greatly underestimated the magnitude of shorter-term goal-directed interventions clinical psychology: Concluding vitriolic attacks from proponents of such have some evidence of efficacy. However, thoughts, and constructive remedies. In practices; this has greatly impacted my the more broadly focused and extensive S.O. Lilienfeld, S.J. Lynn, & J.M. Lohr career. interventions were the ones of concern (Eds.), Science and Pseudoscience in Clin- What follows is an account of my expe- because of their potential to do harm. Con- ical Psychology (pp., 527-532). New rience in writing about the harmful effects clusions and recommendations of the York: Guilford. of “attachment therapies” and holding and APSAC task force included the following: Lilienfeld, S. O., & Satel, S. (2016). You coercive restraint therapies used in won’t believe the government is support- addressing behavioral problems, mostly a. Treatment techniques or attach- ing this crackpot mental health therapy. with foster and adopted children. Such ment parenting techniques involving Forbes.com practices are lacking in scientific support, physical coercion, psychologically or Mercer, J. (2015). Attachment therapy. In and, in some cases, have resulted in great physically enforced holding, physical S.O. Lilienfeld, S.J. Lynn, & J.M. Lohr (Eds.), Science and Pseudoscience in Clin- harm, including death. Some critics have restraint, physical domination, pro- ical Psychology (pp., 466-499). New characterized this as torture. One of the voked catharsis, ventilation of rage, York: Guilford. most egregious examples of this is that of age regression, humiliation, withhold- Pickup v. Brown, 740 F. 3d 1208 (9th Cir. 10-year-old Candace Newmaker, who in ing or forcing food or water intake, 2014). 2000 was smothered to death by two unli- prolonged social isolation, or assum- Pignotti, M. (2007). Thought field ther- censed therapists in a rebirthing session, ing exaggerated levels of control and apy: A former insider’s experience. that consisted of placing pillows on top of domination over a child are con- Research on Social Work Practice, 17(3), her and having four adults sitting on top of traindicated because of risk of harm 392-407. her small frame, ignoring pleas that she and absence of proven benefit and Report of the American Psychological could not breathe (Mercer, Sarner, & Rosa, should not be used. Association Task Force on Appropriate 2003). However, despite the fact that a b. Prognostications that certain chil- Therapeutic Responses to Sexual Orien- child died and a law was subsequently dren are destined to become psy- tion (2009). American Psychological passed (Candace’s Law outlawing chopaths or predators should never be Association, 22-25. Rebirthing Therapy), similar and equally made based on early childhood behav- S.B. 1172, 2011-2012, S. Reg Sess (Cal. troubling practices continued (see Thyer & ior. These beliefs create an atmosphere 2012) (codified at Cal. Bus. & Prof. Code Pignotti, 2015, Chapter 3, for an overview). conducive to overreaction and harsh § 865-865.2 (West 2013) Enough concern was raised about these or abusive treatment. Professionals United States v. Frye, 293 F. 1013, 1014 types of attachment therapies that a special should speak out against these and (D.C. Cir., 1923). task force was convened by the American similar unfounded conceptualizations Victor, J. (2014). Regulating sexual orien- Psychological Association and the Profes- of children who are maltreated. tation change efforts: The California sional Society on the Abuse of Children c. Intervention models that portray approach, its limitations, and potential alternatives. The Yale Law Journal, 123, (APSAC; Chaffin et al., 2006), which com- young children in negative ways, 1532-1585. piled a report to review and evaluate these including describing certain groups of practices. The APSAC report noted con- young children as pervasively manipu- cern about: lative, cunning, or deceitful, are not ... conducive to good treatment and may . . . a variety of coercive techniques are promote abusive practices. In general, The author has no funding or conflicts of used, including scheduled holding, child maltreatment professionals interest to disclose. binding, rib cage stimulation (e.g., should be skeptical of treatments that Correspondence to Lisa Napolitano, J.D., tickling, pinching, knuckling), and/or describe children in pejorative terms Ph.D., 501 Madison Avenue, Suite 303, New licking. Children may be held down, or that advocate aggressive techniques York, NY 10022; may have several adults lie on top of for breaking down children’s defenses. [email protected] them, or their faces may be held so (Chaffin et al., 2006, p. 86) they can be forced to engage in pro- longed eye contact. Sessions may last Nevertheless, such practices still contin- from 3 to 5 hours, with some sessions ued to be promoted and used by both reportedly lasting longer. (Chaffin et licensed and unlicensed practitioners. It al., 2006, p. 79) was out of concern for the harm (and the potential for harm) being done that the

January • 2018 51 PIGNOTTI nonprofit organization Advocates for Chil- My interest in understanding and pists we had been criticizing, which she dren in Therapy (ACT), was formed in exposing the dangers of pseudoscientific shared with me. The email warned that he 2003. Its mission statement is as follows: practices predates my mental health would be exposing our sexual problems degrees, and began with my 6-year per- and Scientology past. Weeks later, some Advocates for Children in Therapy sonal experience in Scientology. After leav- very derogatory anonymous postings, done (ACT) is a not-for-profit organiza- ing Scientology in the late 1970s, I was through anonymous remailers impossible tion concerned with the methods highly motivated to understand how such to trace, began appearing on public Inter- used in the treatment of children’s groups operated to attract and retain mem- net groups about me and my colleagues at mental health. Specifically with bers, as well as their practices, particularly ACT. Bizarre advertisements were run on respect to psychotherapy, parenting when it came to the extraordinary mental Craigslist and BackPage about me. Some of techniques, and other mental-health health claims being made that were based these advertisements were in the erotic sec- practices applied to children, ACT largely on testimonials and anecdotes, tion under my name. I had to cancel the advocates humane, non-violent and utterly lacking in scientific evidence. Out of text function on my cell phone because I scientifically validated treatments, my desire to learn and practice therapies was receiving obscene texts from men who and opposes the use of unvalidated that were noncoercive and actually helped were answering the ads. I received a phone practices, especially those known to people, I obtained an M.S.W. from Ford- call from a man who wanted me to work at be inhumane and abusive by: ham University in 1996. Following gradua- his erotic establishment. Some of the post- • Raising general public awareness tion, I worked for 5 years at Saint Vincent's ings claimed that I was having an affair of the dangers and cruelty of such Hospital in Geriatric and Palliative Care with my Ph.D. dissertation chair and other practices; research. Additionally, I had a private prac- faculty members and that I had been fired • Opposing governmental support tice in New York City as a certified social from FSU (I was not) and that I was unfit to and subsidy for such practices; worker. Unfortunately, since I did not teach. On the contrary, my course evalua- • Alerting professional organiza- completely understand evidence-based tions were acceptable, there had never been tions to inappropriate advocacy practice at the time, around 1997, I became any complaints against me, and I simply and promotion of such practices, involved with Thought Field Therapy, stopped teaching there after I graduated, as such as in continuing education which was invented by licensed psycholo- all Ph.D. students did (FSU does not hire programs; gist Roger Callahan (see Callahan & Calla- their own former students). One person • Urging appropriate authorities to han, 2000, for a full description). Ulti- even posted a bad review of me on “Rate establish and then enforce stan- mately, this resulted in my conducting a My Professors” at the FSU Pensacola dards of care and professional much-needed controlled experiment (Pig- Campus (I never taught on that campus). ethics to effectively ban the use of notti, 2005) that showed this practice was At the same time, one of the therapists such practices; not what it was claimed to be. whom my colleagues in ACT had criticized • Assisting, with information and During my time in the Ph.D. program wrote a letter to the Dean of the College of advice, in the prosecution of those at Florida State University’s (FSU) College Social Work complaining about me. After who criminally defraud parents of Social Work, I continued to publish arti- explaining the situation to the dean, he and damage children by using such cles related to the exposure and critique of chose to take no action. This was the same practices or by recommending pseudoscientific practices, including ques- individual mentioned previously who had their use; and, tionable attachment and holding therapies also complained to the dean of the univer- • Obtaining some measure of jus- and coercive restraint therapies (Mercer & sity where one of my colleagues was a Pro- tice for the victims of such practices Pignotti, 2007; Pignotti & Mercer, 2007). It fessor Emerita, again fortunately, to no through restitution and compensa- was these articles that made proponents of avail. An anonymous individual also sent tion from the perpetrators (Advo- such therapies aware of my work, which, bizarre emails to faculty members and cates for Children in Therapy, n.d., needless to say, did not please them. For other Ph.D. students at FSU about me. The para. 1-2). example, one of the proponents of such content was so incoherent that none of my therapies contacted the dean at the univer- colleagues believed what was alleged in Obviously, these are all laudable goals that sity where one of the critics worked, alleg- them, but being a target was not helpful to few ethical mental health professionals, ing that she was mentally unbalanced, had my reputation. Very little was known about especially those who take an evidence- personal problems, and was transsexual cyberstalking at the time, and there were based approach, would disagree with, in (which, in addition to the obvious bigotry people who tended to take a "blame the spite of the virulent attacks this organiza- in such an accusation, was not true). victim" attitude, wondering how I had tion has received from proponents of the Although I was aware already of some indi- gotten myself into this situation. Some methods that they exposed. viduals who had been the target of vicious people believed the old adage "where In 2006, I was honored to accept, as a personal attacks and harassment after crit- there's smoke, there's fire," and were unable service to the profession, a position on their icizing questionable mental health prac- to entertain the idea that the targets of such Board of Directors, where I served for 4 tices, I was not expecting what was to attacks were completely innocent and were years (2006–2010). Even though I had pub- follow. In the summer of 2009, I defended instead being attacked for doing something lished peer-reviewed articles, the audience my dissertation and was teaching classes at to try to help others. for such articles was small, and the general FSU’s College of Social Work. These attacks were happening at the public, especially potential consumers of In the spring of 2009, a blogger who was same time as I was on the job market for a such practices, needed to be educated so a survivor of attachment therapy as a child tenure-track faculty position, and this was they could make informed choices about and was exposing it on her blog, received a being brought up at some of my on- treatments for their children. threatening email from one of the thera- campus interviews. Although the faculty I

52 the Behavior Therapist EXPOSING PSEUDOSCIENTIFIC PRACTICES interviewed with were largely sympathetic, something that no one wanted inflicted could be fulfilled being in a profession my situation was also difficult for most of upon any faculty at an establishment that where I had to keep silent in order to get them to understand and, to make things might have hired me. It was as if I had a ahead; I would feel as though I sold out. If even worse, there were some who were contagious disease; although it was not my my colleague and other experienced social sympathetic to some of the people I had fault, people were sympathetic, it was not work faculty members who had warned me criticized. Universities aligning themselves something anyone wanted to be around. about the “small world” of the profession with pseudoscientific practices is, unfortu- Everything came to a head in December had been right, that I needed to remain nately, not uncommon, and I had written a 2010 when one of the therapists sued me, silent until getting a position and then get- piece (Pignotti, 2007) exposing this prac- along with five of my colleagues, for ting tenure, I could not have lived with that tice at a top-ranked school of social work defamation and interference with business. decision. where energy-tapping therapies were being Interestingly, while the lawsuit was under Are there things I would do differently? taught. At the time, a well-meaning way, the anonymous postings, which had Of course. I would have posted less lengthy member of the profession who was a strong been occurring on an almost daily basis, responses and explanations to my critics on proponent of evidence-based practice had almost completely stopped. Fortunately, my blog—the feedback I received indicated warned me about this, saying that the social we were able to have the suit escalated to a that such responses did not help and made work profession was a small world and federal court, where the case was dismissed me look unbalanced. I would have instead there could be consequences for writing before the discovery phases and trial. After limited myself to one statement refuting such pieces. I had dismissed this warning, the lawsuit was dismissed, the anonymous the lies that were posted about me. It is dif- believing that the better, more evidence- attacks resumed with a vengeance, includ- ficult to determine, though, whether that based establishments would see value in ing a fake posting about me on a site would have made a difference or lessened what I did and in fact, some of them did, designed to expose adulterers, where some- the attacks, as my colleagues who were but ultimately, not enough to want to hire one accused me of having an affair with her silent when attacked were still just as me. In fact, one director of research of a husband in a city I wasn’t even living in. I viciously attacked as I was, the only differ- reputable university, after I had presented was only able to get the site to agree to take ence being, they were not seeking faculty my research and other evidence to docu- it down after I proved to them they had positions or already had tenure, so did not ment the problem of pseudoscience in the copied the story from elsewhere and suffer the consequences I had. social work profession, still dismissed the changed the person’s name to mine. When Hillary Clinton, who has been the target notion that the profession had any problem the therapist lost the lawsuit, he put up a of a much more highly publicized and and implied that my area of interest in derogatory document about all of us on his broader attacks, recently expressed regret investigating such usage by practitioners business’ website, saying that as a public that she hadn’t been more vociferous in her was not a valid one. Even though I pointed figure, his lawsuit against us had been responses and fought back harder. Being out the high percentage of licensed clinical unwinnable. Actually, the case was dis- silent did not stop the attacks, nor did it social workers that are in private practice, missed due to failure to state a claim upon help her win the election. These types of he maintained that the agencies were all which relief can be granted and jurisdic- attacks place the target in a double-bind sit- using evidence-based practice now and tion. The judge had noted that he would be uation. If we fight back hard, we are por- that there was no problem in the profes- likely considered a public figure, had the trayed as mentally imbalanced and any- sion, which ran contrary to my own inves- case progressed, but that was not the thing we say, no matter how seemingly tigations and research (Pignotti & Thyer, reason the case was dismissed. Rather, First innocuous, can further be twisted and dis- 2009, 2012). I had to wonder how many Amendment rights to express our opinions torted. On the other hand, if we do not others with whom I had interviewed agreed absent factually false statements gave him fight back, people believe that the accusa- with this research director, but were too no case. In addition to being a victory for tions must have some truth in them or that polite to be as blunt as this particular indi- Internet free speech, this is also a victory the person has something to hide or does- vidual had been. for academic freedom. n’t care. After 5 years of a job search and over The attacks continued through 2011 Since cyber abuse of this kind is a rela- 100 applications, I failed to obtain a faculty and finally, by 2012, suddenly lessened tively new phenomenon, we really do not position of any kind. While there is no way with only an occasional blog post. How- know what tactics would be effective in for me to prove a direct cause-and-effect ever, when it came to my academic career, stopping it. There is still a tendency to relationship, what I do know is that every the damage had been done. Being 3 years blame the victims, thinking that if only we one of my peers in my Ph.D. cohort who out from graduation made it even more had behaved differently, this would not sought faculty positions obtained them— difficult for me to obtain a faculty position, have happened. Hopefully, there will be and even though my credentials, teaching, and although I continued to try, after hun- more empirical study of this phenomenon and research experience were at least dreds of applications, I did not obtain a fac- to find out what works and what doesn’t equivalent to theirs (I had more peer- ulty position. I continue to write and pub- work when dealing with cyber abuse. reviewed publications than anyone in my lish on understanding and exposing I have also been asked what advice I cohort), I was not able to obtain such a pseudoscience and disseminating evi- would give to students interested in acade- position. I believe this was the consequence dence-based practice, but I make my living mic careers who are concerned about the of the focus of my work in exposing and outside the profession. problem and wish to expose it. What I pseudoscientific practices. In addition to What are the lessons learned from this would advise is to make an informed the more general problem faculty might experience? I have been asked if I would do choice. I had been exposing various pseu- have had with my involvement, the bizarre what I did again, now knowing what the doscientific practices for years with very material on the Internet, even though none consequences could be. Essentially, my little consequences, until I angered the of them believed it was true, was likely answer would be yes: I do not think I wrong people by criticizing their particular

January • 2018 53 PIGNOTTI

practice. That is a risk that anyone takes Chaffin, M., Hanson, R., Saunders, B. E., CLASSIFIED who chooses to expose such practices and Nichols, T., Barnett, D., & Zeanah, C. ... someone who wants an academic career Miller-Perrin, C. (2006). Report of the needs to realize that it could interfere with APSAC task force on attachment ther- FULL TIME THERAPIST POSITION apy, reactive attachment disorder, and AVAILABLE Dec 2017 their ability to get hired or get tenure. One attachment problems. Child Maltreat- Due to our continued growth, Mountain option would be to, instead, as a student ment, 11, 76-89. Valley Treatment Center seeks an addi- and a new graduate, focus on disseminat- Mercer, J. & Pignotti, M. (2007). Shortcuts tional licensed clinician to join our excep- ing evidence-based approaches and leave cause errors in systematic research syn- tional clinical team as a primary therapist the exposure of pseudoscience to others thesis: Rethinking evaluation of mental at its beautiful new campus in Plainfield, with more secure positions, but even then, health interventions. The Scientific NH. Mountain Valley, a short term resi- there have been severe consequences as we Review of Mental Health Practice, 5, 59- 77. dential treatment program, serves male can see with what Elizabeth Loftus had to Mercer, J., Sarner, L., & Rosa, L. (2003). and female adolescents and emerging endure as a result of her research on recov- ered memory. This is an informed personal Attachment therapy on trial: The torture adults, 13 – 20 years old, from around the and death of Candace Newmaker. West- professional choice that each person will globe with debilitating anxiety and OCD. port, CT: Praeger Publishers/Greenwood Our newest campus, located near need to make for themselves, weighing the Publishing Group. Hanover, NH and Dartmouth College, importance of their values, the benefits and OpEd Project (n.d.). Public Voices Fellow- provides a unique professional and treat- possible consequences. What I do know is ship. Retrieved on October 1, 2017 from ment environment as well as a locale to that if such risks are not taken, these prac- https://www.theopedproject.org/public- conveniently implement in-vivo expo- tices will continue to be promoted, espe- voices-fellowship/ sure exercises. cially on the Internet, and writing for jour- Pignotti, M. (2005). Thought field therapy Mountain Valley adds clinically inten- nals that only academic colleagues read is voice technology vs. random meridian point sequences: A single-blind con- sive CBT and ERP within an experiential not enough. Fortunately there is a recent trend in the academic community, with trolled experiment. The Scientific Review education program and mindfulness- of Mental Health Practice, 4(1), 72-81. based milieu. Our program was recently projects such as the Public Voices Fellow- ship (OpEd Project, n.d.), to encourage Pignotti, M. (2007). Questionable inter- featured in the October 15, 2017 New ventions taught at top-ranked school of York Times Magazine as well as other people in various academic disciplines, social work. The Scientific Review of local and national media venues high- especially those that impact the public, who Mental Health Practice, 5, 78-82. lighting the great work being done. regularly publish little-read peer-reviewed Pignotti, M. & Mercer, J. (2007). Holding Primary Therapists manage a caseload articles, to extend their writing and voicing therapy and Diadic Developmental Psy- of three to five private pay residents over of opinions to the larger community in the chotherapy are not supported and their 90-day treatment stay, providing form of op-eds, blogs, Tweets, and other acceptable practices: A systematic individual, group, and family therapy. media where their knowledge and exper- research synthesis revisited. Research on Social Work Practice, 17, 513-519. Designing and implementing exposures tise is so badly needed. Pignotti, M. & Thyer, B. A. (2009). The use with their clients both on our 25-acre Exposing pseudoscience and other mis- information disseminated to the public is of novel unsupported and empirically campus and within local communities supported therapies by licensed clinical provides a unique professional experi- truly an interdisciplinary effort that all social workers. Social Work Research, 33, ence unmatched at any other residential health and mental health professions, as 5-17. treatment setting. well as perhaps sociologists and anthropol- Pignotti, M. & Thyer, B. (2012). Novel and The ideal candidate will have, at a mini- ogists, could be involved in. I am not alone empirically supported therapies: Patterns mum, a Master’s degree, be currently in challenging such practices and I am of usage among licensed clinical social licensed or license-eligible in New deeply grateful to all my colleagues who workers. Behavioural and Cognitive Psy- Hampshire, and have an understanding have taken these risks, in spite of all the chotherapy, 40, 331-349. of CBT based modalities such as DBT, consequences they suffered. Thyer, B. A. & Pignotti, M. (2015). Science and pseudoscience in social work practice. ACT and ERP. Prior experience serving New York: Springer. clients with OCD and anxiety disorders References preferred. Advocates for Children in Therapy (n.d.). ... Mountain Valley offers above average Mission Statement. Retrieved from salary, full benefits package, relocation http://www.childrenintherapy.org/ and temporary housing assistance, and mission.html on July 8, 2017. The author has no funding or conflicts of sponsored professional development Callahan, R.J. & Callahan, J. (2000). Stop interest to disclose. opportunities such as attending ABCT, the nightmares of trauma. Chapel Hill: Correspondence to Monica Pignotti, ADAA and IOCDF conferences. Casual Professional Press. Ph.D., [email protected] work and team focused environment. Mountain Valley supports the profes- sional growth of all its staff. Please contact Don Vardell, Executive Director at dvardell@mountainval- leytreatment.org for more information or to apply.

54 the Behavior Therapist Nominate the Next Candidates for ABCT Office

Every nomination counts! Encourage col- I nominate the following individuals: leagues to run for office or consider running yourself. Nominate as many full members as you like for each office. The results will be tal- PRESIDENT-ELECT (2018–2019) lied and the names of those individuals who receive the most nominations will appear on the election ballot next April. Only those nomination forms bearing a signature and postmark on or before February 1, 2018, will be counted. REPRESENTATIVE-AT-LARGE(2018–2021) Nomination acknowledges an individual's and liaison to Convention and Education Issues leadership abilities and dedication to behav- ior therapy and/or cognitive therapy, empiri- cally supported science, and to ABCT. When completing the nomination form, please take into consideration that these individuals will be entrusted to represent the interests of SECRETARY-TREASURER (2019–2022) ABCT members in important policy decisions in the coming years.Only full and new mem- ber professionals can nominate candidates. Contact the Leadership and Elections Chair for more information about serving ABCT or to get more information on the positions. NAME (printed) SIGNATURE (required) Complete, sign, and send form to: David Pantalone, Ph.D., Leadership & Elections Chair, ABCT, 305 Seventh Ave., New York, NY 10001.

Good governance requires participation of the mem- bership in the elections. ABCT is a membership organiza- tion that runs democratically. We need your participation to continue to thrive as an organization. Three Wa ys to Nominate

NOTE: To be nominated for President-Elect of ABCT, it " Mail the form to the ABCT office is recommended that a candidate has served on the (address above) ABCT Board of Directors in some capacity; served as a " Fill out the nomination form by hand coordinator; served as a committee chair or SIG chair; and fax it to the office at 212-647-1865 served on the Finance Committee; or have made other " Fill out the nomination form by hand significant contributions to the Association as deter- and then scan the form as a PDF file and email the PDF as an attachment to our mined by the Leadership and Elections Committee. committee: [email protected]. Candidates for the position of President-Elect shall ensure that during his/her term as President-Elect and President of the ABCT, the officer shall not serve as The nomination form President of a competing or complementary professional with your original organization during these terms of office; and the candi- signature is date can ensure that their work on other professional required, boards will not interfere with their responsibilities to ABCT during the presidential cycle. regardless of how This coming year we need nominations for three elected you get positions: President-Elect, Secretary-Treasurer, and Repre- it to sentative-at-Large. Each representative serves as a liaison us. to one of the branches of the association. The representa- tive position up for 2018 election will serve as the liaison to ✹ Convention and Education Issues Coordinator. A thorough description of each position can be found in ABCT’s bylaws: www.abct.org/docs/Home/byLaws.pdf.

January • 2018 55 ABCTawardsr& ecognition 2017 51st Annual Convention | November 17 | San Diego

(left) David DiLillo Outstanding Service to ABCT

(right) Marsha Linehan Lifetime Achievement Award (2016)

(NOTE: The 2017 Lifetime Achievement is awarded to Dianne L. Chambless)

(left) President Gail Steketee with President’s New Researcher Christian A. Webb

(right) Graduate Student Research Grant, Hannah Lawrence (l), and Honorable Mention Amanda L. Sanchez (r),

(below) Alexandra Kredlow accepting the Virginia Roswell Student Dissertation Award

Leonard Krasner Student John R. Z. Abela Student Anne Marie Albano Dissertation: Shannon Dissertation: Early Career Award: Michelle Blakey Carolyn Spiro Carmen P. McLean

56 the Behavior Therapist ABCTawards&recognition 2017

(left) Outstanding Training Program: Lee Cooper, Director, Clinical Science Ph.D. Program, Virginia Polytechnic Institute

(right) Jennifer P. Read Outstanding Contribution to Research

Elsie Ramos First Author Memorial Poster Award Winners (left to right) Awards Committee member Sara Elkins, with Kate Kysow, Chloe Hudson, & Christian Goans Student Travel Award Winner Dev Crasta

ADAA Travel Award Winners (left to right) President Gail Steketee, Andrea Niles, Amy Sewart, Jennie Kuckertz, and Awards Chair Katherine Baucom

January • 2018 57 !!!!!!!!!!!!!!!! #!$" Call for Award Nominations to be presented at the 52nd Annual Convention in Washington, DC

The ABCT Awards and Recognition Committee, chaired by Cassidy Gutner, Ph.D., of Boston University School of Medicine, is pleased to announce the 2018 awards program. Nominations are requested in all categories listed below. Given the number of submissions received for these awards, the committee is unable to consider additional letters of support or supplemental materials beyond those specified in the instructions below. Please note that award nominations may not be submitted by cur- rent members of the ABCT Board of Directors.

Career/Lifetime Achievement Eligible candidates for this award should be members of ABCT in good standing who have made significant contributions over a number of years to cognitive and/or behavior therapy. Recent recipients of this award includeThomas H. Ollendick, Lauren B. Alloy, Lyn Abramson, David M. Clark, Marsha Linehan, and Dianne L. Chambless. Applications should include a nomination form (available at www.abct.org/awards), three letters of support, and the nominee’s cur- riculum vitae. Please e-mail the nomination materials as one pdf document to [email protected]. Include “Career/Lifetime Achievement” in the subject line. Nomination deadline: March 1, 2018

Outstanding Mentor This year we are seeking eligible candidates for the Outstanding Mentor award who are members of ABCT in good stand- ing who have encouraged the clinical and/or academic and professional excellence of psychology graduate students, interns, postdocs, and/or residents. Outstanding mentors are considered those who have provided exceptional guidance to students through leadership, advisement, and activities aimed at providing opportunities for professional development, networking, and future growth. Appropriate nominators are current or past students of the mentor. Previous recipients of this award are Richard Heimberg, G. TerenceWilson, Richard J. McNally, Mitchell J. Prinstein, BethanyTe achman, and Evan Forman. Please complete the nomination form found online at www.abct.org.Then e-mail the completed form and associated materials as one pdf document to [email protected].. Include “Outstanding Mentor” in your subject heading. Nomination deadline: March 1, 2018

Distinguished Friend to Behavior Therapy Eligible candidates for this award should NOT be members of ABCT, but are individuals who have promoted the mission of cognitive and/or behavioral work outside of our organization. Applications should include a letter of nomination, three letters of support, and a curriculum vitae of the nominee. Recent recipients of this award include Mark S. Bauer,Vikram Patel, Benedict Carey, and Patrick J. Kennedy. Applications should include a nomination form (available at www.abct.org/awards), three letters of support, and the nominee’s curriculum vitae. Please e-mail the nomination mate- rials as one pdf document to [email protected]. Include “Distinguished Friend to BT” in the subject line. Nomination deadline: March 1, 2018

Mid-Career Innovator Eligible candidates for the Mid-Career Innovator Award are members of ABCT in good standing who are at the associate pro- fessor level or equivalent mid-career level, and who have made significant innovative contributions to clinical practice or research on cognitive and/or behavioral modalities.The previous recipient was Carla Kmett Danielson. Please complete the nomination form found online at www.abct.org.Then e-mail the completed form and associated materials as one pdf docu- ment to [email protected].. Include “Mid-Career Innovator” in the subject line. Nomination deadline: March 1, 2018

58 the Behavior Therapist Anne Marie Albano Early Career Award for Excellence in the Integration of Science and Practice Dr. Anne Marie Albano is recognized as an outstanding clinician, scientist, and teacher dedicated to ABCT’s mission. She is known for her contagious enthusiasm for the advancement of cognitive and behavioral science and practice.The purpose of this award is to recognize early career professionals who share Dr. Albano’s core commitments.This award includes a cash prize to support travel to the ABCT Annual Meeting and to sponsor participation in a clinical treatment workshop. Eligibility requirements are as follows: (1) Candidates must be active members of ABCT, (2) New/Early Career Professionals within the first 5 years of receiving his or her doctoral degree (PhD, PsyD, EdD). Preference will be given to applicants with a demon- strated interest in and commitment to child and adolescent mental health care. Applicants should submit: nominating cover letter, CV, personal statement up to three pages (statements exceeding 3 pages will not be reviewed), and 2 to 3 supporting letters. Application materials should be emailed as one pdf document to [email protected].. Include candidate's last name and “Albano Award” in the subject line. Nomination deadline: March 1, 2018 Student Dissertation Awards • Virginia A. Roswell Student Dissertation Award ($1,000) • Leonard Krasner Student Dissertation Award ($1,000) • John R. Z. Abela Student Dissertation Award ($500) Each award will be given to one student based on his/her doctoral dissertation proposal. Accompanying this honor will be a monetary award (see above) to be used in support of research (e.g., to pay participants, to purchase testing equipment) and/or to facilitate travel to the ABCT convention. Eligibility requirements for these awards are as follows: 1) Candidates must be student members of ABCT, 2)To pic area of dissertation research must be of direct relevance to cognitive-behavioral therapy, broadly defined, 3)The dissertation must have been successfully proposed, and 4)The dissertation must not have been defended prior to November 2017. Proposals with preliminary results included are preferred.To be considered for the Abela Award, research should be relevant to the development, maintenance, and/or treatment of depression in children and/or adolescents (i.e., under age 18). Self-nominations are accepted or a student's dissertation mentor may complete the nomination.The nomination must include a letter of recommendation from the dissertation advisor. Please complete the nomination form found online at www.abct.org/awards/. Then e-mail the nomination materials (including letter of recom- mendation) as one pdf document to [email protected]. Include candidate’s last name and “Student Dissertation Award” in the subject line. Nomination deadline: March 1, 2018

President’s New Researcher Award ABCT’s 2017-18 President, SabineWilhelm, Ph.D., invites submissions for the 40th Annual President’s New Researcher Award.The winner will receive a certificate and a cash prize of $500.The award will be based upon an early program of research that reflects factors such as: consistency with the mission of ABCT; independent work published in high-impact jour- nals; and promise of developing theoretical or practical applications that represent clear advances to the field.While nomina- tions consistent with the conference theme are particularly encouraged, submissions will be accepted on any topic relevant to cognitive behavior therapy, including but not limited to topics such as the development and testing of models, innovative practices, technical solutions, novel venues for service delivery, and new applications of well-established psychological princi- ples. Requirements: candidates must be the first author, and self-nominations are accepted; 3 letters of recommendation must be included; the author's CV, letters of support, and paper must be submitted in electronic form. E-mail the nomination materials (including letter of recommendation) as one pdf document to [email protected]. Include candidate’s last name and “President's New Researcher” in the subject line. Nomination deadline: August 1, 2018

Nominations for the following award are solicited from members of the ABCT governance: Outstanding Service to ABCT Please complete the nomination form found online at www.abct.org/awards/.Then e-mail the completed form and associated materials as one pdf document to [email protected]. Include “Outstanding Service” in the subject line. Nomination deadline: March 1, 2018

January • 2018 59 ABCT’s 52nd Annual Convention November 15–18, 2018 • Washington, DC

Preparing The ABCT Convention is designed for scientists, practitioners, students, and schol- ars who come from a broad range of disciplines. The central goal is to provide edu- cational experiences related to behavioral and cognitive therapies that meet the to Submit needs of attendees across experience levels, interest areas, and behavioral and cognitive theoretical orientations. Some presentations offer the chance to learn an Abstract what is new and exciting in behavioral and cognitive assessment and treatment. Other presentations address the clinical-scientific issues of how we develop empir- ical support for our work. The convention also provides opportunities for profes- sional networking. The ABCT Convention consists of General Sessions, Targeted and Special Programming, and Ticketed Events. ABCT uses the Cadmium Scorecard system for the submission of general ses- sion events. The step-by-step instructions are easily accessed from the Abstract Submission Portal, and the ABCT home page. Attendees are limited to speaking (e.g., presenter, panelist, discussant) during no more than FOUR events. As you pre- pare your submission, please keep in mind: • Presentation type: Please see the two right-hand columns on this page for descriptions of the various presentation types. • Number of presenters/papers: For Symposia please have a minimum of four presenters, including one or two chairs, only one discussant, and 3 to 5 papers. The chair may present a paper, but the discussant may not. For Panel Discussions and Clinical Round tables, please have one moderator and between three to five panelists. • Title: Be succinct. • Authors/Presenters: Be sure to indicate the appropriate order. Please ask all authors whether they prefer their middle initial used or not. Please ask all authors their degree, ABCT category (if they are ABCT members), and their email address. (Possibilities for “ABCT category” are current member; lapsed member or nonmember; postbaccalaureate; student member; student nonmember; new professional; emeritus.) • Institutions: The system requires that you enter institutions before entering authors. This allows you to enter an affiliation one time for multiple authors. DO NOT LIST DEPARTMENTS. In the following step you will be asked to attach affilia- Thinking about submitting an tions with appropriate authors. abstract for the ABCT 52nd • Key Words: Please read carefully through the pull-down menu of already Annual Convention in DC? The defined keywords and use one of the already existing keywords, if appropriate. submission portal will be opened from For example, the keyword “military” is already on the list and should be used February 14–March 14. Look for more rather than adding the word “Army.” Do not list behavior therapy, cognitive thera- information in the coming weeks to assist py, or cognitive behavior therapy. you with submitting abstracts for the ABCT • Objectives: For Symposia, Panel Discussions, and Clinical Round Tables, write 51st Annual Convention. The deadline for three statements of no more than 125 characters each, describing the objectives submissions will be 11:59 P.M. (EST), of the event. Sample statements are: “Described a variety of dissemination Wednesday, March 14, 2018. We look for- strategies pertaining to the treatment of insomnia”; “Presented data on novel ward to seeing you in Washington, DC! direction in the dissemination of mindfulness-based clinical interventions.” Overall: Ask a colleague to proof your abstract for inconsistencies or typos.

60 the Behavior Therapist Understanding the ABCT Convention

General Sessions Poster Sessions school, career development, information One-on-one discussions between on grant applications, and a meeting of There are between 150 and 200 general researchers, who display graphic repre- the Directors of Clinical Training. sessions each year competing for your sentations of the results of their studies, attention. An individual must LIMIT TO and interested attendees. Because of the Special Interest Group (SIG) Meetings 6 the number of general session submis- variety of interests and research areas of More than 39 SIGs meet each year to sions in which he or she is a SPEAKER the ABCT attendees, between 1,200 and accomplish business (such as electing offi- (including symposia, panel discussions, 1,400 posters are presented each year. cers), renew relationships, and often offer clinical roundtables, and research spot- presentations. SIG talks are not peer- lights). The term SPEAKER includes roles reviewed by the Association. of chair, moderator, presenter, panelist, Targeted and Special and discussant. Acceptances for any given Programing Ticketed Events speaker will be limited to 4. All general Targeted and special programing events Ticketed events offer educational oppor- sessions are included with the registration are also included with the registration fee. fee. These events are all submitted tunities to enhance knowledge and skills. These events are designed to address a These events are targeted for attendees through the ABCT submission system. range of scientific, clinical, and profes- The deadline for these submissions is with a particular level of expertise (e.g., sional development topics. They also pro- basic, moderate, and/or advanced). 11:59 PM, Wednesday, March 15, 2017. vide unique opportunities for networking. General session types include: Ticketed sessions require an additional Invited Addresses/Panels payment. Symposia Speakers well-established in their field, or Clinical Intervention Training In response to convention feedback who hold positions of particular impor- One- and two-day events emphasizing the requesting that symposia include more tance, share their unique insights and “how-to” of clinical interventions. The presentations by established research- knowledge. extended length allows for exceptional ers/faculty along with their graduate Mini Workshops interaction. students, preference will be given to Designed to address direct clinical care or symposia submissions that include non- Institutes training at a broad introductory level and student researchers and faculty mem- Leaders and topics for Institutes are are 90 minutes long. bers as first-author presenters. selected from previous ABCT workshop Symposia are presentations of data, Clinical Grand Rounds presentations. Institutes are offered as a 5- usually investigating the efficacy or effec- Clinical experts engage in simulated live or 7-hour session on Thursday, and are tiveness of treatment protocols. Symposia demonstrations of therapy with clients, generally limited to 40 attendees. are either 60 or 90 minutes in length. who are generally portrayed by graduate Workshops They have one or two chairs, one discus- students studying with the presenter. sant, and between three and five papers. Covering concerns of the practitioner/ No more than 6 presenters are allowed. Research and Professional Development educator/researcher, these remain an Provides opportunities for attendees to anchor of the Convention. Workshops are Panel Discussions learn from experts about the development offered on Friday and Saturday, are 3 and Clinical Round Tables of a range of research and professional hours long, and are generally limited to 60 Discussions (or debates) by informed skills, such as grant writing, reviewing attendees. individuals on a current important topic. manuscripts, and professional practice. These are organized by a moderator and Master Clinician Seminars include between three and six panelists Membership Panel Discussion The most skilled clinicians explain their with a range of experiences and attitudes. Organized by representatives of the methods and show videos of sessions. No more than 6 presenters are allowed. Membership Committees, these events These 2-hour sessions are offered generally emphasize training or career throughout the Convention and are gen- Spotlight Research Presentations development. erally limited to 40 to 45 attendees. This format provides a forum to debut new findings considered to be ground- Special Sessions Advanced Methodology and Statistics breaking or innovative for the field. A These events are designed to provide use- Seminars limited number of extended-format ses- ful information regarding professional Designed to enhance researchers’ abilities, sions consisting of a 45-minute research rather than scientific issues. For more they are 4 hours long and limited to 40 presentation and a 15-minute question- than 20 years, the Internship and attendees. and-answer period allows for more in- Postdoctoral Overviews have helped depth presentation than is permitted by attendees find their educational path. Continuing Education symposia or other formats. Other special sessions often include See pp. 64-65 for a complete description. expert panels on getting into graduate

January • 2018 61 ticketed 52nd Annual Convention sessions #!"" November 15–18, 2018 | Washington, DC for Ticketed Sessions

Workshops & Mini Workshops Workshops cover concerns of the practitioner/ educator/researcher. Workshops are 3 hours long, are generally limited to 60 attendees, and are scheduled for Friday and Saturday. Please limit to no more than 4 presenters. Mini Workshops address direct clinical care or training at a broad introductory level. They are 90 minutes long and are scheduled throughout the convention. Please limit to no more than 4 presenters. When submitting for Workshops or Mini Workshop, please indicate whether you would like to be considered for the other format as well. | For more information or to answer any questions before you submit your abstract, contact Lauren Weinstock, Workshop Committee Chair: [email protected]

Institutes Institutes, designed for clinical practitioners, are 5 hours or 7 hours long, are generally limited to 40 attendees, and are scheduled for Thursday. Please limit to no more than 4 presenters. | For more information or to answer any questions before you submit your Submissions will now abstract, contact Christina Boisseau, Institute Committee Chair: be accepted through [email protected] the online submission portal, which will be Master Clinician Seminars open until February 1. Master Clinician Seminars are opportunities to hear the most skilled clinicians explain their methods and show taped demonstrations of client sessions. They are 2 hours long, Submit a 250-word are limited to 40 attendees, and are scheduled Friday through Sunday. Please limit to abstract and a CV for no more than 2 presenters. | For more information or to answer any questions before you each presenter. For submit your abstract, contact Courtney Benjamin Wolk, Master Clinician Seminar submission require- Committee Chair: [email protected] ments and information Research and Professional Development on the CE session selec- Presentations focus on "how to" develop one's own career and/or conduct research, tion process, please visit rather than on broad-based research issues (e.g., a methodological or design issue, www.abct.org and click grantsmanship, manuscript review) and/or professional development topics (e.g., evi- on “Convention and dence-based supervision approaches, establishing a private practice, academic produc- Continuing Education.” tivity, publishing for the general public). Submissions will be of specific preferred length (60, 90, or 120 minutes) and format (panel discussion or more hands-on participation by the audience). Though this track is not new for 2018, this is the first time that RPD abstracts are due at the earlier deadline, along with ticketed events/mini workshops, and will also be submitted through the same portal. Please limit to no more than 4 pre- senters, and be sure to indicate preferred presentation length and format. | For more information or to answer any questions before you submit your abstract, contact Cole Hooley, Research & Professional Development Chair: [email protected]

Submission deadline: February 1, 2018

62 the Behavior Therapist 52nd Annual Convention general November 15–18, 2018 • Washington, DC sessions

Call for Papers Theme: COGNITIVE BEHAVIORAL Program Chair: Kiara R. Timpano, Ph.D. SCIENCE, TREATMENT, ABCT has always celebrated advances in clinical science. We now find our- selves at the cusp of a new era, marked by technological advances in a range of and different disciplines that have the potential to dramatically affect the clinical TECHNOLOGY science we conduct and the treatments we deliver. These innovations are already influencing our investigations of etiological hypotheses, and are simi- larly opening new frontiers in the ways that assessments and treatments are developed, patients access help, clinicians monitor response, and the broader field disseminates evidence-based practices. Building on the strong, theoretical and practical foundations of CBT, we have the exciting opportunity to use our multidisciplinary values to identify new and emerging technologies that could catapult our research on mental health problems and well-being to the next level. Portal opens February 14, 2018 The theme of ABCT's 52nd Annual Convention, "Cognitive Behavioral Science, Treatment, and Technology," is intended to showcase research, clinical practice, and training that: Deadline • Uses cutting-edge technology and new tools to increase our under standing for submissions: of mental health problems and underlying mechanisms; March 14, 2018 • Investigates how a wide range of technologies can help us improve evidence- based practices in assessment and the provision of more powerful interven- tions; and • Considers the role technology can have in training a new generation of See p. 60 evidence-based treatment providers at home and across the globe. for information about preparing The convention will highlight how advances in clinical science can be strength- your abstract ened and propelled forward through the integration of multidisciplinary technologies.

Submissions may be in the form of symposia, clinical round tables, panel discussions, and posters. Information about the Convention and how to submit abstracts will be on ABCT's website, www.abct.org , after January 1, 2018.

Submission deadline: February 14, 2018

January • 2018 63 ABCT and Continuing Education

At the ABCT Annual Conventions, there are Ticketed events Advanced Methodology and Statistics Seminars (AMASS) (meaning you have to buy a ticket for one of these beyond the Designed to enhance researchers' abilities, there are generally general registration fee) and General sessions (meaning you get two seminars offered on Thursday or during the course of the in by paying the general registration fee), the vast majority of Convention. They are 4 hours long and limited to 40 atten- which qualify for Continuing Education credit. See the end of dees. Participants in these courses can earn 4 CE credits per this document for the current list of bodies that have approved seminar. ABCT as a CE sponsor. Note that we do not currently offer CMEs. Attendance at each continuing education session in its General Sessions Eligible for CE entirety is required to receive CE credit. No partial credit is There are 200 general sessions each year competing for your awarded; late arrival or early departure will preclude awarding of attention. All general sessions are included with the registration CE credit. For those who have met all requirements according to fee. Most of the sessions are eligible for CE, with the exception of the organizations which have approved ABCT as a CE sponsor, the poster sessions, Membership Panel Discussions, the Special certificates will be mailed early in the new year following the Interest Group Meetings (SIG), and a few other sessions. You are Annual Convention. eligible to earn 1 CE credit per hour of attendance. General sessions attendees must sign in and sign out and Ticketed Events Eligible for CE answer particular questions in the CE booklet regarding each All Ticketed Events offer CE in addition to educational opportu- session attended. The booklets must be handed in to ABCT at nities to enhance knowledge and skills. These events are targeted the end of the Convention. If the booklet is not completed and for attendees with a particular level of expertise (e.g., basic, mod- handed in, CE credit will not be awarded. erate, and/or advanced). Ticketed sessions require an additional payment beyond the general registration fee. For ticketed events General session types that are eligible for CE include: attendees must sign in and sign out and complete and return an Clinical Grand Rounds individual evaluation form to be awarded CE. It remains the Clinical experts engage in simulated live demonstrations of responsibility of the attendee to sign in at the beginning of the therapy with clients, who are generally portrayed by graduate session and out at the end of the session. students studying with the presenter.

Clinical Intervention Trainings (CITs) Invited Panels and Addresses One- and two-day events emphasizing the "how-to" of clini- Speakers well-established in their field, or who hold positions cal interventions. The extended length allows for exceptional of particular importance, share their unique insights and interaction. Participants attending a full day session can earn knowledge on a broad topic of interest. 7 continuing education credits, and 14 CE credits for the two- day session. Mini-Workshops These 90-minute sessions directly address evidence-based Institutes clinical skills and applications. They are offered at an intro- Leaders and topics for Institutes are selected from previous ductory level and clinical care or training issues. ABCT workshop presentations. Institutes are offered as a 5- or 7-hour session on Thursday, and are generally limited to Panel Discussions and Clinical Round Tables 40 attendees. Participants in the full-day Institute can earn 7 Discussions (or debates) by informed individuals on a current continuing education credits, and in the half-day Institutes important topic. These are organized by one moderator and can earn 5 CE credits. include between three and five panelists with a range of expe- rience and attitudes. The total number of speakers may not Workshops exceed 6. Covering concerns of the practitioner/educator/researcher, these remain an anchor of the Convention. Workshops are Spotlight Research Presentations offered on Friday and Saturday, are 3 hours long, and are gen- This format provides a forum to debut new findings consid- erally limited to 60 attendees. Participants in these ered to be groundbreaking or innovative for the field. A lim- Workshops can earn 3 CE credits per workshop. ited number of extended-format sessions consisting of a 45- minute research presentation and a 15-minute question-and- Master Clinician Seminars (MCS) answer period allows for more in-depth presentation than is The most skilled clinicians explain their methods and show permitted by symposia or other formats. videos of sessions. These 2-hour sessions are offered through- out the Convention and are generally limited to 40 to 45 Symposia attendees. Participants in these seminars can earn 2 CE cred- Presentations of data, usually investigating the efficacy or its per seminar. effectiveness of treatment protocols. Symposia are either 60 or 90 minutes in length. They have one or two chairs, one dis- cussant, and between three and five papers. The total number

64 the Behavior Therapist General Sessions NOT Eligible for CE Social Work Membership Panel Discussion ABCT program is approved by the National Association of Organized by representatives of the Membership Social Workers (Approval # 886427222-7448) for 34 contin- Committees, these events generally emphasize training or uing education contact hours. career development. Continuing Education (CE) Grievance Procedure Poster Sessions ABCT is fully committed to conducting all activities in strict One-on-one discussions between researchers, who display conformance with the American Psychological Association’s graphic representations of the results of their studies, and Ethical Principles of Psychologists. ABCT will comply with all interested attendees. Because of the variety of interests and legal and ethical responsibilities to be non-discriminatory in research areas of the ABCT attendees, between 1,400 and promotional activities, program content and in the treatment of 1,600 posters are presented each year. program participants. The monitoring and assessment of com- pliance with these standards will be the responsibility of the Special Interest Group (SIG) Meetings Coordinator of Convention and Continuing Education Issues in More than 39 SIGs meet each year to accomplish business conjunction with the Director of Education and Meeting (such as electing officers), renew relationships, and often Services. offer presentations. SIG talks are not peer-reviewed by the Although ABCT goes to great lengths to assure fair treatment Association. for all participants and attempts to anticipate problems, there will Special Sessions be occasional issues which come to the attention of the conven- These events are designed to provide useful information tion staff which require intervention and/or action on the part of regarding professional rather than scientific issues. For more the convention staff or an officer of ABCT. This procedural than 20 years the Internship and Postdoctoral Overviews description serves as a guideline for handling such grievances. have helped attendees find their educational path. Other spe- All grievances must be filed in writing to ensure a clear expla- cial sessions often include expert panels on getting into grad- nation of the problem. If the grievance concerns satisfaction with uate school, career development, information on grant appli- a CE session the Director of Outreach and Partnerships shall cations, and a meeting of the Directors of Clinical Training. determine whether a full or partial refund (either in money or These sessions are not eligible for CE credit. credit for a future CE event) is warranted. If the complainant is not satisfied, their materials will be forwarded to the Other Sessions Coordinator of Convention and Continuing Education Issues Other sessions not eligible for CE are noted as such on the for a final decision. itinerary planner and in the program book. If the grievance concerns a speaker and particular materials presented, the Director of Outreach and Partnerships shall bring How Do I Get CE at the ABCT Convention? the issue to the Coordinator of Convention and Continuing The CE fee must be paid (see registration form) for a personal- Education Issues who may consult with the members of the con- ized CE credit letter to be distributed. Those who have included tinuing education issues committees. The Coordinator will for- CE in their preregistration will be given a booklet when they pick mulate a response to the complaint and recommend action if up their badge and registration materials at the ABCT necessary, which will be conveyed directly to the complainant. Registration Desk. Others can still purchase a booklet at the reg- For example, a grievance concerning a speaker may be conveyed istration area during the convention. The current fee is $99.00. to that speaker and also to those planning future educational We do not charge a fee that is hidden within general registration. programs. Records of all grievances, the process of resolving the griev- Which Organizations Have Approved ABCT as a CE ance and the outcome will be kept in the files of the Director of Sponsor? Education and Meeting Services. A copy of this Grievance Procedure will be available upon request. Psychology If you have a complaint, please contact the ABCT central ABCT is approved by the American Psychological office at (212) 646-1890 for assistance, or email Association to sponsor continuing education for psycholo- [email protected]. gists. ABCT maintains responsibility for this program and its content. Attendance at each continuing education session in its entirety is required to receive CE credit. No partial credit is awarded; late arrival or early departure will preclude awarding of CE credit. For ticketed events attendees must sign in and sign out and complete and return an individual evaluation form. For general sessions attendees must sign in and sign out and answer particular questions in the CE booklet regarding each session attended. The booklets must be handed in to ABCT at the end of the Convention. It remains the responsibility of the attendee to sign in at the beginning of the session and out at the end of the session.

January • 2018 65 Find a CBT Therapist CBT Medical Educator Directory

Another indispensable resource facility (e.g. medical school, nursing from ABCT—an online directory of school, residency program) and not CBT educators who have agreed to occur exclusively in private consul- be listed as potential resources to tations or paid supervision. findCBT.org others involved in training physi- cians and allied health providers. In Please note that this list is offered as particular, the educators on this list a service to all who teach CBT to the have been involved in providing medical community and is not education in CBT and/or the theo- exhaustive. ries underlying such interventions ABCT’s Find a CBT Therapist to medical and other allied health To Submit Your Name directory is a compilation of prac‐ trainees at various levels. The listing for Inclusion in the Medical is meant to connect teachers across Educator Directory titioners schooled in cognitive and institutions and allow for the shar- If you meet the above inclusion cri- behavioral techniques. In addition ing of resources. teria and wish to be included on this to standard search capabilities list, please send the contact infor- mation that you would like includ- (name, location, and area of exper‐ Inclusion Criteria ed, along with a few sentences tise), ABCT’s Find a CBT Therapist 1. Must teach or have recently describing your experience with offers a range of advanced search taught CBT and/or CB interventions training physicians and/or allied in a medical setting. This may health providers in CBT to Barbara capabilities, enabling the user to include psychiatric residents, med- Kamholz at barbara.kamholz2 take a Symptom Checklist, review ical students, nursing, pharmacy, @va.gov and include “Medical specialties, link to self‐help books, dentistry, or other allied health pro- Educator Directory” in the subject fessionals, such as PT, OT, or RD. line. and search for therapists based on Teachers who exclusively train psy- insurance accepted. chology graduate students, social Disclaimer We urge you to sign up for the workers, or master’s level thera- Time and availability to participate pists do not qualify and are not list- in such efforts may vary widely Expanded Find a CBT Therapist ed in this directory. among the educators listed. It is up (an extra $50 per year). With this to the individuals seeking guidance 2. “Teaching” may include direct addition, potential clients will see to pick who they wish to contact and training or supervision, curriculum to evaluate the quality of the what insurance you accept, your development, competency evalua- advice/guidance they receive. ABCT practice philosophy, your website, tion, and/or curriculum administra- has not evaluated the quality of tion. Many professionals on the list and other practice particulars. potential teaching materials and have had a central role in designing inclusion on this list does not imply To sign up for the Expanded Find and delivering the educational endorsement by ABCT of any partic- a CBT Therapist, click MEMBER interventions, but all educational ular training program or profes- aspects are important. LOGIN on the upper left‐hand of the sional. The individuals in this listing serve strictly in a volunteer capaci- home page and proceed to the 3. Training should take place or be affiliated with an academic training ty. ABCT online store, where you will click on “Find CBT Therapist.” For further questions, call the ABCT’s http://www.abct.org ABCT central office at 212‐647‐ Medical Resources for Professionals ! 1890. Educator Te aching Resources } ! CBT Medical Educator Directory Directory !

66 the Behavior Therapist ABCT’S TRAINING VIDEOS

complex cases `äáåáÅ~ä Deepen master clinicians dê~åÇ } live sessions oçìåÇë

! Steven C. Hayes, Acceptance and Commitment Therapy ! Ray DiGiuseppe, Redirecting Anger To ward Self-Change ! Art Freeman, Personality Disorder ! Howard Kassinove & Raymond Ta frate, Preparation, Change, and Forgiveness Strategies for Tr eating Angry Clients ! Jonathan Grayson, Using Scripts to Enhance Exposure in OCD ! Mark G. Williams, Mindfulness-Based Cognitive Therapy and the Prevention

of Depression your ! Donald Baucom, Cognitive Behavioral Couples Therapy and the Role of the Individual ! Patricia Resick, Cognitive Processing Therapy for PTSD and Associated Depression ! Edna B. Foa, Imaginal Exposure ! Frank Dattilio, Cognitive Behavior Therapy With a Couple ! Christopher Fairburn, Cognitive Behavior Therapy for Eating Disorders ! Lars-Goran Öst, One-Session Tr eatment of a Patient With Specific Phobias

! E. Thomas Dowd, Cognitive Hypnotherapy in Anxiety Management understandi ng ! Judith Beck, Cognitive Therapy for Depression and Suicidal Ideation

3-SESSION SERIES ! DOING PSYCHOTHERAPY: Different Approaches to Comorbid Systems of Anxiety and Depression (Available as individual DVDs or the complete set) ! Session 1 Using Cognitive Behavioral Case Formulation in Tr eating a Client With Anxiety and Depression (Jacqueline B. Persons) ! Session 2 Using an Integrated Psychotherapy Approach When Tr eating a Client With Anxiety and Depression (Marvin Goldfried) ! Session 3 Comparing Tr eatment Approaches (moderated by Joanne Davila and panelists Bonnie Conklin, Marvin Goldfried, Robert Kohlenberg, and Jacqueline Persons)

TO ORDER OR, ORDER ONLINE AT www.abct.org | click on ABCT STORE

Individual DVDs— $55 each • “Doing Psychotherapy”: Individual sessions — $55 / set of three—$200

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U.S./Canada/Mexico 1–3 videos: $5.00 per video Name on Card 4 or more videos: $20.00 Card Number CVV Expiration Other countries 1 video: $10.00 2 or more videos: $20.00 Signature

January • 2018 67 the Behavior Therapist PRSRT STD Association for Behavioral U.S. POSTAGE and Cognitive Therapies PAID 305 Seventh Avenue, 16th floor New York, NY 10001-6008 Hanover, PA 212-647-1890 | www.abct.org Permit No. 4

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