Is Quackery Okay?

A glaring omission in psychology ethics

Posted Sep 04, 2014

Behaving ethically is one aspect of being a competent professional, both as a sign of character but also as a sign of social intelligence (practitioners who behave unethically run the risk of losing their licenses and, thus, their livelihoods). I was recently doing research for an article that will touch on the ethics of professionals using questionable methods, and so I checked online the American Psychological Association’s “2002 Ethical Principles of Psychologists and Code of Conduct, Including 2010 Amendments,” to see what it has to say on the topic. The answer, which surprised me (my practice is entirely consultative, so I had not read the document for a while), was “almost nothing.” The reason I inserted the qualifier “almost” is because there are at least two statements about the importance of using valid methods when engaged in psychological testing, but I did not find a single such statement when it comes to doing psychotherapy.

Following are two statements I found regarding the need to use valid testing methods; they are located in section 9.02 “Use of Assessments”: “(a) psychologists administer, adapt, score, interpret or use assessment techniques, interviews, tests or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques” and (b) “psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. …”

Here is what I found on the need to avoid non-valid methods in the section (number 10), which addresses the ethics of psychologists when conducting psychotherapy: bupkis (a Yiddish word which literally means “beans” but idiomatically means “nothing”). There are statements about offering termination counseling (which all too often consists of trying to talk the client out of leaving), avoidance of conflicts of interest, obtaining informed consent, dealing with a therapist who is sharing one’s client, engaging in sexual intimacies (“don’t”), and so on. About the form of therapy used, there is not a word. (There have undoubtedly been therapists in the past who tried to convince clients that sex with themselves would be therapeutic, but they can no longer make that argument, not because it is an invalid form of therapy but because it involves sex).

To see if the absence of any mention of this issue was restricted to the psychology profession, I checked the ethics codes of three other professions whose members routinely practice psychotherapy: psychiatry, counseling, and social work. All three have professional organizations, and these have published ethics codes that, like the psychology code, are accessible online.

In examining the 2010 edition of the “American Psychiatric Association’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry,” I also found no statement about the requirement to use validated methods, other than a vague admonition to keep up with the scientific literature and seek additional training when needed. The ethical standards are very similar to the ones in place for psychologists, except that there is more mention of money: charging for a missed appointment is okay, while fee-splitting is not okay. I found only one mention of a specific intervention modality, and that was acupuncture: it is okay for a psychiatrist (who by definition is also a physician) to perform acupuncture, but only if he or she is qualified to do so.

The 2014 Code of Ethics of the American Counseling Association is the most detailed with regard to psychotherapy, as one might expect of a profession where therapy is pretty much their only activity, unlike psychology, social work and even psychiatry (where pill-prescribing is now job one). The level of detail is impressive, even down to the level of whether it is okay for a therapist to attend a client’s wedding (answer: okay if it benefits the client). Evidence of any statement regarding the need to use only validated therapy modalities ? None that I could find. Interestingly, although counselors do not do assessments at anything like the frequency of psychologists, the ACA has statements about the need to only use validated testing methods that was similar to ones found in the APA code. The closest I found in the ACA code (and other professional codes) is an admonition to not do anything harmful to a client, without specifying what that might be. (Presumably, therapists who engage in wacky therapy practices do not consider them harmful or they would not use them).

The National Association of Social Workers Code of Ethics was published in 1996, and has apparently not been revised since. The Code has a large number of headings, covering the many different roles which are played by social workers: administrators, researchers, social change agents, group workers, etc. Interestingly, even though individual psychotherapy is a major (maybe the most common) role played by social workers today, there is not even a section heading dealing with psychotherapy, let alone any statement requiring social workers to eschew questionable forms of psychotherapy.

Even though I did not expect anything to come out of it, I checked the ethical codes of two other professions—Nursing and Occupational Therapy—whose members sometimes engage in roles that come close to being considered psychotherapy. My interest in nursing stems from knowing that at one time some professors at the University of Colorado School of Nursing extolled the benefits of “no-touch massage” (basically, laying on of hands) until the State of Colorado legislature, which funds the school, put a stop to that highly questionable practice.

My interest in OT stems from my background in the Intellectual Disability field, and knowing that at one time (I am not sure if it is still the case), OT practitioners prescribed (and were paid well to provide) something called Snoezelen. It is a therapy modality developed in the Netherlands and is aimed at people with very severe cognitive impairments, who are laid on mats in a darkened room equipped with a variety of lava lamps (psychedelic-like lighted displays of moving bubbles that were big in the 70s drug culture) and moved around periodically to different stations, allegedly according to preference (although the people I saw it applied to were incapable of expressing preference).

Anyway, the results of my checking the Ethics codes for nurses and OTs regarding an obligation to use only validated therapy methods? Again, bupkis. However, the American Nursing Association, to its credit, does have a section requiring members to report “questionable practices” but does not provide any guidance regarding what those might be (such as absence of supporting efficacy research).The American Occupational Therapy Association, again to its credit, does have a statement about the need to promote OT based on “current knowledge and research”, although they do not bring that down to the specific level of the therapies used. (Interestingly, the AOTA does have a statement about the need to use only validated assessment methods, even if they do not have a specific statement about the need to use only validated therapeutic methods ).

My interest in wacky therapeutic practice goes beyond my interest in ethics but mainly reflects my interest in gullibility (my 2009 book “Annals of Gullibility” was the first, and is still the only to my knowledge, comprehensive book on the topic of being duped). Although in that book I mainly addressed those who were gullible (and unfortunate) enough to become clients of professionals promoting wacky cures, I have also written, in a book edited by Jacobson and others on “fad” therapies, particularly with clients who have autism (a disorder that is a magnet for therapeutic fads). I proposed several contributing explanations for the gullibility of professionals. One of the factors was the poor level of training in some professions about ethics, about research methods and about specific disorders. For example, Special Educators (who, until recently, took no advanced courses on autism) were particularly enamored of something called Facilitated Communication, where non-verbal and non-literate clients were allegedly communicating complex abstract thoughts while their hands were being held over a keyboard by facilitators who claimed they were just providing control over the clients’ motor apraxia (an explanation totally lacking in scientific support). When that explanation was attacked, some proponents even went so far to invoke ESP as an explanation.

Although I have never read any explanation for why the American Psychological Association and other professional groups have avoided formulating any statements about the need to use only validated therapies, it is not difficult to guess why that is the case. If such a statement were in place, and was actually implemented, at least half, and probably two-thirds, of all psychotherapists would be brought up on ethics charges and in danger of being driven out of business.

Furthermore, there would be open warfare among proponents of different forms of psychotherapy, with the result being chaos. For the fact is that there is no consensus regarding what is a valid form of psychotherapy, and few forms of therapy have been validated scientifically. As one example, consider psychoanalysis, at one time the gold standard for psychotherapy, and something still practiced by many psychologists and psychiatrists, even though its popularity has waned considerably in recent years. Where is the body of research showing that psychoanalysis actually helps people, or that its basic constructs and explanations are true? If there is such a body of research, I would be interested in seeing it. If that is true of a form of psychotherapy that still is considered somewhat mainstream, how much less likely is it to find such supporting research for the dozens of fad therapies that crop up on a regular basis? Most likely, the reason why the two APA’s (and the other professional groups) have not gone after fad therapies is because it would expose practitioners of the more established therapies to the same charge of being non-scientific. To be a little cynical, another likely explanation is that the majority of members have too much of a financial stake in the status quo to allow such a provision to be put into effect.

I want to end by saying a little about what it means to be a true profession (an ethics code is essentially an obligation statement that reflects not only general principles of ethics, but the nature and essence of a particular profession). I will also say why I believe that the practice of psychotherapy has not yet (and likely never will) attain that status.

There are multiple qualities that go into designating a particular occupation or mode of work as a profession, and there are some occupations that are in a transitional state (elementary school teaching is an example) which do not yet exhibit all of these qualities and, thus, can be designated what Etzioni termed “semi-professions.” Among the qualities that define a profession are: specialized and lengthy training, independent and autonomous practice, licensure dependent on passing of difficult tests, colleague control, high standards of excellence, ethics codes with active enforcement mechanisms and which everyone is expected to know, and most importantly a core body of knowledge with a clear definition of what is considered competent application of that core body of knowledge.

While psychologists meet many if not most of those requirements (although state licensure testing is difficult only if one has not read a text for a beginning psychology course), I would argue that there is no core body of scientific knowledge that applies across the board, except in narrow and highly specialized areas. Psychological assessment is clearly one of those areas, which is why psychological testing is one of the few content areas in the APA’s ethics code that requires psychologists to only use scientifically valid methods.

To get some perspective on what a true profession does with regard to requiring use only of scientifically validated methods, take a look at the 2007-updated Code of Ethics for the National Society of Professional Engineers. The document contains at least half a dozen statements along the lines of “engineers shall not complete, sign, or seal plans and/or specifications that are not in conformity with applicable engineering standards…”

When psychologists engage in psychotherapy, there are essentially no professional limits on what they can do, except for general ethical statements about such things as remuneration, maintaining proper boundaries, conflicts of interest and the like. When it comes to specific professional activities, the code or psychologists and professions rarely go beyond very general statements such as “do not inflict harm.” With regard to Beneficence (the ethical principle to “do good”), one of the ethics codes reviewed even mistakenly described it as “be kind,” which is a nice way to behave, but not exactly the same thing as the intended “be effective.” While individual therapy modalities (such as behavior therapists) often have their own quality assurance mechanisms, the basic principle guiding the semi-profession of psychotherapy seems to be caveat emptor, which translates as “let the buyer beware.”

          Copyright Stephen Greenspan