11

SKILLS AND PILLS

Myths about Psychological Treatment

Myth #47 Expert Judgment and Intuition Are the Best Means of Making Clinical Decisions

The title of an opinion piece in the satirical newspaper, The Onion (Kuhtz, 2004), read: “I want to fly a helicopter, not look at a bunch of crazy dials.” The author described the challenges he confronted: “Things are spinning around and coming at you,” such as “the telephone poles that keep popping up right in front of you.” He longed to rely on his judgment and intuition rather than be forced to learn to use the mechanical aids he brushed off as “a bunch of dials, buttons, lights, and levers.”

Flying a helicopter is hardly the only situation in which experts must process a complex array of confusing information. Psychotherapists and other mental professionals need to make equally difficult judgments and decisions virtually every day. Does this client suffer from a major depression? Should I treat this client myself or refer her to another therapist? Is this client suicidal? Would this client benefit from medication along with psychotherapy?

Whether it’s diagnosing mental disorders or coming up with treatment plans, mental health professionals must consider an enormous amount of information. This information can include data gathered through interviews and questionnaires, some of it obtained from parents, spouses, teachers, employers, and a host of other sources. The task of putting all of this information together to reach a decision can be tricky. How trustworthy is each piece of information? How much weight should we give it? What should we do when the information isn’t consistent?

In his blockbuster bestselling book Blink: The Power of Thinking Without Thinking, journalist Malcolm Gladwell (2005) argued that experts reach decisions by focusing on the most relevant information and making accurate snap judgments. They can recognize crucial details without being distracted by anything else, and combine this information using skilled intuition honed by years of training and experience. This model of expertise is what most people expect of mental health professionals. But is there a different way of making clinical decisions?

Over a half century ago, the brilliant clinical psychologist Paul Meehl (1954) provided an insightful analysis of clinical decision-making, outlining two approaches to this task. He referred to the traditional approach, which relies on judgment and intuition, as the clinical method. Meehl contrasted this approach with the mechanical method. When using the mechanical method, a formal algorithm (set of decision rules) such as a statistical equation or “actuarial table” is constructed to help make decisions in new cases. Insurance companies have used actuarial tables for decades to evaluate risk and set premiums. For example, they can use knowledge of someone’s age, sex, health-related behaviors, medical history, and the like to predict how many more years he or she will live. Although actuarial predictions of mortality aren’t perfectly accurate for everyone, they provide a decent basis for setting life insurance premiums. Meehl proposed that a mechanical approach would prove just as useful in clinical decision-making. Was he right?

Meehl (1954) reviewed the 20 studies available at the time to compare the accuracy of clinical and mechanical predictions when researchers supplied both the practitioner and the formula with the same information. To the shock of many readers, he found that mechanical predictions were at least as accurate as clinical predictions, sometimes more. Other reviewers have since updated this literature (Dawes, Faust, & Meehl, 1989; Grove et al., 2000), which now includes more than 130 studies that meet stringent criteria for a fair comparison between the two prediction methods. They’ve found that Meehl’s central conclusion remains unchanged and unchallenged: Mechanical predictions are equally or more accurate than clinical predictions. This verdict holds true not only for mental health experts making psychiatric diagnoses, forecasting psychotherapy outcome, or predicting suicide attempts, but also for experts predicting performance in college, graduate school, military training, the workplace, or horse races; detecting lies; predicting criminal behavior; and making medical diagnoses or predicting the length of hospitalization or death. At present, there’s no clear exception to the rule that mechanical methods allow experts to predict at least as accurately as the clinical method, usually more so.

How can this be? Let’s consider the prior knowledge available for reaching decisions in new cases. For the clinical method, this knowledge consists of cases about which the expert has learned or worked with personally. For the mechanical method, this knowledge consists of cases drawn from the research literature, which is often a larger and more representative sample than is available to any clinician. In addition, even experts are subject to a host of biases when observing, interpreting, analyzing, storing, and retrieving events and information (Meehl, 1992). Mental health professionals, like the rest of us mere mortals, tend to give undue weight to their personal experience rather than the experience of other professionals or research findings (Ruscio, 2006). As a consequence, mechanical predictions usually assign more valid weights to new data than do clinical predictions. Meehl (1986) put it bluntly: “Surely we all know that the human brain is poor at weighting and computing. When you check out at a supermarket, you don’t eyeball the heap of purchases and say to the clerk, ‘Well it looks to me as if it’s about $17.00 worth; what do you think?’ The clerk adds it up” (p. 372).

Lewis Goldberg (1991) described several other advantages of mechanical prediction over clinical prediction. Whereas mechanical predictions are perfectly consistent—that is, reliable—clinical predictions aren’t. For a variety of reasons, experts don’t always agree with each other, or even with themselves when they review the same case the second time around. Even as clinicians acquire experience, the shortcomings of human judgment help to explain why the accuracy of their predictions doesn’t improve much, if at all, beyond what they achieved during graduate school (Dawes, 1994; Garb, 1999).

Yet despite Meehl’s verdict, many psychologists remain unconvinced. Still others aren’t adequately informed. The results of a survey of members of the clinical psychology division (Division 12) of the American Psychological Association revealed that 22% believed that mechanical prediction methods were inferior to clinical prediction methods. Another 13% said they’d only heard of mechanical prediction methods but weren’t well acquainted with them. Most remarkably, 3% had never heard of mechanical decision-making methods (Grove & Lloyd, in preparation)!

In addition to insufficient education, there are several reasons why many psychologists are reluctant to embrace mechanical decision-making methods in their clinical practice (Dawes et al., 1989). William Grove and Paul Meehl (1996) reviewed objections raised by opponents of these methods, some of which may help to explain the continued popularity of the myth of expert judgment. One concern is that a preference for mechanical prediction will lead to clinicians being replaced by computers. This fear is unfounded because mental health professionals do far more than process information to make decisions. They play essential roles in developing reliable and valid measures, knowing which data to collect, and providing services once they’ve reached a decision. Clinicians needn’t worry about being put out to pasture, because no statistical equation or actuarial table can ever take their place in these essential tasks.

Some authors have argued that we shouldn’t be comparing clinical and mechanical prediction methods, because practitioners should use both of them in conjunction. Although this argument may seem appealing at first, on closer inspection it just doesn’t hold up. Consider a clinical psychologist who’s provided years of intensive therapy for a violent sex offender and is asked by a parole board to recommend whether to grant or deny his request. If mechanical and clinical predictions agree, fine: It doesn’t matter which method we use. But what if one method suggests that this prisoner poses no future risk, but the other method suggests that the prisoner poses a high future risk? Clearly, the psychologist can’t recommend both granting and denying parole. The logical flaw in the “use both methods” objection is that these methods sometimes conflict. When they do, you can’t use both.

Some object to mechanical prediction because “probability is irrelevant to the unique individual.” In particular, they claim that knowing the outcomes for other people is of no use when making a decision for a new patient, because “every person is different.” For example, research shows that the probability of successfully treating an individual’s phobia is maximized through exposure-based treatment—treatment that exposes people systematically to their fears (Barlow, 2002). Yet some mental health experts engage in a “counterinductive generalization” (Dawes & Gambrill, 2003): They disregard this finding and recommend a different treatment on the grounds that group-level research doesn’t apply to this unique person. There are two variations of this objection, but both are mistaken.

First, the clinician might think there’s something so unusual about a given patient that he or she is an exception to the rule. No doubt this is sometimes true, but studies show that experts routinely identify too many counterexamples (Grove et al., 2000). They focus too heavily on unique aspects of each case and too little on what it shares with others. Their accuracy suffers as a result.

Second, the clinician might believe that any statement of probability is irrelevant to understanding or predicting an individual’s behavior. A simple thought experiment, concocted by Meehl (1973), shows the fatal flaw—literally—in this reasoning. Suppose you’re to play Russian roulette once, meaning you’ll put a revolver to your head and pull the trigger. Would you prefer that there be one bullet and five empty chambers in the revolver, or five bullets and one empty chamber? We doubt seriously you’d respond, “Well, whether I die is only a matter of probabilities, so it doesn’t matter.” Instead, we’d be safe in assuming that, unless you’re suicidal, you’d prefer the gun that will kill you 1 out of 6 times to the gun that will kill you 5 out of 6 times. Clearly, most of us recognize that probability matters when it comes to our own survival.

A final concern involves the allegedly “dehumanizing” nature of mechanical prediction methods, namely, that we shouldn’t “treat people as mere numbers.” This objection is both erroneous and irrelevant. For starters, there’s no logical connection between how we interact with clients and how we combine information to reach clinical decisions. When we make decisions discreetly during or between sessions, a client typically won’t even know what method we used. Even if clients feel we’re treating them as numbers, feeling comfortable with a decision-making procedure is far less important than being diagnosed correctly and receiving the best treatment. As Meehl (1986) noted, “If I try to forecast something important about a college student, or a criminal, or a depressed patient by inefficient rather than efficient means, meanwhile charging this person or the taxpayer 10 times as much money as I would need to achieve greater predictive accuracy, that is not a sound ethical practice. That it feels better, warmer, and cuddlier to me as predictor is a shabby excuse indeed” (p. 374).

There’s ample evidence to support the use of mechanical decision aids, yet mental health professionals rarely use them when they’re readily available. That’s a shame. Just as judgment and intuition alone aren’t enough to hover, swoop, and steer clear of tall buildings when flying a helicopter, clinicians can make better decisions when they rely on more than just their judgment and intuition. And just as helicopter pilots must learn to use an airspeed indicator, an artificial horizon, and a bunch of “crazy dials,” mental health professionals would serve their patients better if they developed and used statistical equations and actuarial tables to process information more effectively.

Myth # 48 Abstinence Is the Only Realistic Treatment Goal for Alcoholics Alcoholics

If your aunt had a serious problem with drinking, would you be concerned if she had just one drink at a party? The idea that people who drink excessively need to abstain from alcohol completely is deeply etched into the popular imagination. The results of one survey revealed that only 29% of the general population believes that former alcoholics who’ve been treated successfully can later drink in moderation (Cunningham, Blomqvist, & Cordingley, 2007). The book Alcoholics Anonymous (1976) similarly presented a stark, yet still widely accepted, description of the possibility of an alcoholic ever drinking safely:

… here is a man who at 55 years found he was just where he left off at 30 (the man having taken his first drink in 25 years). We have seen the truth demonstrated again and again: “once an alcoholic, always an alcoholic.” Commencing to drink after a period of sobriety, we are in short time as bad as ever. If we are planning to stop drinking, there must be no reservation of any kind, nor any lurking notion that someday we will be immune to alcohol. (p. 33)

The Alcoholics Anonymous (AA) view of “one drink, one drunk” is premised on the popular disease model of alcoholism. According to this model, alcoholism is a fatally progressive disease, caused by an “allergy” or other genetic vulnerability to lose control over drinking. From this perspective, even a single sip of liquor is often enough to trigger an uncontrollable binge (Fingarette, 1988). So, the argument continues, lifelong abstinence is the only acceptable treatment goal for alcoholics. This idea traces its roots to 19th century views of alcoholism, when the term was synonymous with “dipsomania,” a disease-like condition of irresistible craving for alcohol (Miller, 1983).

By the early 20th century, the allure and destructive power of alcohol were front and center in the public eye. When movies were in their infancy, they were already capitalizing on the widespread view that alcohol can hijack people’s willpower and shatter their lives. In 1909, D. W. Griffith directed two films, What Drink Did and The Reformation of an Alcoholic, that cautioned viewers about the evils of taking up a life of drinking. Charlie Chaplin’s movie, Charlie’s Drunken Daze (1915), was one of the first films to put a humorous spin on excessive drinking, but its comedic tension was fueled by the potential for tragedy. The decidedly grim movie, The Lost Weekend (1945), directed by Billy Wilder and based on the book with the same title (written by Charles Jackson), provided perhaps the most shocking depiction of the degradations of alcoholism, tracing the torturous path of a chronic alcoholic writer through a 5-day bourbon binge. More recent Academy Award-winning films, including The Days of Wine and Roses (1962) and Leaving Las Vegas (1995), have brought out the darker side of alcoholism by depicting alcohol’s devastating effects on relationships and mental health, even the prospect of suicide.

Until quite recently, the idea that abstinence is the only treatment goal for alcoholics—people with a physical and psychological dependence on alcohol, and life problems stemming from drinking—was embraced not only by the general public, but by the alcohol treatment community, as exemplified by the popular AA program. Since stockbroker Bill Wilson and surgeon Bob Smith (better known as “Bill and Bob”) founded AA in Akron, Ohio in 1935, it’s become the largest organization for treating alcoholics, boasting nearly 2 million members worldwide (Humphreys, 2003). AA’s famous 12-step program encourages members to admit they’re powerless over alcohol. According to AA, to prevail over the all-consuming mental obsession to drink, members must commit to believing that a Higher Power greater than themselves (who’s often, although not necessarily, God) can restore their “sanity” (Step 2), and turn their will and their lives over to the care of their Higher Power as they understand Him (Step 3).

Treatment programs in hospitals, clinics, and the community based on the 12 steps claim recovery rates as high as 85% (Madsen, 1989). Studies show that drinkers who join AA are more likely to get back on the wagon than those who receive no treatment (Kownacki & Shadish, 1999; Timko, Moos, Finney, & Lesar, 2000). Yet as many as two thirds of drinkers drop out within 3 months of joining AA (Emrick, 1987), and AA helps only about 20% of people abstain completely from alcohol (Levy, 2007). Not surprisingly, people who benefit most from AA are most active in the organization and most attracted to its spiritual emphasis. As helpful as AA may be for some people, AA and other programs based on the traditional disease model are far from successful in treating vast numbers of alcoholics.

Indeed, many researchers have challenged the idea that alcoholism is a progressive and incurable disease, along with the notion that abstinence is a necessary treatment goal for all alcoholics. A survey of 43,093 adults conducted by the National Institute of Alcohol Abuse and Alcoholism (NIAAA, 2001–2002) revealed that nearly 36% of respondents who were alcoholics at least a year before the survey were “fully recovered” when questioned. Interestingly, 17.7% of one-time alcoholics could drink in moderation without abusing alcohol, challenging the popular belief that “once an alcoholic, always an alcoholic.”

Dramatic as these findings are, they weren’t the first to suggest that a treatment goal of less than complete abstinence might be feasible. D. L. Davies’ (1962) study showing that 7% of serious alcoholics could control their alcohol use for long as 11 years was one of the first to expose a sizable chink in the armor of the traditional view of alcoholism. Later, the Rand Report (Armor, Polich, & Stambul, 1976) of outcomes at 45 NIAAA treatment centers indicated that after a 4-year follow-up, 18% of patients were drinking moderately with no problems or dependence on alcohol.

Predictably, these studies created a hullabaloo among many researchers and mental health professionals, who suggested that not setting abstinence as a treatment goal was tantamount to medical blasphemy. But the controversy paled in comparison to the avalanche of criticism unleashed by Mark and Linda Sobell’s (1973, 1976) reports of their successes in training hospitalized alcoholics to control their drinking. They found that at 3-year follow-up, patients trained to drink in moderation consumed less alcohol and had fewer adjustment problems than did those treated with the goal of abstinence. The Sobells’ research was based on the behavioral viewpoint that excessive drinking is a learned habit maintained by a variety of social and physical reinforcers. Like other behaviors, alcohol use can be modified and, in some cases, brought under self-control short of total abstinence.

Some academics attacked the Sobells’ findings on ethical, moral, and scientific grounds (Pendry, Maltzman, & West, 1982), with one researcher going so far as to accuse them of cooking up their findings (Maltzman, 1992). So passionate was the controversy that the media jumped into the thick of it. In 1983, an episode of the CBS news magazine 60 Minutes started with reporter Harry Reasoner in a cemetery near the headstone of one of the Sobells’ patients who was taught skills to control drinking, but who had died as result of alcoholism. Reasoner interviewed patients who’d relapsed in the controlled drinking condition, but didn’t interview any patients in the abstinence condition. Nor did 60 Minutes disclose that, over the same period, more patients assigned to the abstinence condition died than did those assigned to the controlled drinking condition (Sobell & Sobell, 1984). The program’s presentation left viewers with the impression that controlled drinking could prove fatal. Along with the allegation of fraud, this program inspired a series of investigations into the Sobells’ scientific conduct, which exonerated them.

Over the years, scientific controversy around controlled drinking ebbed, yet never disappeared. In the meantime, researchers amassed considerable evidence for the effectiveness of behavioral self-control training (BSCT) programs in studies that set moderate drinking as a treatment goal (Miller, Wilbourne, & Hettema, 2003). In BSCT programs (Miller & Hester, 1980), therapists train people who drink excessively to monitor their drinking, set appropriate limits for their alcohol consumption, control the rate of their drinking, and reinforce their progress. Some self-control programs emphasize teaching coping skills in situations in which drinkers had used alcohol as a coping mechanism (Monti, Abrams, Kadden, & Rohsenow, 1989) and preventing relapse by teaching drinkers to tolerate negative emotions (Marlatt & Gordon, 1985). These programs are at least as effective as 12-step programs (Project MATCH Research Group, 1998).

Relapse prevention (RP) programs run counter to the notion of “one drink, one drunk” by planning for the possibility that people may slip up and resume drinking (Larimer, Palmer, & Marlatt, 1999; Marlatt & Gordon, 1985). The credo of these programs is that a “lapse” needn’t become a “relapse.” To prevent relapse, the trick is for patients to avoid situations in which they might be tempted to drink. Moreover, they learn to understand that if they consume a single drink, it doesn’t mean they’re doomed to resume heavy drinking (Marlatt & Gordon, 1985; Polivy & Herman, 2002). RP programs teach people to think of a lapse as an opportunity to learn to cope with urges more effectively rather than thinking, “I’ve blown it so badly, I might as well keep drinking.” A large body of research demonstrates that RP programs reduce the rates of alcohol relapse (Irvin, Bowers, Dunn, & Wang, 1999).

Like gloves and shoes, one size, or in this case one treatment, doesn’t fit all. Fortunately, a wide range of treatment options is available to alcoholics, including medication, psychotherapy, and support groups. But the goal of abstinence versus controlled drinking may need to be tailored to individual patients. If your aunt at the party we described is severely dependent on alcohol, has a long history of alcohol abuse, or has physical and psychological problems from drinking, you have every reason to be concerned. Research suggests she’d probably be better served by a treatment program with the goal of abstinence (Rosenberg, 1993).

Yet even if controlled drinking isn’t for all alcohol abusers, it probably works for some. The Institute of Medicine (1990) and the Ninth Special Report to Congress on Alcohol and Health (United States Department of Health and Human Services, 1977) endorsed moderation as a treatment goal for some people with drinking problems (MacKillop, Lisman, Weinstein, & Rosenbaum, 2003). The availability of therapies with a controlled drinking goal may help problem drinkers seek help earlier than if abstinence were the only alternative. Controlled drinking is worth trying with patients who’ve failed repeatedly to achieve abstinence in programs that emphasize this goal. After all, people who try dieting, exercising, or other new ways of living often need to try several different approaches before they hit on one that works for them. Over the next decade, it’s likely that researchers will develop more specific criteria to select heavy drinkers for diverse treatments with equally diverse treatment goals. In the meantime, one conclusion is clear: Abstinence isn’t the only realistic treatment goal for all alcoholics.

Myth #49 All Effective Psychotherapies Force People to Confront the “Root” Causes of Their Problems in Childhood

When people think of psychotherapy, they usually conjure up a similar image: a client reclined comfortably on a couch, often recalling and processing painful memories of the distant past. Whether it’s Billy Crystal in the film Analyze This, Robin Williams in the film Good Will Hunting, or Lorraine Bracco in the HBO series, The Sopranos, movie and television psychotherapists usually encourage their clients to look backwards, often decades backwards. Indeed, one of the most popular stereotypes of psychotherapy is that it forces patients to resurrect and confront childhood experiences that presumably are causing problems in adulthood. Moreover, numerous Hollywood films feature the tried-and-true formula of the “sudden cure,” usually triggered by an emotionally charged recollection of a painful event from childhood, such as sexual or physical abuse (Wedding & Niemiec, 2003). That’s not surprising, as the sudden cure makes for an emotionally gripping story line.

We can thank—or blame—Sigmund Freud and his followers for most, if not all, of these popular beliefs. One of Freud’s (1915/1957) most enduring legacies is the idea that our ongoing difficulties are rooted in our childhood experiences, especially traumatic ones. According to this view, memories of early events are particularly revealing, and afford a window into current problems and a starting point for resolving them. Leon Saul, Thoburn Snyder, and Edith Sheppard (1956) similarly argued that early memories “reveal probably more clearly than any other single psychological datum, the central core of each person’s psycho-dynamics, his chief motivations” (p. 229). Harry Olson (1979) affirmed a belief shared by many therapists and the general public: “early memories when correctly interpreted often reveal very quickly the basic core of one’s personality …” (p. xvii). A related widely held idea is that insight into the childhood determinants of problems isn’t merely helpful, but necessary, before enduring change can take place in psychotherapy.

Without question, understanding the history of a problem can sometimes help us appreciate the origins of our current maladaptive behaviors. Among other things, such understanding may help therapists to pinpoint problematic behavior patterns that planted their roots in childhood soil. Nevertheless, early memories sometimes yield a distorted picture of past events (Loftus, 1993). Moreover, there’s no compelling evidence that all or even most adult psychological problems stem from childhood difficulties (Paris, 2000) and, as we’ll soon learn, there’s considerable evidence that insight isn’t always needed to achieve enduring personal change.

For these and other reasons, increasing numbers of clinicians hailing from the more than 500 approaches to psychotherapy (Eisner, 2000) place little or no emphasis on rehashing the past or uncovering childhood memories. As psychologist John Norcross noted, “Average consumers who walk into psychotherapy expect to be discussing their childhood and blaming their parents for contemporary problems, but that’s just not true any more” (Spiegel, 2006). Among the many contemporary schools of psychotherapy that focus primarily on present, but not past, issues are such self-help groups as Alcoholics Anonymous, group therapy, family therapy, and the major schools of therapy we’ll consider next.

Psychodynamic therapists, known as “neo-Freudians,” stood on Freud’s intellectual shoulders, yet parted company with him in significant ways. In particular, many neo-Freudians placed less emphasis on unconscious functioning than their mentor did. Carl Jung (1933) and Alfred Adler (1922), both students of Freud, were among the first therapists to express concerns about conscious aspects of patients’ functioning across the entire lifespan, and attempted to help patients understand how emotionally charged experiences, including those in recent life, contribute to current psychological conflicts.

Humanistic-existential therapists, including Carl Rogers (1942), Victor Frankl (1965), and Irvin Yalom (1980), stressed the importance of striving to reach our full potential in the present, rather than relentlessly scouring our memories for negative past experiences. For example, Frederick (“Fritz”) Perls, the founder of Gestalt therapy, similarly insisted that the key to personal growth is encountering and accepting our feelings in the here-and-now (Perls, Hefferline, & Goodman, 1994/1951). Gestalt therapy was the first of many experiential therapies that recognize the importance of current awareness, acceptance, and expression of feelings. For Perls, an excessive focus on the past can be unhealthy, because it often reflects a reluctance to confront our present difficulties head-on.

Behavior therapists focus on specific current behaviors that create patients’ life problems and the variables that maintain these behaviors (Antony & Roemer, 2003). Behavior therapies are based on principles of classical and operant conditioning and observational learning, as well as rigorous research evidence regarding what works. Behavior therapists see the key to success in therapy as acquiring adaptive behaviors and strategies that clients can transfer to the real world. In most cases, they view achieving insight into the original causes of one’s problems as largely unnecessary.

Cognitive-behavioral therapists, including Albert Ellis (Ellis, 1962) and Aaron Beck (Beck, Rush, Shaw, & Emery, 1979), place their money on identifying and changing irrational cognitions (beliefs), such as “I’m worthless.” When people are freed from the tyranny of self-limiting beliefs, these therapists argue, they can more easily engage in new and healthier behaviors. For example, assigning a shy patient homework to strike up a conversation with 10 strangers over the course of a week can provide a powerful challenge to the irrational belief that “If someone rejects me, it will be catastrophic.”

As we mentioned earlier, research demonstrates that achieving insight and delving into childhood experiences aren’t needed to achieve gains in psychotherapy. In one study of psychoanalytic (Freudian) treatment (Bachrach, Galatzer-Levy, Skolnikoff, & Waldron, 1991), half of 42 patients improved but showed no increases in insight into their “core conflicts.” Just as tellingly, the therapist’s emotional support was more closely related to improvement than was insight.

Extensive research demonstrates that understanding our emotional history, however deep and gratifying it may be, isn’t necessary or sufficient for relieving psychological distress (Bloom, 1994; Weisz, Donenberg, Han, & Weiss, 1995). In fact, treatments that place minimal emphasis on recovering or confronting unresolved feelings from childhood are typically equally effective as, or more effective than, past-oriented approaches. It’s true that psychoanalytic and other insight-oriented approaches can help many people, and that relatively brief versions of psychodynamic treatments are more helpful than no treatment (Prochaska & Norcross, 2007). Nevertheless, reviews of controlled outcome studies show that behavioral and cognitive-behavioral treatments are: (a) effective for a wide array of psychological problems, (b) more effective than psychoanalytic and most other treatment approaches for anxiety disorders (Chambless & Ollendick, 2001; Hunsley & Di Giulio, 2002), and (c) more effective than other treatments for children and adolescents with behavior problems, such as lying, stealing, extreme defiance, and physical aggression (Garske & Anderson, 2003; Weisz, Weiss, Han, Granger, & Morton, 1995). Yet these treatments typically focus almost exclusively on the here-and-now.

A current trend in psychotherapy is for therapists to develop methods suited to the needs of clients based on an eclectic mix of techniques borrowed from diverse traditions, including insight-oriented, behavioral, and cognitive-behavioral approaches (Stricker & Gold, 2003). The good news is that a number of therapies, regardless of their focus on the past or present, can benefit many people, regardless of their socioeconomic status, gender, ethnicity, and age (Beutler, Machado, & Neufeldt, 1994; Petry, Tennen, & Affleck, 2000; Rabinowitz & Renert, 1997; Schmidt & Hancey, 1979). To improve, we don’t need to look backward; looking forward will often do the trick.

Myth #50 Electroconvulsive (“Shock”) Therapy Is a Physically Dangerous and Brutal Treatment

If you’ve ever heard of electroconvulsive therapy (ECT), more popularly called “shock therapy,” close your eyes for a moment and try to picture a typical treatment session. What do you see happening during the session? And what do you see right after it?

If you’re like most Americans, you’ll probably imagine an unwilling patient being dragged into a room, strapped to a narrow bed or gurney, receiving a powerful jolt of electric shock to his temples, and then convulsing violently while a team of doctors and nurses attempt to restrain him. When the patient finally “comes to,” he acts dazed and confused, and he may have lost hefty chunks of his memory. As we’ll soon discover, all of these stereotypes are erroneous, at least in the United States and other Western countries.

Indeed, few if any psychological treatments are the subject of as many misunderstandings as ECT (Kradecki & Tarkinow, 1992). To most people, ECT is a brutal, even barbaric, treatment. In many countries, including the United States, Australia, and European nations, substantial proportions of the general public regard ECT as physically dangerous and psychologically harmful (Dowman, Patel, & Rajput, 2005; Kerr, McGrath, O’Kearney, & Price, 1982; Teh, Helmes, & Drake, 2007). In one study of 200 Americans, 59% stated that ECT is painful, 53% that it leads to nausea and vomiting, 42% that it’s used regularly to punish misbehaving patients, and 42% that it destroys large numbers of brain cells. Sixteen percent believed ECT leaves patients in a permanent zombie-like state (Santa Maria, Baumeister, & Gouvier, 1998). Yet all of these beliefs are inaccurate. The results of another study revealed that 57% of 1,737 members of the Swiss population regarded ECT as harmful to patient’s mental health; only 1% regarded it as helpful (Lauber, Nordt, Falcato, & Rössler, 2005). These negative views have had real-world consequences. In 1972, then U.S. Senator Thomas Eagleton withdrew under pressure as presidential candidate George McGovern’s vice-presidential running mate after news surfaced that Eagleton had received ECT and other psychiatric treatments for severe depression. A decade later, the city of Berkeley, California voted to ban ECT and make its administration punishable by a fine, jail time, or both, although a court later overturned the ban.

People who know the least about ECT tend to view it most unfavorably (Janicak, Mask, Trimakas, & Gibbons, 1985), raising the possibility that education about ECT may reduce stereotypes about it. Yet even many people with medical training harbor negative views of ECT (Gazdag, Kocsis-Ficzere, & Tolna, 2005). A study of University of Arkansas second-year medical students revealed that 53% considered ECT painful, 32% unsafe and potentially fatal, and 20% “barbaric.” Thirty-one percent believed that hospital staff often use ECT to punish aggressive or uncooperative patients (Clothier, Freeman, & Snow, 2001). It’s therefore hardly surprising that ECT has long carried a negative stigma in the United States and other countries. With these widespread beliefs in mind, what are the truths about ECT?

It’s indeed the case that early forms of ECT often produced violent convulsions, and occasionally resulted in broken bones, shattered teeth, and even death (Challiner & Griffiths, 2000). But that hasn’t been true for the past five decades in the United States or most other Western countries, where the method of ECT administration has become far safer and more humane. Nor is it the case that physicians today use ECT to subdue difficult-to-manage patients.

Nowadays, patients who receive ECT—who usually suffer from severe depression or more rarely mania or schizophrenia—first receive a general anesthetic (such as methohexitol), a muscle relaxant (such as succinylcholine), and occasionally a substance (such as atropine) to block salivation (Sackeim, 1989). Then, a physician places electrodes on the patient’s head, either on one side (unilateral ECT) or both sides (bilateral ECT), and delivers an electric shock. This shock induces a seizure lasting 45 to 60 seconds, although the anesthetic—which renders the patient unconscious—and muscle relaxant inhibit the patient’s movements during the seizure.

Nevertheless, in some developing countries (Andrade, Shah, & Tharyan, 2003; Weiner, 1984), parts of Russia (Nelson, 2005), and modern-day Iraq (Goode, 2008), physicians sometimes administer ECT without anesthesia or muscle relaxants. In these countries, the poor reputation of ECT may be partly deserved, as ECT administered without these procedural advances is potentially dangerous.

Even today, there’s no scientific consensus on how ECT works. Still, most controlled research suggests that ECT is helpful as a treatment for severe depression (Pagnin, de Queiroz, Pini, & Cassano, 2004), although it’s typically recommended only as a last resort for this condition after other interventions, including psychotherapy and drug treatments, have failed repeatedly. This isn’t to say, though, that ECT carries no risks. The death rate among patients who receive ECT is probably about 2 to 10 per 100,000 treatments, although this risk is no higher than the risk from anesthesia alone (Shiwach, Reid, & Carmody, 2001). Overall, the risk of dying from ECT is about 10 times lower than that of childbirth (Abrams, 1997). ECT is also associated with a heightened risk for unpleasant side effects, like headaches, muscle aches, nausea, and most notably, memory loss, mostly for events that take place immediately before each treatment (Sackeim, 1988). Nevertheless, there’s also evidence that some memory loss persists for 6 months following treatment in at least some patients who receive ECT (Sackeim et al., 2007). ECT certainly isn’t harmless, but it’s far from the psychologically and physically dangerous treatment that many people assume.

Interestingly, one group of individuals seems to hold markedly less negative views of ECT than others: patients who’ve undergone ECT. In fact, most patients who’ve received ECT report that the treatment is less frightening than a trip to the dentist (Abrams, 1997; Pettinati, Tamburello, Ruetsch, & Kaplan, 1994). In one study, 98% of patients who received ECT said they’d undergo it again if their depression recurred (Pettinati et al., 1994); in another, 91% of patients who received ECT said that they viewed it positively (Goodman, Krahn, Smith, Rummans, & Pileggi, 1999). Kitty Dukakis, wife of former U.S. presidential candidate Michael Dukakis, is a case in point. In her co-authored book Shock: The Healing Power of Electroconvulsive Therapy (Dukakis & Tye, 2006), she eloquently recounts her experiences with ECT following severe depressive episodes that failed to respond to other treatments. According to Dukakis,

It is not an exaggeration to say that electroconvulsive therapy has opened a new reality for me … Now I know there is something that will work and work quickly. It takes away the anticipation and the fear … It has given me a sense of control, of hope. (Dukakis & Tye, 2006, p. 120)

What, then, are the sources of the principal misconceptions regarding ECT? Certainly, some of these misconceptions are understandable given ECT’s checkered past, and once relatively brutal method of administration. Moreover, some laypersons are probably troubled by the prospect of passing electricity through a person’s brain, and assume this procedure must be hazardous (Kimball, 2007). In this case, they may be reasoning by representativeness (see Introduction, p. 15), and assuming that because electricity is often dangerous, anything containing electricity must damage the brain.

Nevertheless, much of ECT’s sordid reputation surely stems from its inaccurate coverage in the entertainment media. From 1948 to 2001, at least 22 American films, including two that won Academy Awards as best picture—One Flew over the Cuckoo’s Nest (1975) and Ordinary People (1980)—contained direct references to ECT, most of them strikingly negative (McDonald & Walter, 2001). In addition, the 2001 Academy Award-winning film, A Beautiful Mind, showed mathematician John Nash, portrayed by Russell Crowe, suffering violent convulsions following an ECT-like procedure (insulin coma therapy, an early and now outmoded form of convulsive therapy) that some movie reviewers (for example, Singleton, 2001; Stickland, 2002; http://plus.maths.org/issue19/reviews/book4/index.xhtml) confused with ECT.

In many of the 22 films featuring ECT, hospital staff administered treatment not to deeply depressed patients, but to patients displaying severe antisocial or criminal behavior, especially those who were rebellious or disobedient. Some of the films depicted patients as fully conscious and even reacting in terror to the shock (Walter & McDonald, 2004). The most frequent ECT side effect portrayed in these films was acting like a zombie or losing one’s memory or language. In six films, patients who received ECT became worse or even died. Probably no film transformed the American public’s perception of ECT more than the 1977 movie, One Flew Over the Cuckoo’s Nest. One unforgettable scene portrayed the main character, Randall McMurphy (played brilliantly by Jack Nicholson), receiving a brutal ECT treatment, complete with violent convulsions and grunting, after he led an unsuccessful patient revolt on the psychiatric unit (Figure 11.1).

Figure 11.1 This powerful scene from the 1977 film, One Flew over the Cuckoo’s Nest, featuring actor Jack Nicholson in an Academy Award-winning performance, almost certainly contributed to the public’s negative perception of ECT.

Source: Photofest.

Evidence suggests that viewing films about ECT may alter our perceptions of it. In one study, medical students who viewed clips from One Flew over the Cuckoo’s Nest, Ordinary People, Beverly Hillbillies, and several other films featuring ECT or references to ECT ended up with less favorable attitudes toward this treatment (Walter, McDonald, Rey, & Rosen, 2002). Nevertheless, because the researchers didn’t include a control group of medical students exposed to non-ECT films, the investigation doesn’t allow us to draw definite causal conclusions. On the positive side, there’s evidence that education concerning ECT can reduce myths about it. One team of researchers found that students who either viewed a video or read a pamphlet containing accurate information about ECT exhibited fewer misconceptions regarding ECT, such as beliefs that ECT is painful, causes long-term personality changes, and is used to control aggressive patients, than did a control group of students who received no corrective information (Andrews & Hasking, 2004).

The public’s lingering misconceptions regarding ECT remind us of a central theme of this book: The popular psychology industry shapes the average person’s stereotypes in powerful ways. At the same time, research on the effects of educational interventions on ECT gives us ample reason for hope, because it reminds us that the best means of combating psychological misinformation is providing people with accurate psychological information.

Chapter 1 1: Other Myths to Explore

Fiction	Fact
A psychologically caused disorder requires psychotherapy; a biologically caused disorder requires medication.	The cause of a disorder has no implications for its treatment, or vice versa; for example, headaches aren’t caused by a deficiency of aspirin in the brain.
More experienced therapists tend to have much higher success rates than less experienced therapists.	Most research shows weak or even nonexistent associations between the number of years practicing as a therapist and therapeutic effectiveness.
Psychiatrists and psychologists are essentially identical.	Psychiatrists have M.D.s, whereas most psychologists have Ph.D.s or Psy.Ds; moreover, aside from two states (Louisiana and New Mexico), only psychiatrists can prescribe medications.
The “school of therapy” is the best predictor of treatment effectiveness.	For most disorders, the characteristics of therapists are better predictors of their effectiveness than their theoretical orientation.
All people who call themselves “psychotherapists” have advanced degrees in mental health.	In most U.S. states, the term “psychotherapist” isn’t legally protected, so virtually anyone can open a clinical practice.
Most psychotherapy involves using a couch and exploring one’s early past.	Most modern therapists no longer use a couch, and most don’t focus excessively on childhood experiences.
Most modern therapies are based on the teachings of Sigmund Freud.	In recent surveys, only about 15% of psychologists and 35% of psychiatrists and social workers are predominantly psychoanalytic or psychodynamic in orientation.
Psychotherapy did not exist prior to Freud.	Psychotherapies were present in the U.S. by the mid to late 1800s.
Psychotherapies can only help, not hurt.	At least some therapies, such as crisis debriefing for trauma-exposed individuals, sometimes produce negative effects.
Most psychotherapists use empirically supported therapies.	Surveys suggest that only a marked minority of therapists use empirically supported therapies for anxiety disorders, mood disorders, eating disorders, and other conditions.
Drug Resistance and Education (DARE) programs are effective.	Controlled studies demonstrate that DARE programs are ineffective in preventing drug use, and perhaps even slightly harmful.
People who’ve experienced a trauma must fully “process” the trauma to improve.	Many or most patients who’ve experienced a trauma get better on their own; moreover, some therapies that require such processing, like crisis debriefing, are ineffective or perhaps harmful.
Psychotherapies that don’t address the “deeper causes” of problems result in symptom substitution.	There’s no evidence that behavior therapies and other “symptom-focused” treatments result in symptoms being expressed in another disorder.
Few people can quit smoking on their own.	Studies of community samples show that many people quit smoking without formal psychological intervention.
Nicotine is far less addictive than other drugs.	Many researchers have rated nicotine as more addictive than heroin, cocaine, or alcohol.
Attention-deficit/hyperactivity disorder is caused by excess sugar in the diet.	There’s no evidence that sugar exerts marked effects on children’s hyperactivity or related behaviors.
Antidepressants greatly increase suicide risk.	Antidepressants may increase suicide risk slightly in some vulnerable individuals; nevertheless, they probably decrease suicide risk overall.
Antidepressants often turn people into “zombies.”	Antidepressants don’t make people extremely apathetic or unaware of their surroundings.
Antidepressants are much more effective than psychotherapy for treating depression.	Both forms of treatment are about equally effective, and cognitive-behavioral therapy has often been found to be superior to medication for preventing relapse.
Most newer antidepressants, like Prozac and Zoloft, are more effective than older antidepressants.	Most newer antidepressants are no more effective than older antidepressants, although newer antidepressants generally produce fewer side effects and carry a lower risk of overdose.
Placebos influence only our imagination, not our brains.	Placebos exert genuine effects on brain functioning, including increases in the activity of dopamine and other neurotransmitters tied to reward.
Herbal remedies are superior to antidepressants for improving mood.	There’s no evidence that any herbal remedies, such as St. John’s Wort, are more effective than conventional antidepressants, although some herbal remedies may be helpful for mild depression.
The fact that a substance is “natural” means that it’s safe.	Many substances found in nature, such as arsenic, mercury, and snake venom, are extremely dangerous.
Acupuncture works only if one inserts the needles in specific points in the body.	Researchers have generally found acupuncture to be equally effective when the needles are inserted in the “wrong” locations.
Electroconvulsive therapy is rarely administered today.	Over 50,000 Americans receive electroconvulsive therapy each year for severe depression that hasn’t responded to other treatments.

Sources and Suggested Readings

To explore these and other myths about psychological treatment, see Bickman (1999); Cautin (in press); Dawes (1994); Dowman, Patel, and Rajput (2005); Gaudiano and Epstein-Lubow (2007); Lacasse and Leo (2005); Lilienfeld (2007); Lilienfeld, Lynn, and Lohr (2003); McNally, Bryant, and Ehlers (2003); Perry and Heidrich (1981); Tryon (2008).