Distrusting Experts

Judith Warner has had two recent posts (the first here and the second here) in her New York Times blog, Domestic Disturbances, reporting on studues on overscheduling children. In her second post, she states,

When I first read about Mahoney’s study, in Newsweek and then in the Boston Globe, I slipped the stories into a file folder I’ve kept in my office for some time now, labeled “Meaningless Social Science.” Mostly, it is filled with studies on day care. You know the kind: Day Care Causes Aggression, followed two weeks later by Day Care Causes Tooth Decay, followed two weeks later by Day Care Does Nothing Much at all.

This fall brought a wide variety of new entries: Time magazine had a story on whether TV causes autism, while Child had one saying that – contrary to popular belief – TV doesn’t cause attention deficit disorder. The American Educator had an interview with a cognitive scientist debunking everything other scientists have told us is true about left/right and girl/boy brain-based learning styles.

Reading these stories together, and bearing in mind all the contradictory “scientific” studies I have read over time about all kinds of aspects of childhood, motherhood and the interaction of the two, I thought: all these earnest, tightly structured, controlled, peer-reviewed, gleamingly scientific studies don’t have much meaning. Not individually, not reliably, for what they say (or dispute) about TV or A.D.D. or boy/girl cognition or after-school activities.

One commenter to her blog also made a sneering reference to "experts." Since, I guess I'm an expert, I take offense to all this.

It bothers me that the term "expert" has become a synonym for "fool." There has always been an anti-intellectual trend in America, and attacks on expertise (and, by extension, scientists) are a classic part of anti-intellectualism. These attacks seem to become particularly nasty during political eras dominated by demagogues. The McCarthy era of the 1950's was one example. Today is most certainly another. Why? That brings me to my main point.

In one sentence: Reality is not simple. Experts know this; most people don't want to believe it. They want good and bad to be be clear. If you do these things, you're a good parent; if you do this you're a bad parent. We are the good guys; they are the bad guys. My religion is good; your religion is bad. Demagogues play on this desire for simplicity. Unfortunately, if social science has taught us anything, it's that almost everything is open to qualification.

For example, we all agree that divorce is undesirable. Right-wing demagogues often decry the high divorce rate and declare that we have to go back to the good old days and make divorce harder. That way, people will just stay in their marriages, work harder at them, and everything will be fine. A nice, simple solution. But then the scientist says,

"Wait a minute. That nice simple solution won't work. Marriages are more complicated than that." Then the research starts to unfold, yielding complicated, conflicting results, raising more complicated questions:

Yes, children from divorced families are often more depressed and anxious than children from intact households. Hey, but some children do better after divorce when there's a lot of conflict prior to the divorce. But, wait a minute, how do you define conflict? How much is too much conflict? How about the ages of the children at the time of the divorce, how does that affect how well they do? And don't forget about the socioeconomic status of the parents.

All of this challenges the nice, tidy solution of the demagogue. So, it's not surprising that demagogues attack expertise. Today, they have so many outlets on radio, television, and the internet, that their ideas have wide distribution, and it's hard not to be influenced by it. But if you distrust experts, ask yourself this: Who do you want to design a bridge? Who do you want to operate on your heart? Who do you turn to if you're getting depressed?

In the social sciences, experts can inform and make recommendations about social policy and about personal choices. The data is always sloppy and conflicting because research is conducted at the fringes of our knowlege. The perfect answer is never clear. People read stories about the conflicting research in magazines and newspapers and become confused. How does one decide what to do when the experts don't know? This is when they often turn to demagogues and anti-intellectualism. But, those answers are the worst answers.

My answer to this problem is simple: Consider the data. Look in your heart. Then make the best decision you can. That's good enough.

More Complaining about Evidence-Based Treatment

The most recent edition of the National Psychologist contains two articles concerning evidence-based treatment. Unfortunately, the online edition hasn't been updated yet and the articles are only out in hard copy.

For those of you who are not of the cognoscenti, evidence-based treatment is simply treatment with a clear research base. The research establishes that certain procedures are helpful for certain types of problems. My previous post describes an evidence-based treatment for OCD.

The first article, by Thomas Habib, opens with a bizarre story. Apparently a managed care network, Managed Health Network, wants to establish a category of, what Habib calls, an "elite clinician." I'm not sure if it's Habib's words or theirs'; I couldn't find it on their web site. Essentially, this elite clinician would be someone who has been trained in and practices evidence-based treatment. I assume that these elite clinicians would be given priority in referrals.

Habib is worried about the perceived deadly combination of managed care and evidence-based treatment. He states,

No one is against evidenced based practices. As mentioned above, how this goal was pursued and the disregard of how this might strait jacket psychology and be misused by mangled care is the problem.

"Mangled care" is an obvious shot at managed care. Certainly somewhat deserved, but then, our hands aren't entirely clean, either. There have been far too many clinicians who weren't good at getting change, but were very good at keeping clients in therapy for extended periods of time.

Managed care credentialing for clinicians doing evidence-based treatment is silly. From experience, I know this will fail, because it won't save MHN any money. Back in the 1980's, when managed care blew into Pennsylvania, I spent an incredible amount of time on the phone with "care managers," who would authorize treatment for my clients. Once I learned what they wanted to hear, it was no problem to get sessions authorized. I got to know a lot of care managers by name and we'd chat about our families before getting down to business. But, eventually, telephone authorizations became too expensive, and most of my telephone friends had to get other jobs. Now, my secretary fills out a page, I add the diagnosis, and sign it. Bingo! Another 10 sessions.

So, let me assure you, Dr. Habib. This will end with a whimper, and you'll be left with a mild bit of bureaucracy. Nothing to get excited about. Managed care isn't going to hurt you with evidence-based treatment requirements because it's too expensive to do so.

But, is evidence-based treatment a "strait jacket?" Absolutely not, and the second article illustrates my point clearly. Surprisingly the author, Frank Dattilio, also thinks he's attacking evidence-based treatment. He should really know better, as he has extensive training and publication in cognitive-behavior therapy. In his article, he tells the story of Corey, a young psychiatrist completing his fellowship. Corey brought him a tape of a therapy session, of which he was very proud. Dattilio viewed the tape and said,

Much to my dismay, the same things kept cropping up repeatedly during the course of the session--a dry, robotic type of interaction that almost appeared as though it was scripted.

At the end, Corey said to me, "So what do you think?" I was speechless. Before I had a chance to say anything, he interrupted me by saying, "I think it's classic cognitive-behavior therapy. I don't believe I left one thing out."

"Well, there is one thing that is missing," I replied. Corey looked at me perplexed, "What did I forget?" "You!" I exclaimed, "You, the therapist is missing."

It's a wonderful story, and a great cautionary tale to young therapists, who, unsure of themselves, want to retreat into "techniques." Since the 1950's, we've known the quality of the therapeutic relationship has a strong effect on therapeutic outcomes. Wampold (2001) has a good review of the data. Maintaining a good relationship with the client, being empathic and supportive, is part of any evidence-based treatment. Just look at Beck, Rush, Shaw, and Emery (1979).

The sad thing is that we continue to argue about evidence-based treatment even though we consider psychology to be a science. If psychology is a science, we believe the data. If psychology is a science, we opt first for treatments that the data shows are worthwhile. No one expects us to give up our clinical judgment and our empathy in the process. Being empathic and supportive is just another evidence-based therapy.

All psychotherapies are like seeds. They cannot grow into a beautiful flower without the fertile soil that the humanity of a good therapist provides. Clinicians do not need to fear evidence-based therapies.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Dattilio, F. M. (2006). Evidence based treatment may be too confining. National Psychologist, 15(5), 23.

Habib, T. A. (2006). A profession in search of legitimacy. National Psychologist, 15(5), 14.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Earlbaum Associates.