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Discredited Psychological Treatments and Tests

Discredited Psychological Treatments and Tests

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Discredited Psychological Treatments and Tests: A Delphi Poll
John C. Norcross
University of Scranton
Gerald P. Koocher
Simmons College
Ariele Garofalo
University of Scranton
In the context of intense interest in evidence-based practice (EBP), the authors sought to establishconsensus on discredited psychological treatments and assessments using Delphi methodology. A panelof 101 experts participated in a 2-stage survey, reporting familiarity with 59 treatments and 30 assessmenttechniques and rating these on a continuum from
not at all discredited 
certainly discredited 
. Theauthors report their composite findings as well as significant differences that occurred as a function of the experts’ gender and theoretical orientation. The results should be interpreted carefully and humbly,but they do offer a cogent first step in consensually identifying a continuum of discredited procedures inmodern mental health practice.
Delphi Poll, discredited technique, evidence-based practice, psychological assessment, psy-chotherapy, quackery
Which psychotherapies are effective? Psychologists have beeninundated with lists of treatment guidelines, empirically supportedtherapies, practice guidelines, and reimbursable therapies. Butwhat about demonstrably
effective treatments and tests?The burgeoning evidence-based practice (EBP) movement inmental health attempts to identify, implement, and disseminatetreatments that have been proven demonstrably effective accordingto the empirical evidence. This movement has provoked enormouscontroversy within organized psychology, and, with the exceptionof the general conviction that psychological practice should rely onempirical research, little consensus currently exists among thevarious stakeholders on either the decision rules to determineeffectiveness or the treatments designated as “evidence-based”(Norcross, Beutler, & Levant, 2005).We believe that it might prove to be as useful and probablyeasier to establish what does
work—discredited psychologicaltreatments and tests. Far less research and clinical attention havebeen devoted to establishing a consensus on ineffective proceduresas compared to effective procedures.Recently, several authors have attempted to identify pseudosci-entific, unvalidated, or “quack” psychotherapies (e.g., Carroll,2003; Della Sala, 1999; Eisner, 2000; Lilienfeld, Lynn, & Lohr,2003; Singer & Lalich, 1996). Parallel efforts are underway toidentify assessment measures of questionable validity on psycho-metric grounds (e.g., Hunsley, Crabb, & Mash, 2004; Hunsley &Mash, 2005).These pioneering efforts suffer from at least two prominentlimitations. First, none of the efforts systematically relied onexpert consensus to determine their contents. Instead, the authorsassumed that a professional consensus already existed, or theyselected entries on the basis of their own opinions. Second, theseauthors provided little differentiation between credible and uncred-ible treatments and between unvalidated and validated tests. Thisdemarcation problem (Gardner, 2000)—the challenge of formulat-ing sharp distinctions between validated and unvalidated—plaguedearlier efforts, leading to rather crude and dichotomous judgments.Thus, we conducted a poll of leading mental health profession-als to help secure a consensus and to establish more refinedcharacterizations of treatments and tests ranging from
not at alldiscredited 
certainly discredited 
Delphi Poll
We searched broadly and collected nominations for discred-ited mental health treatments and tests via literature searches,electronic mailing list requests, and peer consultations. Theinclusion criterion stated that the treatment or test was usedprofessionally during the past 100 years in the United States orWestern Europe. Note that, for inclusion, the treatment or test
C. N
earned his PhD in clinical psychology from the Uni-versity of Rhode Island and is professor of psychology and distinguisheduniversity fellow at the University of Scranton. His areas of researchinclude psychotherapy, clinical training, and self-initiated behavior change.G
P. K
earned his PhD in clinical psychology from theUniversity of Missouri at Columbia and is dean of the School for HealthStudies at Simmons College. His research areas include adaptation tochronic illness, coping with bereavement, and ethical issues in psychology.A
earned her BS in psychology at the University of Scranton and is now a doctoral candidate in clinical psychology at NovaSoutheastern University. Her research areas include psychoanalytic treat-ments, projective testing, and personality disorders.P
were presented at the 113th AnnualConvention of the American Psychological Association, Washington, DC,August 2005.W
the participation of the 101 experts and thecontributions of Scott O. Lilienfeld, Roger Greene, and John Hunsley tothis study.C
should be addressed to John C.Norcross, Department of Psychology, University of Scranton, Scranton,PA 18510-4596. E-mail: norcross@scranton.edu
Professional Psychology: Research and Practice Copyright 2006 by the American Psychological Association2006, Vol. 37, No. 5, 515522 0735-7028/06/$12.00 DOI: 10.1037/0735-7028.37.5.515
was used professionally for mental health purposes but was notnecessarily used by psychologists themselves. Exclusion crite-ria were controversial theories of psychology that do not di-rectly involve mental health (e.g., subliminal perception orsleep learning), broader unusual phenomena regarding humanbehavior (e.g., fire-walking, channeling, or extra sensory per-ception) that have not yielded pertinent treatments, treatmentsor assessments that have never found advocacy in mental health(e.g., astrology and numerology), medications or biochemicalsubstances (including conventional, herbal, naturopathic, orhomeopathic preparations), and practices used primarily outsidethe United States and Western Europe.Using these criteria, we listed separately 59 treatments and 30assessment techniques on a questionnaire. Items were presentedalphabetically and with reference to a particular purpose. Forexample, “acupuncture for the treatment of mental/behavioral dis-orders” and “age-regression methods for treating adults who mayhave been sexually abused as children” were listed under thetreatment section, and “Adult Children of Alcoholic (ACOA)checklists” and “anatomically detailed dolls or puppets to deter-mine if a child was sexually abused” were listed under the testsection.The instructions to the respondents read as follows:
For the purpose of this Delphi poll of experts, we operationally define
as those unable to consistently generate treatment out-comes (treatments) or valid assessment data (tests) beyond that ob-tained by the passage of time alone, expectancy, base rates, or credibleplacebo.
subsumes ineffective and detrimental interven-tions but forms a broader and more inclusive characterization. We areinterested in identifying disproven practices.Please rate the extent to which you view the treatment or test asdiscredited from
not at all discredited 
certainly discredited 
. Atreatment or assessment tool can be discredited according to severaltypes of evidence: peer-reviewed controlled research, clinical prac-tice, and/or professional consensus. Please think in terms of thecriteria for expert opinions as delineated in the
KumhoTire Co
(1999). legal standards. For example, in
(1993) theSupreme Court cited factors, such as testing, peer review, error rates,and “acceptability” in the relevant scientific community, some or allof which might prove helpful in determining the validity of a partic-ular scientific “theory or technique.”If you cannot make a rating because you are unfamiliar with thetreatment or test, then kindly circle
. If you are unfamiliar withthe treatment/test’s research or clinical use, then kindly circle
.You may also circle both.
The response options were structured as a 5-point, Likert-typeformat in which 1
not at all discredited 
, 2
unlikely discred-ited 
, 3
 possibly discredited 
, 4
 probably discredited 
, and 5
certainly discredited 
. Respondents could also circle
not  familiar with this treatment/tes
not familiar with itsresearch or clinical use.
The expert panelists were informed that:
Upon completion of the enclosed Delphi poll, your replies will bepooled with those of the other experts. Subsequently, you will beasked to complete a slightly modified form of the Delphi poll con-taining the preliminary findings. In this manner, the panel of expertswill exchange opinions and arrive at a general consensus. Yourindividual responses will
be identified.
Expert Panel
In October 2004, we mailed the five-page questionnaire to 290doctoral-level mental health professionals: 100 randomly selectedfellows of American Psychological Association (APA) Division12 (Clinical Psychology), 45 randomly selected fellows of APADivision 17 (Counseling Psychology), 23 randomly selected fel-lows of APA Division 16 (School Psychology), 46 randomlyselected fellows of the American Psychological Society (APS)with a major field in clinical psychology, 57 current and formereditors of scholarly journals in mental health, 14 members of theAPA Presidential Task Force on Evidence-Based Practice, and 5chairs or editors of the
Diagnostic and Statistical Manual of  Mental Disorders.
Following the initial mailing and a subsequentreminder, we received 138 responses for a total return rate of 48%.However, 37 of these were unusable for a multitude of reasons,principally retirement (
26), which left 101 experts for a usableresponse rate of 35%.We did not detect any systematic bias relating to gender orprofession between persons who returned the questionnaire andthose who did not. However, we did not have a reliable means of determining the theoretical orientations or professional activitiesof the nonrespondents, so it remains an open question if thesefactors influenced participation in the Delphi study.Of the responding experts,
93% had trained as psychologists,82% identified themselves as male, and 9% reported belonging toa racial/ethnic minority group. Table 1 summarizes the profes-sional characteristics of this clinically experienced and theoreti-cally diverse panel of experts.
Second Round
The experts’ responses to the first questionnaire (Round 1) werepooled and analyzed. The same instrument was then redistributedto the 101 panelists in February 2005 along with feedback on theresponses of the panel as a whole. Feedback was provided for eachitem in terms of means and standard deviations, depicted bothnumerically and graphically. Following two mailings and ane-mail prompt, 85 of the original 101 (84%) panelists responded tothe second round. The demographic and professional characteris-tics of the experts responding to the second round mirrored thoseof the first round; statistical analyses did not detect any significantdifferences in these characteristics between Round 1 respondentsand Round 2 respondents.The second round questionnaire was identical to that of the firstround in structure, directions, and items with three exceptions.
Members of the expert panel who allowed us to report their nameswere: Marvin W. Acklin, George J. Allen, Elizabeth Altmaier, JuanArellano-Lopez, David H. Barlow, Larry E. Beutler, David L. Blustein,Jeff Braden, Jeffrey M. Brandsma, Charles D. Claiborn, Elaine Clark,Karina W. Davidson, George DuPaul, Darwin Dorr, Colin D. Elliott,Albert Ellis, Al Finch, Michael First, Gerald B. Fuller, Charles J. Gelso,Roger L. Greene, Carol Goodheart, David Haaga, Steve Hollon, Bertram P.Karon, Bill Kinder, David Lachar, O. B. Leibman, Barbara McCrady, A.Scott McGowan, Julian Meltzoff, Greg Neimeyer, Mary Ann Norfleet, EdNottingham, Thomas H. Ollendick, Eugene G. Peniston, Mick Power,Michael C. Roberts, John Robinson, Wendy Silverman, Derald Wing Sue,Laura C. Toomey, Bruce Wampold, Drew Westen, and Danny Wedding.
First, as noted previously, the second round questionnaire pre-sented the pooled responses from the first round, which is thestandard procedure in Delphi polls. Second, we eliminated the fourtreatments (Goggle therapy, holotropic breath work, Pesso BoydenPsychomotor System, and the Sedona method) and five tests(Manson Evaluation, MAPS, Mira Myokinetic PsychodiagnosticTest, Pigem Test, and Zamboni Test) on the second round ques-tionnaire that were rated by fewer than 25% of the experts duringthe first round. Third, precipitated by our difficulty in determiningthe cut off for the percentage of experts rating any particular item,we inserted a final question on the second round questionnaireconcerning the percentage of responding experts that would con-stitute a respectable minority (see later discussion for details).As expected, the variability among the expert ratings decreasedfrom Round 1 to Round 2. In other words, the pooled feedback from the initial round led to greater consensus among the panel.Specifically, the standard deviations decreased on 50 of the 54treatment ratings. The mean difference was
.20. Similarly, thestandard deviations for 23 of the 25 tests decreased, with anaverage difference of 
.15 from the first to second round. Themean ratings evidenced less change: there was a net increase (i.e.,in the direction of more discredited) of .11 for the treatments and.04 for the tests.
Discredited Psychological Treatments
Table 2 presents, in ranked order, the experts’ mean ratings of 55 potentially discredited treatments. Table 2 presents the mean,standard deviations, and percentage of experts not familiar with(and thus not rating) each item for both rounds of data collection.For those treatments rated by at least 25% of experts, considerableconvergence existed on treatments consensually viewed as
cer-tainly discredited 
(mean rating of 4.50 or higher on the 5-pointscale). For the specific purpose listed, experts considered as cer-tainly discredited 14 psychological treatments: angel therapy, useof pyramid structures, orgone therapy, crystal healing, past livestherapy, future lives therapy, treatments for post-traumatic stressdisorder (PTSD) caused by alien abduction, rebirthing therapies,color therapy, primal scream, chiropractic manipulation, thoughtfield therapy, standard prefrontal lobotomy, and aroma therapy.Another 11 treatments were consensually designated as
(mean rating of 4.0 or greater), including Erhard Sem-inar Training (EST) and age-regression methods, for various spe-cific purposes.On the other end of the continuum, a handful of treatments wereconsensually judged to be unlikely discredited. Treatments receiv-ing mean scores below 3.0 were behavior therapy for sex offend-ers, thought stopping procedures for ruminations, psychosocial(i.e., nonbehavioral) therapies for attention deficit and hyperactiv-ity disorder (ADHD), laughter or humor therapy for depression,Bion’s method of group analysis, Moreno’s psychodrama, and eyemovement desensitization and reprogramming (EMDR) as a treat-ment for trauma.
Discredited Psychological Tests
Table 3 displays the mean ratings of 25 potentially discreditedtests in ranked order. As with the treatments, Table 3 presents theitem mean, standard deviation, and the percentage of the expertslacking familiarity with that test for both rounds. No test receiveda mean rating above 4.50. Five tests rated by at least 25% of theexperts in terms of being discredited for a specific purpose re-ceived mean scores of 4.0 or higher: Lu˝scher Color Test, SzondiTest, handwriting analysis (graphology), Bender Visual MotorGestalt Test (for assessment of neuropsychological impairment),eneagrams, and Lowenfeld Mosaic Test.Several instruments were consensually viewed as unlikely dis-credited, at least for the specific purpose listed on the question-naire. Those tests receiving mean ratings below 3.0 were office-based cognitive task assessments for ADHD, use of IQ scores anddiscrepancy formulas to identify specific learning disabilities, The-matic Apperception Test (TAT) for personality assessment,Myers-Briggs Type Indicator for assessment of personality, sen-tence completion tests for personality assessment, Adult Childrenof Alcoholic (ACOA) checklists, and the Rorschach Inkblot Test(Exner’s comprehensive system) to diagnose specific disorders.
Defining a Respectable Minority
As noted earlier, we struggled with the question of what per-centage of experts would need to have familiarity with a givenpsychological treatment or test to qualify it for inclusion in ourresults. We decided to ask the expert panelists on the second roundquestionnaire.
We would ask for your help with one additional question. We areattempting to set a threshold of familiarity among experts by which toinclude a particular approach in our study. That is, what percentage of experts needs to be familiar with a given treatment or test for contin-ued inclusion or discussion about discredited approaches? We feelstymied in reaching a reasoned criterion.
Table 1
Professional Characteristics of the 101 Experts
N % M Mdn SD
Highest degreePhD 94 93MD 3 3Other 4 4Year of highest degree 1971 1972 11.0Years of mental health experience 33.2 33.0 10.6Percent of time devoted toClinical work 20.5 10.0 24.5Teaching 20.1 20.0 16.2Research/writing 31.7 30.0 24.6Supervision 8.6 10.0 8.7Administration 12.5 5.0 18.6Primary employment settingUniversity department 60 62Private practice 14 15Medical school 11 12Other 11 12Primary theoretical orientationBehavioral 24 25Cognitive 18 19Eclectic/integrative 21 22Humanistic/existential 8 9Interpersonal (IPT) 5 5Psychoanalytic/psychodynamic 7 7Systems/family systems 3 3Other 9 10

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