By Scott O. Lilienfeld, Samuel Candler Dobbs Professor, Department of Psychology, Emory University
Breakthroughs. Miracle cures. Paradigm shifts. Dramatic advances.
As someone who received his psychology Ph.D. in 1990 (University of Minnesota, clinical psychology), I’ve heard all of these phrases, and many more, over the years. In the intervening 28 years, I’ve lost count of the number of psychological and medical interventions that I’ve seen described as “cures “ or quick fixes for serious or even intractable conditions, such as autism spectrum disorder (autism), schizophrenia, depression, and posttraumatic stress disorder.
Barely a week goes by that I don’t receive an email in my inbox or a flyer in my mailbox that advertises a workshop on a new “breakthrough” clinical method, such as an energy therapy for anxiety disorders or a brain-based therapy for clinical depression. The field of psychotherapy, family therapy in particular, is especially susceptible to this trend (Meichenbaum & Lilienfeld, 2018). To take merely one example among hundreds and perhaps thousands, one website promotes “The Bulimia Breakthrough Method-2018,” a technique that relies on hypnosis to “work below consciousness to interrupt the addictive behaviours”, as a powerful intervention for eating disorders. Perhaps the Bulimia Breakthrough Method really does help patients with bulimia nervosa; I don’t know, and despite a literature search, I couldn’t locate a single published study on its efficacy. But I’m exceedingly dubious that it is a breakthrough. Why? There have been few or no increases in the average effect size of psychological interventions over the past three decades (Budd & Hughes, 2009), and even the most effective psychological interventions, such as prolonged exposure for obsessive-compulsive disorder and cognitive-behavioral therapy for major depression, still leave significant numbers of patients with significant residual symptoms (Arkowitz & Lilienfeld, 2006). All of these findings should be grounds for humility in our claims. The same goes for such extensively hyped methods as psychedelic-assisted psychotherapy, described in a recent academic article as a “paradigm shift” (Schenberg, 2018). Perhaps it will indeed prove to be a paradigm shift, but until more compelling evidence is in, I am holding off on encouraging my clinical colleagues to purchase hallucinogens for their therapy clients.
In my experience as an instructor of graduate students in clinical psychology and allied fields for three decades, one of the most widespread thinking errors that I have encountered, among even the best and brightest of students, is what I term “breakthrough-ism” (Lilienfeld, 2017): the tendency to regard novel interventions as breakthroughs rather than merely as potentially promising techniques that may be worthy of investigation (Lilienfeld, 2017). Breakthrough-ism is potentially dangerous, as it can lead us to latch on to ineffective or even harmful fads. As the literature on placebo effects teaches us, genuine hope can be helpful (Kirsch, 2005), but false hope can be detrimental, not to mention cruel to patients and their loved ones, whose hopes are dashed. In my view, teaching graduate students to avoid the seductive temptations of therapeutic hype is among our foremost responsibilities as teachers.
Even graduate students in non-clinical fields, such as experimental psychology, developmental psychology, and neuroscience, must be vigilant of claims regarding breakthroughs. Hence, although I am cautiously optimistic about the prospects of genome-wide association studies, epigenetics, the microbiome, computational psychiatry, big data, machine learning, and any number of relatively recent trends in psychological fields, I view them with at least a dose of healthy skepticism, as I’ve witnessed far too many heavily hyped advances not live up to their billing. As one example, I vividly recall when I was a graduate student in the 1980s, many psychologists and psychiatrists were confidently forecasting that positron emission tomography (then a new kid on the neuroscience block) and other newly emerging brain imaging techniques would soon render the field of neuropsychology obsolete. They would also, we were assured, soon replace the in-person clinical interview as a method of arriving at formal psychiatric diagnoses. Well, neither promise materialized, and neither seems to be close to coming to fruition. When the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) appeared in print five years ago, it did not contain a single brain imaging finding for any of its 300+ mental disorders.
How can we combat breakthrough-ism? I don’t know for sure, but I suspect that learning more about the histories of psychology and psychiatry is a partial corrective (Lilienfeld, 2017). In particular, the appreciation that scores of well-intentioned interventions once widely assumed to be therapeutic breakthroughs did not pass the test of time may help to temper our premature enthusiasm regarding the prospects of contemporary treatments. Regrettably, few of today’s graduate students know much about the history of the discipline, largely because the teaching of the history of psychology has been increasingly de-emphasized in many graduate programs. Several years ago, my own psychology department at Emory University voted to eliminate the history of psychology requirement for its graduate students; I was among the few dissenters.
In a useful article, Braslow (1999) reviewed the often-sordid history of somatic treatments for mental disorders, including those that turned out to be disastrously ineffective and dangerous, such as prefrontal lobotomy malaria fever therapy, and insulin coma therapy. To that list, one could add a host of others, such as bleeding, blistering, purging, tranquilizing chairs, the Utica crib, and the surgical removal of bodily organs (for a horrific recounting of the latter, see Scull (2007). We rarely teach today’s students about these mistakes of the past, and when we do, we often impart the wrong lessons about them. Specifically, we typically emphasize how cruel and inhumane these interventions were, and how far we have come since the bad old days. Yes, these were indeed cruel and inhumane interventions. Yet, as Braslow wisely observes, the far more important lesson is that most practitioners of the time were earnestly trying to help, and sincerely believed these methods to be beneficial. Indeed, two of these interventions – prefrontal lobotomy and malaria fever therapy – earned their principal practitioners Nobel Prizes in Medicine or Physiology (Egas Moniz for the former and Julius Wagner-Jauregg for the latter).
Such sobering reminders can help to imbue in us a sense of modesty regarding new techniques proclaimed by their advocates to be breakthroughs. I take the liberty of quoting Braslow at length:
What does this teach us about our present-day efforts at evidence-based medicine? First, this history should encourage a sense of humility despite our scientific and therapeutic advances. Every generation believes in what they deem as "evidence" and, as this history illustrates, what counts as evidence is not fixed, but evolves over time. Second, this history should encourage us to ask critical questions about our contemporary methods of producing evidence and treating patients, since, if history is any guide, these methods will no doubt be subject to revision (p. 238).
By all means, let us remain open to new and exciting developments in our field, and be willing to subject them to systematic inquiry should they appear promising. At the same time, however, let us recall how often well-meaning practitioners of bygone eras who were just as bright as us were woefully mistaken. In this respect, learning more about the history of our discipline should be an essential element of graduate education in psychology. Humility should be our watchword, and nothing can keep us more humble than learning about the errors of the past.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Washington, D.C.: Author.
Arkowitz, H., & Lilienfeld, S. O. (2006). Psychotherapy on trial. Scientific American Mind, 17(2), 42-49.
Braslow, J. T. (1999). History and evidence-based medicine: Lessons from the history of somatic treatments from the 1900s to the 1950s. Mental Health Services Research, 1, 231-240.
Kirsch, I. (2005). Placebo psychotherapy: synonym or oxymoron? Journal of Clinical Psychology, 61, 791-803.
Lilienfeld, S.O. (2017). Knowledge of the history of clinical psychology: A partial antidote against “breakthrough-ism.” Society for a Science of Clinical Psychology Newsletter, 20 (3), 2-3. Retrieved from http://www.sscpweb.org/resources/PDFs/Newsletter/2017/Clinical%20Science%2020(3)%20Fall%202017.pdf.
Meichenbaum, D., & Lilienfeld, S. O. (2018). How to spot hype in the field of psychotherapy: A 19-item checklist. Professional Psychology: Research and Practice, 49, 22-30.
Schenberg, E. E. S. (2018). Psychedelic-assisted psychotherapy: a paradigm shift in psychiatric research and development. Frontiers in Pharmacology, 9, 733.
Scull, A. (2007). Madhouse: A tragic tale of megalomania and modern medicine. New Haven, Connecticut: Yale University Press.
Dr. Lilienfeld received his B.A. in Psychology from Cornell University in 1982 and his Ph.D. in Clinical Psychology from the University of Minnesota in 1990. He completed his clinical internship at Western Psychiatric Institute and Clinic in Pittsburgh, Pennsylvania from 1986-1987. He was assistant professor in the Department of Psychology at SUNY Albany from 1990 to 1994, and has been a faculty member in the Department of Psychology at Emory since 1994. He is editor-in-chief of Clinical Psychological Science. He is also a visiting Professor at the University of Melbourne in Australia.