Playing Without a Full Deck : HOUSE OF CARDS: Blurred Roles of Therapists and Research Psychologists Gives Unsettling Credentials to Some Popular Beliefs, <i> By Robyn M. Dawes (Free Press: $22.95; 338 pp.)</i>
I no longer tell people I’m a “social psychologist”; they think it means I’m a therapist who likes parties. They listen politely as I try to explain that research psychologists--the people who conduct empirical studies of child development, thinking, memory, prejudice, mob violence, language or any other aspect of human behavior--are not the same as clinical psychologists or any other kind of psychotherapist. My efforts usually fall on deaf ears. “How many patients do you see a week?” they ask, or maybe, “What do you make of this really interesting dream I had . . .?”
It was not always thus. In 1959 the American Psychological Assn. (APA) consisted of 18,000 members, of who only 2,500 specialized in clinical or counseling work. By 1988, there were 68,000 members, of whom 40,000 were in clinical or counseling. Today the proportion within the APA is even greater, and that does not include all the therapists who are not Ph.D. psychologists but who have various other degrees (such as marriage and family counselors or social workers) or no degrees at all. Accordingly, the word “psychologist” has, in the public mind, become synonymous with “therapist.”
The reason this matters, argues Robyn Dawes in “House of Cards,” is the widening gap between researchers and therapists in what they know and how they know it. In the rapid and explosive growth in the sheer numbers of therapists, the practice of psychology has abandoned its original commitment to establish a mental health profession based on research findings, using well-validated techniques and principles. On the contrary, Dawes shows, the training of most psychotherapists has come loose from its original moorings in scientific procedures (such as the use of control groups before concluding that one method is better than another) and empirically based knowledge (such as observing how children actually recover from trauma), instead, many therapists actively disdain research as being irrelevant to their practices; they know, they say, from “clinical experience” and “intuition” what is right.
Such claims make Dawes rightfully angry, as over and over again he reveals the unwarranted arrogance of therapists whose claims to expertise rest entirely on air. Drawing on more than 300 empirical investigations, he shows why “professionals’ claims to superior intuitive insight, understanding, and skill as therapists are simply invalid” (Page 8). Psychotherapy has grown and achieved status, Dawes observes, while ignoring research that contradicts its claims, adopting principles that are “known to be untrue,” and using techniques “known to be invalid” (Page vii). Dawes debunks dozens of incorrect ideas promulgated by psychotherapists who know little or nothing of psychological research. For example:
--Belief: Abused children invariably become abusers; children of alcoholics become alcoholic. Fact: The majority do not.
--Belief: Childhood trauma inevitably creates predictable adult psychopathology. Fact: Most children are resilient and outgrow traumatic experiences. Our “belief in the tyranny of childhood,” says Dawes, “has little more foundation than a belief in a mountain god.”
--Belief: Memory works like a tape recorder, faithfully recording everything that happens from the moment of birth. Fact: For normal physiological and psychological reasons, adults do not remember events that happened roughly before the age of 3, even if Roseanne says so. Memory is not recorded in perfect form; it is constantly being reconstructed from aspects of the event, subsequent interpretations and one’s current feelings and beliefs about the past event.
--Belief: Self-esteem is the key ingredient in well-being and achievement; low self-esteem is the main cause of drug abuse, violence and teen-age pregnancy. Fact: Literally thousands of studies have failed to support this belief, which guided the California Task Force on Self-Esteem. As Dawes observes, the task force performed an unintended public service; it demonstrated that “the Holy Grail of pop psychology"--the belief that high self-esteem is the ticket to happiness and low self-esteem is the cause of social problems--"is nothing more then a mirage.” What research does show is that children need a sense of competence and mastery at learning new skills. Self-esteem will follow.
--Belief: The more impressive the credentials, the better the therapist. Fact: Studies repeatedly show that for the everyday problems of life for which people seek advice and help, all that is necessary is a kind and empathetic counselor. The credentials of the “expert” are unrelated to the success of therapy.
--Belief: Clinical psychologists and other therapists are better than the rest of us at predicting, from interviews, whether a paroled prisoner will be violent, whether a student should be accepted to college or graduate school and whether an employee will cheat. Fact: They aren’t.
As American society becomes ever more “psychologized,” therapists are having an increasingly powerful impact on the solutions that people seek for their troubles, on educational practices, on legal issues and on jury decisions. The reasoning of a juror who voted to convict a young woman of sexually abusing children at the North Carolina Little Rascals Day Care Center is, Dawes notes, typical of the regard, even awe, that the public has for anyone called a “therapist.” “There was no really good evidence (to convict), “the juror said. “It was the therapist’s notes that convinced me she was guilty.” After reading “House of Cards,” you will know why this remark is so scary.
Dawes, who is a professor in the Department of Social and Decision Sciences at Carnegie-Mellon University, began his career as a clinical psychologist, working in a hospital psychiatric unit. “During my first year, I became increasingly skeptical that those of us responsible for patient treatment really know what we were doing,” he reports (Page ix). “It was in my second year that I was introduced to the unwarranted arrogance of ‘clinical experience,’ and I quit.” One such experience involved an extremely intelligent 16-year-old girl, hospitalized by her parents against her will. The girl was diagnosed as being a “pseudo-neurotic schizophrenic” on the basis of one of her replies on the Rorschach Test--a test know then, and verified since, to be utterly without validity or predictability. It is nonetheless still widely used.
“House of Cards” is not easy reading. Dawes has some exasperating habits (such as too many parenthetical remarks) and he is often repetitive. More seriously, one conceptual contradiction in particular weakens his basic argument. Having said that psychotherapy at all, he then proceeds to indict psychotherapy for abondoning its ties to scholarship and or promoting foolish and unsupported ideas. So wherin lie its benefits? A “caveat emptor” paragraph tries to resolve this inconsistency: the studies of therapy’s effectiveness were done more than a decade ago, says Dawes, before “an explosion in numbers (assured) that there will be more poor therapists around in the 1990s than at the time when the studies were initiated.”
In spite of its flaws, I believe this book is important for anyone interested in therapy, for attorneys and judges, for teachers, for legislators, anyone required to take a projective test that supposedly reveals something about one’s character or behavior--in short, everyone who has reason to seek the expertise of psychotherapists or who has been victimized by their claims of expertise. But the one group that needs this book most is also the least likely to read it.
In June, the American Psychiatric Assn. will publish the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, yet another of its recurring efforts to paper over the subjective nature of diagnosis with a scientific veneer. Every therapist and clinician in the country will have to read this book if they are to pigeonhole their clients into a diagnosis the insurance companies will compensate. If only they were also required to read “House of Cards.”