October 2009
Volume 22, Number 8
‘An Unconscionable Embarrassment’
A century ago, American medicine was an unregulated and unscientific craft, with little research to support its practice. In 1910, The Flexner Report, published by early 20th century educator Abraham Flexner, under the auspices of the Carnegie Foundation for the Advancement of Teaching, exposed the sorry state of medical practice, leading to major reform of both the training and practice in medicine. Among other things, the report revealed that half of the nation’s medical schools were sub-par, and many were closed down as a result. The remaining schools adopted rigorous admissions and training standards for their students, focusing on the scientific approach to medical education and practice that is still evident today.
Newsweek.com | Mind Matters
Drifting from Our Scientific Roots: The Rorschach Debate
Wikipedia recently published all 10 of the inkblots that Swiss psychiatrist Hermann Rorschach first introduced in his book Psychodiagnostik back in 1921—along with the most common “answers” for each of the inkblots. Wikipedia’s move has sparked a firestorm among psychotherapists who claim that publishing the norms could skew the test’s results—or worse, allow patients to fool their therapists, to game the system. Free-speech advocates — including many other therapists—dismiss those claims as nonsense.
But this heated debate has failed to raise (or answer) the most important question of all: does the Rorschach work? The answer is no, and here is the best evidence: The journal Psychological Science in the Public Interest (PSPI) published an exhaustive review of all data on the Rorschach (and other similar “projective” tests) in 2000. The authors — psychologists Scott Lilienfeld, James Wood and Howard Garb — find the Rorschach wanting. The test lacks what testing experts call “scoring reliability”… and with the exception of schizophrenia and similarly severe thought disorders, the Rorschach fails to spot any common mental illnesses accurately.
Despite this damning evidence, the most recent survey data indicates that four in 10 clinical psychologists still use the Rorschach “always or frequently” with patients. The test was roundly criticized back in the ‘50s for lacking standardization and norms. Those problems were presumably corrected in the ‘70s, with the introduction of an elaborate system of instructions for therapists, and many newly trained therapists incorporated the revised test into their practices. Even so, it is this revised version of the Rorschach that still fails on both reliability and validity, according to the PSPI report.
The same psychological journal will in a few months be publishing another major review of clinical practice, with the goal of weeding out therapies and techniques that have no scientific evidence to back them up. This dust-up over the Rorschach could be just the beginning of a major intellectual housecleaning in a field that’s drifted from its scientific roots. Does anyone else see a battlefield in that amorphous inkblot?
- Wray Herbert
Excerpts from “Analyze This: The real problem with the Rorschach test: It doesn’t work” originally published on Newsweek.com July 30, 2009. For more information about the Rorschach debate, see the PSPI report “The Scientific Status of Projective Techniques” by Scott O. Lilienfeld, James M. Wood, and Howard N. Garb, Volume 1(2).
Clinical psychology is in a situation similar to where medicine was in the early 20th century. While there are many therapeutic practices that are grounded in science and proven to work, far too many lack any scientific rigor. This is in part because many of the training programs — especially some Doctorate of Psychology (PsyD) programs and for-profit training centers — make little effort to ground their training in the latest psychological science. It’s time for professional psychology to take the bold steps that medicine did a century ago.
A new report in the APS journal Psychological Science in the Public Interest (Vol. 9, No. 2)by Tim Baker, University of Wisconsin-Madison; Richard McFall, Indiana University; and Varda Shoham, University of Arizona, exposes the sorry state of clinical practice today and calls for a new accreditation system to force the field into correcting its course.
APS Past President Walter Mischel, who wrote the editorial for the PSPI report, calls the disconnect between science and practice “an unconscionable embarrassment” and “a case of professional cognitive dissonance with heavy costs.” The widening gap between clinical practice and scientific progress in psychology has serious consequences not only for the profession but for the mental health consumer as well. The prevalence of mental health disorders in this country has nearly doubled in the past 20 years. Both the demand and costs for health and mental health care have risen dramatically over the past 30 years, a trend that shows no sign of slowing. Yet these patients rarely receive treatments that have been rigorously tested and shown to be both therapeutic and cost-effective. For example, psychological interventions have been effectively coupled with medications in smoking cessation programs, but these treatments are often unavailable. Similarly, family-focused therapy is a powerful tool in schizophrenia treatment and exposure therapy in the treatment for obsessive compulsive disorder, yet many practicing therapists fail to use these beneficial techniques in their practices.
Psychology and psychological interventions should be a major topic in the current debate about health care reform, but it hasn’t been. “Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective-disseminable, cost-effective, and scientifically plausible,” note the authors of this report. The problem is that, in the absence of standardized science-based training that would lead psychologists to uniformly apply them, empirically supported treatments go unused. For example, cognitive-behavioral therapy (CBT) has been shown to be the most effective treatment for Post-Traumatic Stress Disorder (PTSD), yet many psychologists do not use this method. Baker and colleagues cite one study in which only 30 percent of psychologists were trained to perform CBT for PTSD and only half of those trained elected to use it. In this study, six of every seven sufferers in treatment were not getting the best care available. Furthermore, CBT shows long-term benefits as a treatment for PTSD, whereas medications have shown 25 to 50 percent relapse rates.
So the question is: How can we ensure that a psychologist is using scientifically supported treatments? Baker and colleagues suggest a new accreditation system for reformed training in clinical psychology, one with established criteria for training in mental and behavioral treatment. Further, this accreditation system must monitor the pulse of clinical psychology, adapt to changing economic health care needs, and still maintain the standards and scientific progress associated with experimentally supported treatments.
These needs are being addressed by the new Psychological Clinical Science Accreditation System (PCSAS). The goals of PCSAS are to “allow the public and employers to identify scientifically trained psychologists, stigmatize a scientific training programs and practitioners, produce aspirational effects, thereby enhancing training quality generally, and help accredited programs improve their training in the application and generation of science.” (For more about PCSAS, see the March 2009 Observer and their website, www.pcsas.org.) The founding of PCSAS, and this PSPI report, are two early steps toward bridging the gap between science and treatment.
- Catherine West
