Science and pseudoscience in clinical practice: a brief review and Christian perspective.

Tan, Siang-Yang

This article will briefly review the second edition of an important book, Science and pseudo-science in clinical psychology (2nd ed.), edited by Lilienfeld, Lynn, and Lohr (2015), which David Barlow has endorsed as required reading for every student of clinical psychology, and I would add, for everyone in clinical practice in the mental health professions. I have therefore broadened the significance and impact of this book to apply to all of clinical practice and not just specifically to clinical psychology. A Christian perspective on science and pseudoscience in clinical practice will also be provided.

In the Foreword to this book, Carol Tavris (pp. ix-xx) reviewed the scientist--practitioner gap a decade later after the publication of the first edition (Lilienfeld, Lynn, & Lohr, 2003). She listed the following examples of beliefs asserted by many psychotherapists or counselors that have been widely accepted by the public, although these beliefs have been dispelled or invalidated by empirical evidence: "Almost all abused children become abusive parents. Almost all children of alcoholics become alcoholic. Children never lie about sexual abuse. Childhood trauma invariably produces emotional symptoms that carry on into adulthood. Memory works like a tape recorder, clicking on at the moment of birth. Hypnosis can reliably uncover buried memories. Traumatic experiences are usually repressed. Hypnosis reliably uncovers accurate memories. Subliminal messages influence behavior. Children who masturbate or "play doctor" have probably been sexually molested. If left unexpressed, anger builds up like steam in a teapot until it explodes in verbal or physical aggression. Projective tests like the Rorschach validly diagnose personality disorders, most forms of psychopathology, and sexual abuse" (pp. xii-xiii).

Tavris emphasized that such widely held but erroneous beliefs can have, and have had substantially negative or devastating effects in the lives of people. However, because American culture has a low tolerance for uncertainty, she wrote: "In such a culture, pseudoscience is particularly attractive because pseudoscience by definition promotes certainty, whereas science gives us probability and doubt. Pseudoscience is popular because it confirms what we believe; science is unpopular because it makes us question what we believe. Good science, like good art, often upsets our established ways of seeing the world" (p. xvi). She then asserted: "Pseudoscientific therapies will always remain with us because so many economic and cultural interests are promoting them. But their potential for harm to individuals and society is growing, which is why it is more important than ever for psychological scientists to explore their pretenses and dangers. As Richard McNally is fond of saying, the best way to combat pseudoscience is to do good science" (p. xvii).

A Brief Review of Science and Pseudoscience in Clinical Psychology (Second Edition) (Lilienfeld, Lynn, & Lohr, 2015)

In addition to the Foreword by Carol Tavris, this book contains an introductory chapter (chapter 1) and a closing chapter (chapter 17), with 15 other chapters divided into 4 major parts or categories: Part I on Controversies in Assessment and Diagnosis (chapters 2-5), Part II on Overarching Controversies in Psychological Treatment (chapters 6-9), Part III on Controversies in the Treatment of Adult Disorders (chapters 10-12), and Part IV on Controversies in the Treatment of Child and Adolescent Disorders (chapters 13-16). There are therefore a total of 17 chapters in this book.

Introductory Chapter

In the introductory chapter (chapter 1, pp. 116), Lilienfeld, Lynn, and Lohr presented their initial thoughts, reflections, and considerations on science and pseudoscience in clinical psychology or clinical practice. They provided a brief primer on the differences between science and pseudoscience, including the following most frequent features of pseudoscience:

" 1. An overuse of ad hoc hypotheses designed to immunize claims from falsification; 2. Absence of self-correction; 3. Evasion of peer review; 4. Emphasis on confirmation rather (than) refutation; 5. Reversed burden of proof; 6. Absence of connectivity; 7. Overreliance on testimonial and anecdotal evidence; 8. Use of obscurantist language; 9. Absence of boundary conditions; 10. The mantra of holism!' (pp. 7-10).

They also pointed out that the major goal of this second edition of their edited book is to help readers to differentiate between techniques in clinical psychology or clinical practice that are scientifically supported or promising from techniques that are scientifically unsupported or untested.

Part I. Controversies in Assessment and Diagnosis

In chapter 2 (pp. 19-41), on understanding why some clinicians use pseudoscientific methods, findings from research on clinical judgment were reviewed by Garb and Boyle. They noted that while much research has been done on cognitive processes, feedback, and why it is difficult to learn from experience, there is a lack of empirical work specifically focusing on clinicians who employ pseudoscientific methods, and their characteristics, beliefs, and cognitive processes. They concluded that while clinical lore includes the belief that clinicians learn from experience or by doing, the empirical research actually shows that it is difficult to learn from experience. Clinicians need to know this research and realize why it is difficult to learn only from experience, in order to be more accurate in their clinical judgment. In addition to this chapter, a recent article by Lilienfeld, Ritschel, Lynn, Cautin, and Latzman (2014) on why ineffective psychotherapies appear to work, a taxonomy of causes of spurious therapeutic effectiveness (CSTEs) was provided with 26 possible causes of such CSTEs. Four general underlying cognitive impediments to accurate clinical judgement and evaluation of improvement in psychotherapy noted are: naive realism, confirmation bias, illusory causation, and the illusion of control. The taxonomy of possible causes of CSTEs include the following three overall categories: (a) the perception of client change when it is actually absent; (b) misinterpretations of actual client change that is due more to extra-therapeutic factors; (c) misinterpretations of actual client change that is due more to nonspecific treatment factors. More accurate clinical judgment and evaluation of improvement in psychotherapy are therefore needed, and evidence-based practice is crucial for achieving this, by providing essential methodological safeguards.

In chapter 3 (pp. 42-82), Hunsley, Lee, Wood, and Taylor cover controversial and questionable assessment techniques, and psychological tests. After reviewing the empirical research available, they concluded: "Among the tests we reviewed, we found scant support for most Rorschach scores, a few promising avenues for the TAT (although no support for this measure as it is currently used in clinical practice), only very limited promise for holistic scoring of some projective drawings, no support for anatomical dolls as a screening instrument for evidence of sexual abuse, and evidence that the MBTI (Myers-Briggs Type Indicator) is a self-report measure that lacks convincing reliability and validity for types derived from the test" (p. 70). Great care and caution should therefore be exercised by clinicians using such assessment techniques and psychological tests, and especially in their clinical interpretations and conclusions derived from such measures. Some clinical researchers may even argue against using such assessment measures at all.

In chapter 4 (pp. 83-112), McCann, Lynn, Lilienfeld, Shindler, and Hammond Natof reviewed the empirical research available on the science and pseudoscience of expert testimony in which professional clinicians serve as expert witnesses in legal proceedings. Although judges are the ultimate gatekeepers for deciding what expert testimony would be admissible in a legal case in court, McCann et al. suggested the following guidelines for competent forensic practice that is based on science and empirical research and not on pseudoscience: First, use the DSM-5 (although it is not perfect and there are some controversial diagnoses that have been critiqued, e.g., autistic spectrum disorders) and the empirical research available in presenting expert testimony and opinions to the court. Second, there are some areas of expert testimony that have more of an empirical research base to support and guide competent expert opinion, for example, certain psychological assessment measures with peer review that are commercially available with technical manuals, violence risk assessment, and eyewitness testimony. Methods or measures used should have empirical support for their reliability and validity. Finally, expert witnesses should also share the limits of their competence and the empirical or evidential bases (or lack thereof) for their expert opinions.

In chapter 5 (pp.113-152), Lilienfeid and Lynn provided a contemporary scientific perspective on the controversial diagnosis of dissociative identity disorder (DID), formerly known as multiple personality disorder (MPD). They covered two major models for DID: the Posttraumatic Model (PTM) that views DID as a natural consequence or response to early trauma, including child abuse, and the Sociocognitive Model (SCM) that views DID as more of a socially based and culturally influenced condition. The PTM therefore assumes that DID is an actual disorder that is discovered by therapists, whereas the SCM views DID as a condition that is created by therapists (p. 122). These two major models are not mutually exclusive, and therefore it is possible that further empirical research may support an integration of at least some features of these two models.

After reviewing the empirical research available to date, Lilienfeld and Lynn summarized 11 findings that are consistent with the major aspects of the SCM, including the following examples: the dramatic increase of patients diagnosed with DID in the last few decades, and the similar increase in the number of alters in each DID patient, both of these increases occurring when public and therapist awareness of DID has dramatically increased; treatment techniques for DID used by some proponents of the PTM may end up reinforcing patients' manifestations of multiplicity; many, if not, most patients with DID did not show obvious signs of this condition before they started therapy; clinicians using hypnosis tend to have greater numbers of patients with DID than those who do not use hypnosis; most of the patients diagnosed with DID are seen by a relatively small number of therapists who tend to specialize in DID; non-clinical subjects in laboratory studies can reproduce many of the obvious features of DID when given appropriate prompts and cues; diagnoses of DID were mainly limited to North America where it has had widespread media coverage, until quite recently, but DID is also being diagnosed with greater frequency in other countries such as Holland and Turkey, where it is also receiving much more publicity; and childhood DID seems to be very rare or nonexistent outside of the treatment context (see pp. 140-141). They therefore concluded that multiple converging sources of empirical support for the SCM are now available, putting the burden of proof on the advocates of the PTM to provide more substantial research evidence to support their position.

Part II. Overarching Controversies in Psychological Treatment

In Chapter 6 (pp. 155-190) of Part II of this book, Gaudiano, Dalrymple, Weinstock, and Lohr covered the science of psychotherapy and focused on developing, testing, and promoting evidence-based treatments, especially empirically supported treatments or ESTs. After reviewing the empirical research literature on ESTs and other psychotherapy research topics, they concluded that there are now "numerous effective interventions for individuals suffering from psychological disorders and their families. Research has demonstrated that many of these interventions are as or more effective than psychiatric medications for common conditions, such as mood and anxiety disorders. Furthermore, treatment guidelines often recommend evidence-based psychotherapies as frontline approaches for children, adults, and the elderly. However, many practicing therapists still are using untested or less effective approaches, and more work is needed to promote the use of evidence-based practices... More sophisticated statistical techniques have fostered increased attention to elucidating the 'active ingredients' of effective treatments so that they can be improved and refined'" (p. 181).

It should be pointed out that the area of empirically supported therapy relationships or ESRs has also continued to make some advances in recent years (see Norcross, 2011).

In chapter 7 (pp. 191-209), the topic of new age and related novel unsupported therapies (NUSTs) in mental health practice was covered by Pignotti and Thyer. They reviewed whatever empirical research is available on therapies such as recovered memory therapies (RMTs) for DID, Thought Field Therapy (TFT) involving finger tapping on purported acupressure points on the body while focusing on an emotionally disturbing issue or a traumatic event or fear, and the Emotional Freedom Technique (EFT) from energy psychology involving body tapping methods. They concluded that the core principles of New Age psychotherapies (e.g., thoughts can influence the external environment of an individual; the existence of energy fields, meridians, purported acupressure points, chakras, auras; the ability of some psychotherapists to detect these things) have yet to be validated or supported by conventional science or empirical research (see p. 204). They therefore stated: "We do not believe that the vast majority of the instances in which New Age or other NUSTs are applied by psychotherapists are consistent with the Helsinki Declaration's principle of providing informed consent, or of conducting research on the intervention's safety and efficacy. It is rare that the books, training workshops, CDs, or DVDs advertising training in these treatments or offering them to the public as legitimate therapies, include a disclaimer" (p. 205). They also raise the issue of troubling ethical questions related to a therapist using a New Age or other NUST with a particular client, when scientific evidence for its efficacy is lacking, or when there are other more empirically supported medical or psychosocial treatments that are available.

In chapter 8 (pp. 210-244), the topic of constructing the past and the use of problematic memory recovery techniques is dealt with by Lynn, Krackow, Loftus, Locke, and Lilienfeld. After reviewing the empirical literature including laboratory studies on memory recall or recovery, they noted that while findings from laboratory studies cannot be generalized to clinical situations, they suggested that it is plausible that factors such as expectancies, suggestive procedures, and demand characteristics play a much greater role in clinical contexts than in experimental conditions. The negative or problematic effects of hypnosis, guided imagery, suggestion and symptom interpretation as memory recovery techniques on memory may therefore be more significant in a clinical situation compared to a laboratory or experimental context.

Lynn et al. recommended that therapists should avoid using such problematic memory recovery techniques to help patients in psychotherapy to uncover memories of abuse because of the great danger of creating or uncovering false memories. They clarified, however, that their findings do not mean that all memory recovery techniques are problematic (e.g., the "revised cognitive interview" can be helpful), or that all uses of hypnosis in psychotherapy are problematic (e.g., hypnosis can be a useful intervention in cognitive-behavioral therapy, pain management, obesity treatment, and treatments for smoking cessation), or that all memories recovered after many years of forgetting are always false. Nevertheless, they stated that "the conclusion that certain suggestive therapeutic practices, particularly those that we have discussed in this chapter, can foster false memories in some clients appears indisputable. We urge practitioners to exercise considerable caution when using these techniques in psychotherapy and to base their memory-related therapeutic practices on the best available scientific evidence" (p. 235).

In chapter 9 (pp. 245-274), Rosen, Glasgow, Moore, and Barrera covered self-help therapy, and reviewed recent developments in the science and business of giving psychology away. They noted that today self-help or advice-giving efforts by various authors can be provided not only through books, but also through audiotapes and videotapes, computerized programs, phone apps, and the Internet. However, after 40 years of hindsight and empirical work since the 1970s, they concluded that self-help has not made substantial advancements over the last 40 years and will probably not make any more significant progress over the next 40 years unless a new direction is taken. They recommended a new and more wide-ranging approach to the development, use, and evaluation of self-help therapies. Many self-help programs are not effective with high failure rates evidenced by people who try using them (e.g., 80% of mothers who could not successfully use a toilet training program for their children, or 100% of males who could not successfully use a self-help program for sexual dysfunction). Instead of putting the responsibility solely on the author of a self-help program to evaluate its effectiveness, Rosen et al. strongly advocated for a public health approach to self-help that involves the joint efforts of health organizations, clinician groups, government agencies, and professional associations, and that uses a checklist of questions in the framework of RE-AIM under the headings of Reach, Effectiveness, Adoption, Implementation, and Maintenance, before program marketing is done (see pp. 264-266). They therefore concluded that the "future of an empirically sound self-help movement lies in this vision of 'program-based' methods rather than 'individually authored' products" (p. 266).

Part III. Controversies in the Treatment of Adult Disorders

In chapter 10 (pp. 277-321) of Part III of this book, the topic of science--and non-science-based treatments for trauma-related stress disorders was reviewed by Lohr, Gist, Deacon, Devilly, and Varker. They listed eye movement desensitization and reprocessing (EMDR), critical incident stress debriefing (CISD) and management (CISM), and psychological first aid (PFA) as pseudoscientific treatments for trauma-related disorders. EMDR is an efficacious treatment for PTSD and comparable to CBT or prolonged exposure, but the eye movements and other bilateral stimulation techniques do not seem to be necessary and they do not specifically make unique contributions to clinical outcomes. The empirical evidence for the efficacy of CISD and PFA is not only lacking, but CISD has been found to be less effective than non-intervention controls or alternative treatments, and routine debriefing in the occurrence of traumatic events is now contraindicated. The science-based treatments for trauma-related disorders that were reviewed include cognitive behavioral treatments (CBT) such as prolonged exposure, anxiety management training (AMT), and cognitive processing therapy.

Lohr et al. also briefly covered resilience training for post event high-risk, high impact groups such as the military, and mentioned programs such as comprehensive soldier fitness (CSF) and battlemind or resilience training for the U. S. military, and battleSMART (Self-Management and Resilience Training) that is CBT-based for the Australian Defence Force. However, controlled clinical outcome research is lacking and much needed, especially for CSF. They also mentioned with cautious optimism, a pre-event training program for high-risk, high-impact groups.

It should be noted that a more recent meta-analysis of a small number of 12 randomized controlled trials of psychosocial interventions and posttraumatic growth suggested that active intervention can help facilitate posttraumatic growth in people who had experienced adversity or trauma (see Roepke, 2015).

In chapter 11 (pp. 332-363), MacKillop and Gray dealt with controversial treatments for alcohol use disorders (AUDs). They included the following as controversial treatments for AUDs: The Johnson intervention (or "an intervention" referring to a structured confrontation of the person with an AUD by family and friends to persuade him or her to stop drinking and start seeking treatment), Alcoholics Anonymous (AA), controlled drinking as a treatment outcome, and Drug Abuse Resistance Education (DARE). However, they pointed out that there are crucial distinctions among these controversial treatments. The Johnson Intervention and DARE are relatively clear examples of pseudoscientific approaches that have received negligible empirical support or even negative findings. At the other end is controlled drinking which is still often not accepted or used, even though there is evidence for its efficacy for some people. In between is AA, which has received some empirical support for its efficacy for AUDs, but mainly because of its mutual-help group aspects. MacKillop and Gray included the following as evidence-based treatments with empirical support for their efficacy with AUDs: reinforcement-based treatment, cognitive-behavioral treatment (CBT), relapse prevention (RP), motivational interviewing (MI), marital and family treatment, brief interventions (e.g., SBIRT or screening, brief intervention, and referral to treatment), and efficacious medications (i.e., disulfiram or Antabuse, naltrexone or ReVia in tablet form, and in depot injection or Vivitrol, and acamprosate or Campra, all four of which have been approved by the Food and Drug Administration or FDA). They pointed out that while empirically supported treatments for AUDs are now available, there is still a problem with the adoption and dissemination of such treatments more widely in the field.

In chapter 12 (pp. 364-388), herbal treatments and antidepressant medication are covered by Walach and Kirsch, focusing on similar data but with divergent conclusions. They reviewed the empirical research evaluating the efficacy of antidepressant medication, including a meta-analysis involving the use of antidepressant medications such as tricyclics, selective serotonin reuptake inhibitors (SSRIs), and monoamineoxidase inhibitors (MAOIs). They concluded that only modest benefits of antidepressant medications over placebo have been found from clinical trial data. Despite such contrary data, antidepressant medication is still often touted by the health industry to be very effective and should be the frontline treatment for depression. Similar data have been found for the efficacy of herbal treatments or remedies but very different or divergent conclusions have been made from such data. The herbal treatments or phytotherapeutics reviewed include: hypericum or St. John's wort (often used by German naturopaths to treat depression), with mixed empirical findings regarding its efficacy for mild to moderate depression; ginkgo biloba and its use for treating dementia, coronary heart disease, and tinnitus, with mixed results from empirical studies; and kava kava or Piper methysticum, with mixed empirical findings for its efficacy in treating anxiety disorders. Walach and Kirsch pointed out that the relatively small difference between active substances and placebos have resulted in a prejudiced view that herbal remedies or complementary and alternative treatments are "nothing but placebos." Yet a similar data set on conventional antidepressants has not negatively impacted their reputation, which has actually still remained intact and positive. Although different treatments for depression produce similar responses, the risks of such treatments can differ greatly. Antidepressants have side-effects such as sexual dysfunction (in 70-80% of patients taking SSRIs), possible increased risk of suicidal ideation in young people, death in the elderly, miscarriages in women who are pregnant, and autism in the children of those taking antidepressants (see p. 380). Antidepressants should therefore not be used as a frontline treatment, but used more typically as a last resort.

Part IV. Controversies in the Treatment of Child and Adolescent Disorders

In chapter 13 (pp. 391-430) of Part IV of this book, empirically supported, promising, and unsupported treatments for attention-deficit/hyperactivity disorder (ADHD) are reviewed by Waschbusch and Waxmonsky. They included the following as empirically supported treatments (ESTs) for ADHD: Stimulant medications (e.g., by trade names, Aderall XR, Concerta, Vyvanse, Focalin and Focalin XR, and Daytrana); non-stimulant medications (e.g., by trade names Strattera, and alpha agonists Kapvay and Intuniv); behavior therapy (e.g., behavioral parent training, and classroom contingency management); and combined treatments (of behavior therapy and stimulant medication, e. g., the Multimodal Treatment for ADHD (MTA) study). They also described several promising treatments for ADHD that included: peer-directed interventions; self-directed interventions; neurofeedback; cognitive treatments (e.g., verbal self-instruction, problem-solving strategies, and cognitive modeling, and forms of cognitive treatment that focus on enhancing executive functioning skills, including working memory and self-control, using several methods such as computer-based programs like CogMed, physical activity, and school-based curricula); dietary restriction of artificial food colorings and preservatives; and nutritional and dietary supplements (e.g., omega 3 fatty acids). Finally, they included the following as unsupported treatments for ADHD: antidepressants; dietary restriction of sugar and sweeteners; sensory integration interventions; and traditional play therapy.

In chapter 14 (pp. 431-465), Romanczyk, Turner, Sevlever, and Gillis reviewed the status of treatment for autism spectrum disorders (ASD) focusing on the weak relationship of science to interventions in this area. They divided treatments for ASD into two major categories: efficacious treatment and nonefficacious treatments. The efficacious treatment that has received substantial empirical support is intensive behavioral intervention (IBI) or applied behavior analysis (ABA). On the other hand, there are over 400 purported treatments that can be found from websites, with less than 1% of them having any empirical support from outcome research (see p. 440). Non-efficacious treatments for ASD that have received weak or absent empirical support for their efficacy included the following small sampling: vitamin B6; the developmental, individual-difference, relationship-based model (DIR) or "Floortime"; facilitated communication (FC) or "supported typing"; dolphin-assisted therapy (DAT); chiropractic manipulation (for the correction of cranial misalignments); auditory integration training; chelation therapy; gluten--and casein-free diets; hyperbaric oxygen therapy; and sensory integration training.

Romanczyk et al. noted that a positive development in the last decade has been the partnering of many parents, service providers, and caregivers with Autism Speaks (www.autismspeaks.org) which is the nation's largest organization for autism science and advocacy. It seeks to advance and spread the use of empirically supported treatments for ASD, especially IBI or ABA, as well as to advocate for laws that will require insurance companies to fund evidence-based behavioral health science (i.e., IBI) for the treatment of ASD.

In chapter 15 (pp. 466-499), attachment therapy (AT) is covered by Mercer. AT is an unconventional intervention in the mental health field that has been more widely accepted by popular culture than many other interventions. Most clients treated by AT are adopted children and adolescents, and the treatment has unfortunately led to some documented cases of injuries and even deaths (e.g., the death of Candace Newmaker in 2000). Other names for AT include "z-therapy, rage reduction therapy, holding therapy or holding time, prolonged parent-child embrace, or Festhaltentherapie" (p. 466). AT seems to exist in two major versions: the older version (AT1) uses physical restraint and at the same time poking, tickling, or shouting to provoke a child's anger, while the second version or form (AT2) also uses physical contact with a hold that is supposed to be more cradling or nurturing and not restraining, with prolonged mutual gaze or "eye contact" as a major component in both versions. It should be noted that AT is not the same as "attachment-focused therapy" or attachment-based therapy or more conventional relational therapies that emphasize attachment in psychotherapy (e.g., see Wallin, 2007) that do not use the physical methods of AT.

Mercer, after reviewing the empirical research literature on AT, concluded: "The principles and practices of AT are not plausible with respect to established theory and research, nor are they based on systematic evidence meeting stringent criteria. Nevertheless, AT beliefs have been embraced by popular culture and are communicated daily through the internet and other media" (p. 492). Mercer therefore recommended that clinicians need to be educated about alternative psychotherapies like AT since many of them have never even heard of AT, and that public education on early emotional development in children should receive more focus and attention.

In chapter 16 (pp. 500-525), antisocial behavior of children and adolescents is covered by Petrosino, MacDougall, Hollis-Peel, Fronius, and Guckenburg, focusing on harmful treatments, effective interventions, and novel strategies. After reviewing the relevant empirical research literature, they listed the following as examples of harmful (or ineffective) psychological and other treatments: individual casework; peer group interventions; juvenile transfer laws; Scared Straight and other juvenile awareness programs (involving organized visits to prison facilities, usually for adults, to deter or scare juvenile delinquents or youth who are at-risk from future offending); juvenile processing; and boot camps. Effective treatments with empirical support included the following: multisystemic therapy (MST) which is a family-based treatment providing a wide array of services to meet multiple areas of need, using individual, family, peer-based, school, and community-based interventions; functional family therapy (FFT) which seeks to change family interaction patterns, with clearer communication among parents and children, and to reduce conflict between family members, using modeling, prompting, and reinforcement; multidimensional treatment foster care (MTFC) which uses individual-focused therapeutic care for adolescents living mainly in foster care, and parent management training; and cognitive-behavioral therapy (CBT) which includes modification of negative thinking or cognitive distortions that can lead to harmful behaviors, and other interventions such as social skills training, moral reasoning, and management of anger and aggressive behavior.

Finally, the following were listed as novel or untested treatments for antisocial behavior: attachment therapy (see also chapter 15 by Mercer), which uses interventions such as "rebirthing", "reparenting", and "holding"; mentalizing-based therapy (MBT); animal-assisted therapy (AAT), especially using dogs and dolphins; and plastic surgery for juvenile offenders.

The concluding chapter 17 (pp. 527-532) by Lilienfeld, Lynn, and Lohr provided some concluding thoughts and constructive remedies on science and pseudoscience in clinical psychology that can be more widely applied to clinical practice. They proposed six constructive remedies to help cure the problem of pseudoscience in clinical psychology:

1. "All clinical psychology training programs must require formal training in critical thinking skills, particularly those needed to distinguish scientific from pseudoscientific methods of inquiry (p. 528).

2. The field of clinical psychology must focus on identifying not only empirically supported treatments (ESTs), but also treatments that are clearly devoid of empirical support... we must also work toward identifying techniques that are either clearly inefficacious or harmful (pp. 528-529).

3. The American Psychological Association and other psychological organizations must play a more active role in ensuring that the continuing education of practitioners is grounded in solid scientific evidence (p. 529).

4. The American Psychological Association and other psychological organizations must play a more visible public role in combating erroneous claims in the popular press and elsewhere (e.g., the Internet) regarding psychotherapeutic and assessment practice (p. 529).

5. The American Psychological Association and other psychological organizations must be willing to impose stiff sanctions on practitioners who engage in assessment and therapeutic practices that are not grounded in adequate science or that have been shown to be potentially harmful (p. 530).

6. ... the field of clinical psychology must actively address the continued sources of resistance to evidence-based practice among many mental health professionals (pp. 530-531)."

A Christian Perspective on Science and Pseudoscience in Clinical Practice

I have previously written on empirically supported treatments (ESTs; Tan, 2001a), empirically supported therapy relationship (ESRs; Tan, 2003), empirically supported (or based) principles (ESPs) of therapeutic change (Tan, 2007), potentially harmful therapies (PHTs; Tan, 2008), and evidence-based practice in psychology (EBPP; see Tan, 2007), with a brief biblical or Christian perspective on these topics. I have more recently summarized such a biblical perspective in a major textbook on counseling and psychotherapy from a Christian perspective (Tan, 2011; see also Tan, 2001b) that can also be applied more generally to science and pseudoscience in clinical practice, as follows:

" ... biblical guidelines for effective, efficient, and ethical therapy must have first priority. For example, we should use ESTs, ESRs, or ESPs. only if they are consistent with biblical truth, ethics, and values. Whatever contradicts the Bible and its teachings, even if empirically supported, should not be accepted or applied in clinical practice by Christian therapists. The primacy of agape love (1 Cor. 13) as the foundation and center of Christian counseling and psychotherapy means that ESTs cannot be used without ESRs, including the importance of a good therapeutic alliance between therapist and client based on empathy, which is a crucial component of agape love. EBPP is a more comprehensive approach to using ESTs, ESRs, and ESPs. EBPP not only stresses the need to use the best available research. in effective therapy. It also emphasizes the need to use the clinical expertise of the therapist and to incorporate the client's characteristics, culture, and preferences, including religious and spiritual values and preferences. As such, EBPP is relatively more consistent with a biblical perspective on effective therapy. that affirms biblical values and ethics" (pp. 398-399).

An appropriate respect and appreciation for good scientific research (see Worthington, 2010), including the use of randomized controlled trials (RCTs) in evaluating psychotherapy outcomes is important for Christian therapists and researchers, who should be challenged to conduct more and better controlled outcome research on the efficacy of Christian therapeutic interventions as part of religious and spiritual therapies (e.g., see Hook et al., 2010; Worthington, Hook, Davis, & McDaniel, 2011). However, a Christian perspective on efficacy or outcome studies will have a wider view of and broader approach to the research methods used in conducting such studies. As I have previously written (Tan, 2011): "We can value experimental methods such as RCTs without viewing them as the only valid research methods to use. More qualitative research methods such as phenomenological, hermeneutical, and narrative approaches can also be validly used, especially in investigating religious or spiritual phenomena and experiences. even in therapy outcome studies. It is important not to fall into a psychological reductionism that is based too much on logical positivism, which views reality only in physicalistic, naturalistic ways. However, we can still have a healthy respect for good science without embracing scientism (the worship of science and naturalism) and thereby excluding the supernatural or spiritual realm" (p. 399).

Siang-Yang Tan

Fuller Theological Seminary

References

Hook, J. N., Worthington, E. L. Jr., Davis, D. E., Jennings, D. J., II, Gartner, A. L., & Hook, J. P. (2010). Empirically supported religious and spiritual therapies. Journal of Clinical Psychology, 66, 46-72.

Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (Eds.). (2003). Science and pseudoscience in clinical psychology. New York, NY: Guilford Press.

Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (Eds.). (2015). Science and pseudoscience in clinical psychology (2nd ed.). New York, NY: Guilford Press.

Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2014). Why ineffective psychotherapies appear to work: A taxonomy of causes of spurious therapeutic effectiveness. Perspectives on Psychological Science, 9, 355-387.

Norcross, J. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York, NY: Oxford University Press.

Roepke, A. M. (2015). Psychosocial interventions and posttraumatic growth: A meta-analysis. Journal of Consulting and Clinical Psychology, 83, 129-142.

Tan, S. Y. (2001a). Empirically supported treatments. Journal of Psychology and Christianity, 20, 282-286.

Tan, S. Y. (2001b). Integration and beyond: Principled, professional, and personal. Journal of Psychology and Christianity, 20, 18-28.

Tan, S. Y. (2003). Empirically supported therapy relationships: Psychotherapy relationships that work. Journal of Psychology and Christianity, 22, 64-67.

Tan, S. Y. (2007). Empirically based principles of therapeutic change: Principles of therapeutic change that work. Journal of Psychology and Christianity, 26, 61-64.

Tan, S. Y. (2008). Potentially harmful therapies: Psychological treatments that can cause harm. Journal of Psychology and Christianity, 27, 61-65.

Tan, S. Y. (2011). Counseling and psychotherapy: A Christian perspective. Grand Rapids, MI: Baker Academic.

Tan, S. Y. (2012). Principled, professional, and personal integration and beyond: Further reflections on the past and future. Journal of Psychology and Theology, 40, 146-149.

Wallin, D. J. (2007). Attachment in psychotherapy. New York, NY: Guilford Press.

Worthington, E. L. Jr. (2010). Coming to peace with psychology: What Christians can learn from psychological science. Downer's Grove, IL: IVP Academic.

Worthington, E. L. Jr., Hook, J. N., Davis, D. E., & McDaniel, M. A. (2011). Religion and spirituality. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 402-420). New York, NY: Oxford University Press.

Please address all correspondence to: Siang-Yang Tan, Ph.D., Professor of Psychology, Graduate School of Psychology, Fuller Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101; siangyangtan@fuller.edu

Siang-Yang Tan, Ph.D. (McGill University) is Professor of Psychology at the Graduate School of Psychology, Fuller Theological Seminary in Pasadena, CA, and Senior Pastor of First Evangelical Church Glendale in Glendale, CA. He has published numerous articles and 13 books, the latest of which is Counseling and Psychotherapy: A Christian Perspective (Baker Academic, 2011).