Book Review-House of Cards: Psychology and Psychotherapy Built on Myth

What would you do if you worked in a profession that ignored its own best practices? What if your industry claimed to be able to do things that they simply couldn’t do? How could you move a profession forward when you knew that most of your colleagues weren’t in the know? I’m not talking about one of my professions, software development, instead I’m talking about psychology and the spot that Robyn Dawes found himself in. (Most software developers haven’t bothered to pick up a single book on software development theory or practices.) Dawes’ response as a concerned professional and an educator was to focus on what he knew is right in his classrooms and to write a book about the problems with his industry – House of Cards: Psychology and Psychotherapy Built on Myth.

I’ve personally seen the good and the bad of psychology. I’ve reviewed The Heart and Soul of Change which focuses on what works in psychotherapy. I’ve also seen the dark side as I reviewed The Cult of Personality Testing and Science and Pseudoscience in Clinical Psychology.
I believe, as Dawes does, that there are ways to help people through psychology; but I also understand that the difference in efficacy between those who are substantially trained and have years of clinical experience compared those who are only minimally trained is trivial. In short, even though we have built a profession around psychology, it’s not a profession whose techniques drive performance forward – at least not yet.

Crystal Balls

The greatest challenges to psychology don’t come from therapy. They don’t come from how the profession helps people – though, as mentioned above, the efficacy differences are minimal. Where the greatest challenges come from is when psychology oversteps the bounds of what is known and what isn’t known. Despite plenty of evidence to the contrary, “psychology experts” testify about the future behaviors of subjects. They state that they know how people will behave in the future even though the research proves this isn’t possible.

Perhaps they have the magical crystal ball that can see into the future, and they’re hiding their prize possession, cloaking it in the mysticism of psychology. In truth, there is no absolute predictor. Anyone that states that they know with certainty the future behavior of another person is a liar. They’re either lying to themselves and others or they’re just lying to others.

Though Dawes goes into length about the problems with the projective techniques that many psychologists use to make these predictions, I won’t reiterate the problems with projective tests – I’ve got rather complete coverage of these problems in The Cult of Personality Testing.

However, one thing that’s important is discussing the limits of identifying personality types. Even comprehensive systems of cataloging values and their relative importance, such as Reiss’ system covered in Who am I? and The Normal Personality, don’t have the predictive power. Paul Ekman explains in his work with micro expressions that you can identify the emotion but not the cause. (See Emotional Awareness for more on Paul Ekman’s work.)

In other words, even the best models for people – either based on values or on observable phenomena – aren’t able to predict behavior in the future. The reality is that we all have scars from our past. We have places of brokenness. No tool, conversation, or therapy can discover all of these wounds. We can’t even discover these wounds ourselves. We have to simply live life and confront our wounds as they surface. When the wound is triggered, the person will seek to relieve that pain – often unconsciously. However, stating what an alcoholic will do, whether they will take a drink or call a friend when they’re struggling is just a guess., It’s not a guess that anyone should take seriously.

Discover the Truth

Licensing

Every state has been licensing psychologists since the 1970s. The fundamental idea being that the licensing procedure protects the public from charlatans and con men who would trick them out of their money and provide no value. The requirements are generally high: a doctorate degree and years working with a licensed provider. The model resembles the medical model in that there is a sort of residency (supervisory period) but that’s where the similarity ends. There’s scant evidence that the residency (supervisory period) is useful.

Instead of protecting the public and insisting that professionals behave in ways that are consistent with best practices, professionals are allowed to continue to utilize techniques which have been repeatedly disproven. The licensing process serves to create a barrier to entry, but it doesn’t serve as a way of ensuring a level of performance.

I was having a conversation with a psychologist friend some years ago, when I shared with him that I enjoyed being of help to others, and that I was lightly considering the idea of becoming a licensed psychologist. His advice: “Don’t do it.” When I probed on the issue, I realized that he didn’t feel like his peers did anything with the licensing process except make it difficult. This, he felt, was to protect their revenues. His suggestion was that I pursue “coaching”. Dawes points out that you can’t prevent people from providing assistance to others for a fee, so consulting and coaching are always an option.

Coaching, as it turns out, is a very viable alternative. In fact, another friend who was previously licensed marriage and family counselor but decided to let his license lapse has become a coach – because it’s easier. The only disadvantage to not being licensed? You can’t accept payments from third party payers, including insurance and the government. In most cases, this isn’t a kind of payment that psychologists want even though it can be lucrative.

To reform psychology, it seems like it may be necessary to change the licensing procedure from the ground up, to require that psychologists only use research-supported techniques, or tell their clients when they’re not. As it turns out, I’ve read the ethical guidelines from the American Psychological Association (APA). While their standards state these things, it appears that, in practice, their members and the licensed psychologists in each state are rarely held to these standards.

Licensing as a Minimum Bar

The key to licensing is the same key as to certifications with which I’ve had a lot of experience. A certification is most simply defined as “meets a standard.” The question that should be in everyone’s mind is, what standard are they meeting? In truth, standards for IT tests are based on a group of purported “experts” – some of which, I can assure you through my direct experience, are not – who create the desired skill set. The next step after the skills identification is question writing. When this is done, a beta testing period is created. During this beta period, candidates complete the test without receiving their scores immediately.

Psychometricians then process the data and eliminate questions that don’t meet standards for consistency – either because the supposed right answer doesn’t match the answers given by the most highly qualified candidates or the highly qualified candidates didn’t get it right often. Then the passing score – and thus the standard for the test – are set using psychometric methods designed to provide a reasonable pass/fail rate. Ultimately this process is designed to establish the minimum bar for what certified professionals must know.

The hidden challenge here is that it’s an average standard across all of the testing objectives. There may be certain areas where the candidate has zero skills. This is particularly common when testing scopes are set too broadly.

The reality of IT certification testing, which I’m familiar with, is that it’s far more predictive of the desired skills than the kinds of tests created for state licensure. That’s because of the much larger pool of candidates that can be drawn across the country than could possibly be pulled for the psychologists in a single state. After all requirements for taking a beta test would be the same high requirements of licensure.

While all certifications and licensing has some value, it’s unclear how one could determine what the minimum bar is that the licensure is measuring.

Learning and Experience

What do stock traders, politicians and psychologists have in common? The fact that getting good, reliable feedback about their solutions is very hard. This lack of good feedback creates an illusion of good practice where none exists. It creates the illusion that you’ve discovered a way to help folks solve a problem, when differences in performance in any of these categories is minimal and random.

The key problem with psychologists isn’t that they’re not good people. The key problem is that the dynamics of the environment make it hard for them to become better. By interrupting the feedback cycle that we all need in order to learn, they’re losing their ability to improve their practice. Because psychological services are unique, and monitoring would be required to have others improve their practice, and such monitoring is difficult and can interfere with the therapeutic effects, very little is done. (See The Heart and Soul of Change for the relative impact of patient-therapist alliance.)

The other barrier to learning (as discussed in Peak) is that there isn’t a clear set of standards as to what constitutes the principles of practice. With bad feedback cycles and a lack of clearly defined principles of practice, psychology is missing the requirements necessary to get better.

American Psychological Association

The APA is the functional equivalent of the American Bar Association (ABA) for lawyers. Lawyers are admitted to the bar in each state by demonstrating professional competency, and in order to practice in the state they must be a member. While states don’t necessarily require APA membership to be a licensed psychologist, in most states the ethical standards that are used are the standards of the APA.

The APA has a history of well-intended, visionary leaders who had the desire of making help available to everyone. This well-intentioned interests poured fuel on the self-help movement, as was discussed in Science and Pseudoscience in Clinical Psychology. Through the years, there have been leaders who have tried to elevate the practice of psychology through the power of the organization. Unfortunately, there hasn’t been enough attention to the transfer of knowledge from the researchers who are doing research about efficacy of treatments and the practitioners who are seeing patients.

A more challenging concern with the organization is that it seems unable (or unwilling) to ensure the standards of practice are being met.

Statistical Probability

Everyone needs to feel like they’re unique and different. That in some way they’re special. This is a part of our need for acceptance: the balance between being similar enough to be liked and different enough to be special. This desire to be special means that we’re often pushed into believing that the statistical norms don’t apply to us. At some level that’s true. Averaging people tends to eliminate their differences, which can be a bad thing when it leads to unexpected results (see The Black Swan.) However, from the other perspective it allows us to say what works for most people in most situations.

The value of using statistics to record probability is that it allows us to know what seems to work and what doesn’t seem to work in most cases. In short, it allows treatments to be identified as useful or not. Studies have proven that psychologists who rely upon the statistical probabilities of treatments, and who treat patients in the manner which is statistically most likely to succeed, do in fact get better outcomes.

Despite claims to the contrary by experienced psychologists, their predictive capabilities are limited by their imperfect and skewed experience with poor feedback, and as a result, their results with patients are poorer than if they trusted the statistics and went with them.

As a pilot, I’m trained to believe my instruments even when my feelings and beliefs are different. Obviously, I have to cross check instruments to make sure there is no error; however, I’ve learned to trust my instruments more than I’ve learned to trust myself. Most psychologists haven’t been taught this important lesson.

Alleviating Distress

Psychology is supposed to be about eliminating mental distress. However, the evidence points to greater distress today than there was in the past. In fact, according to Leading from the Emerging Future, suicide rates in the last 45 years are up 60%. Other statistics are equally concerning. If psychology is effective at reducing mental destress, at the very least we know that its current levels of efficacy aren’t sufficient.

We know from studies that there is some level of effect conveyed by psychological help, though the effect size still appears to be relatively limited. As House of Cards says “If treated, a cold will go away in seven days, whereas if left alone, it will last a week.” In other words, there seems to be little impact on treating a cold. Many of the psychological symptoms that people come in to seek help with have similar profiles.

The Necessity of Guilt

In Changes that Heal, Dr. Cloud asserts that guilt is a major barrier to growth. There I disagreed, and since then I’ve spoken about the difference between guilt and shame while discussing Brené Brown’s work. (See The Gifts of Imperfection, Daring Greatly, and Rising Strong (Part 1 & Part 2) In short, shame is “I am bad”, and guilt is “I have done bad”.

Dawes makes a point that a society without guilt (as some people propose would be good) would be a society of psychopaths. If we didn’t have any guilt for our actions, how would we maintain the standards of society? If we felt no pangs of pain, because we didn’t feel guilty about the things that we’ve done or the people we’re harmed, we’d do only what is good for us – and would have the behavior of a psychopath.

The Psychology of Victimization

Dawes makes the point that much of what is done to convince people that they’ve been abused through intensive therapy trying to recover these memories (which can’t be recovered) only creates the perception that they were abused, whether that is truth or not. Further, he indicates that, once people believe they’ve been abused, they’ll behave as if they have been abused even if they never were.

The challenge with this is that the focus on the abuse is the victim component. This has the effect of immobilizing people and preventing them from taking action. I’ve discussed before how problematic victimhood is. (See Boundaries, Beyond Boundaries, Daring Greatly and Change or Die.)

Only Rational Thought Can Be Responsible

Perhaps the problem is that psychology hasn’t decided what it’s doing yet. I’ve stated that I love the Rider-Elephant-Path model to describe the relationship between emotional and rational components of our thinking. (See The Happiness Hypothesis and Switch for more on the model.) However, psychology hasn’t figured out how to address the periods when the elephant is in control. Whether it’s called irresistible impulses or temporary insanity, there are places where psychology hasn’t figured out what to do. Maybe you can get a clearer picture if you read House of Cards.