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Rants and Raves

 

Herewith, occasional and largely informal commentary on issues relating to psychology as a discipline and a profession, including mental-health policy issues.

 

Mental Health Parity

Link to a letter to the editor published in the New York Times (December 15, 2001), and expanded commentary.

 

Truth Serum

Link to a letter to the editor of the Wall Street Journal (submitted June 20, 2002).

 

On Changing the Name of the American Psychological Society

A very ill-conceived idea.  Link to PDF.

 

Great Books in Psychology

On January 13, 2005, I circulated a message to three listservs, the Society of Experimental Psychologists, the Society for a Science of Clinical Psychology, and the Society for Personality and Social Psychology, inviting listmembers to contribute short lists of fondly remembered, perhaps life- or career-changing textbooks, read either as undergraduates or graduate students, along with a sentence or two about the effect they had on them.  Link to the results of the poll.

 

Social Neuroscience

Does Neuroscience Constrain Social-Psychological Theory?  Link to an invited commentary published in Dialogue, the newsletter of SPSP (2006).

 

On EBPs in Mental Health

Regarding my chapter in the volume, Evidence-Based Practices in Mental Health, a few individuals have written to question my strong position favoring EBPs.

Correspondent #1:  I am a graduate student... reading Evidence-Based Practices in Mental Health.  In reading your paper, entitled "Scientific Research", I was struck with a few questions that I am hoping you may be able to answer.
You make the statement that until very recently the medical profession had few effective treatments for diseases, thus most treatments were palliative in nature.  Your implication is that this treatment is not effective and certainly not respected.  Of course ideally treatments in both the medical and psychological profession would "cure" patients, but it is often not a possibility.  When that is the case, how is it not beneficial to receive palliative care for physical or mental ailments?  

I don't mean to imply that palliative treatments aren't effective and not respected.  When a disease is incurable, palliation is one possible approach.  But I think that the goal of medicine, including mental health, should be to move beyond palliation with all deliberate speed -- to cure disease when possible, and when it is not, to maximize symptom relief; actively help the patient manage chronic illness, and promote rehabilitation where appropriate.  In many cases, there is much more that we can do besides palliation, and when there is, we should do it.  And I think that where palliation is the choice, the provider has the obligation to make sure that the palliative treatment actually   -- well, palliates.  So even in the case of palliative care, we need EBPs to make a rational choice among treatment options in the best interests of the patient.  Palliative treatments that work are beneficial. Palliative treatments that do not work are not, and should be abandoned.

You state that insurance companies and managed care will be more likely to reimburse clients for services proven to be EBPs or ESTs, however hospice coverage is widely available.  In roughly 47 states it is provided by both Medicare and Medicaid and by many private providers.  If palliative care is covered for medical conditions why is it not covered for mental conditions? 

Yes, but hospice care is an extreme measure, to ease the situation of a dying patient for whom nothing more can be done.  Excepting suicide, nobody dies from mental illness, so hospice care is not a good analogy.  Whether MD or PhD, the doctor's first task is to do no harm; his/her second task is to make the patient well, or at least better.  Now, it may be that in some cases of chronic mental illness, long-term hospitalization is the best alternative for the patient, and these costs should be reimbursed by third-party payers, just as long-term hospitalization for, say, polio or tuberculosis would be (it is clear now that it was a mistake to empty the state mental hospitals, instead of improving the conditions of the patients housed in them).  But even in that case, I believe that there is an obligation to deploy EBPs directed toward management and rehabilitation (which is what should have been done).

You also make the statement that patient values are important, but not as important as scientific evidence.  I strongly disagree with this assertion.  Patients have a right to seek out whatever medical treatment they wish.  Eastern and Western medicines are both used in this country.  Why can't there be multiple types of therapies as well?  How is the opinion of the client in terms of their improvement not the most valid marker of the improvement?  

I stand by my statement.  Patients have a right to seek out any treatment they wish, and to pay for it out of their own pockets; but providers have an obligation to provide treatments that are effective, and third-party payers are under no obligation to pay for treatments that are ineffective.

My position is very simple: the status of clinical psychology as a profession, including its autonomy from psychiatry and its eligibility for third-party payments, depends on its adherence to its scientific base.  Or, put another way: if someone had cancer, or heart disease, they'd insist that their doctor try a proven method.  Why would anyone treat their mind differently than their body?

 

Correspondent #2 wrote: "In his 2006 PsycCRITIQUES review of the volume Evidence Based Practices in Mental Health, Sher expressed his concern about the lack of the consumer viewpoint...."  S/he also enclosed a manuscript which discussed clinical trials from a statistical and consumer vantage point.
Ken Sher is right that the book didn't explicitly contain an expression of the consumer viewpoint, but I thought that I at least addressed some consumer-oriented issues in my contribution, where I discussed the  Rosenblatt/Atkisson framework for evaluating outcomes (p. 29).  The implication of their "cube" is that there are actually a lot of different consumers of mental health services, not just the individual patient, and each of them probably evaluates the outcome of treatment according to different criteria.
"There are many consumer-oriented issues related to psychotherapy and evidence-based practice; some were very briefly touched on in the volume, but this is a very broad area that warrants much more discussion -- perhaps to the extent of a volume of its own. For example, the Rosenblatt/Attkisson paper addresses these issues for severe mental illness, which is quite different from the more ordinary issues a typical clinical psychologist deals with in everyday practice.  As I mention in my first paragraph, "No one client can expect to represent all, but this client would like to provide some commentary on the volume in the hope that it might be seriously considered by at least some in the mental health profession." As you will see, one way in which I am not a typical client is that I have a decent statistical and scientific background, and consequently bring up questions of statistical validity in clinical trials."

I agree that clinical trials pose some difficult statistical issues, epitomized by the difference between statistical and clinical significance, and the fact that we're dealing with average outcomes, which may hide the fact that even an effective treatment doesn't work for everyone who gets it.  But these problems shouldn't serve as an excuse for doing nothing about the scientific basis of clinical practice -- which, frankly, is the position taken by a number of leading figures in the American Psychological Association, some of whom are authors in the Norcross book.  As I've said many times, clinical psychology owes its professional status, including its autonomy from psychiatry and its eligibility for third-party payments, to the assumption that it's practices are justified by a firm scientific base.  But all too many of the leaders in clinical psychology want to practice business as usual.

I'll defend the Rosenblatt/Atkisson cube as a model for representing consumer interests in EBP.  Yes, they focus on severe mental illness, but their basic point is that in any case of mental illness, there are a number of different consumers -- the patient him- or herself, his/her family, employer and colleagues, neighbors and the larger community, all of whom have an interest in whether the patient gets well.  Whoever the consumer is, beginning with the patient, consumer interests are best served by providing services that are both effective and cost-effective.  And the only way we have to identify those services is scientific research, modeled on clinical trials.

 

Ulric Neisser, Social Cognitive Psychologist

Link to some comments on the "godfather" of cognitive psychology, who died on February 17, 2012.

 

Free Will and the Libet Experiment

On July 14, 2012, I sent the following letter to the Editor of the New York Times Book Review, concerning a review by Daniel Menaker of Free Will by Sam Harris. Daniel Menaker seems too willing to accept Sam Harris’s conclusion that free will is an illusion – and not even a necessary one, at that (“Have It Your Way”, July 15, 2012). But the relevant science does not support Harris’s view. Benjamin Libet is no longer alive to defend his experiment, but the latest evidence indicates that his results were wholly an artifact of his procedures. And while a host of evidence in cognitive and social psychology shows that automatic, unconscious processes play some role in our experience, thought, and action, none of it demonstrates that they overwhelm conscious control. So Harris's arguments about free will are based more on ideology than evidence. How free will works is indeed a problem for neuroscientists. But they’ll never solve it so long as they keep denying it.

 

Duncan Luce (d. 2012)

Duncan and I didn't have too much in common: I barely can do a t-test, after all. But he was a great colleague during my time at Harvard. I was appointed in the Personality and Developmental Studies area, at a time when the Department was just being put back together and those institutional distinctions actually still meant something. But the only available office space was on the 9th floor of William James Hall. A big corner office, and I was happy to have it, but it was embedded in the Laboratory of Psychophysics, where I felt a little like a fish out of water. Maybe it was the Penn Connection, but Duncan and Dave Green (and Douwe Yntema and Edwin Newman) were very friendly and supportive, and even invited me to Fechner Day celebrations. Later, after I had left Harvard, I had the privilege of working with Duncan on an NRC project to identify the "Leading Edges in Behavioral and Social Science". There I learned just how broad Duncan's interests were -- it turned out that we had more in common than I had imagined at the outset.

 

This page last revised 08/14/12 02:10:37 PM.