Friday, January 2, 2015
Several days ago I received a message from Change.org about a petition whose goals I certainly share, but I hesitated to sign it because of some of the language used and its implications, As far as I can tell, these messages only allow you to join or stay out of the petition, rather than to comment or suggest statements. Yesterday I received a comment on this blog from reader Marianne M., and I responded to her, but I’m going to go into this further today. (If you read my response to Marianne’s message, at http://childmyths.blogspot.com/2014/12/mistaken-attachment-beliefs-persuasion.html, please excuse some repetition here.)
The Change.org petition was triggered by the suicide of a girl who had been subjected to Conversion Therapy, the “alternative psychotherapy” claimed to alter sexual orientations, now illegal in several states for mental health professionals to use with minors (but legal everywhere when practiced by members of the clergy). Marianne commented on the text of the petition as follows: “Children in distress should have access to *RESEARCH”-based therapies to help them with their depression and/or other mental health issues. Conversion Therapy is quackery at best. Torture under the name of ”therapy” at worst. It should be banned, as should all other therapies applied to under-age children, until supported by research. We control substances that treat mental health through the FDA. Why shouldn’t other treatments be effectively regulated?” [1/4/14 PLEASE NOTE that in writing this I originally confused a statement that Marianne M. had made with the actual text of the petition, so read this para as a more general comment on whether it's possible to prohibit all but evidence-based therapies.--JM]
Let me begin my comments by saying that Conversion Therapy is very much an “alternative psychotherapy”. It has no basis in outcome research; it is implausible in the sense that it is incongruent with well-established principles of emotional development; and it has been associated with harm and distress to clients. Because commercial speech is so well protected in the United States, I doubt that we can ever prove that the treatment is fraudulent when used with adult patients or prohibit it by law for adults, but legal protection for minors is much easier to establish, and this fact has permitted legislation to prevent mental health professionals from using the method to treat minors. I applaud that legislation and hope that more states will pass similar laws.
But why am I hesitating about the rest of the language about research bases, when I’ve put so much energy into fighting Attachment Therapy and other alternative child psychotherapies? Although I agree strongly with the petition’s aspirations and Marianne M.'s comments, I have two problems with the suggestion that an evidentiary foundation for a psychotherapy shows that it is a desirable practice. One is that I am not at all sure what everyone means by research-based therapies. There are several levels of research evidence that can be adduced to support the effectiveness of a treatment. The use of the terms “research-based” or “evidence-based” has become exceedingly vague outside disciplines like psychology that use these terms technically. Proponents of some treatments call their methods “evidence-based” when the research is at a much lower level than what that term technically means. Others call a program “evidence-based” when only one of many components meets this standard. This is not how it should be, but is how it is.
To establish the highest level of evidence for a child psychotherapy is difficult, time-consuming work, and most treatments now in use fall short of having that level of evidence. Some have never been subjected to systematic investigation. Legislation prohibiting the use of treatments with weak or no evidence bases would potentially make criminals of therapists who used Dance and Movement Therapy or Sensory Integration Therapy with minors. Although in a perfect world this might be a desirable outcome, I don’t see such legislation as being supported by professional groups in the foreseeable future.
So, I am worried about defining what is “research-based” and about the logical outcome of legislation banning child psychotherapies that are not well-supported by research evidence. But I have another worry too, about a concern that I would place at a higher level even than the need for evidence-based treatment. This concern has to do with adverse events associated with a child psychotherapy. It’s well-known that medical treatments, even those that are effective cures for a problem, may have side effects that can range from dandruff to death. It’s less well-understood that psychological treatments can also have side effects. Awareness of this fact advanced with news about child deaths associated with Attachment Therapy/HoldingTherapy. A 2013 paper by Michael Linden, “How to define, find,and classify side effects in psychotherapy: From unwanted events to adverse treatment reactions” (Clinical Psychology and Psychotherapy,4, 286-296) did an admirable job of spelling out the adverse events that can accompany psychotherapy. Linden proposed an event he referred to as the “emotional burden” of psychotherapy-- distress and unhappiness caused by the treatment, but not necessarily needed as an instrument of change. Linden pointed out that if there are treatments that do not involve making people cry and feel unhappy, those treatments that are emotionally painful should never be chosen.
I believe that , wonderful though the goals are, it's a mistake to focus on the research basis of child psychotherapies before considering the problem of adverse events from suicide to unnecessary emotional pain. In my opinion, regulation of psychotherapies should begin with examination of their actual or potential adverse effects—of which Conversion Therapy has many. Prohibiting the use of treatments associated with adverse effects is a most important first step in controlling the use of therapies whose evidence basis may not be well established. Legislation or regulatory guidelines based on the potential harmfulness of a child psychotherapy would be far easier to put into place than regulation on the basis of outcome research evidence. I would be very happy to sign a petition that took that approach rather than using the language as presently written.
In closing, though, let me note once again that prohibition of Conversion Therapy by legislation has affected only mental health professionals. To prevent members of the clergy from doing this “treatment” would require a major First Amendment battle and would probably work only if there were more suicides to function as poster children for this issue. For myself, I do not know that I would want to win the victory on those grounds.