Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Friday, September 30, 2011

Authority versus Evidence: Arguing About Adoption and Psychological Interventions

Off and on for a couple of years, but especially in the last few months, I’ve found myself upholding the idea that there must be an evidence basis for treatment, against others who believe that statements by people who claim authority are the most powerful of all arguments. I’ve referred to this conflict as a “culture war”, and I am convinced that it is an argument between ideological, a priori assumptions about the world, on the one hand, and positions based on systematic observations and evidence, on the other-- same old Plato versus Aristotle, if you like.

Von and other adoption bloggers argue strongly for a Primal Wound, on the basis of their own experience and on the authority of Nancy Verrier (who, incidentally, has not yet answered the questions I asked a month or so ago). They reject the systematic research evidence provided by Michael Rutter and the English-Romanian Adoptees Project or by other investigators, showing that most adopted children, even those adopted late and after intense social deprivation, do quite well in the long run. For Von and friends, the vividness of personal experience and the statement of an authority establish a set of assumptions that do not need to be tested against other evidence. For Rutter and other researchers, evidence is to be explored carefully as a test of existing assumptions.

Valle Oberg, a proponent of Ronald Federici’s methods of dealing with post-institutionalized children, also appeals to authority as the foundation of her argument. She states (in comments on this blog) that Federici has worked with thousands of children (although the arithmetic on this does not seem to work out very well) and has “saved” them, and that her own children were among those. Therefore, she argues, what she says, and what Federici has said, must be correct. In addition, she proposes that peer-reviewed publication of outcome research is not evidence that methods are effective. Oberg dismisses the view that Federici needs to report his evidence to the public before his methods are said to be effective.

While mulling over these disagreements, I came across a letter to the editor published in Science in 2004 (a silent testimony to the number of papers on my desk). That LTE was in response to discussion at that time about hormone replacement therapy and the way it failed to provide the benefits to heart health that had been expected of it. The authors, Philip Guzelian and Christopher Guzelian, pointed out that it was not surprising or anomalous that the predicted results did not occur. They commented that the outcome was a “dramatic example of the difference between authority-based conclusions (arising from opinion, experience, intuition, judgment, and scientific inference)… and evidence-based conclusions (derived from an objective, unbiased, and systematic analysis of scientific knowledge)… The lesson is quite generalizable. Uncritical acceptance of authority-based opinions as conclusive evidence is pervasive, even though top authorities unsuccessfully predict what scientific knowledge will be preserved as ‘fact’ “. Guzelian and Guzelian noted that there are times when decisions need to be made without adequate scientific evidence, but warn against confusing them with evidence-based conclusions and propose that “the obvious solution is to explicitly acknowledge when shortcomings in the amounts or quality of evidence necessitate a reversion to authority”.

An important point in the contribution of Guzelian and Guzelian is the acknowledgment that evidence-based conclusions are not always available. Those authors were not talking about psychological interventions, but that acknowledgement is an important one in discussion of psychological treatment, where design and implementation of research can be extraordinarily challenging. Although Guzelian and Guzelian did not mention levels of evidence (the idea that some forms of research offer stronger arguments than others), they did imply the need to balance evidence and authority differently in different situations. When evidence is strong, it should be weighed far more heavily than authority; when evidence is weak or non-existent, authority and personal experience are better to rely on than flipping a coin or casting the I Ching.

Perhaps the most important message in the Guzelians’ letter is the need for explicit statement that in the absence of systematic evidence, one is appealing to authority for support of a claim. This is only appropriate, of course, if there is no evidence or if the existing evidence is weak or open to interpretation, and if the maker of the claim can show that this is the case. It is not sufficient to do as Von, Valle Oberg, and many others have done-- to ignore the existing evidence and put forward instead a contradictory claim based on authority, and not only authority, but the authority whose views are welcome.

But, of course, if your way of thinking is to appeal to authority, this will make sense to you only if stated by an authority of your choice.

9 comments:

  1. Interestingly enough I do not ignore existing evidence, never have and am surprised you have made that assumption.What I and my fellow adoptees find to be true from our own experiences will never be tested as no experiment will ever be approved by an ethics committee.Some experiments such as the 'stranger at the door' have sailed very close to the wind and in my view are unethical.That is a very convenient position for those who do not support our views to find themselves in.

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  2. When I say evidence, I mean events that other people can observe, not just my personal experience. I wouldn't demand experimental work for most of these issues-- somewhat lower levels of evidence are commonly accepted, but you need to make it clear that it is a lower level of evidence.

    This is the second time you've said the "stranger" technique is unethical. Why do you think so, given that there must have been informed consent from the parent? Would you also say that the Strange Situation procedure is unethical?

    Do you consider it ethical to use unvalidated treatment methods or to claim that they're known to be effective?

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  3. I don't know if you have been following the Conrad Murray trial in the death of Michael Jackson, but some of the testimony is providing a powerful illustration of what happens when people place blind trust in authorities and "experts" as they are often encouraged to do. Kenny Ortega provided testimony that he could see something was obviously terribly wrong with Michael and yet when he expressed his concerns to Conrad Murry, Ortega testified that Dr. Murray's response was basically, trust me, I'm the expert. Given the evidence that is coming out, that kind of misplaced trust in authority may very well have contributed to the death of Michael Jackson. I have to wonder, what if people had stood up to Dr. Murry, insisted something was very wrong and demanded that something be done or at the very least, have another doctor offer a second opinion? We'll never know, but I have to wonder. This is not to blame Kenny Ortega or others, though, because this is what people in our society are conditions to do -- place blind trust in authority.

    Next time someone who is engaging in a practice that, to the average lay person, looks really abusive and/or harmful, I hope people will think twice before putting trust in a person, simply because they declare themselves to be an "expert" and demand trust. Trust needs to be earned by offering sound evidence and it is high time we hold licensed professionals accountable to do so.

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  4. It's interesting, though, that people don't seem to think trust is enough for physics and chemistry , but they do trust "authorities" on medicine and psychology. I just came across a guy named Maximilian Toch, who in the 19th century apparently successfully fought the "authority" concept in chemistry. Today we have David Sackett and others trying to do more of the same-- but not yet with complete success.

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  5. I would think that Michael Jackson would have to be held somewhat accountable for his authority of choice, just like everyone else who makes the decision to place their faith/trust in figures of authority who will tell them what they want to hear, or in Michael Jackson's and others' cases, give them the drugs they want to take.

    This is not to say these authorities have no culpability. They do, especially when they may have created a situation that has gotten out of control, taken on a life of it's own, and turned people into addicts, given people permission to impose dangerous questionable therapies on others, or influenced impressionable people to feel or believe in something harmful they may never have thought of if not for the authority's influence and the societal pressure to assimilate.

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  6. "Why do you think so, given that there must have been informed consent from the parent? "

    What do you mean by that?

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  7. Mei-Ling, this is what I mean: before Zeanah and Smyke could do a study in which they came to people's front doors and asked children if they wanted to take a walk, they would have to have their research proposal vetted for ethical and other issues by their university's Institutional Review Board, a group made up of individuals from various disciplines, usually including someone with a focus on religious concerns. They would have to show the IRB an informed consent document (to be read and signed by parents) that described what would be done and the advantages and disadvantages of participating. The IRB members would examine the document and might ask for wording to be changed to make it easier to understand. Only if parents agreed to participate and signed the document would their children be included in the study.

    Not only would it be necessary for the IRB to agree that the procedure was ethical on all points, including the genuineness of informed consent, but both the IRB and the researchers would consider practical issues. In the case of the "stranger at the door", it would be essential that the parents knew what was happening and agreed to it. Otherwise they would do what anyone else would do if a stranger walked up to the front door and asked their child to go for a walk-- scream, slam and lock the door, and call the cops! Even if there had been no requirement to consider ethical issues, informed consent would have been necessary in order to carry out this study at all.

    But there is a requirement in any university, hospital,or similar institution that receives Federal funds, that all research on human beings is approved by the IRB. In addition, most professional journals refuse to publish work that should have included informed consent documentation, if it has not done so, or if it has not been passed by an IRB. IRBs are especially cautious about research involving children.

    I would still like to see Von's opinions on the ethical issues I mentioned above.

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  8. Thank you Jean.My view is that parents as we all know often do things that are unethical, particularly under pressure. If something they are asked to do by researchers goes against what is responsible parenting then in my book it is unethical.

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  9. By "unethical" do you mean simply "wrong"? If not,if you use "unethical" with a specific meaning, can you say what ethical principles are violated by this procedure? And are there other research methodologies that you also think are unethical-- like the Strange Situation, for instance?

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