The Rumors of My Death Have Been Greatly Exaggerated
Review of The Death of Psychotherapy: From Freud to Alien Abductions by Donald A. Eisner
Donald A. Eisner's The Death of Psychotherapy (2000) is an ambitious but ultimately unsuccessful review and critical analysis of the threats posed by pseudoscientific treatment methods in clinical psychology, psychiatry, and other mental health disciplines. The author, a licensed psychologist and attorney, takes aim not only at the burgeoning industry of New Age and fringe psychotherapies, but also at the widespread claims of efficacy emanating from the field of mainstream psychotherapy. The end result is an occasionally enlightening and engaging, but often less than rigorously reasoned, evaluation of the contemporary state of psychotherapy.
On the positive side, Eisner's book covers a good deal of useful ground and should serve as a helpful starting point for individuals who are undertaking investigations of largely untested psychotherapies. Perhaps the book's greatest strength is its wide-ranging historical perspective. Eisner takes readers on a guided tour from Freud and the early days of psychoanalysis through such contemporary therapeutic approaches as recovered memory therapy, Thought Field Therapy (TFT), and eye movement desensitization and reprocessing (EMDR). In the process, he helps to elucidate some of the theoretical underpinnings of today's unsubstantiated psychotherapies.
These positive features, however, are overshadowed by the book's numerous shortcomings. First and perhaps most important, Eisner paints his critical palette with too broad a brush. In particular, Eisner does not provide readers with sufficient research-based information to distinguish scientifically appropriate from inappropriate therapeutic practices, leading to a blurring among many or most forms of psychotherapy. In the final and perhaps weakest chapter of the book, Eisner calls into question the efficacy of psychotherapy in general: "The ultimate conclusion is that there are no empirically supportable therapies" and that "as a scientific enterprise, psychotherapy should be declared dead" (p. 23).
But in drawing these conclusions, Eisner gives extremely short shrift to the numerous meta-analyses (quantitative literature reviews) demonstrating that some psychological treatments-particularly behavioral and cognitive-behavioral therapies-are clearly efficacious for certain psychological problems (moreover, for reasons that are unclear, Eisner twice refers to "so-called meta-analyses"). The only meta-analyses to which Eisner explicitly refers are those of Smith and Glass (1977) and Prioleau, Murdock, and Brody (1983). The former, which was the first published meta-analysis, was also the first major review to unambiguously document the overall efficacy of psychotherapy. The latter was a small and now outdated review whose largely negative findings and conclusions have since been superceded by numerous and more comprehensive meta-analyses.
Eisner also does not review the growing literature demonstrating the superiority of behavioral and cognitive-behavioral treatments relative to other treatments for obsessive-compulsive disorder, panic disorder, and related conditions (see Chambless & Ollendick, 2001). Nor does he review the growing controlled evidence suggesting that interpersonal therapy is efficacious for certain severe disorders, including major depression and bulimia nervosa. As a consequence, Eisner ends up throwing out the empirically supported baby with the empirically unsupported bathwater. Eisner's critiques of many empirically unsubstantiated treatments, including primal scream therapy, neurolinguistic programming, rage reduction therapy, palm therapy, Buddha psychotherapy, angel therapy, Emotional Freedom Technique, and Silva method, are cogent and well taken. Nevertheless, these otherwise trenchant critiques lose much of their force in light of Eisner's attacks on treatments that possess considerably more persuasive evidentiary support.
Second, much of the book is substantially out-of-date. The most recent article Eisner cites on the efficacy of EMDR is a 1995 investigation by Wilson and colleagues, despite the fact that a large body of outcome literature on EMDR has emerged in the intervening years that greatly amplifies and adds to Eisner's preliminary conclusions. This newer literature compellingly demonstrates that although EMDR is more efficacious than no treatment for posttraumatic stress disorder, it is no more efficacious for this condition than are standard behavioral and cognitive-behavioral therapies. In addition, there is persuasive evidence that eye movements and other forms of lateral stimulation are irrelevant to EMDR's therapeutic effects (see Lohr, Tolin, & Lilienfeld, 1998, for a review). The chapter on recovered memory therapies is among the strongest in the book, but it features scant coverage of recent laboratory work on the reconstructive nature of memory. For example, the pioneering work of Elizabeth Loftus and Steve Ceci on the laboratory induction of false memories in adults and children receives only brief mention. Not even discussed is the research of Ira Hyman demonstrating that false memories of quite bizarre events (e.g., spilling a punch bowl over the bride at a wedding reception) can be readily implanted into nonclinical participants, or the work of Ulric Neisser demonstrating that even confidently held "flashbulb" memories of highly disturbing events (e.g., the 1986 explosion of the space shuttle Challenger) can be strikingly inaccurate.
Third, Eisner overemphasizes placebo effects as common factors that account for the reported efficacy of many psychotherapies to the exclusion of other nonspecific explanations for client improvement, such as regression to the mean, spontaneous remission, demand characteristics, and maturation (see Cook & Campbell, 1979). These omissions lead Eisner to accord too large a causal role to client expectations in psychotherapy, although there is little question that such expectations often play an important role in improvement. A response following a placebo is not the same as a response to a placebo, as the former is attributable to a variety of nonspecific influences, only one of which is a placebo effect. This error is commonly made when discussing the high "placebo response rates" of certain conditions (e.g., major depression, panic disorder) to inert substances. These "placebo response rates" are in actuality the improvement rates following administration of these substances, not the improvement rates directly due to these substances.
Fourth, several of the chapters are imbalanced in coverage. The chapter on behavioral and cognitive-behavioral therapies is particularly problematic in this regard. Flooding and systematic desensitization receive only about as much coverage in this chapter as EMDR. Readers largely unfamiliar with this literature may erroneously conclude that EMDR occupies just as important a place on the clinical landscape as do well-validated behavioral treatments, which is clearly not the case. Compounding the problem, Eisner confuses flooding therapy with implosion therapy, which, in contrast to flooding, is grounded largely in psychodynamic assumptions.
Fifth, although the book covers a great deal of ground, there are a few notable omissions. In particular, Eisner does not discuss the growing problem of unsubstantiated and in some cases discredited treatments for childhood disorders. For example, such treatments as such as facilitated communication and sensorimotor integration for autistic disorder and neurofeedback (EEG biofeedback) for attention-deficit/hyperactivity disorder receive no coverage. Another important omission is the continued spread of Twelve-Step programs for alcoholism and other addictive problems (e.g., gambling, obesity), whose extraordinary popularity substantially outstrips the relatively modest and often equivocal evidence for their efficacy. Alcoholics Anonymous, for example, receives only one brief mention (p. 16) and no critical evaluation.
Sixth and finally, much of the book is awkwardly written and poorly copyedited. As a consequence, readers are forced to wade through many unwieldly and even ungrammatical sentences. For example, early on in the book Eisner posits that "[t]he critical question is whether a factual basis exists for the alleged active ingredients in psychotherapy as well as the purported positive results that are superior to no treatment or just giving advice in a supportive environment" (p. 18). In the concluding chapter, Eisner writes that "[i]n general, looking at psychoanalysis, as pointed out in Chapter 2 that there is a virtually nonexistent scientific basis for the theoretical rationale and any significant scientific outcomes" (p. 218). Many other sentences are not significantly better, rendering large sections of The Death of Psychotherapy a laborious reading experience.
In summary, Eisner's book may offer a useful road map for readers seeking to obtain a bird's-eye view of the scientist-practitioner gap and the serious quality control problems afflicting the present-day field of psychotherapy. Nevertheless, readers hoping for an up-to-date and balanced analysis that carefully distinguishes scientifically supported from unsupported claims regarding psychotherapeutic efficacy are likely to come away disappointed.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.
Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design and analysis for field settings. Chicago: Rand McNally.
Eisner, D. A. (2000). The death of psychotherapy: From Freud to alien abductions. Westport, CT: Praeger.
Lohr, J. M., Tolin, D. F., & Lilienfeld, S. O. (1998). Efficacy of eye movement desensitization and reprocessing: Implications for behavior therapy. Behavior Therapy, 29, 123-156.
Prioleau, L., Murdock, M., & Brody, N. (1983). An analysis of psychotherapy versus placebo studies. Behavioral and Brain Sciences, 6, 275-310.
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752-760.
O. Lilienfeld, Ph.D., Editor
The Scientific Review of Mental Health Practice