Does "Anything Go" in Mental Health?
Review of the Handbook of Complementary and Alternative Therapies in Mental Health edited by Scott Shannon
In this review, we see Shannon and contributors to his Handbook of Complementary and Alternative Therapies in Mental Health (2002) inadvertently highlight the endemic problems of advocacy and misrepresentation of research in the mental health field. The well-known Dodo bird verdict of psychotherapy equivalence ("All have won and all must have prizes") resounds loudly throughout the chapters of this volume (Wampold, et al., 1997; Hunsley & Di Giulio, 2002). In this broad sampling of the many complementary and alternative medicine (CAM) practices dotting the contemporary mental health landscape, Shannon and his contributors set forth a bewildering array of theories and therapies spanning the gamut of such quasi-physical approaches as osteopathy, diet, and acupuncture and such controversial or undocumented approaches as Therapeutic Touch, body-centered psychotherapy, and process work.
In fairness to Shannon and his contributors, a reasonable observer could admit that there is a great deal of controversy about what "really" works in mental health. This uncertainty may account for why "data wars" are frequently waged among the many therapy camps composed of fiercely loyal practitioners and patients and an equally vocal, but often outnumbered, band of critics. Shannon's book faces these critics head-on, and succeeds in providing the reader with a thorough collection of apologetics for the budding holistic or integrative movement in mental health care. Although Shannon claims that his book presents a balanced picture of the evidence for and against CAM therapies, the resulting volume provides a rather uncritical overview of the many unsubstantiated or understudied treatment approaches described in its pages.
Shannon lays the groundwork for why he believes the volume is necessary: Hordes of patients and mainstream practitioners are dissatisfied with the current, "biomedicine-dominated" paradigm of scientific theory development and testing therapies. Shannon argues that many conventional therapies are ineffective, unsafe, or otherwise inappropriate for many patients and that their prevalence stems largely from the undue influence of the "powers that be" of Western medicine rather than their established superiority. Although many of these points may contain a kernel of truth, they are grossly overstated variations on an all-too-familiar mantra of the CAM movement. As his alternative, Shannon proposes an ambitious metatheory he calls "holism," which endeavors to unify all the otherwise conflicting and at times contradictory therapies peddled by practitioners. Although achieving this integration may be a laudable goal, he paints a muddied picture that relies on pseudoscientific arguments, vague spiritual-metaphysical concepts, and the now infamous misapplication of ideas from quantum physics to bolster the credibility of "holistic health care" (see Stenger, 1995, for a critique).
The reader is led on a circuitous journey from the never-never land of mind-body-spirit and the "web of life" to the seemingly inescapable conclusion that the CAM movement is advancing the frontiers of modern medicine. Shannon appears to be arguing that we are on the brink of a revolution in medicine and health care, and that CAM practitioners are bravely dismantling artificial barriers constructed by Western biomedicine. After all, Shannon might have us wonder, isn't the CAM movement ultimately about the betterment of patients, practitioners, and society? Although we might be compelled by the undeniable emotional sway of these arguments, we must remember that the tenets of CAM and their influx to the mental health field are a natural outgrowth of evolving market forces (e.g., practitioner oversupply, coupled with increasing demand for personal services among educated, wealthy consumers) rather than breakthroughs in scientific knowledge or advances in clinical practice. Shannon freely acknowledges this point in the opening and concluding chapters.
The author's claims for a "new paradigm" must be understood in historical context. There was a strikingly similar backlash in the early 1800s among the Romantics in Germany and other industrialized Western nations toward the supposed inhumanity and "reductionism" of early scientific medicine. Shannon often invokes theoretical musings from disparate sources to support his claims for the need for a "new paradigm" in health care. Nevertheless, none of his arguments is convincing on the epistemological grounds of rigorous clinical research. Shannon's claims lack the cogency or clarity required of serious philosophical analysis. The logic of Shannon and his contributors' claims are tautological and self-affirming, as they appeal to social (marketplace) needs in their defense of CAM, but they then erroneously conclude from this argument that conventional scientific methods are inadequate to test CAM therapies.
Although the authors are called to present evidence for their theories and therapies, they more often than not appeal to personal experience, poorly designed research published in nonscientific sources, case reports, expert opinion, or patient testimonials. Shannon openly advocates for a reliance on one's clinical intuition and personal experience (there is actually an entire chapter devoted to this form of therapy). The authors tend to gloss over the implications of their sparse database, even in the few cases in which they openly acknowledge the lack of empirical support for their approaches. The chapters read more like "brochures with citations" for this-or-that school of CAM than authoritative examples of scholarly work.
Shannon's intellectual effort, however ambitious, falls considerably short of an effective exposition of the state of CAM research. Still, his volume is informative and may be worth the read to illustrate the breadth of claims made in the CAM literature regarding treatment for mental health problems, and the accompanying paucity of evidence pointing to their effectiveness.
Shannon makes some useful points about the strengths and limitations of traditional scientific research designs. He presents these points as an attempt to critique them and thereby presumably bolster the credibility of CAM research, but he succeeds only in highlighting the complexity of the research enterprise in mental health. Shannon appears to make the classical error of "throwing the baby out with the bathwater" in his calling for the now-clichéd "paradigm shift" trumpeted throughout the mental health field. Shannon's book appears to be a romantic attempt to incorporate into the fray many theories and therapies that have been marginalized by mainstream Western medicine.
The most problematic aspect of Shannon's book is not so much its advocacy of a "holistic" approach to health care or the CAM approaches he chose to include, rather that the book exudes a decidedly self-congratulatory tone in a field that requires a large degree of healthy skepticism. This uncritical perspective leaves the reader seeking balance disappointed. Whatever useful contributions the book makes are lost in a morass of disconnected concepts, misapplied or misunderstood science, discredited theories, and unsubstantiated practices.
Shannon's tendency to feminize his holistic philosophy for health care is puzzling. He criticizes the gender stereotyping of health care, accusing conventional medicine of being a "masculine system." Moreover, he tops off this assertion with the brazen claim that psychiatry is suffering from "penis envy" (!) by its emphasis on precise diagnosis and careful scientific research. This careless application of cultural metaphors and innuendo targeted at the lay reader are common throughout the book.
Not surprisingly, the chapters culled from disparate practice traditions have a disconnected quality, leaving the reader to wonder what some of the topics have to do with another (for example, nutritional supplements and music therapy). A reader cannot be expected to read the book cover to cover and emerge with a coherent understanding of CAM approaches. At best, the volume may serve as a general reference source to the growing but disturbing utilization of CAM in mental health.
Shannon concludes the book with the proclamation that "there is no controversy here." Oh, yes there is; however, if readers limit their study of CAM to Shannon's book alone, they may actually come away with the mistaken belief that most of the important challenges to the CAM movement have been addressed. Shannon knocks down the house that science built, but he does not erect livable alternate accommodations, leaving the reader feeling homeless. Aside from vague references to "health outcome studies," Shannon neglects to present a tangible alternative to conducting research in the much-maligned "closed system" of traditional scientific research designs.
Shannon's concluding chapter, brimming with the zeal of a true cultural crusader, can be read to imply that the CAM movement should stop at nothing short of reinventing health care, concepts of health and disease, our views of human nature, and society as a whole. We are left to wonder whether the dismantling or diluting of scientific progress in understanding and treating mental illness will be a regrettable outcome of this movement.
Hunsley, J., & Di Giulio, G. (2002). Dodo bird, phoenix, or urban legend? The question of psychotherapy equivalence. The Scientific Review of Mental Health Practice, 1, 11-22.
Shannon, S. (2002). Handbook of complementary and alternative therapies in mental health. San Diego, CA: Academic Press.
Stenger, V. J. (1995). The unconscious quantum: Metaphysics in modern physics and cosmology. Amherst, NY: Prometheus Books.
Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "all must have prizes." Psychological Bulletin, 122, 203-215.
Regional Neuroscience Center
Conemaugh Health System