David X. Swenson PhD LP MSSA 2014

1. F : A Critical Review of Therapies David X. Swenson PhD LP MSSA 2014

2. So… what’s a lizard skull got to do with it?

3. Agenda • What are “ways of knowing”? • Overview the popular growth of CAM • Explore reasons for CAM proliferation • Identify assumptions & problems with some of claims • Recommend cautions and considerations for practice "The trouble with the world is not what people don't know; it's what they know that ain't so." -‑ Artemus Ward

4. How accurate is clinical judgment?

5. Some propositions • Some MH conditions are not effectively treated by any currently known means • Some responses to intervention are negligible or very slow to develop • Some interventions may not lead to improvement, but may prevent further deterioration; some make people worse • Clients and their families (and sometimes therapists) are often desperate for any treatment that holds hope for recovery • They are often vulnerable to the extreme claims of fad or scam treatments, or receive only limited or biased information • Untested, unconventional, bizarre, ineffective, and even dangerous methods have been popularized for use

6. Some CAM procedures have demonstrated efficacy & become more mainstream • As professional practitioners we are obligated to use evidence-based procedures that are scientifically shown to be effective and to “do no harm” • Various “ways of knowing” have some advantage, but the scientific method generally shows the most effectiveness, advantage, safety, and advancement of knowledge • We should promote awareness and critical examination of the ethical and methodological problems with non-scientific methods and poorly done science • We should promote awareness of guidelines for determining sound approaches to therapy

7. Professional Ethics & Standards • Medicine: “First, do no harm” (AMA) • Psychology (APA) • “take care to no harm” • “promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology.” • Boundaries of competence: “boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.” • Basis for judgment: “Psychologists’ work is based upon established scientific and professional knowledge of the discipline.

8. Social Work (NASW) • “Do no harm” • Social workers should base practice on recognized knowledge, including empirically based knowledge, relevant to social work and social work ethics. • Counselors (ACA) • “…avoid harming…” • “Counselors continually monitor their effectiveness as professionals” • “Counselors use techniques/procedures/modalities that are grounded in theory and/or have an empirical or scientific foundation.”

9. Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2(1), 53-70

11. But they have a long history… • Prolonged bedrest (latter half 19th c. for “hysterical” women & post surgery) • Bloodletting (antiquity to late 18th c.) • Radiated water (early 1900s) • Human subject research (uninformed, dangerous) • Maggot debridement of wounds • Inducing insulin coma & seizures to cure schizophrenia • Trepanation (antiquity to present) • Lobotomies (peak during 1930-50s) • Heroin cough syrup for children (sold by Bayer 1900s) • Treatment of syphilis with mercury & malaria-infected blood

12. An early solution to Oppositional Defiant Disorder…lobotomy! • In 1966 12 year-old Howard Dully became the youngest recipient of the icepick transorbital lobotomy for: “being unbelievably defiant…objects going to bed…daydreaming…and says ‘I don’t know.’” • Lobotomy developer, Dr. Walter Freeman travelled the US in his “Lobotomobile” conducting up to 2500 of the 10 minute procedures in 23 states from 1936-1967

13. What is considered “conventional treatment” changes over time I have an earache: 2000 B.C.B Here, eat this root. 1000 A.D.B That root is heathen. Here, say this prayer 1850 A.D.B That prayer is superstition. Here, drink this potion. 1940 A.D.B That potion is snake oil. Here, swallow this pill. 1985 A.D.B That pill is ineffective. Here, take this antibiotic. 2000 A.D.B That antibiotic is artificial. Here, eat this root --anon

15. What are Complementary and Alternative Methods? (NIH categories) • Alternative medical systems– acupuncture, ch’igong, t’ai chi, massage, indigenous systems, homeopathy, radionics, naturopathy • Bioelectromagnetics– use of magnets & electromagnetic fields • Biofield– use of subtle energy fields, Therapeutic Touch, Reiki, ch’i gong • Biologically-based– herbalism, special diets, macrobiotics, orthomolecular therapy, dietary supplements • Lifestyle & disease prevention– electro-dermal diagnostics, intuitive healing, stress management, self regulation • Manipulative & body-based– chiropractic, bodywork, reflexology, rolfing, polarity, colonics • Mind-body– yoga, meditation, biofeedback, prayer, remote healing Be very, very careful what you put into that head, because you will never, ever get it out --Thomas Cardinal Wolsey http://nccam.nih.gov/

16. Who uses CAM-- • Middle aged (30-50) • Women (43%), Men (33%) • Baby Boomers • College educated • Health factors; Worried well or desperately ill • Used for anxiety, depression, headaches, back pain • Positive attitudes toward holism, environmentalism, feminism, spiritualism, self-determination, naturalism, and personal growth psychology Bishop, F. L., & Lewith, G. T. (2010). Who uses CAM? A narrative review of demographic characteristics and health factors associated with CAM use. Evidence Based Complementary and Alternative Medicine, 7(1), 11-28.

17. 10 most common complementary health approaches among adults (2007) Natural Products Natural Products Deep Breathing Meditation Massage Homeopathy Yoga Guided Imagery Diet-Based Therapies Progressive Relaxation Chiropractic/Osteopathic http://nccam.nih.gov/health/whatiscam

18. A survey of 53 Medical Schools topics showed: • Acupuncture (76.7%) • Herbs and botanicals (69.9%) • Meditation and relaxation (65.8%) • Spirituality, faith, prayer (64.4%) • Chiropractic (60.3%) • Homeopathy (57.5%) • Nutrition and diets (50.7%) • Minimal contact hours (2 to <20) • Elective course in the 1st or 4th year of medical school • 78.1% taught by individuals identified as being CAM practitioners or prescribers of CAM therapies. • Only 17.8% emphasized a scientific approach to the evaluation of CAM effectiveness. Brokaw, J. J., Tunnicliff, G., Raess, B.U., & Saxon, D. W. (2002). The teaching of complementary and alternative medicine in U.S. medical schools: a survey of course directors. Academic Medicine, 77(9), 876-881.

19. Full Moon Effect Scientific Illiteracy: The Full Moon Effect, or… why do you think they call it homicide rate traffic accidents crisis calls to police or fire stationsdomestic violence births of babies suicide major disasterscasino payout rates kidnappings aggression by professional athletes violence in prisons psychiatric admissions agitated behavior by nursing home residents assaults, gunshot wounds, stabbings emergency room admissions alcoholism sleep walking epilepsy • 43% of University students • 80% ER nurses • 64% ER physicians believe in the Full Moon Effect (Boesveld, 2012)

20. Scientific Illiteracy • 91% do not know what a molecule is • 34% believe UFOs have visited earth • 50% believe in ESP, telepathy, precognition • 50% of Americans do not know the earth orbits the sun annually • 48% believe that humans and dinosaurs coexisted • 53% believe in spiritual/faith healing • 28% mental communication with the dead • 28% believe in astrology & it is scientific • 38-43% believe in ghosts and haunted houses • 25% believe in reincarnation • 14% believe in fortune telling • 12 of most popular school science texts have 500 pages of errors National Science Board & National Science Foundation, 2002

21. Change Drivers

22. Cultural Factors in CAM proliferation • Stress awareness: Recognition of stress & potentially lasting effects of trauma • Entitlement: Belief that everyone deserves “the good life” • Immediacy: Belief in and need for quick fixes, everything has a solution • Crisis orientation: Preoccupation with trauma, crises, emergency, violence, excitement • Postmodernism: Widespread uncritical acceptance of Magical thinking, paranormal, personal realities • Globalization & diversity: curiosity and unquestioning acceptance of cross-cultural practices • Scientific illiteracy: ignorance or misinformation about scientific inquiry, reasoning, & evidence • “McDonaldization”: faster, better, cheaper!

23. Managed Care Factors in the Proliferation of CAM • Competition: Extremely competitive service environment • Financing: Generate revenues with high client loads and rapid turnover • Cost containment: Cost-effective treatment, efficiency • Public demand: Reimbursement for some non-traditional methods • Prevention: Early treatment may cut costs • Control: unconventional treatments need to be under conventional control

24. Reasons for hospitals & clinics starting a CAM program http://scienceblogs.com/insolence/2011/09/22/surveying-integrative-medicine-landscape/

25. Client factors in proliferation of CAM • Desperation: Pain, despair, suffering, need to find solution when traditional methods don’t work • Dissatisfactionwith limits & assembly line of traditional care; less invasive, misperception CAM is safer & less expensive • Dislike heavy emphasis on medication & side effects • Media promotion: Web testimonials, infomercials, “news,” requests for advertised/popular approaches • Cost: Limited financial resources for traditional services, do not see long term & hidden costs and risk in CAM • Uncritical thinking: many people are not willing or able to think through complex information; peripheral processing • Superstition & magical thinking: is alive & well “I don’t want reality, I want magic.” --Blanche DuBois A Streetcar Named Desire

26. Therapist/Provider factors in proliferation of CAM • Good intentions to be effective practitioner, desire to help • Anyone can be a “Founder” or “Discoverer” • Frustration: discouragement with treatment resistance and unresponsive conditions • Power & control: need for influence • Reputation: need for status, recognition as a specialist & become the “Ultimate Therapist” • Faith in utility: Belief that “so long as it works” so what? • Extreme belief in constructed reality: “If you can think of it, it’s real,” it’s our personal realities that are real • Snake oil: create dependency, scams, take advantage of vulnerable people

27. ASSUMPTIONS & CLAIMS

28. Discussion Example: The Energy Therapies

29. Roger Callahan PhD Founder of TFT David X. Swenson PhD LP 2006

30. Now Only $7,797 David X. Swenson PhD LP 2006

31. Therapeutic “Touch” • Based on Ayurvedic concepts of aura and chakras • 100,000 people trained worldwide, 50,000 in healthcare • Training in >100 colleges & universities • North American Nursing Diagnosis Association included “Energy Field Disturbance” in nomenclature • Energy field can be detected and manipulated by brushing “congested energy” and shaking it off the hands Delores Krieger PhD RN David X. Swenson PhD LP 2006

32. Magical Thinking: Assumptions of “Energy” Therapies • all living things have an energy field • this field reflects life energy and health • energy flows through channels and is • expressed through aura • energy can be blocked by physical, emotional, • psychological, or toxic causes • blocked energy produces symptoms of illness • energy treatments seek to unblock energy and reestablish balance

33. McTherapy Claims • Works rapidly, often within minutes, “instant relief” • Money back guarantees • Non-invasive, painless process with little or no discussion of painful memories • Long lasting or permanent results • Results where others fail; 85% - 99% success rate • Eliminates problems even when you don’t know what the problems are • Dramatic testimonials • Based on centuries old traditional techniques of healing, new discoveries in neurology or physics • One size fits all regardless of type of disorder • Simple, easy, painless, anyone can do it • Training available to anyone who wants to be a healer; certification available

34. Then there’s the “QUANTUM” connection… • quantum are packets of subatomic particles that show unusual properties, such as being in two places at once • events are reducible to both matter and wave form • energy and matter are interchangeable SO… • thinking is energy • thinking makes it so– creates reality • thinking can block and unblock energy • since thoughts can be in two places at once, one can • heal from a distance (also ESP, remote reading, etc.) Except… • even physicists can’t agree on how quantum physics works • there is no evidence whatsoever that quantum events influence macro events • the idea that “the observer makes the difference” is a misinterpretation • experimental results in CAM don’t even come close to the rigor of physics • it is questionable transferring concepts from one discipline into another

35. New Particle: The “thoton” QUANTUM FIELD PSYCHOLOGY The Thoton Particle TheoryRon Dalrymple PhD, a licensed psychologist in Arizona, Florida, Idaho, Kansas, Maryland, Missouri, Pennsylvania and New Zealand, has developed an integration of modern day psychologies with Einsteinian physics and topological mathematics known as Quantum Field Psychology.  David X. Swenson PhD LP 2006

36. Proliferation of Energy “McTherapies” • Therapeutic Touch (TT):Delores Krieger’s nursing technique for healing by brushing & balancing your body’s energy fields (no touch) • Brief Strobic phototherapy (BSP): use of colored light on subtle energies of emotion • Thought Field Therapy (TFT):Roger Callahan’s algorithmic tapping to balance body energies • Emotional Freedom Techniques (EFT):Gary Craig’s modification of TFT • Tapas Acupressure Technique (TAT):modification of TFT by Tapas Fleming • Miracle Acupressure Tapping Technique (MATT):more of the same • Energy Psychology (EP):still more by Fred Gallo • Touch and Breathe (TAB).Diepold’s combination of tapping and breathing • Attractor Field Therapy (AFT):Acupressure for universal energy fields • Acupressure Chakra Technique (ACT):acupressure & yogic energy centers • Creating, Allowing, Receiving Technique (CART): Tapping 1-2 meridians for the future • Be-Set-Free Fast (BSFF):Nims’ four-step tapping to resolve unconscious energies

37. Conditions Treated by Energy Therapies-- One size fits all? • Abuse trauma • Addictions (food, cigarettes, alcohol, drugs) • Allergies • Anxiety and Panic Attacks • Anger • Attraction to the wrong people • Cancer • Compulsions & obsessions • Depression and sadness • Dyslexia • Eating disorders • Fears and phobias • Fibromyalgia • Frustration • Gambling • Grief and loss • Guilt • Immune deficiency problems • Insomnia • Learning blocks & dyslexia • Low self esteem • Migraine headache • Negative memories • Nightmares • Obsessive-compulsive disorders • Pain management • Peak performance • Phobias • PTSD • Procrastination • Rejection • Self image • Sexual abuse issues • Sexual problems

38. The problem with “energy” therapies… • “energy” is poorly defined (magnetic, electro-chemical, heat…) • scientific instruments measure physiological processes not “energy” per se • pseudo scientific instruments misrepresent measurements • Chinese journals have had notoriously poor designs & statistics (53%-78% flawed) • American CAM journals presume energy & test differences • very low inter-rater reliability • conflicting opinions in diagnosis • inconsistent conceptualizations Emily Rosa testing therapist sensitivity to “energy” Rosa, L., Rosa, E., & Barrett, S. (1998). A close look at therapeutic touch. JAMA, 279(13), 1005-1010.

39. Repressed Memory Therapies Past lives, birth trauma, satanic ritual abuse, and other trauma that affect adjustment are repressed and must be uncovered Alien Abduction Therapy John Mack, MD– Harvard psychiatrist & Pulitzer Prize Winner writes on the spiritual effects and treatment of alien abduction experiences

40. Crystal and Indigo Children– may be misdiagnosed as having ADHD when in fact they are the next step in human-angel spiritual evolution to the next multi-dimensional level of consciousness “Energized” music, bracelets, water, and other items claim to balance with “healing energy” the disruption of one’s energy system that currently produces symptoms of mental and physical illness "Put a pair of earphones around your mixed gallon of clustered distilled water and play the CD .. delivering the healing frequencies back to the solution."

41. Rebirthing & Attachment Therapy • While Attachment Theory (e.g., Bowlby, Ainsworth) is supported by research, other concepts have been applied without justification • It uses methods contrary to ethical treatment: uses prolonged holding for purposes other than safety, prolonged noxious stimulation, & interference with bodily functions Therapists Connell Watkins, left, and Julie Ponder enter court Friday, where they were convicted in Candace Newmaker's death. They were sentenced from 16-48 years. • Rebirthing has resulted in emotional disturbance, injury and death to clients, and liability to therapists • There is insufficient evidence that holding produces bonding or resolution to attachment or behavioral problems

42. Dolphin Assisted Therapy (DAT) Baby with microcephaly– “The baby was floated in water and attended by 4 dolphins. One dolphin put its rostrum at the medulla (base of the skull), two others came to both sides of the neck, with the forth at the base of the spine. The dolphins made produced sounds or "ensonified" the child for about 20 minutes at a time, a few times per day for about a week. At the end of this period the skull plates were developing normally.” Facilitated Communication “The autistic or brain injured child can communicate through the hand of the facilitator to spell out words or complete thoughts. Through the facilitators, previous mute children could recite poetry, carry on high level conversations, and show above average intelligence.” Advance for Occupational Therapists 11/25/96 p.14.

43. David X. Swenson PhD LP 2006

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45. “So long as it works, I don’t care…” …except that: • it may delay effective treatment, cause injury, or complicate further treatment • it is misleading (false hope) • it defies informed consent • some assumptions imply external locus of control or even self blame • it neglects what we know about placebo effect • professionals are obligated to identify what works and how • it contributes to the popular belief that such treatment has been validated • it predisposes some people to more vulnerability to exceptional beliefs and claims

46. Problems with some CAM Approaches • Few or no articles in peer reviewed, refereed, conventional, professional journals • Poor design & methodology • Unclear and insufficiently established diagnoses • Faulty logic & pseudoscientific comparisons • Reliance on self report rather than more objective measures • Unfounded transfer of concepts-- physics to psychological processes • Sale and use of quasi-scientific instruments at high prices • Diagnosis through unestablished procedures • Poorly defined and untestable concepts • Denial and rejection of established explanations • Non-falsifiability of approach • Defiance and claimed irrelevance of established science

47. Alternate explanations of McTherapy cures: Likely but not fancy • Natural history and cyclicity of disease • Condition runs it course • Regression to the mean • Suggestion • Counter-irritation • Distraction • Hawthorne Effect • Audience demand characteristics • Confirmation bias • Stockholm Effect (please powerful figure) • Fatigue • Avoidance of painful memories • Misattribution to CAM when combined with conventional methods • Cognitive dissonance • Temporary mood improvement confused with cure • Habituation • Desensitization • Lake Wobegon Effect • Placebo Effect These are the alternate explanations that must be controlled for with research design in order to establish what is treatment effect and what is not.

48. What's really Going on here?

50. The Placebo Effect: what you see is what you think you get • Became prominent with Beecher using normal saline when morphine ran out during WWII (33% effectiveness) • Krebiozen case (Klopfer, 1950) • A study of antidepressants showed that 75% of effect was due to expectation (Kirsch & Sapirstein, 1998) • Nocebo effect with 57 Japanese students allergic to lacquer tree; real touch did not react, fake touch reacted (Ikemi & Nakagawa, 1962) • Sham orthoscopic knee surgery showed 60 Ss with improved gait & pain (Moseley, et al., 2002; Sihvonen, et al., 2013) • Placebo effect has been documented in cases involving pain conditions, headaches, cough, senile dementia, common cold, arthritis, sea sickness, ulcer, hypertension, anxiety, depression, and schizophrenia • Placebo effect ranges from an average of 33% to as high as 75% • Level of effect depends on client’s beliefs, practitioner confidence, & beliefs resulting from interaction (Benson, 2000)