Discredited Psychological Treatments and Tests: A Delphi Poll
John C. Norcross
University of Scranton
Gerald P. Koocher
Simmons College
Ariele Garofalo
University of Scranton
In the context of intense interest in evidence-based practice (EBP), the authors sought to establish
consensus on discredited psychological treatments and assessments using Delphi methodology. A panel
of 101 experts participated in a 2-stage survey, reporting familiarity with 59 treatments and 30 assessment
techniques and rating these on a continuum from not at all discredited to certainly discredited. The
authors report their composite findings as well as significant differences that occurred as a function of
the experts’ gender and theoretical orientation. The results should be interpreted carefully and humbly,
but they do offer a cogent first step in consensually identifying a continuum of discredited procedures in
modern mental health practice.
Keywords: Delphi Poll, discredited technique, evidence-based practice, psychological assessment, psychotherapy,
quackery
Which psychotherapies are effective? Psychologists have been
inundated with lists of treatment guidelines, empirically supported
therapies, practice guidelines, and reimbursable therapies. But
what about demonstrably ineffective treatments and tests?
The burgeoning evidence-based practice (EBP) movement in
mental health attempts to identify, implement, and disseminate
treatments that have been proven demonstrably effective according
to the empirical evidence. This movement has provoked enormous
controversy within organized psychology, and, with the exception
of the general conviction that psychological practice should rely on
empirical research, little consensus currently exists among the
various stakeholders on either the decision rules to determine
effectiveness or the treatments designated as “evidence-based”
(Norcross, Beutler, & Levant, 2005).
We believe that it might prove to be as useful and probably
easier to establish what does not work—discredited psychological
treatments and tests. Far less research and clinical attention have
been devoted to establishing a consensus on ineffective procedures
as compared to effective procedures.
Recently, several authors have attempted to identify pseudoscientific,
unvalidated, or “quack” psychotherapies (e.g., Carroll,
2003; Della Sala, 1999; Eisner, 2000; Lilienfeld, Lynn, & Lohr,
2003; Singer & Lalich, 1996). Parallel efforts are underway to
identify assessment measures of questionable validity on psychometric
grounds (e.g., Hunsley, Crabb, & Mash, 2004; Hunsley &
Mash, 2005).
These pioneering efforts suffer from at least two prominent
limitations. First, none of the efforts systematically relied on
expert consensus to determine their contents. Instead, the authors
assumed that a professional consensus already existed, or they
selected entries on the basis of their own opinions. Second, these
authors provided little differentiation between credible and uncredible
treatments and between unvalidated and validated tests. This
demarcation problem (Gardner, 2000)—the challenge of formulating
sharp distinctions between validated and unvalidated—plagued
earlier efforts, leading to rather crude and dichotomous judgments.
Thus, we conducted a poll of leading mental health professionals
to help secure a consensus and to establish more refined
characterizations of treatments and tests ranging from not at all
discredited to certainly discredited.
Delphi Poll
We searched broadly and collected nominations for discredited
mental health treatments and tests via literature searches,
electronic mailing list requests, and peer consultations. The
inclusion criterion stated that the treatment or test was used
professionally during the past 100 years in the United States or
Western Europe. Note that, for inclusion, the treatment or test
JOHN C. NORCROSS earned his PhD in clinical psychology from the University
of Rhode Island and is professor of psychology and distinguished
university fellow at the University of Scranton. His areas of research
include psychotherapy, clinical training, and self-initiated behavior change.
GERALD P. KOOCHER earned his PhD in clinical psychology from the
University of Missouri at Columbia and is dean of the School for Health
Studies at Simmons College. His research areas include adaptation to
chronic illness, coping with bereavement, and ethical issues in psychology.
ARIELE GAROFALO earned her BS in psychology at the University of
Scranton and is now a doctoral candidate in clinical psychology at Nova
Southeastern University. Her research areas include psychoanalytic treatments,
projective testing, and personality disorders.
PRELIMINARY RESULTS OF THIS STUDY were presented at the 113th Annual
Convention of the American Psychological Association, Washington, DC,
August 2005.
WE GRATEFULLY ACKNOWLEDGE the participation of the 101 experts and the
contributions of Scott O. Lilienfeld, Roger Greene, and John Hunsley to
this study.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to John C.
Norcross, Department of Psychology, University of Scranton, Scranton,
PA 18510-4596. E-mail: norcross@scranton.edu
Professional Psychology: Research and Practice Copyright 2006 by the American Psychological Association
2006, Vol. 37, No. 5, 515–522 0735-7028/06/$12.00 DOI: 10.1037/0735-7028.37.5.515
515
was used professionally for mental health purposes but was not
necessarily used by psychologists themselves. Exclusion criteria
were controversial theories of psychology that do not directly
involve mental health (e.g., subliminal perception or
sleep learning), broader unusual phenomena regarding human
behavior (e.g., fire-walking, channeling, or extra sensory perception)
that have not yielded pertinent treatments, treatments
or assessments that have never found advocacy in mental health
(e.g., astrology and numerology), medications or biochemical
substances (including conventional, herbal, naturopathic, or
homeopathic preparations), and practices used primarily outside
the United States and Western Europe.
Using these criteria, we listed separately 59 treatments and 30
assessment techniques on a questionnaire. Items were presented
alphabetically and with reference to a particular purpose. For
example, “acupuncture for the treatment of mental/behavioral disorders”
and “age-regression methods for treating adults who may
have been sexually abused as children” were listed under the
treatment section, and “Adult Children of Alcoholic (ACOA)
checklists” and “anatomically detailed dolls or puppets to determine
if a child was sexually abused” were listed under the test
section.
The instructions to the respondents read as follows:
For the purpose of this Delphi poll of experts, we operationally define
discredited as those unable to consistently generate treatment outcomes
(treatments) or valid assessment data (tests) beyond that obtained
by the passage of time alone, expectancy, base rates, or credible
placebo. Discredited subsumes ineffective and detrimental interventions
but forms a broader and more inclusive characterization. We are
interested in identifying disproven practices.
Please rate the extent to which you view the treatment or test as
discredited from not at all discredited to certainly discredited. A
treatment or assessment tool can be discredited according to several
types of evidence: peer-reviewed controlled research, clinical practice,
and/or professional consensus. Please think in terms of the
criteria for expert opinions as delineated in the Daubert and Kumho
Tire Co (1999). legal standards. For example, in Daubert (1993) the
Supreme Court cited factors, such as testing, peer review, error rates,
and “acceptability” in the relevant scientific community, some or all
of which might prove helpful in determining the validity of a particular
scientific “theory or technique.”
If you cannot make a rating because you are unfamiliar with the
treatment or test, then kindly circle NFT. If you are unfamiliar with
the treatment/test’s research or clinical use, then kindly circle NFR.
You may also circle both.
The response options were structured as a 5-point, Likert-type
format in which 1 ϭ not at all discredited, 2 ϭ unlikely discredited,
3 ϭ possibly discredited, 4 ϭ probably discredited, and 5 ϭ
certainly discredited. Respondents could also circle NFT ϭ not
familiar with this treatment/test and NFR ϭ not familiar with its
research or clinical use.
The expert panelists were informed that:
Upon completion of the enclosed Delphi poll, your replies will be
pooled with those of the other experts. Subsequently, you will be
asked to complete a slightly modified form of the Delphi poll containing
the preliminary findings. In this manner, the panel of experts
will exchange opinions and arrive at a general consensus. Your
individual responses will not be identified.
Expert Panel
In October 2004, we mailed the five-page questionnaire to 290
doctoral-level mental health professionals: 100 randomly selected
fellows of American Psychological Association (APA) Division
12 (Clinical Psychology), 45 randomly selected fellows of APA
Division 17 (Counseling Psychology), 23 randomly selected fellows
of APA Division 16 (School Psychology), 46 randomly
selected fellows of the American Psychological Society (APS)
with a major field in clinical psychology, 57 current and former
editors of scholarly journals in mental health, 14 members of the
APA Presidential Task Force on Evidence-Based Practice, and 5
chairs or editors of the Diagnostic and Statistical Manual of
Mental Disorders. Following the initial mailing and a subsequent
reminder, we received 138 responses for a total return rate of 48%.
However, 37 of these were unusable for a multitude of reasons,
principally retirement (n ϭ 26), which left 101 experts for a usable
response rate of 35%.
We did not detect any systematic bias relating to gender or
profession between persons who returned the questionnaire and
those who did not. However, we did not have a reliable means of
determining the theoretical orientations or professional activities
of the nonrespondents, so it remains an open question if these
factors influenced participation in the Delphi study.
Of the responding experts,1
93% had trained as psychologists,
82% identified themselves as male, and 9% reported belonging to
a racial/ethnic minority group. Table 1 summarizes the professional
characteristics of this clinically experienced and theoretically
diverse panel of experts.
Second Round
The experts’ responses to the first questionnaire (Round 1) were
pooled and analyzed. The same instrument was then redistributed
to the 101 panelists in February 2005 along with feedback on the
responses of the panel as a whole. Feedback was provided for each
item in terms of means and standard deviations, depicted both
numerically and graphically. Following two mailings and an
e-mail prompt, 85 of the original 101 (84%) panelists responded to
the second round. The demographic and professional characteristics
of the experts responding to the second round mirrored those
of the first round; statistical analyses did not detect any significant
differences in these characteristics between Round 1 respondents
and Round 2 respondents.
The second round questionnaire was identical to that of the first
round in structure, directions, and items with three exceptions.
1
Members of the expert panel who allowed us to report their names
were: Marvin W. Acklin, George J. Allen, Elizabeth Altmaier, Juan
Arellano-Lopez, David H. Barlow, Larry E. Beutler, David L. Blustein,
Jeff Braden, Jeffrey M. Brandsma, Charles D. Claiborn, Elaine Clark,
Karina W. Davidson, George DuPaul, Darwin Dorr, Colin D. Elliott,
Albert Ellis, Al Finch, Michael First, Gerald B. Fuller, Charles J. Gelso,
Roger L. Greene, Carol Goodheart, David Haaga, Steve Hollon, Bertram P.
Karon, Bill Kinder, David Lachar, O. B. Leibman, Barbara McCrady, A.
Scott McGowan, Julian Meltzoff, Greg Neimeyer, Mary Ann Norfleet, Ed
Nottingham, Thomas H. Ollendick, Eugene G. Peniston, Mick Power,
Michael C. Roberts, John Robinson, Wendy Silverman, Derald Wing Sue,
Laura C. Toomey, Bruce Wampold, Drew Westen, and Danny Wedding.
516 NORCROSS, KOOCHER, AND GAROFALO
First, as noted previously, the second round questionnaire presented
the pooled responses from the first round, which is the
standard procedure in Delphi polls. Second, we eliminated the four
treatments (Goggle therapy, holotropic breath work, Pesso Boyden
Psychomotor System, and the Sedona method) and five tests
(Manson Evaluation, MAPS, Mira Myokinetic Psychodiagnostic
Test, Pigem Test, and Zamboni Test) on the second round questionnaire
that were rated by fewer than 25% of the experts during
the first round. Third, precipitated by our difficulty in determining
the cut off for the percentage of experts rating any particular item,
we inserted a final question on the second round questionnaire
concerning the percentage of responding experts that would constitute
a respectable minority (see later discussion for details).
As expected, the variability among the expert ratings decreased
from Round 1 to Round 2. In other words, the pooled feedback
from the initial round led to greater consensus among the panel.
Specifically, the standard deviations decreased on 50 of the 54
treatment ratings. The mean difference was Ϫ.20. Similarly, the
standard deviations for 23 of the 25 tests decreased, with an
average difference of Ϫ.15 from the first to second round. The
mean ratings evidenced less change: there was a net increase (i.e.,
in the direction of more discredited) of .11 for the treatments and
.04 for the tests.
Discredited Psychological Treatments
Table 2 presents, in ranked order, the experts’ mean ratings of
55 potentially discredited treatments. Table 2 presents the mean,
standard deviations, and percentage of experts not familiar with
(and thus not rating) each item for both rounds of data collection.
For those treatments rated by at least 25% of experts, considerable
convergence existed on treatments consensually viewed as certainly
discredited (mean rating of 4.50 or higher on the 5-point
scale). For the specific purpose listed, experts considered as certainly
discredited 14 psychological treatments: angel therapy, use
of pyramid structures, orgone therapy, crystal healing, past lives
therapy, future lives therapy, treatments for post-traumatic stress
disorder (PTSD) caused by alien abduction, rebirthing therapies,
color therapy, primal scream, chiropractic manipulation, thought
field therapy, standard prefrontal lobotomy, and aroma therapy.
Another 11 treatments were consensually designated as probably
discredited (mean rating of 4.0 or greater), including Erhard Seminar
Training (EST) and age-regression methods, for various specific
purposes.
On the other end of the continuum, a handful of treatments were
consensually judged to be unlikely discredited. Treatments receiving
mean scores below 3.0 were behavior therapy for sex offenders,
thought stopping procedures for ruminations, psychosocial
(i.e., nonbehavioral) therapies for attention deficit and hyperactivity
disorder (ADHD), laughter or humor therapy for depression,
Bion’s method of group analysis, Moreno’s psychodrama, and eye
movement desensitization and reprogramming (EMDR) as a treatment
for trauma.
Discredited Psychological Tests
Table 3 displays the mean ratings of 25 potentially discredited
tests in ranked order. As with the treatments, Table 3 presents the
item mean, standard deviation, and the percentage of the experts
lacking familiarity with that test for both rounds. No test received
a mean rating above 4.50. Five tests rated by at least 25% of the
experts in terms of being discredited for a specific purpose received
mean scores of 4.0 or higher: Lu˝scher Color Test, Szondi
Test, handwriting analysis (graphology), Bender Visual Motor
Gestalt Test (for assessment of neuropsychological impairment),
eneagrams, and Lowenfeld Mosaic Test.
Several instruments were consensually viewed as unlikely discredited,
at least for the specific purpose listed on the questionnaire.
Those tests receiving mean ratings below 3.0 were officebased
cognitive task assessments for ADHD, use of IQ scores and
discrepancy formulas to identify specific learning disabilities, Thematic
Apperception Test (TAT) for personality assessment,
Myers-Briggs Type Indicator for assessment of personality, sentence
completion tests for personality assessment, Adult Children
of Alcoholic (ACOA) checklists, and the Rorschach Inkblot Test
(Exner’s comprehensive system) to diagnose specific disorders.
Defining a Respectable Minority
As noted earlier, we struggled with the question of what percentage
of experts would need to have familiarity with a given
psychological treatment or test to qualify it for inclusion in our
results. We decided to ask the expert panelists on the second round
questionnaire.
We would ask for your help with one additional question. We are
attempting to set a threshold of familiarity among experts by which to
include a particular approach in our study. That is, what percentage of
experts needs to be familiar with a given treatment or test for continued
inclusion or discussion about discredited approaches? We feel
stymied in reaching a reasoned criterion.
Table 1
Professional Characteristics of the 101 Experts
Characteristic N % M Mdn SD
Highest degree
PhD 94 93
MD 3 3
Other 4 4
Year of highest degree 1971 1972 11.0
Years of mental health experience 33.2 33.0 10.6
Percent of time devoted to
Clinical work 20.5 10.0 24.5
Teaching 20.1 20.0 16.2
Research/writing 31.7 30.0 24.6
Supervision 8.6 10.0 8.7
Administration 12.5 5.0 18.6
Primary employment setting
University department 60 62
Private practice 14 15
Medical school 11 12
Other 11 12
Primary theoretical orientation
Behavioral 24 25
Cognitive 18 19
Eclectic/integrative 21 22
Humanistic/existential 8 9
Interpersonal (IPT) 5 5
Psychoanalytic/psychodynamic 7 7
Systems/family systems 3 3
Other 9 10
517DISCREDITED PSYCHOLOGICAL TREATMENTS
Table 2
Experts’ Ratings of Mental Health Treatments in Ranked Order
Treatment
Round 1 Round 2
M SD
% not
familiar M SD
% not
familiar
Angel therapy for treatment of mental/behavioral disorders 4.92 0.28 71.4 4.98 0.14 46.4
Use of pyramids for restoration of energy 4.89 0.32 31.7 4.98 0.13 28.0
Orgone therapy (use of orgone box or orgone energy
accumulator) for treatment of mental/behavioral disorders 4.92 0.28 26.0 4.97 0.17 16.9
Crystal healing for treatment of mental/behavioral disorders 4.82 0.44 34.0 4.95 0.21 21.0
Past lives therapy for treatment of mental/behavioral disorders 4.81 0.44 22.8 4.92 0.27 7.2
Future lives therapy for treatment of mental/behavioral disorders 4.67 0.80 42.4 4.88 0.33 30.5
Treatments for PTSD caused by alien abduction 4.69 0.68 26.7 4.85 0.40 20.5
Rebirthing therapies for treatment of mental/behavioral disorders 4.58 0.82 10.9 4.75 0.46 4.8
Color therapy for treatment of mental/behavioral disorders 4.56 0.56 59.6 4.68 0.62 50.6
Primal scream therapy for treatment of mental/behavioral
disorders 4.51 0.77 5.9 4.61 0.72 4.8
Chiropractic manipulation for mental/behavioral disorders 4.36 0.70 29.3 4.57 0.60 14.6
Thought Field Therapy for treatment of mental/behavioral
disorders 4.21 1.08 56.0 4.56 0.66 46.4
Standard prefrontal lobotomy for treatment of mental/behavioral
disorders 4.44 0.90 9.9 4.55 0.80 8.3
Aromatherapy for treatment of mental/behavioral disorders 4.33 0.77 32.3 4.55 0.63 20.2
Erhard Seminar Training for treatment of mental/behavioral
disorders 4.29 0.78 37.4 4.47 0.85 28.7
Age-regression methods for treating adults who may have been
sexually abused as children 4.12 0.97 4.1 4.41 0.77 8.3
Craniosacral therapy for treatment of anxiety and depression 4.20 0.76 67.7 4.38 0.78 58.5
Preventive intervention for “born criminals” 4.19 1.13 66.3 4.36 0.85 49.4
Sexual reorientation/reparative therapy for homosexuality 4.25 1.00 9.1 4.29 0.91 7.1
Holding therapy for reactive attachment disorder 4.14 1.06 37.8 4.29 0.71 33.7
Treatments for mental disorders resulting from Satanic ritual
abuse 3.98 1.31 34.7 4.28 1.05 22.0
Healing touch (not massage therapy) for treatment of mental/
behavioral disorders 4.10 1.12 41.4 4.13 0.96 25.6
Psychological treatments of schizophrenia based on the
schizophrenogenic theory of schizophrenia 3.81 1.17 18.2 4.04 0.98 13.4
Reparenting therapies for treatment of mental/behavioral
disorders 3.84 1.13 24.8 4.03 0.94 13.4
Bettelheim model for treatment of childhood autism 3.94 1.19 19.4 4.01 0.90 14.3
Dolphin-assisted therapy for treatment of developmental
disabilities 3.73 1.34 63.6 3.97 0.96 52.4
Equine therapy for treatment of eating disorders 3.64 1.15 70.7 3.96 0.73 69.5
Neuro-Linguistic Programming (NLP) for treatment of mental/
behavioral disorders 3.57 1.06 26.7 3.87 0.92 24.1
Psychosynthesis for treatment of mental/behavioral disorders 3.69 1.29 68.0 3.83 1.04 65.1
Scared Straight programs for prevention of conduct disorders
and criminal behavior 3.48 1.10 23.0 3.80 0.87 20.7
Emotional Freedom Technique for tx of mental/behavioral
disorders 3.77 1.15 74.7 3.80 0.77 81.2
DARE programs for prevention of substance abuse/dependence 3.65 1.23 23.2 3.79 0.99 18.3
Family therapy for schizophrenia based on the double-bind
theory of schizophrenia 3.73 1.30 10.2 3.76 1.07 6.2
Jungian sand tray therapy for treatment of adolescent and adult
disorders 3.49 1.34 38.4 3.76 0.94 39.8
Rage reduction therapy for depression 3.71 1.14 42.6 3.72 1.01 36.9
Freudian dream analysis for treatment of mental/behavioral
disorders 3.65 1.35 2.0 3.67 1.21 3.7
Facilitated communication for treatment of autism 3.49 1.48 26.3 3.67 1.20 21.0
Bioenergetic therapy for treatment of mental/behavioral
disorders 3.37 1.11 47.5 3.63 0.86 33.3
Insight-oriented psychotherapies for sex offenders 3.47 1.32 7.1 3.54 0.99 3.6
Catharsis/ventilation treatment for anger disorders 3.32 1.23 9.1 3.53 0.94 8.4
Psychotherapy for the treatment of penis envy 3.60 1.51 22.8 3.52 1.34 18.3
Marathon encounter groups for treatment of mental/behavioral
disorders 3.43 1.21 12.9 3.49 1.02 12.0
Acupuncture for treatment of mental/behavioral disorders 3.53 1.08 24.5 3.48 0.94 23.8
Psychotherapy for castration anxiety 3.42 1.52 25.7 3.26 1.34 20.7
518 NORCROSS, KOOCHER, AND GAROFALO
We want to use the “respectable minority” standard typically applied
in medical malpractice cases. This legal standard notes that not every
practitioner will follow the same approach; we want to include approaches
recognized by a respectable minority of practitioners. What
percentage of experts would need to be familiar with an approach to
consider it a “respectable minority” for this purpose?
_____ % of responding experts would constitute a respectable
minority.
The responses ranged from 10% to 49% and averaged 30.4%
(Mdn ϭ 30.0, mode ϭ 25, SD ϭ 9.08). It is interesting to note that
10 experts were either confused by the question or disagreed with
the legal standard of respectably minority in that they provided
percentages above 50%. As a result, we ignored these 10 responses
in the data analysis for this question.
Gender and Orientation Differences
In the context of discovery, we conducted a series of analyses to
investigate differences in item ratings as a function of the experts’
gender (t tests) and theoretical orientation (univariate analyses of
variance [ANOVAs]) using a two-tailed alpha level of .025 to
minimize Type I errors. We discovered nine statistically significant
differences between men and women in our panel of experts
among the 80 comparisons (55 treatments, 25 tests) in the second
round data. Women accorded higher mean ratings (indicative of
being discredited) to aromatherapy, family therapy based on the
double-bind theory of schizophrenia, future lives therapy, primal
scream therapy, and sexual reorientation/reparative therapy for
homosexuality than did the men. Men accorded higher mean
ratings to Jungian sand therapy, House-Tree-Person Technique,
Kahn Test of Symbol Arrangement, and the Lu˝scher Color Test.
These mean differences ranged from .16 to 1.17 and averaged .62.
These were modest differences, but they were sufficient to alter the
conclusion of whether a particular procedure warrants consideration
as discredited for a specific purpose.
We conducted a parallel series of analyses on second round
ratings among those experts self-identifying as (a) cognitive and
behavioral, (b) eclectic and integrative, or (c) psychodynamic and
humanistic in their primary theoretical orientation. Table 4 summarizes
the ANOVA results among these groups of panelists
(Student Newman–Keuls post hoc tests, bidirectional alpha of .05).
As seen in Table 4, we discovered 35 differences on the 80 items.
Cognitive and behavioral therapists rated the procedures higher or
more discredited in 34 of the 35 differences. Psychodynamic and
humanistic therapists rated the procedures lower or less discredited
in 29 of these 35 differences. The eclectic and integrative therapists,
as a group, tended to occupy the middle ground of ratings.
Cautions and Caveats
Several factors demand that we exercise caution in interpreting
these findings. First, many of our experts lacked familiarity with
the many “fringe” therapies or “unusual” assessment techniques.
Second, some might challenge the relatively modest size of our
panel of experts. Third, our reliance on traditionally trained and
academically vetted experts with a disproportionate number of
cognitive–behavioral therapists might be too narrow. Fourth, the
robust rating differences due to theoretical orientation (see Table
4) indicate that the epistemological commitments of the expert
panel materially influence the results and thus the conclusions of
what is discredited. Fifth, several panel members noted that a
single item assessing the credibility of an omnibus assessment
measure for a given purpose was insufficient. In particular, we
wish that we had presented additional items on ability of the
Rorschach to diagnose specific disorders (e.g., schizophrenia) and
the Wechsler to identify specific learning disabilities.
We recommend interpreting these results carefully and humbly.
Professional consensus does not equal an epistemic warrant; even
experts can be and have been wrong. Expert opinions may be
widely held because they are correct or because most experts
simply share the same worldview. Test validity is conditional;
clinical utility is purpose- and context-specific. A treatment or test
considered discredited for one purpose might be credible for
another. We should take care not to threaten innovation and
Table 2 (continued)
Treatment
Round 1 Round 2
M SD
% not
familiar M SD
% not
familiar
Critical incident stress debriefing (CISD) for acute trauma 3.02 1.43 15.5 3.25 1.06 11.0
Psychosocial therapies for treatment of pedophilia 3.30 1.26 16.8 3.23 1.04 14.5
Neurofeedback for ADHD 3.10 1.08 38.0 3.14 1.00 30.1
Classical psychoanalysis for removal of Axis I symptoms 3.22 1.31 1.0 3.10 1.07 3.7
Eye movement desensitization and reprocessing (EMDR) for the
treatment of trauma 2.88 1.13 4.0 3.06 1.20 2.4
Moreno’s psychodrama for treatment of mental/behavioral
disorders 2.95 1.14 25.7 2.93 0.95 17.1
W. R. Bion’s method of group analysis for treatment of mental/
behavioral disorders 2.93 1.36 67.0 2.91 1.13 60.7
Laughter or humor therapy for treatment of depression 2.83 0.92 36.6 2.81 0.74 24.1
Psychosocial (nonbehavioral) therapies for ADHD 2.85 1.12 17.8 2.79 1.02 13.6
Thought stopping procedures for ruminations/intrusive worry 2.25 1.10 6.9 2.20 0.94 2.4
Behavior therapy for sex offenders 1.97 1.03 7.1 2.05 0.91 3.6
Note. Ratings made on a 5-point, Likert-type scale where 1 ϭ not at all discredited, 2 ϭ unlikely discredited, 3 ϭ possibly discredited, 4 ϭ probably
discredited, 5 ϭ certainly discredited. PTSD ϭ post-traumatic stress disorder; tx ϭ treatment; ADHD ϭ attention deficit hyperactivity disorder.
519DISCREDITED PSYCHOLOGICAL TREATMENTS
creativity in psychological practice by branding all nonresearched
procedures as discredited. We must avoid hubris by remembering
that contemporary treatments and tests may become discredited 30
years from now. We must avoid false pride, as science should be
ever vigilant and self-correcting.
Research Implications
Before turning to the practical implications of our findings, we
would amplify several methodological limitations of our study and
point to corresponding improvements for future studies.
Our operational definition of discredited treatments and tests
may have merged, for some experts, untested and demonstrably
ineffective, unvalidated and invalidated. To paraphrase Justice
Oliver Wendell Holmes, the absence of evidence is not the evidence
of absence. Untested procedures are not necessarily ineffective
procedures; they are merely untested. We left the criteria for
making the discredited ratings to the experts on the basis of
“several types of evidence: peer-reviewed controlled research,
clinical practice, and/or professional consensus.” Studies in the
future might provide separate ratings for psychological procedures
that are considered untested versus those that are considered tested
and found wanting or between procedures that are discredited by
controlled research versus those discredited by clinical practice.
Several entries on our questionnaire were listed more than once
for specific uses (e.g., Bender-Gestalt for assessment of neuropsychological
impairment and again for assessment of personality),
whereas other tests were listed only once as a generic use (for
personality assessment). In the latter instance, the experts did not
have the opportunity to render differential ratings. In the future, we
advise investigators to offer multiple ratings on popular instruments
for their different uses, such as the Rorschach, TAT, and
sentence completion tests.
Expert in our study was defined by status as journal editor or
association fellow, which predictably produced a disproportionate
percentage of academics and cognitive–behavioral proponents.
Were we to repeat the study, we would expand our definition of
expert by more heavily sampling stellar practitioners of various
theoretical orientations. More inclusive sampling might result in
Table 3
Experts’ Ratings of Mental Health Tests in Ranked Order
Test
Round 1 Round 2
M SD
% not
familiar M SD
% not
familiar
Lu˝scher Color Test for personality assessment 4.19 0.81 73.3 4.48 0.58 67.1
Szondi Test for personality assessment 4.15 1.05 44.6 4.46 0.85 36.6
Handwriting analysis (graphology) for personality assessment 4.36 0.70 10.0 4.27 1.00 8.5
Bender Visual Motor Gestalt Test for assessment of neuropsychological
impairment 4.92 0.28 9.1 4.23 1.33 14.5
Eneagrams for personality assessment 3.37 1.11 72.0 4.14 0.59 65.9
Lowenfeld Mosaic Test for personality assessment 3.48 1.27 39.0 4.05 0.74 74.4
Bender Visual Motor Gestalt Test for assessment of
personality 3.82 1.20 14.0 3.93 1.04 13.3
Anatomically detailed dolls or puppets to determine if a child
was sexually abused 4.12 0.97 14.0 3.90 0.95 7.1
Blacky test for assessment of children’s personality and
pathology 3.84 1.12 29.0 3.85 1.10 20.5
Hand Test for personality assessment 3.32 1.23 52.5 3.84 1.06 47.0
Kahn Test of Symbol Arrangement for personality
assessment 3.52 1.16 67.0 3.77 0.94 63.9
Use of Wechsler IQ scale scores for personality assessment 3.52 1.37 14.9 3.42 1.18 6.1
Voice stress analysis for lie detection 3.07 1.18 45.5 3.31 0.97 34.9
Rosenzweig Picture Frustration Study for personality
assessment 3.42 1.27 39.0 3.29 1.03 38.6
House-Tree-Person for personality assessment 3.22 1.31 9.0 3.23 1.18 6.0
Human Figures Drawings for personality assessment 3.13 1.37 5.9 3.19 1.18 6.1
Child Sexual Abuse Survivor checklists 3.00 1.14 60.0 3.07 1.02 44.6
Thematic Apperception Test—Thompson modification for
personality assessment of ethnic/racial minorities 3.05 1.52 55.4 3.03 1.16 55.6
Rorschach (comprehensive system) to diagnose specific
disorders 3.12 1.48 4.0 2.84 1.24 3.6
Adult Children of Alcoholic (ACOA) checklists 2.62 1.09 56.6 2.71 0.85 38.1
Sentence completion tests for personality assessment 2.64 1.20 7.0 2.67 0.99 1.2
Myers-Briggs Type Indicator for assessment of personality 2.60 1.25 18.8 2.63 1.09 9.6
Thematic Apperception Test for personality assessment 2.60 1.31 4.0 2.51 1.21 3.6
Use of IQ scores and discrepancy formulas to identify
specific learning disabilities 2.41 1.23 15.0 2.26 0.88 3.6
Office-based cognitive task assessments for ADHD 2.35 1.09 55.0 2.23 0.89 47.0
Note. Ratings made on a 5-point, Likert-type scale where 1 ϭ not at all discredited, 2 ϭ unlikely discredited, 3 ϭ possibly discredited, 4 ϭ probably
discredited, 5 ϭ certainly discredited. PTSD ϭ post-traumatic stress disorder; ADHD ϭ attention deficit hyperactivity disorder.
520 NORCROSS, KOOCHER, AND GAROFALO
broader representation and avoid the temptation of non-CBT psychologists
to simply put these results aside as being the selffulfilling
prophesy of academic clinicians who are largely of
cognitive–behavioral persuasions.
Practice Implications
The results of our Delphi poll demonstrate widespread unfamiliarity
with unusual mental health procedures, theory-driven divergence
in opinions, and yet substantial consensus on what qualifies
as psychoquackery. In closing, we advance several practice implications
emanating from these three principal results.
A surprising finding to us was the large percentage of experts
unfamiliar with the listed practices. For example, in the first round,
56% were not sufficiently familiar with Thought Field Therapy to
render a rating and 37% were not familiar with Erhard Seminar
Training. These numbers may help us to understand one important
and perhaps unappreciated reason for the relative apathy of many
mental health experts toward discredited practices: many experts
simply do not know much about them.
At the same time, and equally surprising, a large number of
expert panelists informed us that completing the initial questionnaire
prompted them to secure and read critical reviews of the
treatments and tests on the questionnaire. Although many experts
did not know much about these psychological interventions, they
apparently had a keen interest in knowing more. We hope our
study and this article facilitate such awareness among the practitioner
community.
Experts of disparate theoretical orientations differed in many
cases on the degree to which psychological treatments and tests
were discredited. In 97% (34 of 35) of the significant differences,
cognitive–behavioral panelists considered the procedure to be
more discredited, perhaps reflecting their greater interest in experimental
verification or their shared biases. Large orientation differences
materially impact interpretation of the results. In the
largest difference, on Freudian dream analysis for treatment of
mental/behavioral disorders, the mean rating of cognitive–
behavioral therapists was 4.4 (between probably and certainly
discredited), the mean rating of eclectics was 3.4 (between possiTable
4
Summary of Statistically Significant Differences in Discredibility Ratings as a Function of Experts’ Theoretical Orientation
Item Orientation differences F df p
Catharsis/ventilation treatment for anger disorders CBT Ͼ PD-HUM 4.5 2, 68 .015
Classical psychoanalysis for removal of Axis I symptoms CBT Ͼ ECL, PD-HUM 14.0 2, 68 Ͻ .001
DARE programs for prevention of substance abuse/dependence CBT Ͼ PD-HUM, ECL 7.8 2, 60 .001
Erhard Seminar Training for tx of behavioral/mental disorders ECL, CBT Ͼ PD-HUM 5.6 2, 52 .006
Family therapy for schizophrenia based on double-bind theory CBT, ECL Ͼ PD-HUM 14.7 2, 66 Ͻ .000
Freudian dream analysis for tx of mental/behavioral disorders CBT Ͼ ECL Ͼ PD-HUM 17.1 2, 69 Ͻ .000
Healing touch for tx of mental/behavioral disorders CBT Ͼ ECL Ͼ PD-HUM 8.9 2, 56 Ͻ .000
Holding therapy for reactive attachment disorder CBT Ͼ ECL, PD-HUM 5.4 2, 50 .007
Insight-oriented psychotherapies for sex offenders CBT Ͼ ECL, PD-HUM 8.8 2, 72 Ͻ .000
Jungian sand tray therapy for tx of adolescent and adult disorders CBT Ͼ ECL 4.3 2, 44 .02
Marathon encounter groups for tx of mental/behavioral disorders CBT, ECL Ͼ PD-HUM 10.1 2, 65 Ͻ .000
Moreno’s psychodrama for tx of mental/behavioral disorders CBT Ͼ PD-HUM 6.3 2, 60 .003
Neurofeedback for ADHD CBT Ͼ PD-HUM, ECL 10.8 2, 52 Ͻ .000
Neuro-Linguistic Programming for tx of mental/behavioral disorders CBT Ͼ PD-HUM 5.1 2, 57 .009
Primal scream therapy for tx of behavioral/mental disorders CBT Ͼ PD-HUM 4.3 2, 70 .017
Psychotherapy for castration anxiety CBT Ͼ ECL, PD-HUM 8.7 2, 59 Ͻ .000
Psychotherapy for the treatment of penis envy CBT Ͼ ECL, PD-HUM 10.7 2, 61 Ͻ .000
Rage reduction therapy for depression CBT Ͼ PD-HUM 6.6 2, 48 .003
Bion’s group analysis for tx of mental/behavioral disorders CBT Ͼ ECL, PD-HUM 7.9 2, 27 .002
Anatomically detailed dolls or puppets to determine if a child was
sexually abused CBT, PD-HUM Ͼ ECL 4.2 2, 69 .020
Bender Visual Motor Gestalt Test for assessment of personality CBT Ͼ PD-HUM, ECL 6.1 2, 63 .004
Blacky test for assessment of children’s personality and pathology CBT Ͼ PD-HUM 4.3 2, 57 .018
Eneagrams for personality assessment CBT, ECL Ͼ PD-HUM 4.8 2, 23 .018
Hand Test for personality assessment CBT Ͼ PD-HUM 5.1 2, 39 .011
Handwriting analysis (graphology) for personality assessment CBT, ECL Ͼ PD-HUM 12.4 2, 67 Ͻ .000
House-Tree-Person for personality assessment CBT Ͼ ECL, PD-HUM 9.0 2, 68 Ͻ .000
Human Figures Drawings for personality assessment CBT Ͼ ECL, PD-HUM 9.8 2, 67 Ͻ .000
Rorschach (comprehensive system) to diagnose specific disorders CBT Ͼ ECL, PD-HUM 18.3 2, 72 Ͻ .000
Rosenzweig Picture Frustration Study for personality assessment CBT Ͼ ECL, PD-HUM 11.4 2, 45 Ͻ .000
Sentence completion tests for personality assessment CBT Ͼ ECL, PD-HUM 13.4 2, 71 Ͻ .000
Szondi test for personality assessment CBT, ECL Ͼ PD-HUM 8.8 2, 44 .001
Thematic Apperception Test for personality assessment CBT Ͼ ECL, PD-HUM 10.8 2, 70 Ͻ .000
Thematic Apperception Test—Thompson modification for
personality assessment of ethnic/racial minorities CBT Ͼ ECL, PD-HUM 5.0 2, 30 .013
Use of Wechsler IQ scale scores for personality assessment CBT Ͼ ECL, PD-HUM 10.5 2, 67 Ͻ .000
Note. CBT ϭ cognitive and behavior panelists; PD-HUM ϭ psychodynamic and humanistic panelists; ECL ϭ eclectic and integrative panelists; tx ϭ
treatment; ADHD ϭ attention deficit hyperactivity disorder.
521DISCREDITED PSYCHOLOGICAL TREATMENTS
bly and probably discredited), and the mean rating of
psychodynamic–humanistic therapists was 2.8 (between unlikely
discredited to possibly discredited). These differences underscore
the robust effect of theoretical orientation in determining what
constitutes discredited (and perhaps what stands as effective). Such
findings remind us that panels, tasks forces, and commissions
intent on identifying discredited (and effective) therapies should
ideally include persons of various theoretical orientations, genders,
ethnicities/races, sexual orientations, and so on if their goal is to
create a professionwide consensus.
The recent APA Presidential Task Force on Evidence-Based
Practice (2005) exemplified such diversity in its composition and
provided a reasonably consensual definition: “Evidence-based
practice in psychology (EBPP) is the integration of the best available
research with clinical expertise in the context of patient
characteristics, culture, and preferences.”
Our Delphi study systematically compiled clinical expertise on
credibility, based perhaps in part on the best available research.
Clinical consensus is only one valuable source of evidence that
should be used in conjunction with empirical research and patient
characteristics in assisting practitioners in determining what works
and what does not work.
The consensus emerging on this Delphi poll on potentially
discredited treatments and tests leaves us feeling encouraged.
Multiple books, several Web sites (e.g., Quackwatch, Skeptic’s
Dictionary), and a journal (The Scientific Review of Mental Health
Practice) have dedicated themselves to publicizing psychological
myths and discredited procedures. Psychological science tends to
be self-correcting in that its foundation lies in empirical evidence
(more than most professions, anyway). As a field, we have made
progress in differentiating science from pseudoscience in the practice
of psychology.
We believe that our study offers a cogent, positive first step in
consensually identifying the “dark side,” “soft underbelly,” or
“quack factor” of modern mental health practice and in providing
a more granular analysis of the continuum of discredited procedures.
Mature sciences and professions should have the ability to
publicly shun discredited practices. The President’s New Freedom
Commission on Mental Health (2003; www.mentalhealthcommission.gov)
called attention to both the underuse of proven treatments
and the overuse of treatments for which little empirical
evidence exists. We can simultaneously use (inclusively defined)
EBPs to promote what does work and avoid (consensually identified)
discredited practices to eradicate what does not work.
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Received May 24, 2005
Revision received January 27, 2006
Accepted February 7, 2006 Ⅲ
522 NORCROSS, KOOCHER, AND GAROFALO