Psychotherapy and Evidence Based Practice? – Stephen Appel

Evidence based medicine emerged as a way for medical doctors to find out what is current best clinical practice. It has been defined as:

the consientious, explicit and judicious use of current best evidence in making decsisions about the care of individual patients, based on skills which allow the doctor to evaluate both personal experience and external evidence in a systematic and objective manner. (Sackett, et al., 1997, 71)

Evidence based practice (EBP) is a descendant of evidence based medicine and it is employed in all manner of fields.

In this short paper I will elaborate two ways in which evidence based practice has come to be employed over the years. I will argue that it will be constructive for psychotherapy to adopt the one, and destructive for the practice and profession of psychotherpy to adopt the other.

Among psychotherapists there is considerable concern about EBP.

While health research documents outline the usefulness of a hierarchy of evidence with the randomized-controlled trial (RCT) as the ‘gold standard when thinking at a populations level, the psychotherapist has a different focus. Ours is the consideration of what the ‘evidence’ means for the client we sit with session after session. (Milton, 2002, 161)

This concern is justified. Over time an ambiguity has been built into the term itself and so EBP has flowed down two channels as this quotation from Wikipedia shows:

Examples of a reliance on ‘the way it was always done’ can be found in almost every profession, even when those practices are contradicted by new and better information. Evidence-based practice is a philosophical approach that is in opposition to rules of thumb, folklore, and tradition.

Here professional experience is actively opposed. The first sentence exemplifies what I will call ‘lighthouse EBP’, the second ‘gatekeeping EBP’.

Lighthouse EBP

According to this view certain practices have been shown to be effective and so should be considered in treatment; certain practices have been shown to be harmful and should be avoided. Everything else is regarded as a non liquet (it is yet to be proved). A less circumscribed view, it determines what might be done and what is discredited: Y and anything but Z. A couple of examples.

What not to do
Martin Seligman expresses his frustration at the post-disaster counselling industry which kicks into action immediately there has been a disaster. Psychological research has shown that it is best to allow the person’s natural defences to cope. If after three months the person is still having problems then some kind of treatment is called for. But, he says, the research goes much further. The chances of developping PTSD symptoms are greater if counselling is engaged in straightaway. If this is correct and we ignore the research, we break the rule to first do no harm.

What to do
The depressed brain is unable to do depth psychotherapy, says Klaus Grawe (2007). What is needed is psychoeducation and three to four weeks of cognitive work (plus, perhaps, medication) before the patient is neurologically capable of deeper work. Again, if this is right, it is surely worth considering adapting one’s practice accordingly – i.e. basing one’s practice on the evidence.

When EBP is used as a lighthouse it can warn us which paths to avoid and which are advisable. Further than that the lighthouse leaves it up to each captain which precise route to take.

This approach assumes current practice works until proven otherwise or unless another practice has been shown to work better. It tends to cast a wide net with regards evidence: scientific experiments and cohort studies and considered alongside qualitative reserach, anecdotal case reports, and expert opinion – and, of course, professional experience.

Gatekeeping EBP
According to this view only those practices which have been emprically shown to be efective may be practiced. It is an attempt to define precise standards to decide all clinical decisions. Before one may employ any particual practice its effectivity must first have been proven. Compared to the lighthouse view it is a circumscribed view which states what may be done: X and nothing but X.  The second approach to EBP tends regard as proof randomised control trials and the like.

Perhaps the two approaches still seem very similar. After all, does a practice work or doesn’t it? If so do it, if not don’t do it. But matters are not so simple, especially in a field like psychotherapy. What counts as research? What has been researched? What can be researched? What should be researched? What hasn’t yet been researched?

Gatekeeping EBP often comes into play to reduce costs. It limits professional autonomy, and has a distorted view of science. “Research…is not the same thing as knowledge” (Clive James). Behavioural therapy, for example, now routinely includes the threrapeutic relationship as a curative factor even though it is a theroretical ‘confound’. The first problem arise under the rubric of ‘proof’. If proper evidence is limited to empirical studies then many entire modalities are going to fall under the bus precisely because how they operate and what they operate on are very difficult to measure. Take the question of meaning, as in ‘life having meaning’. Surveys and questions on such a matter will produce trivial and/or misleading evidence, while anecdotal case studies and philosophical relflection may indeed be clinical useful.

Given that funding, etc. may be tied to EBP, it is not inconceivable that the entire works of Winnicott, Yalom, … could go by the board depending on how EBP is defined. Instead what would  remain would be techniques whose efficacy with regards pre-and post-therapy scales has proven to be statistically valid. Now that psychotherapy in New Zealand is to become a registerd profession we are in a unique postion of being able to strongly influence which way in which we take Evidence Based Practice on board.

To summarise
1. Taken as it was originally intended – as an ecouragement to practitioners to keep up to date with research and to guide their practices accordingly – EBP could re-vitalize psychotherapists. This is EBP as lighthouse.

2. Taken as gate-keeping – as constraints on what is permissible – and EBP psychotherapy becomes reduced to a collection of minor truths about homo sapiens.

3. Ignore EBP and we are likely to remain stuck in our pasts:

They say the biggest influence on the therapy you practice – and the therapy you aspire to, your imago of therapy – is the therapy you experience as a patient. And this holds for me, if you add the admission that I remember few details of the treatment. (Kramer)

References
Grawe, K. (2007). Neuropsychotherapy: How the neurosciences inform effective psychotherapy. Lawrence Erlbaum: Mahwah, NJ.

Milton, M. (2002). Evidence-based practice: Issues for psychotherapy, Psychoanalytic Psychotherapy, 16(2), 160-172.

Sackett, D.L., Richardson, W.S., Rosenber, W. & Haynes, R.B. (1997). Evidence-Based Medicine: How to practice and teach EBM. Churchill Livingstone: New York.
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‘Evidence Of Wings’, originally uploaded by vintage girl

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2 Responses to Psychotherapy and Evidence Based Practice? – Stephen Appel

  1. Colleen Emmens says:

    I loved this article, it articulated what I have felt to be is the unseen in evidence based practice. It has felt like a bridge to what I knew but couldn’t quite get a grasp of.

  2. Stephen Appel says:

    Thanks, Colleen. EBP hasn’t hit psychotherpay in NZ yet, but it can’t be far off. The trick will be to make it work for us (and not us work for it).

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