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Where is the Evidence for Evidence Based Therapies?

2013/10/16 admin 13
Where is the Evidence for Evidence Based Therapies? By Jonathan Shedler, PhD A study from a prestigious psychology journal recently crossed my desk. It found that clinicians who provide Cognitive Behavior Therapy or CBT—including the most experienced clinicians—routinely depart from the CBT techniques described in treatment manuals. “Only half of the clinicians claiming to use CBT use an approach that even approximates to CBT,” the authors wrote. The finding is not surprising, since there is no evidence that treatment manuals improve outcomes, and therapists in the real world naturally adapt their approaches to the needs of individual patients. Their practice methods also evolve over time as they learn through hard-won experience what is helpful to patients and what isn’t. In fact, studies show that when CBT is effective, it is at least in part because the more skilled practitioners depart from the manuals and use methods that are fundamentally psychodynamic. These include open-ended, unstructured sessions (versus following an agenda from a manual), working with defenses, discussing the therapy relationship, and drawing connections between the therapy relationship and other relationships. So the research finding was no surprise. Something would be seriously amiss if experienced clinicians practiced like beginners, following an instruction manual like a consumer trying to assemble an appliance. What caught my eye was the authors’ conclusion that clinicians should be trained to adhere to CBT interventions “to give patients the best chance of recovery.” The study did not examine therapy outcome, so the authors did not know which therapists were effective or which patients got better. They just presumed, in the absence of any information whatsoever, that departure from treatment manuals means poorer therapy. And this presumption— which flies in the face of the actual scientific evidence— slipped right past the “evidence oriented” reviewers and editors of a top-tier research journal. They probably never gave it a second thought. The Big Lie Academic researchers have usurped and appropriated the term “evidence based” to refer to a group of therapies conducted according to step-by-step instruction manuals (“manualized” therapies). The other things these therapies have in common are that they are typically brief, highly structured, and almost exclusively identified with CBT. The term “evidence based therapy” is also, de facto, a code word for “not psychodynamic.” It seems not to matter that scientific research shows that psychodynamic therapy is at least as effective as CBT (see my original research article, The Efficacy of Psychodynamic Psychotherapy or for a popularized version, see Getting to Know Me: What's behind psychoanalysis). Advocates of “evidence based therapy” tend to denigrate psychodynamic treatments (or more correctly, their own stereotypes and caricatures of psychodynamic treatment). When they use the term “evidence based,” it is often with an implicit wink and a nod and the unspoken message: “Manualized treatment is Science. Psychodynamic treatment is superstition.” Some explanation is in order, since this is not how things are usually portrayed in textbooks or college classrooms. In past decades, most therapists practiced psychodynamic therapy or were strongly influenced by psychodynamic thought. Psychodynamic therapies aim at enhancing self-knowledge in the context of a deeply personal relationship between therapist and patient. Psychodynamic or psychoanalytic clinicians in the old days were not especially supportive of empirical outcome research. Many believed that therapy required a level of privacy that precluded independent observation. Many also believed that research could not measure crucial treatment benefits like self-awareness, freedom from inner constraints, or more intimate relationships. In contrast, academic researchers routinely conducted controlled research trials comparing manualized CBT to control groups. These manualized forms of CBT were therefore termed “empirically validated” (the preferred term later morphed into “empirically supported” and more recently, “evidence based”). No research findings ever suggested that manualized CBT was more effective than psychodynamic therapy. It was just more often studied in research settings. There is a world of difference between saying that a treatment has not been extensively researched in controlled trials and saying it has been empirically invalidated. But academic researchers routinely blurred this distinction. A culture developed in academic psychology that promoted a myth that research had proven manualized CBT superior to psychodynamic therapy. Some academic researchers—those with little regard for actual scientific evidence—even began saying it was unethical to practice psychodynamic therapy because research had shown CBT to be more effective. The only problem is that research showed nothing of the sort. This may shed some light on why the authors of the study I described above could so cavaliely assert that therapists should adhere to CBT treatment manuals to give patients the best chance of recovery—and how this scientifically false statement could sail right through the editorial review process of a prestigious research journal. Stay tuned for Part 2, where I will discuss whether “evidence based therapies” actually help people get better. The answer may surprise you. Jonathan Shedler, PhD is a Clinical Associate Professor at the University of Colorado School of Medicine. He lectures to professional audiences nationally and internationally and provides clinical consultation and supervision by videoconference to mental health professionals worldwide. Source: http://m.psychologytoday.com/blog/psychologically-minded/201310/where-is-the-evidence-evidence-based-therapies
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