Understanding Psychotherapy Research and Evidence Based Practice

A recent trend in psychotherapy due to the abundance of psychotherapy research has been a call for "evidence based practice."

Let's take a look at what that means and what may be in store for us in the future.

First of all, this movement means that there is a desire to protect the public from quackery.  If, as a psychotherapist, I am constrained or compelled to only use empircally validated techniques, I cannot just use whatever comes to mind at that moment.  I cannot tell my patients to wear copper bracelets to get better.  I cannot simply smile and be pleasant.

Secondly, it means that some traditionally accepted treatments may not make the cut either.  For some disorders, psychoanalysis may not have been shown to work.  Hypnotherapy may not have been shown to work.  Transactional Analysis or Gestalt Therapy may not have, either.

Thirdly, it means that patients have a fighting chance of getting better.  No therapy is perfect.  No therapy has been shown to work 100% of the time.  And even when therapy works, it often does not work 100% effectively for an individual.  But the patient has a fighting chance because people have been shown to get better with that therapy.

Now let's look at some drawbacks to movement.  First, just because a treatment has been shown to be effective doesn't mean that my patient may be ready to accept it.  Exposure to a feared stimulus (phobia) has been shown to be an effective treatment for that type of anxiety disorder.  However, patients may not want to use that treatment because it means that they have to confront the feared stimulus first.

Secondly, while research has shown certain treatments to be effective for certain disorders, it is important to understand what that means.  It means that there is a statistically significant difference between the beginning and end of treatment or between two groups--a treatment group and a control group. It does not mean that people receiving that treatment get "well."

Thirdly, just because a treatment has not been shown to be effective does not mean that it isn't.  It may only mean that no research group has devoted the time and monetary resources to test the treatment.  A treatment rejected today because of lack of evidence could well be supported by research next year.

Fourthly, when a patient walks into my office, they often do not want to be treated as a disorder.  They often do not want to be known as a case of "agoraphobia."  And so they may not want a packaged treatment for that disorder.  They may want more than anything for someone to just listen to them.  What if the empirically verfied treatment does not call for "listening" as a primary therapeutic ingredient?

Fifth, the patient may not tell me why they are there at first.  Shame may keep them from revealing the true nature of their issues until they get to know me better.  What if I start treating them for the symptom picture they present with, but then six sessions later they tell me a rather different issue that really what is bothering them the most?

Sixth, patients are complex.  They are rarely just a single symptom picture.   They often have several different symptom issues, such as ADHD, mild depression, and anger issues.  Which of the three guides me in determining the empirically verfied treatment?

The above problems are not to say that we cannot or should not use empircally verfiied treatments.  We need to.  The history of psychotherapy research (only about fifty years) has been productive in testing out some treatments and helping us understand what works.  It also has pointed to the importance of the therapeutic alliance in therapy outcome.  Psychotherapy has to be scientific to the extent that it is possible.  It is not mumbo jumbo. Or if it is, then it needs to be taken out of the field of medicine.

But psychotherapy is somewhat unique in the field of medicine.  If a person needs a shot, or an MRI, or an antibiotic, then the doctor's pleasant demeanor is a nice bonus.  But it is not totally necessary.  The relationship is of utmost importance in psychotherapy.  The patient is not an object.  They are a person.  And that is why the who issue of evidence based practice has to be approached very carefully.