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A Needed Course Correction for the “Evidence-Based” Movement?

“Every psychotherapist recognizes that what works for one person may not work for another; we embrace the maxim, ‘Different strokes for different folks.’”
John Norcross

In recent times, much fuss has been made about evidence-based treatments (EBT). In our case, this refers to psychotherapy treatments that have been “proven” to work for certain diagnoses. In a separate article, I made the argument that psychologists reject EBTs because the science behind them is too primitive to be useful. Here I look at a possible way that the “evidence-based” movement may have actual value to people who do psychotherapy in the field and not just for publishing journal articles in an academic environment.

Let’s take the example of a treatment method for Posttraumatic Stress Disorder (PTSD) called Prolonged Exposure (PE). The theory behind PE says that PTSD symptoms arise as a result of avoiding trauma-related thoughts, reminders, activities, and situations. “Prolonged exposure” to these things is thought to reduce symptoms. The Department of Veterans Affairs (VA) and the Department of Defense (DoD) have systematically implemented PE as one of the EBTs approved for the treatment of Posttraumatic Stress Disorder (PTSD).

Interestingly, the research behind the evidence did not include subjects that have diagnoses such as Borderline Personality Disorder (BPD) or Dissociative Identity Disorder (DID; aka multiple personalities), both thought to result from severe childhood trauma. Further, many of the subjects in the study actually dropped out of the study after as few as one session. People in the know theorize that these subjects simply did not like it. I can’t say I blame them. During the PE process, subjects or clients are strongly encouraged to continually re-visit traumatic events in their minds. Would you want “prolonged exposure” to some of the worst moments of your life? Me neither.

At any rate, the “evidence” thus demonstrates that PE works great for people who have only experienced a relatively mild trauma (as opposed to someone who, for example, was repeatedly sodomized by his father for ten years starting at age three) and who are willing to white-knuckle their way through very uncomfortable memories (assuming they even had such memories, which many traumatized people don’t have due to their brains’ survival mechanisms). In addition, I would be interested in a study of the long-term staying power of PE, given there does not seem to be much emphasis on the body, where the strongest memories of trauma are known to be stored.

At any rate, it is not my main purpose here to rag on PE (believe it or not), but to look at other variables that research might examine that would prove more useful than trying to match up cookbook therapy methods with relatively narrow sets of symptoms.

Enter the concept of evidence-based therapy relationships! Here, rather than trying to match treatments with symptoms, we try to match the characteristics of treatment with the characteristics of the particular, unique client with whom we’re working. For example, we note above that many PE research subjects dropped out. Could it be that the characteristics of PE did not match the characteristics of these drop-out subjects? What if some other method or style of the therapist relationship was more appropriate? Wouldn’t it be nice to figure this out in advance of subjecting people to ineffective therapy experiences?

I will admit that paying attention to the therapeutic relationship and the characteristics of the unique client is a messy business with maybe an infinite number of variables. However, John Norcross (quoted above) and others have been doing research in the area of the therapy relationship for many years. His book, “Psychotherapy Relationships that Work,” was published in 2011. Another good book to look at on this subject is “The Heart and Soul of Change.” Going back even further in time, Carl Rogers was all about this stuff since back in the 1940s, well before many of us were born. He even won the American Psychological Association’s very first Award for Distinguished Scientific Contributions back in 1956. So, why the focus on matching the treatment method to the diagnosis within the context of psychotherapy?

Well, first let me introduce something called “the medical model,” coming from allopathic (western) medicine. Here, the doctor decides what’s wrong (makes a diagnosis) based on asking the ignorant (of medical matters) patient a few questions and performing some tests. The doctor then provides the appropriate medication or surgery (treatment) to address the identified problem. The patient may be treated as an object to be worked on (much like the cadavers that are the first “patients” that med students work on in their training). Your visits to a family doctor have probably been much like this. This is all well and good within the context of a relatively mature science where the physical body has been studied and understood for centuries. The concept of evidence-based medicine came out of medical practice in England, where they have a nationalized medical system and want to get down to business as quickly as possible to save taxpayers money.

Now, enter the world of the mind, something that until about a hundred years ago had been the purview of religion and philosophy. It was (and is) not very well understood or studied from a scientific viewpoint. Enter also the early psychotherapists, such as Freud, who was a neurologist, and others, most or all of whom had medical degrees. They, too, wanted to apply the medical model to help their patients because that’s what they knew, but they had no pills or scalpels to offer to the mind. So, they developed theoretical models and “talk therapy.” Over time, many hundreds of these models and theories were developed. Most were autobiographical, based on how the therapy provider saw the world and their patients. Nobody bothered to ask the actual patients about this since they were thought to be ignorant of their own maladies. Not much evidence-based research went on because it was nearly impossible to do so on this wily thing called the mind.

Eventually, two things happened. One, the pharmaceutical companies that made the pills that helped treat medical problems started coming up with pills that (they believed) could help people with problems of the mind. For example, methamphetamines were used to treat depression back in the 1940s. Cocaine was also used back then. (Good times!) And so mind doctors had a way of applying their beloved medical model to their patients (they weren’t called “clients” until Carl Rogers invented the term around the same time and it eventually caught on, but I digress).

The other thing that happened was that Cognitive-Behavioral Therapy (CBT) was developed. Here, at last, was a therapy method that could be summarized in “cookbooks” (with book titles like “Feeling Good“). This made therapy research much easier because you could apply exactly the same treatment to each research subject (object?) and see what you got. Wow! Now psychology was starting to look more like a science that could play with the big boys in medicine. Yippee!

So everyone is happy. The pharmaceutical companies are making big bucks from pushing their pills. The therapists are enlarging their egos and bank accounts by looking and acting more and more like real doctors. Researchers are able to write journal articles about stuff that looks like real medicine. Everyone is happy. Well, with the exception of the patients/clients. We’ve had psychotherapy for over a hundred years now and are we, as a general population, becoming more mentally healthy? Whoops! What’s going on here?

In my view, we’ve made the mistake of forgetting about the actual patient/client. We think that everyone (including a young adult woman with Asperger’s, a 60-year-old man with a touch of bipolar, or a middle-aged woman who lives with several dozen personalities in the same body) is the same. Therefore, they will respond exactly the same to whatever treatment seemed to work for slightly over 50% of the college freshman who participated in the mandatory psychological experiment as part of their grade for Psych 101. OK, I admit I am terribly cynical on this topic. But, do I care about my clients? Well, I’ll let you decide.

Maybe it’s the 21 years I spent in the corporate world that makes me look for “what’s the game being played here.” I prefer to think critically about what actually does work for each client with whom I work, rather than take someone’s word for it who has never met my client and knows nothing about them.

Alright, enough of this particular rant. I will end on the positive note that at least some research funding is starting to target the characteristics of both therapist and client, which seem to be the real factors of successful psychotherapy. More about this in the future.

Copyright 2014 Daniel J. Metevier

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