A Doctoral Student’s Perspective on Becoming an Evidence-Based Practitioner
The evidence-based practice in psychology (EBPP) movement can be considered a response to the medicalization of psychology, where pharmaceuticals are at risk of becoming the primary treatment option. The “year of the brain” illuminated connections between neurobiological markers and psychological phenomena, and as Paris (2015) argues, the field of psychiatry welcomed neuropsychology as a means to gain credibility in the science and medical fields. Once we could see that abnormalities in neurotransmission coincided with the presence of psychological impairment or distress, psychopathologies became defined as brain disorders and thus could be remedied with pharmacological interventions. However, if you believe, like I do, that humans are more than just “brains in a jar,” then psychopathology cannot accurately be described as a brain disorder. The human mind is a complex organ that exists within, interacts with, and is impacted by its environment. Sure, we can see changes in brain functioning and neurotransmission, but those conditions do not occur in a vacuum. Instead, they are shaped through the bi-directional interaction of our biology and our environment. Therefore, it follows that the treatment of psychopathology should involve a correctional interaction with our environment through social, emotional, and cognitive experiences.
Fortunately, many academic and professional psychologists, encouraged by many years of research and clinical experience, felt compelled to reassert psychotherapy as a viable, if not preferred method of treatment. The APA Presidential Task Force on Evidence Based Practice (2006) aimed to increase awareness of the utility of psychotherapy by identifying specific treatments and interventions that could be found to be effective. In order to compete with pharmaceutical options, which are typically time- and cost-effective, psychotherapy needed to be proven to work.
Psychotherapy Research: What are we looking for?
An essential question to consider when proposing extensive psychotherapy research is what evidence are we looking for? Are we looking to prove the theoretical underpinnings of the root of psychopathology and treatment? Are we interested in investigating what the therapeutic relationship should look like or what specific interventions we should use? Are we looking to identify common factors of therapeutic change? Is there a protocol that can dictate the entire process? Which existing treatments, if any, can be applied or modified across cultural identities?
Ideally, we would be interested in all of these questions, however, the search for empirically-supported treatments (EST)—treatments that can be shown to work for specific disorders—has dominated much of the EBPP movement. ESTs are manualized protocols that have been tested through randomized clinical trials (RCT). This research method relies on the assumption that the variables of therapeutic change are identifiable and able to be controlled. Beutler (2009) argues that ESTs, by way of RCTs, do not actually fit into the paradigm of psychotherapy because they do not control and operationalize all of the potential active variables involved in the therapeutic process. In clinical practice, any treatment intervention, whether it is manualized or not, is mediated by the interaction between the characteristics of the clinician and the characteristics and needs of the patient, thereby making psychotherapy an exceptionally dynamic process. “If, as we have proposed, these aspects of character, preference, fit, and expectation, contribute more consistent and stronger predictive power in outcome assessments than the technical aspects of interventions, then they ARE THE TREATMENT” (Beutler, 2009, p. 25).
This leads me to wonder whether RCTs are proving anything at all about psychotherapy. If a RCT is investigating a specific set of interventions which are to be delivered in a precise and timely manner, however, the study does not account for the qualities of the therapist, the unique characteristics of the patient (personality, temperament, perception of distress, perception of treatment, expectations of treatment, cultural variables, past experiences with treatment, etc.) can we even be sure that the protocol is the main agent of change? Will this protocol hold up in a variety of clinical applications? Tanenbaum (2005) addresses this, as well, and argues that RCTs measure efficacy instead of effectiveness and stress reliability over validity. Beutler proposes that we expand our understanding of EBP by moving away from ESTs serving as the primary bridge between research and practice, toward research informed practice (RIP); a more complex and dynamic application of psychotherapy research that takes into account the wide away of variables which cannot be randomized.
I imagine that in a push toward a more dynamic approach to psychotherapy research, we might start to see the validation of more varied therapeutic approaches. It seems that cognitive behavioral therapy (CBT) is so often tested and mythically touted as the gold standard treatment because it so neatly fits into the paradigm of RCTs (Tanenbaum, 2005, p. 166). Like RCTs, CBT focuses more on techniques and specific interventions and not as much on the relational aspects of therapy. However, I wonder still if RCTs do not account for human characteristics and relational variables, then again are the components of CBT even really validated?
In line with Beutler’s take on EBP, The APA Presidential Task for on EBP (2006) calls for “the integration of the best available research, with clinical expertise, in the context of patient preferences.” In their report, the Task Force addresses some of the concerns that psychologists in the field were having about psychotherapy research, the use of ESTs, and direction of EBP in general. They acknowledge that many different research methods can contribute to our understanding of psychopathology and treatment including single case studies, qualitative research, and clinical observation. They also stress that just because a technique or intervention has not been studied, it does not mean it is worthless, it just is not proven. I think that this is important for practitioners and patients to keep in mind, however managed care organization and insurance companies often only cover treatments which have been empirically supported in RCTs. This puts us in a difficult position, limiting the type and quality of care that we provide and putting more pressure of the research community to address other treatments. I think this is also particularly relevant when considering multicultural applications. Since we are unsure of the clinical utility of many treatment types across many cultural and social identities, how do we proceed with clinical practice?
Evidence-Based Multicultural Practice
Sue (2009) addresses evidence-based multicultural competence, arguing for more culture-specific research, while also proposing that a multiculturally competent practitioner develop scientific mindedness and utilize dynamic sizing. When applying treatments that have not yet been tested and empirically supported to work for a patient of a certain background, the practitioner should weigh incoming information about the patient against a hypothesis. If the hypothesis is disconfirmed, the practitioner formulates a new hypothesis. The clinician should also be able to move between generalizing based on specific cultural knowledge, and individualizing based on individual-level differences (Sue, 2009, p. 5) Here, I also think it is useful to apply the concept of the “local clinical scientist.” Because we are in need of more research on how to apply empirically validated treatments across diverse populations, clinicians can contribute to this knowledge by tracking patient progress and collecting data. Something that I found compelling is the question of whether we should focus energy into testing existing treatments on diverse populations, and adapting as needed, or work to develop new interventions like “cuento” therapy for individuals of Puerto Rican descent (Sue, 2009, p. 9).
Evidence-Based Group Practice
Paquin (2015) applies these positions to group therapy research, noting that the unrandomizable variables that make studying psychotherapy difficult are even more complicated when looking at group dynamics. In group therapy, there are countless interconnected variables that undoubtedly impact the process of therapeutic change. Paquin echoes the sentiments of others previously mentioned in arguing for more dynamic research methods that account for the less easily controlled variables like therapist characteristics, group member characteristics, multicultural components, and intragroup characteristics. Again, because more research is needed in this area, the local clinical scientist is essential to building this knowledge base.
EBPP and Issues with Diagnostics
Another issue that complicates EBPP is how we define and categorize psychological disorders. It is essential that we attempt to have a clear idea of what we are trying to treat or correct. Paris (2015) reminds us that unlike physical medicine, which can utilize diagnostic imaging, blood tests, and other biological markers to determine the cause and progression of an illness, psychology and psychiatry have to rely nearly exclusively on subjective observations and self-reports of symptoms. Brain scans tell us very little about physical abnormalities and functions of the brain, therefore we cannot scientifically trace the etiology of a disorder. Moreover, the subjective observations and self-reports that we do have are relative to their cultural context, which further underscores the idea that the way in which we conceptualize psychopathology is socially constructed, therefore not easily scientifically validated. Paris argues that because we cannot currently scientifically validate psychological disorders, EBPP or the development of validated treatments, is actually not even possible (Paris, 2015, p. 11).
The DSM has served as a way to define, categorize, and organize our understanding of psychopathology. With each new version, we see the addition of many new disorders. Again, these disorders are born out of clinical observation and psychological theory and are essentially based on what clinicians have been seeing in their clients. As we try to tease apart symptoms and differentiate between disorders, we see the birth of many new diagnostic categories. Paris (2015) argues that this is leading to the over-pathologizing and over-treating of the normative human experience, however, I think this is only a problem as long as two conditions persist: (1) the stigma surrounding psychological distress and (2) psychotropic medication serves as the first line of defense in mental illness.
As long as counseling and psychotherapy are the primary treatment modality, as opposed to psychotropic medications, then I do not see over-treatment as being problematic. If clinicians are held to the ethical standard of carrying out the appropriate treatment for the appropriate amount of time, then psychotherapy is unlikely to cause harm. If everyone who falls within a diagnostic category gets medication, then over-treatment is a significant problem.
I would disagree with Paris’ argument that the categorical method of diagnoses is preferred to the spectrum method. I think that conceptualizing psychopathology as existing on a spectrum can help to reduce stigma. It can make those on the extreme end feel less like they are so far outside of normative human behavior, which can help to build positive momentum when entering treatment. Furthermore, those with less severe symptoms may be able to get essential preventative treatment. While I disagree with some of Paris’ arguments about psychopathology, I do appreciate the concern that expanding diagnostic categorization to the spectrum method can lead to trivializing serious mental illness.
Something that I have noticed across several articles on EBPP is the distinction between treating serious mental illness and optimizing the lives of relatively healthy people. Psychiatrists are typically interested in understanding and treating serious mental illness, whereas I think that many Counselors and Counseling Psychologists, who come from an ecological approach, would also want to address the complications of every-day life. I am wondering if it is actually the counseling mindset that is unintentionally pulling diagnostics into the over-pathologizing realm?
We recognize the distress that can arise out of racial injustice or the death of a loved one and we think it is important to address. We are interested in helping with a wide range of human problems and while our intention has not been to label these issues as illness, we think that counseling can help. That mindset, coupled with the need to define disorders for psychotherapy research and insurance purposes has led us to make many parts of the human experience disordered. Again, I rest on the idea that if there is significant distress and dysfunction, there is no stigma for having such distress and dysfunction, and we do not rely on medication, then what harm is done in pathologizing?
Any trainee, researcher, or clinician in psychotherapy would undoubtingly agree that psychotherapy is an exceptionally dynamic and complicated process to undertake, let alone measure. In any given therapy dyad or group, there are an exponential number of variables relating to the personal characteristics of both the client and the therapist, few of which can be easily identified and controlled for. The functions that occur within therapy, whether they are manualized or not, present their own unique issues regarding measurement. Finally, the distress that we are intending to alleviate has been corralled into discrete categories in order to prove that we can do as we intend. As many psychology scholars before me have suggested, evidence-based practice in psychology requires an accompanying paradigm of research that makes room for the dynamic and complex processes at play. It also relies on involvement from the local clinical scientist, whose work should inform research.
Cite This Article
Kelly, M. E. (2019, August). A doctoral student’s perspective on becoming an evidence-based practitioner. [Web article]. Retrieved from https://societyforpsychotherapy.org/a-doctoral-students-perspective-on-becoming-an-evidence-based-practitioner
APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. The American Psychologist, 61(4), 271.
Beutler, L. E. (2009). Making science matter in clinical practice: Redefining psychotherapy. Clinical Psychology: Science and Practice, 16(3), 301-317.
Paris, J. (2015). The Intelligent Clinician’s Guide to the DSM-5RG. Oxford University Press.
Paquin, J. (2015). Evidence-based practice in group therapy. American Group Psychotherapy Association, NY. http://www.agpa.org/home/practice-resources/evidence-based-practice-in-group-psychotherapy
Sue, S., Zane, N., Hall, G. C. N., & Berger, L. K. (2009). The case for cultural competency in psychotherapeutic interventions. Annual review of psychology, 60, 525.
Tanenbaum, S. (2005). Evidence-Based Practice As Mental Health Policy: Three Controversies And A Caveat. Health Affairs, p. 163-172.
What you think and write is congruent with the roots of Psyche and therapy ad such words meant epistemologically from the first rational and scientific applications of therapy since 2500 years ago in the pythagorean school. ( cfr. Alexander, Selesnick “ History of Psychiatry) …and my clinical practice since the 1980 in southern Italy. Thank you!