Evidence-based Practice or Practice-based Evidence?

In the mental health community, we have all come to live under the hegemony of “empirically based care,” led by payors, auditors, governmental authorities (read SAMSHA), our own licensing boards, and administrators—like myself—desperate to demonstrate that their psychotherapeutic services are cost effective.

But are they? I’m not convinced that we are doing our profession or our clients a great service by following this policy, and I’m unsure where it ultimately leads us.

Recently, I saw Scott Miller, a Chicago-based psychologist and founder of the International Center for Clinical Excellence (www.scottdmiller.com), at a recent National Association of Social Worker’s event and was utterly galvanized. His work seemed to cut through much of all the dueling theories/evidence-based practice noise and focused instead upon the dynamic nature of the relationship between therapist and client, which he feels is crucial to successful intervention.

I believe he makes a strong case. And I admit, with a slight involuntary twinge of hesitation, that as a therapist, I agree with him: the power of a relationship, not the specific treatment method or theory, is the primary catalyst for change. If that makes me the Che Guevara of the sweater-vest therapist set, allow me to explain why I feel this way. 

Moving on from the Old Therapeutic Models

In deference to its early practitioners—and in order to achieve mainstream legitimacy—we have always preferred to label psychotherapy a “medical/scientific” intervention. Like what my doctor does. He applies a treatment (cholesterol lowering medication), which cures me of or protects me from unwanted medical events (prevents a first heart attack). Likewise, psychotherapists apply an empirically-based treatment method such as cognitive behavioral therapy (CBT), which cures the client of their condition (anxiety), right? That seems to be what many professionals claim.

But I say, hogwash.

When I look back on my practice, my interventions on behalf of those I served have always been characterized by a particular kind of “clinical experience,” namely the process of their relationship with me as I brought certain techniques and methods into it. The interventions were useful tools, but they weren’t cures or treatments in the way medications are. Instead, they provided a medium where the client and I could connect and relate as we worked together on achieving his or her goals.

That’s what I believe. Unfortunately, these days, it isn’t popular to be like me.

I have witnessed many empirically-based interventions come and go over my professional life and for the most part, marveled at their lack of complexity or creativity.

For example—and I hope that this isn’t perceived as arrogant—CBT is in many ways a retread of platonic philosophy, which has been around for 2,500 years.

Rational Emotive Behavior Therapy (REBT) seems a tad too easy for me, and my experience with it has born out my suspicions. Albert Ellis once cured me of my nervousness about an upcoming wedding ceremony in front of a room full of clinicians.Needless to say, it didn’t stick.

Structural Family Therapy grew out of 1950s developments in the understanding of biologic systems—the guys in Palo Alto thought they could cure schizophrenia, if only they could get the mother to change. I loved it because I loved utilizing myself strategically to challenge the organization of a family system.  It works, but I’m not exactly clear why.

Dialectical Behavior Therapy seemed to have more than a little to do with Eastern thought, mindfulness, and meditation. “Wise Mind” indeed, but nothing new.

Frankly, there doesn’t seem to be anything new going on with any of them. And change, I’ve found, is not mediated by applying any particular theory. It is mediated by the client’s desire to change, and I’ve found I can affect that desire.

What Works Versus Evidence-based

No one is comfortable with the idea that “what works” might be an extremely multivariate reality beyond simple “adherence to a practice model.” “What works” might lurk somewhere in the shadows of a healing relationship, where the light of science might not so easily penetrate.

So, like many, I took my training in CBT, Trauma-Informed CBT, etc. etc.But I still always held that those methods were not the real levers of change.

Miller’s book, The Heroic Client, lays out his research and philosophy in an extremely compelling way, and he comes to the same conclusions I have: it is not the method that makes the change, but rather client’s perception of the quality of the relationship with the therapist. And paradoxically, he gathered piles of data to support this decidedly “low tech, unempirical” conceptualization of our practice.

Now, to be clear, unmediated by ANY overarching method, therapy is vague, and vague therapy equals vague results. What we need is a process which demands accountability to a goal mutually derived by the client and therapist, and a method to respond when progress toward that goal is in question.

We need a process that forces us to be clear about what we will achieve, and forces us to measure progress to that goal concretely, while allowing each of us flexibility to exercise the particular method or set of methods that work for us and our clients. And frankly, if we have lots of therapists measuring the effectiveness of their creative efforts on behalf of their clients, it will provide “practice—based evidence,” which I think, at the end of the day, is better than “evidence-based practice.”

By the way, I believe Grafton’s Goal Mastery Initiative (www.grafton.org/goal-mastery) provides this tool. The goal mastery process provides a structured and sustainable system to identify, monitor, and evaluate client progress and embed data-based decision-making into trans-disciplinary treatment and instruction planning.

So what’s your perspective on this? Do you agree that psychotherapy achieves value more through the therapist/client relationship than through the application of any particular approach? Or should we continue to follow the current of so-called evidence-based practice? Perhaps one sustains the other? And if you do agree with me, how do we begin to shift the focus of the therapeutic community?

I look forward to you joining our conversation.