Tuesday, May 15, 2018

Research shows that “evidence-based” therapies are weak treatments. Their benefits are trivial. Most patients do not get well. Even the trivial benefits do not last.

Where Is the Evidence for “Evidence-Based” Therapy? Jonathan Shedler. Psychiatric Clinics of North America, Volume 41, Issue 2, June 2018, Pages 319-329. https://doi.org/10.1016/j.psc.2018.02.001

Buzzword. noun. An important-sounding u sually technical word or phrase often oflittle meaning used chiefly to impress.
“Evidence-based therapy” has become a marketing buzzword. The term “evidence based” comes from medicine. It gained attention in the 1990s and was initially a call for critical thinking. Proponents of evidence-based medicine recognized that “We’ve always done it this way” is poor justification for medical decisions. Medical decisions should integrate individual clinical expertise, patients’ values and preferences, and relevant scientific research.1

But the term evidence based has come to mean something very different for psychotherapy.  It has been appropriated to promote a specific ideology and agenda. It is now used as a code word for manualized therapy—most often brief, one-sizefits- all forms of cognitive behavior therapy (CBT). “Manualized” means the therapy is conducted by following an instruction manual. The treatments are often standardized or scripted in ways that leave little room for addressing the needs of individual patients.

Behind the “evidence-based” therapy movement lies a master narrative that increasingly dominates the mental health landscape. The master narrative goes something like this: “In the dark ages, therapists practiced unproven, unscientific therapy.  Evidence-based therapies are scientifically proven and superior.” The narrative has become a justification for all-out attacks on traditional talk therapy—that is, therapy aimed at fostering self-examination and self-understanding in the context of an ongoing, meaningful therapy relationship.

Here is a small sample of what proponents of “evidence-based” therapy say in public: “The empirically supported psychotherapies are still not widely practiced. As a result, many patients do not have access to adequate treatment” (emphasis added).2 Note the linguistic sleight-of-hand: If the therapy is not “evidence based” (read, manualized), it is inadequate. Other proponents of “evidence-based” therapies go further in denigrating relationship-based, insight-oriented therapy: “The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment.”3 The news media promulgate the master narrative. The Washington Post ran an article titled “Is your therapist a little behind the times?” which likened traditional talk therapy to pre-scientific medicine when “healers commonly used ineffective and often injurious practices such as blistering, purging and bleeding.” Newsweek sounded a similar note with an article titled, “Ignoring the evidence: Why do Psychologists reject science?”

Note how the language leads to a form of McCarthyism. Because proponents of brief, manualized therapies have appropriated the term “evidence-based,” it has become nearly impossible to have an intelligent discussion about what constitutes good therapy. Anyone who questions “evidence-based” therapy risks being branded anti-evidence and anti-science.

One might assume, in light of the strong claims for “evidence-based” therapies and the public denigration of other therapies, that there must be extremely strong scientific evidence for their benefits. There is not. There is a yawning chasm between what we are told research shows and what research actually shows.  Empirical research actually shows that “evidence-based” therapies are ineffective for most patients most of the time. First, I discuss what empirical research really shows. I then take a closer look at troubling practices in “evidence-based” therapy research.

PART I: WHAT RESEARCH REALLY SHOWS

Research shows that “evidence-based” therapies are weak treatments. Their benefits are trivial. Most patients do not get well. Even the trivial benefits do not last.