Rectifications (14) – Evidence-based practice…1
Torrey Orton2– August 31, 2009
I realised this morning, after three weeks' intermittent work on this post, that I am struggling with a much longer piece which doesn't fit in this format. My issue with 'evidence-based practice' is essentially the same as that with 'the research shows' and its correlates. 'Evidence-based' is another mantra mouthful parading the subsequent substantive matters – mental and physical health in particular, but also increasingly other domains - where the government (and some commercial enterprises) want to cloak their activities in a more promising cloth than they deserve.
This is worth pointing out as another example of spin language which intends to sidetrack accountability. As the rains do not come in Victoria it will be interesting what signage goes up on the waterless north-south pipeline meant to save the government from asking people to acknowledge some things cannot be guaranteed to them by the hands of mankind. And interesting, too, what spin the greasy Minister for Waters can deploy in denial of the patently obvious.
The following argument/exploration has more to do with the limits or pretensions of real evidence-based, i.e. scientific, work. Here-in there are serious problems of evidence, and these matter to the political and social discourse we are not having. I will leave them here for those with such interests.'
"Evidence-based practice" and practice realities
"Taking account of research evidence sounds simple until you consider the volume and diversity of research evidence that exists - more than 3000 new medical articles are published every day."
A key issue in evidence-based practice is 'what do we really know?' And this issue quickly becomes, 'what can we predict?', since the purpose of evidence-based practice is to improve practice by adding tested, validated or something similar, knowledge to existing practice, or replace existing practices which do not have a validated knowledge base. In fewer words, we are now on about cause(s) of treatment effects. A background assumption is that we have adequate knowledge of the causes of mental health problems and clear conceptualisations of what these problems are. But the repeat performance of diagnostic trials by trained professionals reveals a failure rate well above what we should expect for professional judgments. How we configure the 'problem' concept tells us what to research. And now we have a problem, both in medicine and psychology.
Research has shown that the treatment method (Nathan & Gorman, 2002), the individual psychologist (Wampold, 2001), the treatment relationship (Norcross, 2002), and the patient (Bohart & Tallman, 1999) are all vital contributors to the success of psychological practice.
Pg 8 - Report of the 2005 Presidential Task Force on Evidence-Based Practice1
Ronald F. Levant, EdD, MBA, ABPP, President, American Psychological Association July 1, 2005 http://www.apa.org/practice/ebpreport.pdf
Research shows what?
We have research which cannot really describe real-time occurring events involving the four "vital contributors" listed above. For example, some decades ago someone tried to write a program for learning to ride a bicycle and gave up around page 425 with the task only 1/3 complete. This was to be the template for a correct and complete training process. Programmed learning ambled around schools in the mid-60's with similar hopes for English grammar and such things notionally reducible to bits. Therapeutic practice, on the other hand is concerned with wholes(people) and the aims and processes of repairing them. Analytic scientific processes may have those concerns but cannot produce the results. Hence, the continuing intellectual and political scrabbling between the analytic and integrative disciplines across modern life. See the arguments over the last year about sources and reasons of the GFC for examples.
An hour's psychotherapy videotaped from both participants' viewpoints and a third two-party viewpoint would be the length of Gone with the Wind, and we still wouldn't have the four views fully represented, not to say integrated. Of course the therapist and patient are integrating everything at every moment, with differing degrees of awareness. The emergence of unconscious themes into conscious play over the course of therapy is one of the most reliable signs of progress in internal integration. Exactly when and how this happens is decidedly unpredictable while also being expected and probable. One example appears below as the "fight".
The fight – a scene in 2 minutes
And this brings me to another part of the science here: what is a fact? In psychotherapy a fact may be an interchange. Here's one: I was working with a marginally bi-polar alcoholic man of 35 living expatriated from his home country. He was tired of conflicted situations at home and at work, with matters back in his home country roiling in the substrate of our now.
Some efforts to prevent such situations worked by pre-empting them, by developing workarounds and prevention measures in the relationships. Partly they couldn't work because they were themselves conflicted. His efforts were driven by a system of rules which said 'just over-perform on others' presumed performance criteria and I'll be safe from conflict'. However, the effort to do this was wearing him out. I was trying to point this out. The final straw, however, was that he felt attacked by me for being wrong in trying to maintain this admittedly self-defeating system. Therewith slipped out rules about never being wrong (yielding even greater catastrophes than being conflicted!) which clashed with acknowledging the unsustainability of his conflict pre-emption system.
I suggested at this point that we were having a little fight and he vigorously denied it. I pointed out that his denial was a little fight and he repeated the denial. We had reached the edge of the relationship terrain of acknowedgable experiences. Fight was too close to fighting to be allowed into discussion. Nor, at the time, could we explore our different meanings of 'fight' because the experienced meanings were too volatile3. Stalemate for the moment. Imagine capturing all those levels on a 3 viewpoint video?
Next session he reported having gone home to take the fight for his needs to reduce conflict to a housemate who was at the perceived heart of the problems there. He began to engage his system of denial by taking action against it and did so successfully. We did not mention our fight. No need to. But if we were investigating the process of the patient's struggle with managing fights (or perceived threats that there could be a fight about something, especially about their performance in relevant social roles), this incident of our fight would be one evidence of movement in his desired direction.
The science in this
The science here might be about perceptions of fighting as one indicator of therapeutic effectiveness increasing assertiveness. So, a research survey or interview might inquire about therapy participants' perceptions of fighting in the therapeutic relationship at any point in a session. How would the difference in therapist and patient ratings of a proposition with the word 'fight' in it be interpreted? There is no standard outside their relationship to provide grounds for an interpretation within their relationship – except a discussion between them!! The survey makers would attempt to validate the item against a broad population and comparison of items with such words in them from other validated surveys. All these moves are contaminated by the intrinsic situational variability of a particular usage plus the social approval aura the word does or does not carry in general…and so on to a nil point.
"…. It is important to know the person who has the disorder in addition to knowing the disorder the person has."
Except, except…we have an instance of emergent understanding poised on the brink of a difference of felt meaning between the participants. This is normal process for therapy but not for scripted techniques (called "manualised treatments" ) with presumptive sequences which have to be maintained to achieve comparative equivalence of the 'treatment' over multiple clients with closely similar timeframes! And, if the stats show us that to X percent of reliability, people in therapeutic relationships do 'fights' roughly this or that way to this or that effect, none of them tell us what applies in the therapeutic moment which is the integration of the four "vital contributors" to effectiveness. Nor can they specify specific applicability to a specific patient, just as medicine cannot.
Another take on the science…
We are beginning to enjoy the fruits of the various revolutions in psychology and medicine – most notably of concurrent neuropsych, cognitive psych and therapeutic practices. Among these is the summary work of Carroll Izard in the latest Annual Review of Psychology (2009, pg. 1-24) unpretentiously titled "Emotion Theory and Research: Highlights, Unanswered Questions, and Emerging Issues". One of his basic principles is that "emotion and cognition, though often treated correctly as having separate features and influences…are interactive and integrated or mingled in the brain..." (pg.3). In other words, for practical purposes at least, there is no such thing as a thought without feeling (or also without embodiment, but that's a later point). A pop up implication is that we cannot clarify the mind with thought focussed processes alone. Another is that thought is not the primary instrument of consciousness, it is one of three – thought, feeling and body. This makes bit of a mess out of the CBT concept that thought controls feeling.
Diagnostics and evidence
Access to publically-funded mental health services is via the GP route, as are all specialist health services, both medical and allied health. There's an inherent contradiction, with implications for practice as we may see from the forthcoming audit of Medicare funded psychological services. It is that GP's seldom have the expertise or time to diagnose the conditions for which targeted psychological services are funded. The scientific part of the diagnostics resides in self-report instruments like the K10 and the service provision is shaped linguistically by the actual CBT requirement. I've yet to see a GP who recommends IPT, though it too is an evidence-based treatment. I imagine that many of my colleagues do not know what it is, either.
In our joint therapy practice, concern for audit processes has lead in the direction of case note-taking in the form and language of CBT, a jacket which does not often fit the body of the everyday work. Further, what it would mean to report the stages of treatment, and testable outcomes, is also a wonder. The K10 certainly will not pass muster as an evaluation tool, except of the happy sheet variety.
2 Acknowledgment of interest – I am a practicing psychotherapist with a client load around 25 per week, registered with Medicare and a half dozen private health insurers in Australia.
3 This moment is also an example of requisite therapeutic violence, discussed here.