Evidence-Based Practice in Psychotherapy Timothy C. Thomason Northern Arizona University 2012

Psychotherapy Works Psychotherapy works, but not always or for everyone or for all problems. Psychotherapy involves many difficult-to- measure variables (the client, the therapist, the relationship, the problem, the technique, etc.). Psychotherapy works, but do certain kinds of psychotherapy work better than others for certain client problems or disorders?

Different Perspectives Therapists who see therapy as an art or a special kind of relationship are different from therapists who see it as a craft or a science. Practitioners want to do whatever helps clients. Academics tend to value empirical research.

Different Perspectives Counseling psychology has humanistic origins and focuses on the therapeutic relationship. – Clients have issues, concerns, and problems. – The common factors approach is valued. Clinical psychology is more grounded in the medical model. – Clients have mental disorders listed in the DSM. – Evidence-based treatments are valued.

Two Trends in Psychotherapy The practice of psychotherapy is bifurcating: counseling vs. clinical approaches. Counselors see clients for issues, concerns, and problems, which may not be reimbursable. Clinicians see clients for mental disorders. The evidence-based practice movement is more relevant to clinicians than counselors. Note that there is no clear line between these (eg., both counselors and clinicians use CBT).

Barlow’s Distinction There are psychological treatments that are specific to certain mental disorders. There is generic psychotherapy for problems in living. But problems in living are inextricably intermingled with specific mental disorders, and improvement in symptoms is not the only goal of psychotherapy.

The Battle of the Two Models – The common-factors approach says that therapy is a conversation in the context of a healing relationship; diagnosis, technique, and the medical model are de-emphasized. – The EBP approach says that correct diagnosis and proper treatment techniques are essential for good therapy.

Why the Push for Evidence-Based Practice (EBP)? We know some treatments are not effective. We know some treatments are harmful. Clients deserve to get treatments that are effective and not harmful. If evidence-based treatments can be identified, then they should be used.

Why the Push for EBP, cont. There are financial incentives. – Third-party payers prefer EBP. – Liability insurance providers prefer EBP. – Professional organizations prefer EBP. – Employers of psychotherapists prefer EBP. – Many members of the public prefer EBP. There are public relations incentives. – EBP makes psychotherapy look more efficient, professional, modern, and scientific.

The Insurance Perspective Resources are limited. Insurers cannot afford to pay for unlimited psychotherapy for everyone for every concern they may have. Some kind of “rationing” is unavoidable. Insurers only want to pay for services that are “medically necessary.” They define as medically necessary those disorders in the DSM, not V-Codes.

Not Using EVP Hurts Clients Today, few clients receive evidence-based treatments for their disorders. – For example, there is ample evidence that CBT works for most clients with panic disorder, bulimia nervosa, and CBT, but few clients with these disorders receive it.

Has EBP Won? EBP may not be the most philosophically correct approach for psychotherapy, but the EBP approach seems to be “winning” the battle. However, the war is not yet over. – Counselors and psychologists can still practice in a huge variety of ways. – Currently, mandates for the practice of EBP are rare. This may change in the future.

What is “Evidence” in EVP? There is a hierarchy of types of evidence. At the top, the gold standard is experiments with random assignment of participants, control groups, etc. Then there are experiments and studies with less stringent criteria. Then there is qualitative research, correlational studies, survey research, case studies, etc. At the bottom there are anecdotal reports.

A Hierarchy of Evidence Meta-analysis Randomized controlled trials Process-outcome studies Public health and ethnographic research Single-case experimental designs Systematic case studies Qualitative research Clinical observation and opinion

The APA Definition of EBP The American Psychological Association defines evidence-based practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” This allows psychologists a lot of leeway. The APA does not enforce this requirement. But state psychology boards may enforce it.

Some Therapies Are Best Avoided Some psychologists have lost their license to practice because they used certain treatments that the state psychology licensing board considered outside the boundaries of the standard practice of psychology. – Eg. Thought Field Therapy – Eg. Attachment therapy; Rebirthing – Eg. Exorcism

Categories of Treatments Some treatments have good evidence of their safety and effectiveness. Some treatments have some evidence of their safety and effectiveness. Some treatments have little or no evidence of their safety or effectiveness. Treatments in the third category should probably be avoided until there is more evidence.

APA’s List of EBPs APA’s Society of Clinical Psychology has a list of evidence-based treatments for 17 different mental disorders and a list of about 80 specific evidence-based psychological treatments. psychologicaltreatments.org Many of these treatments are not CBT!

What About Therapies Not on APA’s List? They may or may not be safe and effective. If they are not on the list it means there is not enough evidence that they are effective to put them on the list. There are probably treatments that are effective but lack research to prove it. Some treatments have not been researched enough to know how effective they are. Note that some types of treatment are easier to research than others.

Recommendations Regarding your practice of psychotherapy: – Get a firm foundation in generic relationship skills, the common factors, communication skills, etc. – Develop a preference for a theoretical orientation and learn that orientation as well as possible. – Learn how to practice evidence-based techniques for specific common disorders, such as anxiety and depression, OCD, PTSD, substance abuse, etc.

Recommendations, cont. Obtain specialized training in the therapy approaches or evidence-based treatments you like most or think will be most useful. – Eg. Beck Institute, DBT Training, Motivational Interviewing Avoid treatments that have little or no evidence of their safety or effectiveness. Understand that you can practice from almost any theoretical perspective and also use evidence- based treatments when they are indicated.

Predictions for the Future of Psychotherapy Divergence of EBP and general psychotherapy. Eventually only EBP will be reimbursed by third-party payers. Eventually only psychologists who practice EBP will be able to get liability insurance. Psychologists who do not use EBP will be vulnerable to malpractice liability suits.

Predictions, cont. Non-evidence-based practice will eventually be limited to psychologists who are willing to practice without either third-party reimbursement or liability insurance. Psychotherapy will become briefer and more medicalized. The 50 minute hour will be reduced to 30 minutes or less.

Predictions, cont. There will be much more use of interactive computer systems, telehealth, , and websites (because they are cheaper than individual or group psychotherapy). There will be much less individual therapy. There will be much more group therapy for people with specific disorders.

Predictions, cont. The practice of psychotherapy will become more of a Masters-level profession. Doctoral psychologists who choose to do psychotherapy will have to accept the same fees as Masters-level counselors and therapists. Good specialty areas for psychologists will be neuropsychology, forensic psychology, and health psychology.