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The Dark Side of Evidence-Based Treatment |
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Classic Reprints |
Ron Fox |
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Evidence-based treatment (EBT) is a “red flag” in current debates within the practice community. On one side are those who believe that it represents psychology’s only hope for separat-ing reputable psychologists from practitioners on the fringe of profes-sional respectability, as well as the only viable route to saving our profession in an environment dominated by managed care. On the other side are those who hear the EBT drumbeat as a call for accepting a limited definition of science with a built-in bias against the evidence base favored by psychodynamic and humanistic approaches. Such debates are familiar and neces-sary among professionals who take pride in representing themselves to the public as scientist-practitioners. Although debates about the relative effectiveness of various treatments is probably necessary and healthy, we often fail to realize that EBT has a different meaning, a darker side as it were, when it arises in the midst of discussions with managed care execu-tives about reimbursement for our services. In that context, the phrase is code for, “We are not going to pay you!” When we fail to recognize the code, we are easily sidetracked into a discussion about treatment outcomes rather than reimbursement policies. We confuse a bargaining ploy with a scientific debate. The executives are not scientists. What they are really saying goes something like this: “Our firm is not going to reimburse psychologists for many of their services, nor will we pay a reasonable fee for those we do recognize. But, instead of discussing our bias against mental illness treatments, we prefer to talk about the need for more and better evidence that your treatments actually work. Don’t get us wrong. We want to work with you. We are together with you in wanting the best care for our customers, but at the same time we can’t pay for all the weird claims your people submit. You need to help us figure out what works best and who the competent providers are.” It is a mistake to enter such a discussion in the context of appropri-ate reimbursement. If it were really a matter of data, the discussions would not be taking place. Sufficient data are available now to show that we have effective treatments. In fact, there is a great deal of data to show that we have a great product called psychotherapy that works anywhere from 60 to 70 percent of the time or more. When compared with many accepted medical treatments, that is pretty good. Take angioplasty as just one of many examples. When I had the procedure two years ago, it had been proven successful about 40 percent of the time. Sixty percent of the cleared arteries become blocked again within a few years. No managed care firm gave my physician or me a hard time about this procedure. It was seen as something that often worked, was associated with minimal risks and was better than doing nothing. Psychologists do not have to apologize for their treatments! This is not to say that there is no need for more research and better knowledge about the psychotherapeutic process. Of course there is. But, we cannot allow ourselves to be diverted into such debates when the purpose of the discussion is not to advance scientific knowledge, but to determine whether and how psycho-logical treatments should be reim-bursed. That is a matter dealing with profits and returns on investments. It is not about evidence-based treatment or efficacy, or anything else and we all need to be careful not to fall for it. At the 1999 Practice Directorate Town Hall meeting during APA’s convention, a Motorola executive provided a very public example. In response to a question regarding discriminatory reimbursement policies for mental illness coverage, he offered the EBT argument saying that they would like to be fairer, but businesses needed help in figuring out what worked. Immediately several of our colleagues leaped to the floor to extol the virtues of more research and how our commitment to research was the distinguishing hallmark of our profession. Instead, psychology practitioners should he helping businesses under-stand why they’re not well-served by pursuing EBT. Of course we have colleagues who behave as quacks and who rip off the system to their advantage. So does every other health profession. If the executives who bemoan the existence of psychotherapy quacks were really interested in evidence they would know that there is no evidence to suggest that psychologists have any greater percentages of such practitio-ners than other professions. We have some very good treatments for a variety of disabling conditions. Treat-ment of those conditions should be reimbursed on a par with a host of other disabling conditions. This is not happening at this time, but it is not because we do not have evidence based treatments or good data or too many quacks. Those are red herrings and we would do well to not chase them. |
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