The scientific underpinnings of psychological practice are being hijacked by a group of our own scientists who sincerely believe that they are saving the profession when in fact they are helping to destroy it. I am referring to some scientists in the evidence based practice (EBT) movement who are attempting to impose their own, unique definition of science on our discipline and our profession. By so doing, they are simultaneously diminishing our science and de-professionalizing our profession --- a disciplinary “two fer,” if you will. These are harsh statements, but I do not believe them to be mere hyperbole.

Any group that attempts to impose its own definition of “real” science on others is, paradoxically, acting in a decidedly unscientific manner. Science does not dictate, it reveals and raises new questions. Unfortunately, we have among us some who believe that they have discovered the real truth about the science of psychotherapy and psychological assessment despite considerable evidence to the contrary. In and of themselves, such beliefs are not problematic. Many of us think we know the “real” truth about one controversy or the other. The problem arises when one side attempts to prevail over the other by designing the rules for resolving differences to favor their own views while disadvantaging others. However clothed in scientific language and jargon such attempts may be, they profane and pervert our science and are no different in kind from the kind of thinking that attempts to legitimize one religion or world view over others. This is the strategy of ayatollahs and religious extremists and it is unbecoming of a science struggling with important issues about how best to help others.

It is not my intent to attack EBT per se. Indeed, I agree with APA’s draft policy in this area (APA, 2005) and I believe my conclusions are compatible with it. Further, I do not see how any reasonable person can argue with the intent of the majority of EBT proponents to disseminate data from experimental studies, promote further research and improve practice. My discomfort arises from arguments that the only real evidence of scientific interventions comes from experimental studies, particularly random controlled trials (RCT). Some proponents of EBT consistently put RCTs at the top of the knowledge hierarchy and draw a major distinction between treatments which are clearly supported by random trials and those that are not (e.g. Chambless and Ollendick, 2001; Sackett et al, 1996). In promoting the results of one body of data over all the others, and there are others, they are imposing a kind of scientific measuring rod against which all psychotherapy research should be evaluated. This strategy takes a scientific approach that may or not be useful for evaluating one profession (medicine) and assumes that it is appropriate for another (psychology). Unfortunately, this narrow and unrealistic view is being incorporated in public policy and imposed on practitioners by funding agencies, third party-payers and government agencies. It is scientism masquerading as science.

As I stated before, I do not quarrel with EBT as one approach to evaluating psychotherapeutic and psychodiagnostic methodologies. Manualized treatments for specified disorders certainly provide a basis for understanding how and what to do in some situations; and such treatments are easily evaluated by RCTs. But the very term “evidence-based” can be used to imply that everyone else does not have an evidence base. I do not think that EBT proponents in general are attempting to frame the debate in such a way that all who oppose them have to first prove that they are not against evidence or science. However, I do think that those who believe EBT is the way to go must be careful in how they frame their arguments so as not to imply that theirs is the only approach that is scientific. The general public, the press and legislators want to save money and reduce health care costs but determining how best to do that is far from a simple matter. Faced with a strong desire to resolve a major problem, policy makers may be prone to seize on overly simplistic solutions. Such is the case here. In its extreme form, the EBT movement risks imposing a model developed for medical care that blames physicians for escalating costs because they allegedly do not use the most scientific and cost effective techniques. While that is an uncertain allegation even with respect to medicine, it may be even more problematic with respect to psychology.

By granting greater weight to RCTs some EBT advocates conclude that cognitive behavior therapies are superior to other therapies for treating such emotional disorders `as depression. But, in point of fact, all that has been demonstrated is that EBT, in the form of manualized, brief treatments, are easier to evaluate with RCT methodologies (e.g. Westen, et al, 2004) than several other treatments widely used by psychologists ---and several of those “other” treatments have tons of scientific evidence to support them (e.g. Lambert and Ogles, 2004). Such contrary evidence is not weighted equally by EBT advocates because it does not come from RCTs which they consider to be better science and which, by the way, happens to favor both EBT’s techniques and its epistemology. This is neither good science nor good public policy and it is hurting our science and our profession in significant ways.

One example of such harm comes from the fact that the mere labeling of some psychotherapies as “evidence based” and others as not has provided managed care executives with a scientific rational for restricting access to care. Because many practitioners use techniques other than EBT for all or some clients, denying payment for such services inevitably reduces costs for managed care companies. These reduced costs are then used to justify the companies’ own services and, in turn, convince policy makers that restrictions on providers is the way to reduce costs while providing more “scientific” care. In fact, there is little or no evidence that EBT improves outcomes or reduces costs except by restricting access. Our science is being used improperly to deny needed care to the public by depriving them of other psychotherapeutic services for which there is considerable evidential support -- though not the kind of evidence championed by EBT advocates.

Another example of harm is that EBT advocates’ dismissal of a large body of psychology’s evidentiary base leads policy makers and health care organizations to underestimate the science that under girds our practice. We have literally hundreds of studies demonstrating the effectiveness of psychotherapy in general (e.g. Lambert and Ogles, 2004), but they are ignored because the studies do not meet the particular definitions of scientific proof posited by those who espouse the EBT approach (e.g. Sacket et al, 2000). In addition, psychodynamic and humanistic schools of psychotherapy are deemed less evidence based because they are unsuited to RCT methodologies; i.e. they focus on the therapeutic relationship rather than on a disorder to be treated, emphasize the therapeutic process rather than a pre-determined treatment, and emphasize techniques that are compatible with the therapist’s personality and the needs of the patient over uniformity among therapists (Division 32, 2004). Again, the evidence supporting the power of these approaches to effect patient change is both substantial and significant.

A third negative consequence of EBT’s attempt to manualize and routinize the practice of psychotherapy is that such an emphasis ultimately deprofessionalizes our profession. Instead of recognizing the available mountain of evidence on the central importance of the therapist in the treatment relationship (e.g. Lambert and Okiishi, 1997), EBT proponents would have us focusing on whether the treatment is proceeding according to a manual. In fact, some state mental health plans and private payers have developed lists of EBT treatments with the aim of making manualized treatments the basis for reimbursement. Practitioners who do not conform are, by definition, either unwilling to change, unscientific or both. Such translations of primarily laboratory analogs into models of correct practice are wrong. Furthermore, a manualized treatment is, in the final analysis, one administered by technicians, not professionals. All one has to do is read the manual and follow directions. Thus, the EBT model can easily be used to argue against the advisability of a doctoral degree for psychologists doing psychotherapy. That is not an appropriate model for something as complex as psychotherapy in the opinion of most clinicians and, I believe, a great many scientists as well.

Finally, and perhaps most ironically, EBT and its elevation of the number of RCTs as the standard for identifying the strength of evidence for an intervention, has seriously distorted the evidence regarding psychological versus pharmacological interventions. There are many more RCT studies of drugs than even EBTs for the very good reason that they are much less expensive to do. Thus, according to the evidentiary rules espoused by some, drugs are the superior treatment. Add to this, the fact that it is known that it is common practice for companies to suppress RCTs that do not favor their drug (Angell, 2004). The advantage of drugs compared to psychotherapy has been incorporated into many treatment guidelines (e.g. American Psychiatric Association, 2000) despite studies demonstrating that psychotherapeutic interventions can be just as effective (e.g. Hollon, Thase and Markowitz, 2002) and despite research showing that patients prefer psychotherapy to drugs when they are given a choice (e.g. Hazlett-Stevens et al., 2002).

In sum, I in no way mean to criticize or disrespect many distinguished colleagues who are proponents of EBTs and who are striving to insure that psychological treatment is the best that it can be and is based on the most solid possible evidence. What I do condemn is the fervor of some who confuse preferences with truth and claim exclusive rights to the mantle of science. Such claims do not honor psychology as a science or as a profession. Intolerant condemnation of other legitimate approaches to truth is but another example of intolerance. In its extreme, I do not know how to distinguish it from the intolerance of religious zealots.

References

American Psychological Association Presidential Task Force on Evidence-Based Practice (2005). Draft Policy Statement on Evidence–Based Practice in Psychology. Washington, D.C.: Author.

Angel, M. (2004). The truth about drug companies. How they deceive us and what we can do about it. New York. Random House.

Chambless, D.I. and T.H. Ollendick. 2001. Empirically supported psychological interventions: controversies and evidence. Annual Review of Psychology 53: 685-716.

Division 32 Task Force (2004). Recommended principles and practices for provision of humanistic psychological services: Alternatives to mandated practice and treatment guidelines. Humanistic Psychologist. 32, 3-75.

Hollon, S.D., Thase, M.E., and Markowitz, J.C. (2002). Treatment and prevention of depression. Psychological Science in the Public Interest. 3, 39-77.

Lambert, M.J. and Ogles, B.M. (2004). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (pp139-193). New York: Wiley.

Lambert, M.J. and Okiishi, J.C. (1997). The effects of the individual psychotherapist and implications for future research. Clinical Psychology: Science and Practice, 4, 66-75.

Sackett, D.L., W.M.C. Rosenberg, J.A. Muir-Gray, R.B. Haynes and W.S. Richardson. 1996. Evidence-Based Medicine: What it is and what it isn’t. British Medical Journal 312: 71-72.

Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, and Haynes, R.B. (2000). Evidence based medicine: How to practice and teach EBM (2nd ed.). London: Churchill Livingstone.

Westen, D., Novotny, C.M., & Thompson-Brenner, H. The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychotherapy Bulletin, 130, 631-663.

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