Criterion and Evidence Based Practice: Fad or
Fashion?
Fashion?
| Selected Outline content from Dr. Art Freeman's Keynote/Plenary Address on May 14, 2004 to the General Practice Psychotherapy Association, Toronto, ON Canada |
Arthur Freeman, Ed.D., ABPP
Freeman Institute for Cognitive Therapy
Center for Brief Therapy, P.C.
10319 Dawson's Creek Blvd., Suite J
Fort Wayne, Indiana, USA 46825
May 14, 2004
Toronto, Canada
Hippocrates, the father of modern medicine posited a humeral theory to explain behavior.
Everything was composed of four elements: fire, water, earth, and air.
An overabundance of earth created an abundance of black bile.
This black (melan) bile (coli) was expressed as lethargy, sadness, and general loss of interest.
The term “melancholia” derives from this idea.
Freud’s later work was discredited by classical analysts who believed that his anthropological focus was mistaken.
He is supposed to have said in response to his “Freudian” identity – “I am a psychoanalyst, not a Freudian.”
When therapists think of Carl Rogers’ work they think of a non-directive approach first set out in 1942.
Rogers’ later work was active, directive, and confrontational.
Evidence based therapy (EBT)
Empirically validated therapy (EVT)
Empirically supported therapy (EST)
What is Evidence Based Therapy?
Evidence based therapy is an integration of:
a. best CURRENT research evidence for the treatment of a SPECIFIC disorder
b. clinical expertise
c. clinical experience
d. patient ability to change
e. patient interest in changing
f. clinical context
Evidence-based medicine has been around for a long time. Based on the need to demonstrate the efficacy of what is
done.Gordon Guyatt (1992) at McMaster University first named this model. Emphasis on accountability.
The Gap: Science and practice - Scientists and practitioners
How can we bridge the gap?
How can we speak the same language?
How can practice direct science?
How can science inform practice?
Who “owns” psychotherapy?
What are Evidence-Based Psychotherapy Guidelines?
Systematically derived statements assisting the practitioner in making patient-related decisions.
Designed for SPECIFIC conditions.
Based on research findings OR the consensus of expert clinicians.
The goal is to promote empirical practice.
Increase effectiveness of therapy.
Standardize treatment
Make treatment amenable to research.
The Top Ten Reasons for Not Practicing EST
10 Psychotherapy is different from “real” medicine and I don’t have to follow the same rules.
9 I have done it this way for years with good success.
8 My friends and colleagues agree with me.
7 My treatment model is not amenable to empirical testing.
6 EST’s are part of a governmental or authoritarian conspiracy moving us toward “one-worldism.”
5 I am in practice so that I can work and think independently.
No one should be able to tell me what to do.
4 EST’s require that the therapist slavishly adhere to a set protocol that is the same for all patients.
3 Hang tight! This fad will blow over.
2 I went to a superb school, had fantastic training, and excellent supervision. To do something different from
what I was taught would be disloyal to all of my forebearers
1 All therapies are equally successful. (Seligman “study”)
Impediments to Change
From the patient
From the therapist
From the environment
From the pathology
Readiness for change
Non-contemplation
Anti-contemplation
Precontemplation
Contemplation
Action planning
Action
Prelapse (Redirection)
Lapse (Redirection)
Relapse (Redirection)
Maintenance
Criticisms of EST
Focus on symptoms, not causes.
“Teaching to the test.”
Cannot be tested on all pathology.
Hard to test therapies against one another on a “like-to-like” basis.
Criticisms of EST
Use of “no treatment” or “placebo treatments” border on unethical.
“Fixed” to favor symptom based therapies.
No guarantees of success with EST.
Psychotherapy can never be as scientific as more biological treatments.
People are complex.
Whither manualized treatment?
Manuals are meant to be guides rather than masters.
Manualized treatments are standards for beginning therapy.
Psychotherapy treatments must be research based.
Manualized treatment guidelines represent the science of psychotherapy. What one does within the guidelines is the art.
Conclusions
Skilled and ethical therapists must strive to maintain familiarity with new developments and research.
Interventions are guided by theory, skill, patient needs, training, and expertise.
One should be faithful to a scientific model and be willing to ask the hard questions of any model (e.g. “show me the
data).
One should not be intimidated by scientific or pseudo-scientific bullying.
One should maintain a skepticism about new models and data and explore for themselves the empirical underpinnings.
One does not have to swear allegiance to a set protocol.
One must be a careful consumer.
Freeman Institute for Cognitive Therapy
Center for Brief Therapy, P.C.
10319 Dawson's Creek Blvd., Suite J
Fort Wayne, Indiana, USA 46825
May 14, 2004
Toronto, Canada
Hippocrates, the father of modern medicine posited a humeral theory to explain behavior.
Everything was composed of four elements: fire, water, earth, and air.
An overabundance of earth created an abundance of black bile.
This black (melan) bile (coli) was expressed as lethargy, sadness, and general loss of interest.
The term “melancholia” derives from this idea.
Freud’s later work was discredited by classical analysts who believed that his anthropological focus was mistaken.
He is supposed to have said in response to his “Freudian” identity – “I am a psychoanalyst, not a Freudian.”
When therapists think of Carl Rogers’ work they think of a non-directive approach first set out in 1942.
Rogers’ later work was active, directive, and confrontational.
Evidence based therapy (EBT)
Empirically validated therapy (EVT)
Empirically supported therapy (EST)
What is Evidence Based Therapy?
Evidence based therapy is an integration of:
a. best CURRENT research evidence for the treatment of a SPECIFIC disorder
b. clinical expertise
c. clinical experience
d. patient ability to change
e. patient interest in changing
f. clinical context
Evidence-based medicine has been around for a long time. Based on the need to demonstrate the efficacy of what is
done.Gordon Guyatt (1992) at McMaster University first named this model. Emphasis on accountability.
The Gap: Science and practice - Scientists and practitioners
How can we bridge the gap?
How can we speak the same language?
How can practice direct science?
How can science inform practice?
Who “owns” psychotherapy?
What are Evidence-Based Psychotherapy Guidelines?
Systematically derived statements assisting the practitioner in making patient-related decisions.
Designed for SPECIFIC conditions.
Based on research findings OR the consensus of expert clinicians.
The goal is to promote empirical practice.
Increase effectiveness of therapy.
Standardize treatment
Make treatment amenable to research.
The Top Ten Reasons for Not Practicing EST
10 Psychotherapy is different from “real” medicine and I don’t have to follow the same rules.
9 I have done it this way for years with good success.
8 My friends and colleagues agree with me.
7 My treatment model is not amenable to empirical testing.
6 EST’s are part of a governmental or authoritarian conspiracy moving us toward “one-worldism.”
5 I am in practice so that I can work and think independently.
No one should be able to tell me what to do.
4 EST’s require that the therapist slavishly adhere to a set protocol that is the same for all patients.
3 Hang tight! This fad will blow over.
2 I went to a superb school, had fantastic training, and excellent supervision. To do something different from
what I was taught would be disloyal to all of my forebearers
1 All therapies are equally successful. (Seligman “study”)
Impediments to Change
From the patient
From the therapist
From the environment
From the pathology
Readiness for change
Non-contemplation
Anti-contemplation
Precontemplation
Contemplation
Action planning
Action
Prelapse (Redirection)
Lapse (Redirection)
Relapse (Redirection)
Maintenance
Criticisms of EST
Focus on symptoms, not causes.
“Teaching to the test.”
Cannot be tested on all pathology.
Hard to test therapies against one another on a “like-to-like” basis.
Criticisms of EST
Use of “no treatment” or “placebo treatments” border on unethical.
“Fixed” to favor symptom based therapies.
No guarantees of success with EST.
Psychotherapy can never be as scientific as more biological treatments.
People are complex.
Whither manualized treatment?
Manuals are meant to be guides rather than masters.
Manualized treatments are standards for beginning therapy.
Psychotherapy treatments must be research based.
Manualized treatment guidelines represent the science of psychotherapy. What one does within the guidelines is the art.
Conclusions
Skilled and ethical therapists must strive to maintain familiarity with new developments and research.
Interventions are guided by theory, skill, patient needs, training, and expertise.
One should be faithful to a scientific model and be willing to ask the hard questions of any model (e.g. “show me the
data).
One should not be intimidated by scientific or pseudo-scientific bullying.
One should maintain a skepticism about new models and data and explore for themselves the empirical underpinnings.
One does not have to swear allegiance to a set protocol.
One must be a careful consumer.
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