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Another View of Empirically Supported Techniques
by George Stricker, Ph.D., Adelphi University
Learning Objectives
- Understand the arguments for and against implementing Empirically Supported Techniques or Evidence Based practices as a standard across all approaches.
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Learn some of the arguments for and against practice guidelines and what APA has done to address some of these issues.
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Learn the viewpoints of gearing a practice towards normative standards versus working on a case-by-case basis.
I once read a parody of Longfellow’s
poem “Hiawatha” in which Hiawatha was involved in an archery contest.
He was the fastest and strongest of the competitors, and his shots formed
a tight pattern surrounding the target. Unfortunately, none of them
hit the bullseye. The other contestants were far more erratic, sometimes
hitting the target and sometimes missing wildly. At the end of the tournament,
Hiawatha, a budding statistician, claimed victory because his score
was significantly closer to the target than the score of anyone else.
To his surprise, he was told that, not only didn’t he win, but if he
didn’t start hitting the target he would have to pay for his arrows.
In the June 1997 issue of the Register
Report, my valued colleague and dear friend, Hiawatha Nathan, made a
strong case for empirically supported techniques (EST). His argument,
expectedly, was tightly reasoned, articulately presented, and quite
persuasive. Unfortunately, in my view, it also was wrong.
I do agree with Nathan on several important
points. He identifies correctly the unfortunate dichotomous division
of psychologists, a division that ensures minimal mutual influence for
science and practice. The war psychologists are fighting is over, and
the move toward evidencebased practice (a term I prefer to EST) has
won. Psychiatrists, who are more likely to recognize this, threaten
to preempt this issue; as a result, their practice guidelines, filling
a vacuum as they do, will dominate mental health, just as their DSM
does. It also is accurate to note that behavioral and cognitive behavioral
approaches dominate the list of ESTs, because their proponents have
developed a research methodology consistent with their treatment and
thus have been able to demonstrate efficacy. Psychodynamic approaches
have been slower to develop such a methodology, leading to the appearance
of lack of efficacy. When appropriate methodologies are developed, psychodynamic
approaches are likely to be less consistent with the goals established
by the mental health establishment, currently epitomized by managed
care, because they are less objective and behavioral, but the results
of these approaches can be measurable.
I have some key points of disagreement
with Nathan, however. One is his assertion that ESTs, despite sound
criticisms of their shortcomings in generalizability, could be implemented
now. There are too many questions about whether what works in a controlled
laboratory setting will work in a field setting to justify placing a
straitjacket on the practitioner. Research doesn’t just
appear to be stacked against psychodynamic approaches, as Nathan states;
it genuinely is stacked against them, because the goals of research
are objective and behavioral, whereas the goals of psychodynamic treatment
are more likely to be internal and implicit. However, these too are
measurable aspects of functioning, and the burden is on the psychodynamic
community to develop appropriate methods to suit their goals, as some
true scientist-practitioners have been attempting. Whether these approaches,
even after efficacy can be demonstrated, will be acceptable to third
party payers remains to be seen, but that is another question.
In light of these agreements and disagreements
with Nathan, where do I stand? I do not agree with those psychologists
who assert that the practice of any treatment that has not been empirically
supported is unethical (Nathan is not one of these). This would leave
a very narrow band of acceptable practice. In fact, if this criterion
were applied to physical medicine, it would greatly restrict the practice
of most physicians. However, I do feel that ignoring clear evidence
is unethical, and there are some principles so clearly established that
sound practitioners, regardless of orientation, should incorporate them.
But these are more likely to be principles, such as the value of the
relationship or of exposure, rather than specific techniques. Although
the relationship is more likely to be emphasized by psychodynamic clinicians
and exposure by behavioral clinicians, behaviorists do establish relationships
and psycho-dynamicists do foster exposure, even if only symbolically.
Planned use of these principles cuts across disciplinary boundaries
and
emphasizes the potential value of psychotherapy integration. The use
of available research evidence, when combined with clinical experience
in a loop so that active feedback from research and practice enhance
each other, represents the implementation of the scientist-practitioner
model and provides a demonstration of the local clinical scientist in
action.
The Hiawatha contest echoes one of the
most significant issues in contemporary practice, the difficulty of
translating aggregate results into individual praxis. It also recalls
past competitions pitting reason against faith, rationality against
romanticism. One pole is marked by a rigid adherence to normative findings
without regard to the idiosyncratic demands of the case at hand. This
characterizes many of the advocates of ESTs. At the other pole is the
practitioner who is guided by instinct and experience, oblivious to
the evidence. This is the clinical cowboy. If I had to choose, I would
prefer Hiawatha, who is steady and predictable, to his more variable,
occasionally
brilliant, occasionally irresponsible, opponents. However, I don’t have
to choose. A synthesis of their positions is available, where both the
guidance of evidence and the benefit of experience are combined, and
the results are evaluated in an iterative loop that in-forms future
practice. This is the way of the local clinical scientist, but that
is a story for another day.
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