The Best Approach for Evidence Based Practice

September 12, 2018

485 Shares

Even as a professor of psychology, I sometimes find all the different terms in mental health confusing. Just in terms of licensed professionals, there are psychologists, psychiatrists, counselors, therapists, social workers, and a dozen other lesser used terms that could all describe a person engaging in helping someone to improve their mental health.

The acronyms are even worse: PhD, NCC, LPC, LMFT, LCSW, MHR, LBP, BCBA, LADC, and the list just grows every year. And things can get even more confusing when terms such as “secular therapist” or “Biblical counselor” enter into the mix.

With such a diverse array of training backgrounds, licensure, and scopes of practice, it can be incredibly confusing to the layperson to sort through the differences to see who is most likely able to help them.

One of the more common buzzwords in mental health across the past decade has been “evidence-based.” This is typically used in this way: “I do evidence-based therapy” or “The therapeutic modalities I use are highly evidence-based.”

Often this is paired with giving examples of the kinds of therapy you do before or after that: “I use emotion focused therapy, an evidence-based practice.” Using this term usually conveys that what someone is doing works, and they know it works. But does it? How is that term applied?

Evidence-Based Practice Explained

 With some $200 billion spent each year in the U.S. on direct treatment for mental health issues, we should know if those dollars are being spent on treatments that work.

As defined by the American Psychological Association (2006), evidence-based practice (EBP) is 

…the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.

In plain language, this means that practitioners use those medications and therapies that have been demonstrated to be effective via well-controlled clinical trials. EBP isn’t restricted to a particular type of practitioner but is instead a method of making a decision about what is likely to help a particular person achieve a particular outcome or change.

This means looking at the research evidence to see what particular therapy has been shown to decrease a problematic behavior, cognition, or emotional state.

The literature is quite clear that certain types of psychological treatments work, and work very well, for certain types of problems. They can be safe, with few to no side effects, impact a wide variety of symptoms, tend to have a longer lasting impact than medications, and pay for themselves in terms of increased quality of life and productivity.

The Big Problem

Unfortunately, like many buzzwords, “evidence-based” has become co-opted and often is used in contexts that is inappropriate.

For example, some well-established EBPs include applied behavioral analysis, behavioral and cognitive-behavioral therapy, motivational interviewing, interpersonal therapy, and emotionally focused therapy for couples.

Such gold-standard treatments have reams of evidence from well-controlled, randomized, blinded studies showing that they work for particular problems people experience. This includes depression, anxiety, fear, eating problems, post-traumatic distress, oppositional behavior, insomnia, marital discord, substance use, anger, chronic pain, sexual dysfunction, improving functioning in people with autism, and a host of other problems.

We know this due to careful research that doesn’t just ask “Does this work?”

Instead, good research asks both “Does this work better than a placebo?” and “Would this condition naturally improve over time with no treatment?”

Using randomized, placebo-controlled, double-blind procedures allows us to determine if a particular treatment actually works for a particular problem. This is crucial because studies that don’t meet these standards can easily fall prey to a number of biases, which can lead to results showing that a treatment works when it actually does no such thing.

Sadly, though, for every EBP in psychology, there seems to be a couple dozen (or more!) non-EBPs.

These are treatments that have either been shown to not work or have been shown to be actively harmful. Typically such treatments are also heavily pseudoscientific, being non-falsifiable or having as their basis ideas that are far outside of how we know the world actually is.

Some of the more common ones are the psychoanalytic and psychodynamic theory based treatments, attachment-based therapies, “energy” therapies (like emotional freedom technique, or “tapping”), experiential (art and music based) therapy, “sand tray” therapy, and neurolinguistic programming.

With some estimates finding that there are over 500 distinct “schools” of psychotherapy practiced around the world, it may come as no surprise that the number of non-EBPs far outweighs the effective treatments.

In fact, a very sad aspect of mental health training in the U.S., especially at the master’s level, is that the number of people trained in known EBPs is relatively small. This is especially problematic as two of the largest professional organizations, the American Psychological Association (APA) and the American Counseling Association (ACA), stress in their ethical codes that practitioners should be using current best evidence when determining what therapy to use.

The APA states that “Psychologists’ work is based upon established scientific and professional knowledge of the discipline” while the ACA says “Counselors have a responsibility to the public to engage in counseling practices that are based on rigorous research.” In other words, practicing ethically means using evidence-based practice. Not using treatments that we know work could be considered, and certainly is by myself, practicing in an unethical manner.

Unfortunately, most state licensing boards would not agree. Gaining a mental health licensure has nothing to do with the effectiveness of what therapies you use and instead is usually based on having taken certain types of classes, being granted a particular degree, and passing various examinations.

Making a complaint that a practitioner didn’t use the gold standard treatment for a particular diagnosis or difficulty would be dismissed out of hand.

Conclusions

So how can a person who is not well versed in the latest psychological research find someone who is most likely to practice evidence-based therapies?

Asking a potential therapist what their primary therapeutic orientation is and how they know the type of therapy they do works is a great way to find out if a therapist uses EBP.

The list above is a good starting point, but several great websites can help you really understand if something is likely to be effective.

The Society for Clinical Psychology maintains an extensive list of known EBPs, while the Society for Clinical Child & Adolescent Psychology has great information on what we know works with youth.

Another way to find someone using EBP is to use therapist locators that emphasize such practices.

The Association for Behavioral and Cognitive Therapies runs FindCBT.org, and the Secular Therapy Project (disclaimer: I am the director of the STP) purposefully screens all of the therapists on the site to ensure that they use EBPs.

If you’re looking for someone who does applied behavior analysis, the Behavior Analyst Certification Board maintains an online registry.

Again, psychotherapy works…but only if it’s the right kind. While all practitioners should be striving to be ethical and provide evidence-based practices, only a minority truly do. The onus is, unfortunately, on the consumers of psychological services to make sure that they find providers who are doing up to date, scientifically based treatments.