{"id":2974,"date":"2014-03-18T08:00:48","date_gmt":"2014-03-18T12:00:48","guid":{"rendered":"http:\/\/graftonblog.com\/?p=2756"},"modified":"2015-04-02T13:10:05","modified_gmt":"2015-04-02T17:10:05","slug":"evidence-based-practice-or-practice-based-evidence","status":"publish","type":"post","link":"https:\/\/www.grafton.org\/evidence-based-practice-or-practice-based-evidence\/","title":{"rendered":"Evidence-based Practice or Practice-based Evidence?"},"content":{"rendered":"

In the mental health community, we have all come to live under the hegemony of \u201cempirically based care,\u201d led by payors, auditors, governmental authorities (read SAMSHA), our own licensing boards, and administrators\u2014like myself\u2014desperate to demonstrate that their psychotherapeutic services are cost effective.<\/p>\n

But are they? I\u2019m not convinced that we are doing our profession or our clients a great service by following this policy, and I\u2019m unsure where it ultimately leads us.<\/p>\n

Recently, I saw Scott Miller, a Chicago-based psychologist and founder of the International Center for Clinical Excellence (www.scottdmiller.com<\/a>), at a recent National Association of Social Worker\u2019s event and was utterly galvanized. His work seemed to cut through much of all the dueling theories\/evidence-based practice noise and focused instead upon the dynamic nature of the relationship between therapist and client, which he feels is crucial to successful intervention.<\/p>\n

I believe he makes a strong case. And I admit, with a slight involuntary twinge of hesitation, that as a therapist, I agree with him: the power of a relationship, not the specific treatment method or theory, is the primary<\/i> catalyst for change. If that makes me the Che Guevara of the sweater-vest therapist set, allow me to explain why I feel this way.\u00a0
\n<\/a><\/p>\n

Moving on from the Old Therapeutic Models <\/i><\/b><\/p>\n

In deference to its early practitioners\u2014and in order to achieve mainstream legitimacy\u2014we have always preferred to label psychotherapy a \u201cmedical\/scientific\u201d intervention. Like what my doctor does. He applies a treatment (cholesterol lowering medication), which cures me of or protects me from unwanted medical events (prevents a first heart attack). Likewise, psychotherapists apply an empirically-based treatment method such as cognitive behavioral therapy (CBT), which cures the client of their condition (anxiety), right? That seems to be what many professionals claim.<\/p>\n

But I say, hogwash.<\/p>\n

When I look back on my practice, my interventions on behalf of those I served have always been characterized by a particular kind of \u201cclinical experience,\u201d namely the process of their relationship with me as I brought certain techniques and methods into it. The interventions were useful tools, but they weren\u2019t cures or treatments in the way medications are. Instead, they provided a medium where the client and I could connect and relate as we worked together on achieving his or her goals.<\/p>\n

That\u2019s what I believe. Unfortunately, these days, it isn\u2019t popular to be like me.<\/p>\n

I have witnessed many empirically-based interventions come and go over my professional life and for the most part, marveled at their lack of complexity or creativity.<\/p>\n

For example\u2014and I hope that this isn\u2019t perceived as arrogant\u2014CBT is in many ways a retread of platonic philosophy, which has been around for 2,500 years.<\/p>\n

Rational Emotive Behavior Therapy (REBT) seems a tad too easy for me, and my experience with it has born out my suspicions. Albert Ellis once cured me of my nervousness about an upcoming wedding ceremony in front of a room full of clinicians.Needless to say, it didn\u2019t stick.<\/p>\n

Structural Family Therapy grew out of 1950s developments in the understanding of biologic systems\u2014the guys in Palo Alto thought they could cure schizophrenia, if only they could get the mother to change. I loved it because I loved utilizing myself strategically to challenge the organization of a family system.\u00a0 It works, but I\u2019m not exactly clear why.<\/p>\n

Dialectical Behavior Therapy seemed to have more than a little to do with Eastern thought, mindfulness, and meditation. \u201cWise Mind\u201d indeed, but nothing new.<\/p>\n

Frankly, there doesn\u2019t seem to be anything new going on with any of them. And change, I\u2019ve found, is not mediated by applying any particular theory. It is mediated by the client\u2019s desire to change, and I\u2019ve found I can <\/i>affect that desire.<\/p>\n

What Works Versus Evidence-based<\/i><\/b><\/p>\n

No one is comfortable with the idea that \u201cwhat works\u201d might be an extremely multivariate reality beyond simple \u201cadherence to a practice model.\u201d \u201cWhat works\u201d might lurk somewhere in the shadows of a healing relationship, where the light of science might not so easily penetrate.<\/p>\n

So, like many, I took my training in CBT, Trauma-Informed CBT, etc. etc.But I still always held that those methods were not the real levers of change.<\/p>\n

Miller\u2019s book, The Heroic Client,<\/i> lays out his research and philosophy in an extremely compelling way, and he comes to the same conclusions I have: it is not the method that makes the change, but rather client\u2019s perception of the quality of the relationship with the therapist. And paradoxically, he gathered piles of data to support this decidedly \u201clow tech, unempirical\u201d conceptualization of our practice.<\/p>\n

Now, to be clear, unmediated by ANY overarching method, therapy is vague, and vague therapy equals vague results. What we need is a process which demands accountability to a goal mutually derived by the client and therapist, and a method to respond when progress toward that goal is in question.<\/p>\n

We need a process that forces us to be clear about what we will achieve, and forces us to measure progress to that goal concretely, while allowing each of us flexibility to exercise the particular method or set of methods that work for us and our clients. And frankly, if we have lots of therapists measuring the effectiveness of their creative efforts on behalf of their clients, it will provide \u201cpractice\u2014based evidence,\u201d which I think, at the end of the day, is better than \u201cevidence-based practice.\u201d<\/p>\n

By the way, I believe Grafton\u2019s Goal Mastery Initiative (www.grafton.org\/goal-mastery<\/a>) provides this tool. The goal mastery process provides a structured and sustainable system to identify, monitor, and evaluate client progress and embed data-based decision-making into trans-disciplinary treatment and instruction planning.<\/p>\n

So what\u2019s your perspective on this? Do you agree that psychotherapy achieves value more through the therapist\/client relationship than through the application of any particular approach? Or should we continue to follow the current of so-called evidence-based practice? Perhaps one sustains the other? And if you do agree with me, how do we begin to shift the focus of the therapeutic community?<\/p>\n

I look forward to you joining our conversation.<\/p>\n","protected":false},"excerpt":{"rendered":"

In the mental health community, we have all come to live under the hegemony of \u201cempirically based care,\u201d led by payors, auditors, governmental authorities (read SAMSHA), our own licensing boards, and administrators\u2014like myself\u2014desperate to demonstrate that their psychotherapeutic services are cost effective.<\/p>\n

But are they? I\u2019m not convinced that we are doing our profession or our clients a great service by following this policy, and I\u2019m unsure where it ultimately leads us.<\/p>\n","protected":false},"author":5,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[32,34,35,36],"tags":[56,59,83,136],"class_list":["post-2974","post","type-post","status-publish","format-standard","hentry","category-evidence-based-best-practices","category-innovation","category-mental-health-services","category-outcomes","tag-change-catalyst","tag-clinical-excellence","tag-evidence-based-treatment","tag-therapeutic-relationship"],"acf":[],"yoast_head":"\nEvidence-based Practice or Practice-based Evidence? - Grafton<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.grafton.org\/evidence-based-practice-or-practice-based-evidence\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Evidence-based Practice or Practice-based Evidence? - Grafton\" \/>\n<meta property=\"og:description\" content=\"In the mental health community, we have all come to live under the hegemony of \u201cempirically based care,\u201d led by payors, auditors, governmental authorities (read SAMSHA), our own licensing boards, and administrators\u2014like myself\u2014desperate to demonstrate that their psychotherapeutic services are cost effective. 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