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Notes from the Academy
EST, MCE,
MCC: The Abbreviating of Psychology
Linda J. Young, Ph.D.
Warning: You will not receive continuing education
credits as a reward for reading this opinion piece. Nor are you likely
to be able to demonstrate that reading it has increased your competency
as a clinician. Finally, I offer no empirical evidence that reading this
will reduce the incidence of any DSM IV symptomatology you or anyone
else might diagnose you as having. And folks, that’s the good news.
Because for now, the constricting mandates of “appropriate” treatment,
education and competency still leave open the possibility of that which
lies beyond the pale and that which challenges and interrogates the
status quo. And indeed, it is the status quo that worries me. As I see
it, the abbreviations in the title of this opinion piece are working to
define and delimit the status quo in such a way that options and
freedoms currently enjoyed and taken for granted are being significantly
curtailed. Some of these forces are subtle, others less so. I fear that
once in place within our political and professional landscape, they will
have a half-life that far exceeds what can be easily envisioned now, and
that our professional lives as clinicians will be foreshortened and
abbreviated in all kinds of ways.
For those of you who are unaware of what these
abbreviations mean or what the big deal is, I offer you a cursory sketch
of a piece of history that may be relevant. EST (empirically supported
treatment) refers to those few therapies that use tightly controlled
research methods to claim efficacy in treating specific disorders
diagnosed as Axis 1 disorders of the DSM IV. The idea of creating a list
of empirically supported treatments initially grew out of concerns that
practice guidelines were giving priority to psychopharmacology over
psychotherapy in the absence of sound evidence (Barlow, 1996). In 1995,
the EST movement, which involved a mandate to train professionals
exclusively in the use of these empirically validated therapies, was
bolstered with the publication of what was to be the first of several
task force reports by the American Psychological Association (Task Force
on Psychological Interventions Guidelines, 1995). This is important,
because since then, whether called empirically validated therapies (EVT),
empirically supported therapies (EST), or evidence based practice (EBP),
these generally refer to whatever therapeutic treatments a particular
research methodology has deemed empirically sound and valid—hence,
justifiable forms of practice. By implication, those therapies that do
not make the list are viewed as not being empirically supportable, and
alternative approaches to research are treated as nonexistent or
irrelevant. As pointed out by Edwards, Dattilio and Bromlely (2004),
terms such as evidence-based practice and empirically supported
treatment often have been appropriated by a rhetoric that promotes
simplistic and misleading assumptions, as this rhetoric has been heavily
influenced by particular ideological perspectives and market interests.
There has been pressure for modes of psychological treatment to be
evaluated similarly to the way pharmacology treatments are
evaluated—namely, by means of double-blind, randomly controlled studies.
In these (RCT), one or more treatments are pitted against one another
and a placebo. Furthermore, that which is deemed “treatment” is
necessarily operationalized by means of a treatment manual, specifying
what it is that needs to be done in each session and just how many
sessions there should be (Edwards et al, 2004).
It is important to keep in mind that no matter how
vociferous the claims of scientific neutrality and rigor (challengeable
in themselves as I will describe shortly) these studies are being
developed and contextualized by entrepreneurial forces that interpret
and make use of the “results” in the service of increasing profits. For
instance, health insurance companies themselves create a tremendous
market pressure for ESTs to be both short and standardized as it is
financially in their best interest to determine the minimum amount of
treatment that can be deemed scientifically “effective.” Additionally,
it is too often wrongly assumed that unless a treatment has been tested
in a randomly controlled trial, it has no empirical basis, and therefore
lacks validity as a treatment.
I will not spend a great deal of time enumerating
the many significant ways in which much scientific research on treatment
efficacy is flawed, even when evaluated by its own scientific
assumptions and standards. I refer the reader to an excellent article by
Westen, Novotny, and Thompson-Brenner (2004) on “The Empirical Status of
Empirically Supported Psychotherapies: Assumptions, Findings, and
Reporting in Controlled Clinical Trials.” One of the most important
ideas, for me, in their article is the clear illustration of how, in
most scientific research, the goal is to minimize variability on all
fronts. Variability (aka) individual differences, across subjects,
across treatment protocols and across treating clinicians is anathema to
the randomly controlled trial. Variability due to individual differences
messes up and ‘noises’ up the results, making it impossible to extract a
pure and standardized treatment protocol capable of being performed
uniformly by any clinician trained to apply it.
What this has meant is that, very frequently, only
individuals meeting the narrowest criteria are considered eligible to be
subjects—subjects who in many ways are not at all representative of
‘real’ people with the kinds of complex and inter-related difficulties
that most clinicians see in their offices. Additionally, the creativity
and artistry involved in communication between two uniquely thinking and
feeling beings (therapist and client) is treated as bothersome noise
that only confounds the goals of the research.
And let us be clear. Very frequently, the “goal” of
such psychological research is to be able to certify certain treatment
approaches as credible and valid, using the evidence accrued in
scientific study. To implement cleanly the research protocol, and
ultimately to implement the “evidence based treatment” in a manner which
emanates from and supports the research upon which it is founded, very
specific treatment protocols and manuals are being developed.
Much of this has been felt to be of little
consequence for those clinicians who view their work as being more
humanistic and/or psychodynamic in orientation and consequently more
open-ended, and tailored to the individual client. For many of these
clinicians the emphasis is on process, as much or more than it is on
outcome, and the goals of psychotherapy are determined in ongoing
interaction with the client, ultimately to be decided by the client.
These goals very frequently involve strivings not amenable to
quantitative assessment, such as the expansion of psychic freedom and
the elucidation of meanings. Additionally, for so many of these
clinicians therapy involves a dialogue—an interrogation of meaning and
an unfolding opportunity for exploration—wherever that may lead, and for
whatever amount of time the client wishes to spend doing this.
Therefore, for these clinicians, the very notion of
developing a treatment manual for the work is utterly at odds with the
fabric of what they do. The very definition of “evidence,” which may
very well be grounded in the patient’s associations across time is not
in any way synonymous with the criteria for “evidence” found in most
scientific study. In fact, the very notion of a treatment protocol that
can be developed with pre-determined goals and interventions to be
uniformly applied to individuals, may seem so preposterous as to be
downright laughable. Sadly, it’s time to stop laughing or the last laugh
may be on us. A full decade ago when the Division of Clinical Psychology
of the APA created an EST task force, what was envisioned included:
(1) Establishment of criteria for designating
specific effective treatments for specific problems.
(2) Generation of two lists of ESTs for specific
problems: “well established” and “probably efficacious.”
(3) Dissemination of lists of ESTs to Ph.D.
programs and predoctoral internships in clinical psychology.
(4) Incorporation of ESTs into guidelines for
accrediting doctoral training programs and internships in clinical and
counseling psychology (Strupp, 2001).
Since then, there has been a groundswell of
professional interest in the systematic incorporation of “evidence” into
educational training and clinical programs. Just a few examples include:
the American Psychiatric
As noted in the APA 2005 Presidential Task Force on
Evidence-Based Practice—Draft Policy Statement:
EBP has become a
central issue in the broader health care delivery system, both
nationally and internationally. Numerous initiatives at the state level
have sought to encourage and/or require the use of “evidence-based”
mental health treatments within state Medicaid programs. Currently a
major joint initiative of the NIMH and the DHHS Substance Abuse and
Mental Health Services Administration is focusing on promoting the
implementation of evidence-based mental health treatment practices into
state mental health systems. (p. 3)
The trickle-down effects of this are already being
felt in doctoral and master’s level training programs, insurance and
managed care companies, outpatient clinics and individual consulting
rooms.
It should be noted that there has not been an
absence of vociferous opposition to these trends, and that several
authors describing the divergent worldviews held between and among
various researchers and clinicians have identified what has been
described as a “culture war.” Additionally, a significant movement to
elaborate upon and to diversify definitions of evidence-based practice
is currently underway. These efforts attempt to challenge traditional
notions of research, expose unsubstantiated assumptions upon which much
of this research is based, and offer new and innovative ways of
defining, investigating, and conceptualizing psychological work.
Systematic attention to process as opposed to outcome, studying
“theories of change” which can be integrated into “empirically
informed therapies (Westen et
al., 2004), and championing the role of case-based research with sample
sizes of one (Edwards, Dattilio, & Bromley, 2004), are some prominent
examples.
These attempts are laudable. They may even buy us
some time. But to my mind, they do not really get to the heart of the
matter. The following is one example of a proposed alternative to the
randomized controlled trial form of research. In their article,
Developing Evidence Based Practice: The Role of Case-Based Research,
Edwards et al state:
Like all researchers, those using case-based
methodologies must build in strategies for safeguarding
accuracy, checking
replicability, and ensuring the
validity of arguments. In
psychotherapy research, this goal can be achieved by making sure that
all sessions are tape-recorded, using
independent judges to check that the reduction of the raw data
into case narratives is not biased
(Barker, 1994 cited by Edwards et al., p. 8, italics mine)
It is not surprising, really, to find terms such as
“accuracy,” “replicability” and “not-biased” even when describing single
case studies, as these concepts are essential to most definitions of
science. And, as pointed out in the APA position paper on EBP, “good
practice and science call for the timely testing of psychological
practices in a way that adequately operationalizes them using rigorous
scientific methodology.” (p. 6) But what about those ways of practicing
that do not necessarily rest on scientific principles and assumptions as
traditionally defined? For instance, what about a therapy that does not
claim to know a priori what the
goals and objectives to be attained are? Or a therapy that does not rest
on objectivist, positivistic notions that there can be “objective,”
“independent” measures of an individual’s condition that can be measured
without the “bias” of individual perception? What about a therapy that
never claims to be able to predict the future, including results of
treatment, and that is predicated instead on the idea that what occurs
over time between two unique individuals can never be “replicated” in
another situation? What if the scientific goal of closer and closer
approximations to a “truth out there” has nothing to do with a highly
subjective and idiosyncratic exploration and interrogation of the inner
truth of subjective meanings?
In addition to its scientific assumptions, so much
of psychological research rests on assumptions derived from a medical
model. In this research, a person’s psychic world is viewed through a
lens of health and sickness. The DSM-IV categorizes dilemmas of everyday
life as mental illness and disorders, and psychological conundrums are
framed as “symptoms.” Treatment is understood as the application of a
procedure, like the administration of a medical procedure or the
prescribing of medicine, and its goal is to alleviate or eradicate
“symptoms.” It is nearly impossible to find research on psychological
therapy that does not use the DSM-IV as the basis upon which treatment
outcome and processes are measured.
The very language of empirically supported
treatment and evidence-based practice, even including studies that
extend beyond randomly controlled trials, speaks the assumptions of
science and medicine. And in an effort to not be disincluded from the
club, even clinicians who might not agree philosophically with these
underlying assumptions are scrambling to certify what they do in the
language of the times.
This language of the times includes, literally, the
two other abbreviations in the title of this piece –MCE (Mandatory
Continuing Education) and MCC (Mandatory Continuing Competency). As most
of you are probably aware, there is a pressing movement in states around
the country to impose mandatory continuing education requirements as
well as ongoing competency requirements as pre-requisites for the
renewal of professional licenses. Despite active efforts on the part of
Michigan’s state psychological association, MCE has not become a
requirement for psychologists. Currently in its place however, is a plan
for various professions, including psychology, to require professionals
to demonstrate ongoing professional development and competency through
the obtaining of competency credits. Despite the fact that no compelling
information has been presented either to substantiate the need for this
program or to demonstrate its effectiveness in improving care or in
routing out malpractice, the Michigan Department of Community Health, as
a result of an agreement forged by the MPA’s lobbyist with the
Governor’s office, has agreed to place psychology in a pilot project
involving the mandatory demonstration of ongoing competency. (Ad Hoc
Committee on MCE 2005). I will not go into the many arguments both for
and against this initiative. But I will
say that my understanding of the proposed reasons put forward for this
initiative center on the notion that other states are doing this and
therefore Michigan should too, lest it be seen as inferior and behind
the times in its safeguards to protect the public. It doesn’t seem to
matter much that all kinds of training and licensing criteria are
already in place before someone is eligible for obtaining a license or
that proscriptive and remedial procedures for dealing with psychologists
who are complained about seem to be sufficiently in place. Nor does it
seem to matter that the vast majority of professionals already engage in
all manner of activity that enhances their learning without having to be
forced to do so by the state.
At a recent monthly educational presentation of
MSPP, Melanie Brim, B.S., M.H.A Director, Bureau of Health Professions,
Michigan Department of Community Health, presented information on the
pilot program and responded to questions and comments from the audience.
Several individuals raised concerns. One such concern involved the idea
that however mandated hours of competency credits were achieved e.g.
through attendance at conferences, supervision, study groups,
professional reading, coursework, this could in no way really assure the
public that a particular psychologist was competent and that therefore,
to claim this is to sell the public a false bill of goods. Another
concern, very much concurred with by Ms. Brim, was that attendance at a
conference in no way guaranteed that an individual would necessarily
learn anything or even stay awake, for that matter. There seemed to be a
shared sense of weary resignation over the fact that you can bring a
psychologist to water but you cannot make him/her drink.
Frankly, I am concerned that this is what concerns
people. Personally, it doesn’t much matter to me if the person sitting
next to me at a conference may get his credit while snoozing through the
presentation, rather than drinking it in. What alarms me is the water
being served and the fact that this aliment will both derive from and
subsequently contribute to the growing body of “evidence” used as
nutriment for proliferating standards of care and guidelines used in
defining appropriate ‘state of the art’ practice.
Although it is claimed, at present, that there will
be no stipulations regarding the specific “content” of that which will
pass muster as “competency credit,” it is already written into the
Public Health code that psychologists must receive some training each
year on “pain management.” Conversely, it is stipulated that there can
be no greater than a certain number of courses on the topic of practice
management. How one feels about these stipulations in their specificity
is not really the point. The fact that there already exist stipulations
with regard to the content, is. A precedent has been set. Purportedly,
the psychology licensing board will be drafting guidelines enumerating
the stipulations, in conjunction with the Department of Community
Health. However, as stated in the MSPP meeting with Ms. Brim, these
stipulations are likely to be guided by standards of care and practice
that exist in the profession. And now we circle back to that first
abbreviation—EST. Consider this, as a hypothetical example: If it is
determined that only certain kinds of treatment approaches e.g.
manualized cognitive behavioral treatment are valid for working with a
particular “disorder” e.g., anxiety disorder, I wonder how long it will
be before a case conference exploring a psychoanalytic approach to
working with an individual with anxiety is denied the privilege of
receiving competency credits. And that isn't even the biggest problem,
for whether or not a case conference receives competency credits will
not necessarily deter those who feel it is a valuable expenditure of
their time. What does
make me shake in my boots is the scenario that goes something like this:
I or a colleague of mine works psychoanalytically with an individual
complaining of anxiety. The individual decides to sue the therapist. The
court, presented with guidelines developed by the profession on evidence
based treatment determines that, in using a psychodynamic rather than a
cognitive-behavioral approach, the clinician has engaged in malpractice.
Furthermore, specific conferences and study groups on anxiety that have
received competency credits and those that have been denied them, are
cited as further supporting “evidence” used in this determination.
So, for me the problem with MCE and MCC lies not in
its “silliness,” “wastefulness,” or “empty assurances to the public,” or
even in the impossibility of enforcing it in any meaningful way (such as
forcing attendees to stay awake). That line of argument faults these
programs for their inadequacies--that is, what they are not. My worry
has more to do with what they are. And my concern is that what they are,
are additional nails in the coffin that psychology seems to be building
for itself in its efforts to legitimize itself as a medical, scientific
health profession.
While I may be diagnosed by some as being well on
the way to developing a phobia of abbreviations, my plea is to not be
treated with “exposure therapy.” We as a profession already are being
inundated with and exposed to an ever-growing array of regulations and
standards that will only abbreviate our freedoms further. And however
irrational I may be deemed, I choose to hold onto the belief that the
work I am passionately
For information
about the Academy and/or to discuss this opinion piece further, Dr.
Young can be contacted at (734)665-9692 or at
linadjoy@provide.net
References
Ad Hoc Committee on MCE. Letter to Michigan
Psychologists, February 21, 2005.
Barlow, D. H. (1996) The effectiveness of
psychotherapy: Science and policy.
Clinical Psychology: Science and Practice 1, pp.109-122
Edward, Dattilio, & Bromely (2004) Developing
Evidence-Based Practice: The Role of Case-Based Research;
Professional Psychology: Research and
Practice. Vol. 35 (6) December 2004, pp. 589-597. American
Psychological Association.
McCabe (2004) Crossing the Quality Chasm in
Behavioral Health Care: The Role of Evidence-Based Practice;
Professional Psychology: Research and
Practice. Vol. 35 (6) December 2004 pp. 571-579. Washington,
DC:American Psychological Association
Messer, (2004) Evidence-Based Practice: Beyond
Empirically Supported Treatments;
Professional Psychology: Research and Practice. Vol. 35 (6)
December 2004 pp. 580-588. Washington, DC: American Psychological
Association
Strupp (2001).
Implications of the Empirically Supported Treatment Movement for
Psychoanalysis. New York: Analytic Press.
Wampold, Bhati (2004) Attending to the Omissions: A
Historical Examination of Evidence-Based Practice Movements;
Professional Psychology: Research and
Practice. Vol. 35 (6) December 2004, pp. 563-570. American
Psychological Association
Westen, Novotny, Thompson-Brenner (2004) The
Empirical Status of Empirically Supported Psychotherapies: Assumptions,
Findings, and Reporting in Controlled Clinical Trials;
Psychological Bulletin 2004,
vol. 130 no. 4, 631-663
2005 Presidential Task Force on Evidence-Based
Practice, American Psychological Association Statement;
Draft Policy Statement on
Evidence-Based Practice in Psychology. |
Association’s 2003 efforts to develop EBP guidelines; state health
agencies’ establishment of infrastructures to support EBP initiatives in
behavioral health, including the development of centers for EBP
involving networks of consumers, practitioners and local and state
authorities; the U.S. Surgeon General (1999) calling for measures to
ensure delivery of “state of the art treatments” for mental illnesses;
the Annapolis Coalition for Behavioral Health Workforce Education and
the American College of Mental Health Administration declaring that
behavioral health researchers have identified “evidence-based”
approaches but that these principles and practices go largely ignored
when it comes to training the workforce (McCabe,2004).
committed to doing involves intimate exploration of personal meanings.
It is new and different with every individual with whom I work. It can
never be made abstract, for its subtleties exist in the precise
articulations of a single meaning-making individual. It can never be
manualized, for there is no procedure to follow or regimen to apply. It
can never be generalized, for its truth grows out of the specific
context that is created between a specific individual and me, at a
particular moment in time. It can be deemed competent or incompetent,
but only by the two individuals who have agreed to engage in the work
and by whose definitional meanings and standards the work can be
evaluated. And while it may make for messy research, I choose to rejoice
in the variability that makes each of us as individuals undeniably and
non-replicably unique. For me, the “noise” of the experimental research
setting is not something to be gotten rid of. And as irrational as it
may seem, given the socio/political matrix in which we live, I believe
it is worth trying to maintain as "independent variables" --ourselves,
our work, and the individuals who consult with us. Scientific research
teaches us that variables that can be controlled for lose their
significance in the determination of results. Maybe we can use that
scientific tenet as we fight to preserve the significance of our own
independence as well as our independent variability, before the results
abbreviate the dimensions of our professional lives.