Letter to the APA Task force on Evidence Based Practice

Reply by Art Bohart, Ph.D.

to APA Presidential Task Force on Evidence-Based Practice (EBP TF)

(appointed by 2005 APA President Ronald F. Levant, Ed.D., MBA, ABPP)

Regarding the current draft document of

Evidence-Based Practice in Psychology

Proposed Policy Statement and

Position Paper

I am writing these comments as the Chair of the Psychotherapy Interest Group of Division 32 [Humanistic Psychology]. They represent my views, but have been sanctioned by various members of the Division 32 Board.

 Overall I am pleased by these drafts. I do have some suggestions. First, the draft is written as if psychotherapy is a fairly monolithic practice.  What is not clear from it is that the field of psychotherapy consists of a set of different practices. Although I have some disagreement with his particular version of it, mainly because he emphasizes one form of practice as appropriate for relatively serious psychological disorders, and the other forms for other things, I think David Barlow is on the right track in his recent American Psychologist article where he makes a distinction between psychological treatment and other forms of psychotherapy.

These different practices are different at an underlying paradigmatic level and at a theoretical level.  They construe therapy, the goals of therapy, and the structure of therapy differently. Accordingly they will rely on different conceptions of evidence, and different ways of being grounded in evidence. It is important that the American Psychological Association support this diversity of practice, not only for the sake of consumers, who want different things, but also for the sake of the future evolution of the field. Diverse practices not only may each of something unique to offer, but represent somewhat different takes on the nature of human beings and on the nature of problems. It is important that they continue to exist for the sake of the evolution of our knowledge as well. I specifically propose below that a section be added to the document stating this. In addition, this point is key to several of my other comments. Below I give my more specific comments.

Page 3, lines 186-197.  The Division 32 Task Force document needs to be cited here. It was one of the first responses to the Division 12 guidelines, and a draft copy was published in 1997, before the Division 29 ESR task force was even formed. The reference to the final version is included  in the references below. This document is a good example of construing practice in a different form and then describing how that different form would be grounded in and demand different forms of evidence.

Page 4, lines 267-272.  I believe a corollary needs to be added to this definition. It should say that evidence-based practice is also practice based on evidence relevant to the given form of practice being practiced.

Page 6, lines 318-320. I object to this sentence as I interpret it. It says, ".. .specific interventions that have not been subjected to systematic empirical testing for specific problems cannot be assumed to be either effective or ineffective….good  practice and science call for the timely testing of psychological practices…” The implication seems to be that the timely testing of psychological practices needs to center around testing specific interventions for specific disorders (e.g., existential therapy for depression, solution-focused therapy for anxiety disorders, etc.). But this is a prime example of my point that different forms of practice construe practice differently. There is no a priori reason that specific problems require specific interventions. For example, many forms of practice (client-centered, solution-focused, Mahrer's experiential therapy, narrative therapy) think of therapy in a different way than this. For client-centered, solution-focused, and experiential therapy, the goal is to mobilize clients' own creativity, regardless of the form of their problem. For narrative therapy it is to help clients productively restory their lives and their problems, and although what the therapist does is tailored to the individual client, it is not tailored by "problem" but by individual client and client's life circumstances. Specific interventions X specific problem classes is not how therapy is construed. The focus on intervention versus the focus on overall therapy process may differ as well, with interventions taking a secondary place. Probably better questions from these points of view would have to do with how to maximize different clients utilizing these different approaches most effectively. This might have more to do with better understanding the flow of therapy, client characteristics, and so on.

There are actually innumerable ways one could carve up reality to study different variables that might impact on therapy outcome. To put specific interventions for specific disorders center stage is to privilege one way of looking at therapy. But why not put center stage: stages of change, therapist characteristics, client characteristics (including information-processing differences), life circumstances, the interaction of therapist, client and life circumstances, gender, age, ethnicity, sexual orientation, office environment, and so on. A focus on specific interventions for specific problems clearly reflects the medical-model thinking that dominated the empirically supported treatments approach. It might fit the modern third party payor world. But there is no reason to assume that it reflects reality so much so that it becomes the prime focus of research. To the contrary, myself and many colleagues interpret the evidence as showing that for the most part, specific interventions are not needed for specific problems. Therefore this statement, as I read it,  is not scientifically open, but rather privileges a particular way of construing therapy and evidence-based practice.

Page 6, lines 328-346.  Qualitative research needs to be included in this list. One might mention: grounded theory, phenomenology, hermeneutics, and others as examples.

Page 14, lines 679-681 perpetuates the myth that there is one “scientific method.” As Mahrer (2005) has recently pointed out, based on his study of philosophy of science, there is no one scientific method (see also Rozin, 2001). This should be rephrased as “…that scientific METHODS are the best tools…” etc. and that scientific methods involve ways of thinking that are based on careful, systematic observation and investigation.

Lines 569-636. In the section on clients,  clients, as usual, are at least in part disenfranchised. Although they are accorded the right to have some say over their treatment (lines 627-636), nowhere is the client as an active, creative agent recognized. Psychotherapy is a collaborative enterprise, says the document, but primarily in that “patients and clinicians negotiate ways of working together.” What is emphasized are patient values and preferences, but not patient intelligence, creativity, thoughtfulness, or initiative. I believe there should be a statement that psychotherapy is a collaborative enterprise that is fundamentally different than medicine in that it is ultimately patients who invest their thoughtfulness, expertise, and engagement  into whatever therapists suggest as interventions, and bring them to life. Accordingly, psychotherapists are always in a position of working with patients as intelligent, co-investigators.

Finally, as per my opening comment, I suggest inserting a proposed section on multiple models of practice just after the section on multiple forms of evidence, before the “Future Directions” section starting on page 7, line 360. I suggest the following as an example of the wording:

Multiple Forms Of Practice The American Psychological Association recognizes and values that there are diverse forms of psychological practice, based on diverse models of human beings, of psychological processes, and of healing. These diverse practices pursue different goals in promoting healing, recovery, and adjustment. As such, how evidence is used; and what kinds of evidence are used, to support and clarify different practices will be different. The American Psychological Association values this diversity, recognizing that, in the long run, the existence of these different practices meets the needs of consumers, who value and seek out different approaches. Additionally, their existence supports the future evolution of knowledge about human beings and about psychological healing.

What is important is that each practice makes a systematic effort to clarify its relationship to evidence, and to what kinds of evidence, and to continue to pursue empirical exploration relevant to its form of practice. At a minimum the evidence is strong that certain kinds of therapist-client relationships are optimal across different forms of practice (Norcross, 2002). Therefore, the attempt to establish positive supportive therapy relationships is an evidence-based minimum for all forms of practice. For some forms, this may be sufficient, as the relationship is its main form of practice. For other forms, different kinds of evidence supporting other aspects of practice may be needed.

References

Division 32 Task Force (2004). Recommended principles and practices for the provision of humanistic psychosocial services: Alternative to mandated practice and treatment guidelines. The Humanistic Psychologist, 32, 3-75.

Mahrer, A. R. (2005). Why do research in psychotherapy? Introduction to a revolution. London, England. Whurr Publishers.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work. New York: Oxford University Press.

Rozin, P. (2001). Social psychology and science: Some lessons from Solomon Asch.     Personality and Social Psychology Review, 5, 2-14.

Dr. Bohart is Professor of Psychology at California State University Dominguez Hills. He is also affiliated with Saybrook Graduate School and Research Center in San Francisco, CA.