On evidence-based practice

I READ DR. Levant's president's column with much interest ("Evidence-based practice in psychology," February Monitor). I, too, am concerned that this race to evidence-based practice (EBP) is, as President Levant termed it, a "juggernaut." If we do not act as an informed profession to temper it, it will outrun our influence and sidestep our input. We must craft a workable response that is professionally sound, robust and grounded in cumulative experiences. As economic analyst, Robert Kuttner warns, "...the costs of relying on market forces...are fragmentation of the health care system...and (an) 'assault on the norms of service and altruism'" (p. 49, ibid).

Ours is a science-grounded profession--one of behavior, brain and mind. Evidence-based therapies have a very valuable place in clinical psychology, as do the more subjective and humanistic forms of intervention a psychotherapist employs with her suffering and/or problem-ridden clients.

Of course, operationalized therapies--purposely crafted to render outcomes measurable--tend to sacrifice the very elements of a useful and complex, unique-to-the-individual, holistic appreciation for one's patients. (Burrhus Skinner tried to do the same thing. We were nearly all believers, until we weren't.)

This EBP movement threatens to suffocate the very ministrations on which our wounded and disturbed patients have come to rely.

Are now the monolithic managed-care industry (the 500-pound gorilla) legislatures, and the courts (who turn to us for leadership and expertise beyond their ken) to be the prime movers in sculpting the new face of clinical psychology?

Our research continues to show that the single-most salient element across treatment modalities--often the only significant variable--in terms of patient satisfaction and dedication to the therapeutic process is empathy. More than the type of treatment or the education, training, credentials or prestige of the therapist, empathy accounts for effective outcome in the patients' and therapists' terms. Must we operationalize the molecules of empathy? Can we?

Yes, adapt to the new landscape within which we now work. Don't jettison the very qualities of effective psychotherapy that have resuscitated, buoyed, and promoted growth and health for millions. Acquiescing to commercial and political interests' requirements for accountability, and ultimately, profits, can leave our patients out of the equation in important ways.

Westport, Conn.

IN [APA PRESIDENT RONALD F.] Levant's column in the February 2005 Monitor, he argues that the roles of clinical expertise and patient choice should be considered along with empirical scientific support as part of the APA Presidential Initiative on Evidence-Based Practice. Certainly these two foci are necessary conditions to consider in the process, but are insufficient alone, and indeed must be driven by empirical support and ethical considerations. To use the simple example of snake oil, if we rely primarily on clinical expertise and patient choice, snake oil could be a treatment of choice. Consider a psychological treatment like Facilitated Communication (Jacobson, Mulick & Schwartz, 1995; Jacobson, Foxx & Mulick, 2005), about which APA's Council has issued a cautionary resolution and for which there is no empirical support, but there is plenty of alleged clinical expertise and patient interest to this day. In the absence of sufficient scientific evidence to support the use of these procedures, ethical practice might best be done only with fully informed consent about this lack of empirical support. Informed consent becomes paramount when dealing with children and/or individuals with developmental disabilities, a field in which fad and fashion have exerted an unfortunate effect on practice and the cost-effective use of scarce resources.

Commack, N.Y.

IN THE PRESIDENT'S COLUMN in the February Monitor, Dr. Levant explained his evidence-based practice (EBP) initiative, proposing that we add clinical expertise and patient values to empirical research as bases for clinical decision-making. Despite his good intentions, with this approach there will continue to be a status difference between researchers' quantitative methods of empirical validation and those scientific methods that will fall under the term "clinical expertise."

Currently, the term empirically validated treatments (EVTs) is restricted to treatments shown to be efficacious in controlled, randomized clinical trials in a minimum of two studies conducted by two independent teams of researchers. This stringent limitation of the term empirical validation expresses the following value positions: (1) quantitative research is superior to qualitative research; (2) the gold standard for medical research should be applied for psychological interventions; and (3) respectable scientific research requires institutional support, large groups of patients, and substantial amounts of money.

At least two other methodologies deserve to be included as part of the pillar of empirical validation and not left to the looser category of clinical expertise: (1) qualitative research using grounded theory approaches, where theory about efficacious treatment can be developed from study of small groups of patients; and (2) single-case design methods in clinical practice, through which an appropriate treatment is empirically-validated for a unique client, not for groups of patients who share a diagnostic label.

Pepperdine University
Div. 33 Council Rep.
The Ohio State University

WHY DOES THE MONITOR CONTINUE to conflate "practice" with "clinical therapeutic practice?" As a nontherapist practitioner, I am offended. In the February 2005 issue, for example, page 5 has the APA president talking about "evidence-based practice in psychology," but he really means "evidence-based clinical therapy practice." Page 48 has an article on the "changing face of psychology practice," but the article is really about the "changing face of psychotherapy practice." If we've given up on other areas of psychology outside clinical therapeutics, why not just sell the rights to our journals to APS and get on with it?

Somerville, Mass.

The case against juvenile execution

THE ELECTRIC HIGH CHAIR always did seem unreasonable to me. Three cheers to hear of APA's brief against juvenile execution ("Building a case," February Monitor.)

Emmanuel Bernstein, PhD
Saranac Lake, N.Y.

Broader focus on treatment

I AM WRITING ON BEHALF OF the International Society for the Psychological Treatments of the Schizophrenias and other Psychoses-United States Chapter (ISPS-US) regarding the two articles published on "serious mental illness" in the January Monitor. ISPS is an organization dedicated to promoting the humane, comprehensive treatment of psychotic disorders.

While both articles laudably address the importance of psychological treatments with more seriously disturbed individuals, the focus was exclusively on cognitive, behavioral and skills-training approaches, with no mention of the benefits of psychodynamic, humanistic-existential or other approaches that emphasize the therapeutic action of the therapist-patient relationship.

We cannot address only the cognitive aspects in the treatment of the psychoses, though these are crucial. Contemporary relational psychotherapies address both cognitions and affects, supporting the development of adaptive executive functioning while providing a containment of overwhelming affect. This all takes place in the context of a secure attachment between therapist and patient, where the subjectivity of both is highly valued. There are other aspects of relational psychotherapies that are not emphasized in C-B and skills paradigms. For instance, both supportive and traditional psychodynamic therapies generally include empathic listening, containment/holding, awareness of transference and countertransference issues, an appreciation of defensive functioning, and when appropriate, interpretation [for empirical support of psychodynamic psychotherapy for schizophrenia, see Gottdiener and Haslam (2002)].

Concord, N.H.

Effective science

DR. STEVEN BRECKLER'S ARTICLE ("Legitimate psychological science," December 2004 Monitor) argues for a more inclusive attitude toward fact-finding within our field. The challenge runs deeper than that. Science is never theory free, and no science depends on theory more than the science of mind and behavior because no other realm of human inquiry must contend with our plethora of variables.

The psychological fact-finder's challenge is how to control for all but one independent variable while testing all relevant variables. The experimental psychologist who eschews theory attempts to solve this problem by amassing data from many separate experiments. This approach leads too often to a splay of disconnected psychological facts. To weave the facts into a coherent picture, theory is required, but theory is rightly regarded as a less-disciplined endeavor than experiment. Legitimate psychological science--one that does more than gather un-reconciled facts--will require the development of a rigorous theoretical method to complement rigorous experimental method.

Berkeley, Calif.