Feeling Our Way

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Evidence-Responsive Practice

A treatment plan is a plan, not a recipe.

The term “evidence-based practice” has a long, illustrious history in medicine. It refers to practices based on what works and not on what the ancient authorities said to do. Unfortunately, it has been applied to psychotherapy under the mistaken idea that depression is as uniform an entity as diabetes or a particular virus. In other words, psychotherapy should of course still be evidence-based, but the gold standard of medical evidence (double-blind random clinical trials) simply can’t apply. Therapists cannot be separated from the dose; patients are too different from each other psychologically; one clinical condition is not that much like another. Jonathan Shedler and Paul Wachtel have written convincingly about the problems involved with using so-called empirically-supported therapies on actual people.

Instead, I am trying to promote the term "evidence-responsive practice." The patient communicates information, purposely or not, and the therapist develops a case formulation and plan that accounts for this evidence. The therapist then does things in conformity with the formulation and the plan. If it works, keep doing it; if it doesn’t work, try something else and edit the formulation. This is not a new idea. It’s what Watzlawick was up to what when he said an interpretation should be plausible rather than correct. It’s what Bateson was up to when he said that the patient’s speech after a communication from the therapist should be taken as a metaphorical comment on what the therapist said (i.e., as feedback).

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Interestingly, and not in my opinion coincidentally, when I evaluate parenting by observing an interactional visit, I don’t look for kids to do well or poorly, and I don’t look very hard at parents doing well at poorly. The main thing I look for is whether parents can tailor what they are doing to feedback from the child. I learn the most when kids are dissatisfied, and then I can see whether parents blame the child, blame themselves, blame me, ignore the child, or—ta-da—try something different.

Evidence-responsive practice has all the advantages of evidence-based practice. The problem with following the lore of the ancients, from which evidence-based practice was designed to liberate medicine, arose only when that lore, put into practice, did not work. Then, doctors had to choose between believing the ancient wisdom or their own lying eyes. Naturally, in a world where you could not be blamed for following the manual, they believed the ancients. If they had been responsive to the evidence, they would have persisted with things that work and tried something else when they didn’t. And they would have codified practice in a manual only when every instance of a particular problem was much like another, when the mechanism of effectiveness was understood, and when a treatment approach had stood the test of time. Of course randomized clinical trials would be essential to establishing those factors, but you can see how those factors would be impossible to establish for something as widely varied as personal psychological problems are. Every depressive is depressed in his or her own way.

A treatment manual may have an evidentiary base, but it is by definition not evidence-responsive. A treatment manual becomes a new kind of lore to be blindly followed. I like therapists and parents who keep their eyes open.

Michael Karson, Ph.D., is a professor of psychology at the University of Denver.

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