Compassionate Evidence-Based Treatment
Clients are best served by the best-supported approaches.
Posted Dec 16, 2017
Compassion: adj., sympathetic consciousness of others’ distress together with a desire to alleviate it (emphasis added).
Empathy: adj., the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner.
The above definitions were obtained from Merriam-Webster’s dictionary, and are important to keep in mind in discussions of evidence-based psychotherapy. The supporters of evidence-based treatment approaches often cite a litany of empirical studies that detail the effectiveness of these interventions in alleviating symptoms and improving functioning in a time-efficient manner. Indeed, these are all part of the current standards that were adopted by the Society for Clinical Psychology (Division 12) of the American Psychological Association (Tolin et al., 2015).
Critics of evidence-based interventions often assume these approaches neglect key aspects of therapy, thus resulting in perceived harm to clients. For example, Shedler (2010) heavily criticized cognitive-behavior therapy by suggesting that it deemphasizes the therapeutic relationship, which he considers to be a central way that treatment works. Other critics conflate evidence-based therapy with empirically supported treatment (i.e., Shean, 2016). The American Psychological Association, in 2006 (APA Presidential Task Force on Evidence-Based Practice), convened a work group that defined evidence-based practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences”—in other words, treatment based on systematic application of scientific principles of behavior. On the other hand, empirically supported treatments are specific protocols derived from treatment trials. These critiques miss the fact that no serious psychotherapy scholar would neglect a therapeutic relationship for the sake of administering an evidence-based intervention (Taylor, Abramowitz, & McKay, 2010). These common factors (sound therapeutic relationship, attention to individual clients needs and preferences, management of therapist-client reactions, to name just a few) are widely understood in the therapeutic community to serve as ‘things you should do’ regardless of theoretical perspective. It is also evidence of the ‘either-or’ logical fallacy, something discussed previously on this blog here.
Those arguing for and against evidence-based treatment may be talking past each other. Missing from the arguments between these groups is the role of the client, which is crucial in any discussion of empathy and compassion in delivering therapy. In order to frame this properly, allow me to use a personal example. Several years ago, through routine physical examination, it was determined I had excessive calcium in my bloodstream. After additional testing, it was shown that one of my parathyroid glands was not functioning properly, and it was recommended that it be surgically removed. The surgery was considered low, but not zero, risk. Recovery would be fast, but it was still a painful surgical procedure that would involve additional follow-up procedures. There are alternatives to the surgery, though none as effective and several unproven, and all could still result in a recommendation for surgery. The surgeon recognized the risks, that there would be post-operative pain and need for additional minor procedures. In rendering a recommendation for surgery, I would argue that my surgeon showed considerable empathy for my state while also demonstrating compassion in providing the course of intervention that I ultimately elected to take.
We often don’t think of psychotherapeutic interventions in the same vein as surgical ones. But perhaps we should. Many psychiatric conditions are highly disabling. Consider for example Obsessive-Compulsive Disorder (OCD), which is listed as one of the top ten disabling disorders by the World Health Organization (Markarian, et al., 2010; Veale, 2014). This level of disability for a psychiatric condition would suggest an urgency of treatment akin to one requiring surgery.
Allow me one more anecdote, this time one culled from my clinical practice. Some of the details have been altered to protect the client’s identity. A woman in her late 40s recently came to me seeking treatment for her OCD. She struggled with severe symptoms involving intrusive ideas and images of harming loved ones; held the belief that by having these thoughts there was something fundamentally evil in her; and practiced excessive prayer as a result of her incredible guilt over experiencing these thoughts. She avoided her family due to her symptoms, stopped going to church because she felt she was unworthy of salvation, and lost touch with friends and members of her community, all due to her uncontrollable intrusive thoughts. Prior to coming to my office, she had close to twenty years of treatment with other therapists who engaged in a wide range of interventions, none of them evidence-based for OCD. She had, as she told me, a nice relationship with each one of these prior therapists, but she experienced little relief from the terror due to her disturbing intrusive thoughts over the entire course of her previous treatment. Every prior therapist no doubt felt considerable empathy for her. She was understood, they had vicarious experiences of her anxiety, and communicated this to her. I would argue, however, that these prior therapists, despite an abundance of good intentions, were ultimately lacking in compassion for her since none recommended a course of established evidence-based care.
One of the most widely recommended treatments for OCD involves exposure with response prevention (ERP). ERP helps clients to confront situations that provoke obsessions assists them in resisting rituals that temporarily alleviate the intrusive and frightening thoughts but ultimately maintain the disorder. Through this process, clients learn that feared thoughts and situations are not harmful and thus experience increasing levels of relief, improvement in symptoms, and better functioning (McKay et al., 2015). The challenge with ERP, as with all exposure-based treatments for anxiety disorders, is that many clinicians show tremendous reluctance to offer it. Some are concerned that their clients will not be able to handle the experience. This client-related concern might be expressed through the ‘spun-glass theory of mind’ (Meehl, 1973)—the belief that individuals are very fragile and ill equipped to handle stress. On the other hand, many clinicians shy away from ERP because they fear increased risk of litigation if a client’s symptoms worsen (Richard & Gloster, 2006). The aforementioned woman seeking treatment underwent ERP for her disabling symptoms, and experienced significant relief after 10 sessions, was regularly visiting with family after 15 sessions, and was able to return to church after 28 sessions. So in a period of about six months she regained significant aspects of her life that were steadily eroding for much of the prior two decades despite actively seeking treatment throughout the course of her illness.
Psychotherapists would do well to consider the medical ethics code from the World Medical Association: “A physician shall act in the patient’s best interest when providing care” (Williams, 2015). Prioritizing relief from distressing symptoms is the utmost expression of compassion for the needs of the patient. Empathy in the case of administering evidence-based care is best expressed by helping them access care that will decrease suffering and improve quality of life.
Markarian, Y., Larson, M.J., Aldea, M.A., Baldwin, S.A., Good, D., Berkeljon, A., Murphy, T.K., Storch, E.A., & McKay, D. (2010). Multiple pathways to functional impairment in obsessive-compulsive disorder. Clinical Psychology Review, 30, 78-88.
McKay, D., Sookman, D., Neziroglu, F., Wilhelm, S., Stein, D., Kyrios, M., Mathews, K., & Veale, D. (2015). Efficacy of cognitive-behavior therapy for obsessive-compulsive disorder. Psychiatry Research, 227, 104-113.
Meehl, P.E. (1973). Why I do not attend case conferences. In P.E. Meehl, Psychodiagnosis: Selected Papers (pp. 225-308). Minneapolis, MN: University of Minnesota Press.
Richard, D.C.S., & Gloster, A.T. (2006). Exposure therapy has a public relations problem: A dearth of litigation amid a wealth of concern. In D.C.S. Richard & D.l. Lauterbach (Eds.), Handbook of Exposure Therapies (pp. 409-425). Amsterdam: Academic Press.
Shean, G. (2016). Psychotherapy outcome research: Issues and questions. Psychodynamic Psychiatry, 44, 1-24.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 68, 98-109.
Taylor, S., Abramowitz, J.S., & McKay, D. (2010). Future directions in treating refractory cases. In D. McKay, J.S. Abramowitz, & S. Taylor (Eds.), Cognitive-Behavioral Therapy for Refractory Cases: Turning Failure into Success (pp. 407-413). Washington, DC: American Psychological Association Press.
Tolin, D.F., McKay, D., Forman, E.M., Klonsky, E.D., Thombs, B.D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science & Practice, 22, 317-338.
APA Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285
Veale, D. (2014). Obsessive-compulsive Disorder. British Medical Journal, 348, 31-34.
Wiliams, R. (2015). Medical Ethics Manual (3rd ed.). Ferney-Voltaire, France: World Medical Association.