Evidence-Based Practice in Psychotherapy Lacks Conceptual Consistency

Researcher criticizes the tripartite model of evidence-based practice in psychotherapy as underdeveloped and “scientocentric.”

Zenobia Morrill
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Evidence-based practice in psychology (EBPP) provides current regulations and guidelines to determine best practice in psychotherapy. Although the new tripartite model attempts to integrate clinical expertise and patient preferences into a historically “scientocentric” model, researcher Henrik Berg in Norway argues that EBPP is underdeveloped and conceptually inconsistent. In this recent paper, published in Frontiers in Psychology, Berg highlights how EBPP is dictated by demarcated empirical outcomes neglects ethical and extra-scientific aspects of psychotherapy.

“The policy-statement should be revised to avoid the conceptual inconsistency it currently contains. The solution is to create a genuinely tripartite model to replace the current ‘scientocentric’ one.”

EBPP features a set of principles that guide and regulate psychological practice. It is defined by the American Psychological Association (APA) as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” It is intended, therefore, to be a tripartite model that integrates these three components: (1) research, (2) clinical expertise, and (3) patient characteristics, culture, and preferences. Successful integration of these three components is meant to comprise the “best psychotherapeutic practice.”

Berg argues, however, that this integration is underdeveloped and lopsided. It focuses primarily on defining the importance of clinical expertise and patient preferences based on their relation to “best available research.” As a result of this, critical elements of expertise and patient experiences are neglected. He writes:

“…The policy statement contains a crucial inconsistency. EBPP does not consist of three parts. The two parts, clinical expertise and patient characteristics, culture, and preferences, are legitimated and shaped by the part “best available research” (American Psychological Association, 2016). Consequently, important extra-scientific reasons for including clinical expertise and patient characteristics, culture, and preferences in clinical practice are neglected.”

These issues may represent the persistent effects of EBPP’s history, rooted in the Evidence-Based Medicine (EBM). EBM and previous versions of EBPP have centered “best practice” around the results of randomized controlled trials and meta-analyses. These “scientocentric” features of EBPP and EBM have been criticized, not simply because empirical analyses are thought to have no significant clinical value, but rather, the notion that patient preferences and clinical expertise are only deemed important after they have been justified as scientifically valuable neglects to recognize their importance otherwise.

For this reason, Berg focuses on identifying the “extra-scientific” value of the two underdeveloped aspects of the EBPP model. For instance, clinical expertise is featured alongside the emphasis the expertise is shaped by scientific knowledge and practice. Berg, however, points out that the hallmark of expertise is that it “transcends propositional or scientific knowledge.”

Drawing from the works of philosophers Heidegger, Ryle, and Dreyfus, Berg emphasizes that it is novice-level practice, not expertise, that tends to be rule-bound whereas expertise involves the capability to navigate rich situational and contextual demands as they arise. Berg explains:

“The point is not that the understanding and actions of the expert need to be at odds with scientific results, but that the understanding and actions of the expert are not perpetually controlled by scientific or propositional knowledge.”

Similarly, Berg highlights the extra-scientific argument for valuing patient characteristics, culture, and preferences. Whereas the EBPP model emphasizes the inclusion of patient preferences because it is more effective and scientifically indicated, Berg notes that patients have the right to influence choices involving their own life.

In Berg’s words:

“The inclusion of “patient preferences” is an end in itself and not merely a means to other ends (i.e., improved efficiency or efficacy). This also entails that patient preferences ought to play a significant role in clinical practice even when the patient prefers something that diverges from what science indicates would be, or even de facto is, effective and efficient. The individual patient’s preferences are not determined by scientific findings.”

Berg argues that the ‘scientocentrism’ that forms the foundation of the EBPP tripartite model is riddled with problems. It is unfeasible to expect that the gap between science and practice will be mitigated by theory-driven research that “fails to recognize the ethoses of the various psychotherapy schools.” Furthermore, Berg has argued that EBPP regulates the practice of psychotherapy as ethical when they adhere to utilitarian tenets. His verdict is that a ‘scientocentric’ model is unfit to regulate practice:

“Generally speaking the role values and ethics plays in psychotherapy practice necessitate the active deliberation of a clinical expert and a patient. The deep fact-value entanglements and complexity of psychotherapy make a scientocentric model unfit to regulate psychotherapy practice.”

He provides suggestions for future research and EBPP development:

“Future research should discuss the nature of and relationship between the different parts of EBPP. It should also develop the notion of integration which has been characterized as underdeveloped.”

Berg concludes:

“In a practice as complex as psychotherapy we should expect on-going revisions of the principles regulating the practice and not settle for a solution lacking conceptual consistency.”

 

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Berg, H. (2019). Evidence-based practice in psychology fails to be tripartite:-A conceptual critique of the scientocentrism in evidence-based practice in psychology. Frontiers in psychology10, 2253. doi: 10.3389/fpsyg.2019.02253 (Link)

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Zenobia Morrill
MIA Research News Team: Zenobia Morrill is a graduate of the dual master’s counseling psychology program at Columbia University. As a doctoral student and researcher at the University of Massachusetts in Boston, she seeks to understand the context informing psychology research and the underlying social factors that influence individual psychology. She is currently involved in projects examining the impact of structural violence.

12 COMMENTS

  1. Thanks Zenobia.
    Only when we get to a certain age, do we realize we knew little. Although I dare say
    I’ve not witnessed this happening to many, so perhaps what they know is all they know,
    what they theorize becomes something they present as truth.
    Psychotherapy for adults might benefit by play/therapy, which can be equally
    healing for the therapist and client.

    Imagine the possibilities within a canoe trip with your favorite therapist.

    Every therapist should start the conversation with “I don’t know, and what I know applies to myself
    in the moment”

  2. Why not!?????
    Anyone inducted into psychiatric care giving and having gained privileges that could have been further detained, is truly forced to fail to see the difference between a nurse, a doctor, a guardian, mass media and a serial killer.

    Why not fuss about their preferences!?

    • Yeah, but there’s so much to learn from putting them in little reservoiries like a shell game, to see whether the stupid populace with all of the unwarranted need for honesty they have can figure out what is under what, which hand, why it doesn’t move by itself, and eventually (the populace) only sees (the populace sees, is correct form of the verb to see) what is invisible, because then at least….

      however YOU brought up coding that’s extra-scientific and that’s not even a verb

      Or am I wrong

      Extra-scientific aspects of psychotherapy is coding, which is against alcohol. Ethical aspects is hypnosis against a nervously ticking child.

      I’m surprised you didn’t bring up hypnoses and hippotelexomaniacs related to Rhino it’s brother, that has also made its way into wiki https://en.wikipedia.org/wiki/Nose-picking however, its brother still remains hidden.

      And I don’t know whether in other languages the names for psychiatric diseases use articles that contain gender references.

      For example, if still somewhere homosexuality is seen as a disease of the mind, is that disease then referred to, would a man have it as: “He has her.” “She’s got to be gotten rid of.”
      “We can’t have her around.” “Just read the bible about her.” “The world would be a better place without her.” “If we could just have more laws against her, and better privilege to eradicate her.” “She’s REALLY a danger to our children.” “Just imagine if SHE could actually cause reproduction!?”

    • By the way, Washington Irving had Cowotelexomaniac periods – which also, along with the slang which is used usually by men towards women (could mean they’re jealous of all of the attraction that women have they don’t) – the meaning has of a Dutch word for chewing, pronounced the same as Cow (Kauwen); only Cow as onomatopoeia is without the added syntax of the n’s (or being in them [n’s) and knocking u over), however that’s only in certain verbal forms of the infinitive’s conjugation, formally.

      He still has it too, it’s when the paintings get feverish over plagiarism that’s going on amongst those in the library that they have to sit and look at (they really can’t turn their gaze away without causing undue stress to their otherwise peaceful life), and look at while watching them, something they apparently have second thoughts about, and consequently end up a bit climbing the walls.

      It HAS happened that their eyes have flown off, but that’s more Shakespeare, and what happens to Juliet.

  3. It is interesting that they refer to “clinical expertise” but to “patient preferences.” What about “patient expertise?” or “Patient knowledge?” It seems that framing a patient’s/client’s decisions as “preferences” is disempowering, in that it implies that the patient’s information is irrational or emotionally-driven, rather than being rationally-derived information based on the patent’s own experiences and knowledge base. A normal power distribution would require the patient and the therapist to negotiate an agreement on the actual facts of the situation, assuming each one had an expertise of their own that legitimately informs the mutual understanding of both the problem and the possible solutions. “Preferences” is a very weak term for what is being expressed by the clients in these situations.

    Additionally, the author neglects to observe that the “evidence base” for “EBPs” is based on the categories in the DSM, which psychiatry’s own leaders (like Tom Insel at the NIMH) and the DSM introduction itself acknowledge to be invalid, heterogeneous categories of behavior that do not necessarily indicate any commonalities between those who “qualify” for a particular diagnosis. So saying that “X treatment is more effective for major depression than Y treatment” becomes a nonsensical statement, since depending on which client with that diagnosis presents to you, the required “treatment” may vary wildly.

    If you really want to do “evidence-based treatment,” you have to start with a legitimate grouping of candidates for study. Absent that, the “scientific evidence base” for these therapies is worse than useless – it is actually deceptive.

    • I saw that Steve. The same indoctrination double speak.

      I want to have a psychiatrist convince me of his “expertise”.

      Not just the old “well duh, I went to normal school for 8 years”.
      and “dontcha know it’s a science?”

      I mean seriously, they should be interviewed by the client. Their expertise seems to lie in the ability to slap labels on people, plus write prescriptions.

      • The main valuable expertise I’d be looking for is the ability to convey interest and compassion while I told my story. And from psychiatrists, I can count the ones I’ve see do this on one hand and still have a couple of fingers left over. Most counselors/therapists these days are also bought into the DSM and have stopped talking about unconscious motivations and life goals and sense of purpose and spend their time on “symptom reduction.” It’s a sad situation, and I would value the clients’ expertise over the “mental health professionals” at least 9 times out of 10. Most of what I learned about therapy, I learned from clients letting me know what they felt helped and did not help. There is no other standard for success. It should be the #1 most valued information there is, not relegated to third place after “research” and “clinical expertise.”

        • Well said….And time, Steve.
          There is a person’s lifetime of experiencing.
          Once we think we are not as we could or should be, we often get stuck there.
          There is some subliminal messaging going on for some, it is as old as the idea of sin, getting trapped by a system that concentrates on the “sins”, and a system where we have only a certain amount of time to better get over whatever bothers us, or else we feel the disappointment by psychiatrists, therapists, and families.

          What sense does it make if one is never good enough? Yet they talk against suicide.
          Perhaps they should start putting the word out to people that there are no “expectations” to be lived up to, as far as they are concerned.

          We cannot live up to, aspire to someone elses “expertise”.

    • “It seems that framing a patient’s/client’s decisions as ‘preferences’ is disempowering, in that it implies that the patient’s information is irrational or emotionally-driven, rather than being rationally-derived information based on the patent’s own experiences and knowledge base,” or scientific research.

      Good point, Steve. The psychological and psychiatric professions do like to utilize language as a weapon. And they’re obsessed with calling themselves “professionals,” as if to distinguish themselves from “the unwashed masses”? The “masses” who are NOT actually “unwashed,” nor unable to do scientific research, which destroys the scientific validity of their DSM “bible” theology.

      https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/
      https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome
      https://en.wikipedia.org/wiki/Toxidrome

      “Additionally, the author neglects to observe that the ‘evidence base’ for ‘EBPs’ is based on the categories in the DSM….” I was wondering, when discussing the inadequacies of the current psychological “scientocentric model,” am I correct to understand this term to be a euphemism for the DSM “bible”?

      Irregardless, I don’t know how one can critique the field of psychology today, without discussing the scientific fraud of their DSM billing code “bible.” Which as you’ve pointed out, has been debunked as “invalid” by leaders in the “mental health” industry.

      This entire blog seems like a psychological diversion, a covering up of the fact that the psychologists have been worshipping from the DSM “billing code bible” for decades.

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