An exploration of the history of outcome research controversy may help many gain a better appreciation for what is currently occurring, especially in the APS controversy. As this is a brief history, I will need to leave out many details for the sake of brevity, but this lends well to understanding the politics of outcome therapy research. For a more detailed history, I recommend David Elkins book, Humanistic Psychology: A Clinical Manifesto.
Carl Rogers, to the surprise of many, is really the founder of contemporary outcome research. Prior to Rogers, there were many case histories, which could be seen as a form of outcome research; however, these were not intended so much to evaluate the effectiveness of therapy as to demonstrate or teach therapy. Rogers used multiple methods to evaluate the effectiveness of therapy, most of which involved intensive review therapy videos, audio recordings, and transcripts. To date, this is some of the most intensive analysis of the impact of therapy on a moment by moment basis that has ever been conducted. Ironically, the humanistic therapy that was consistently supported by this research, today is rarely considered "empirically validated" or "empirically supported."
In the 1970s and 1980s, the field of psychotherapy had many problems leading to the emergence of managed care and contemporary outcome research. It is very important that therapists understand much of this was due to the abuses of therapy and third party payer systems by counselors, therapists, psychologists, and psychiatrists. There was extensive double-billing and over-billing, as well as unneeded long-term hospitalizations of clients and other unethical practices. Certainly, something needed to be done to contain the widespread abuses.
The American Psychiatric Association was one of the first to respond by developing the "empirically validated therapies" (EVTs), most of which were medications. Division 12 of the American Psychological Association responded with their own version of the EVTs, then later the Empirically Supported Treatments (ESTs). The move from the EVTs to the ESTs is important. Although this did not reflect a change in the criteria or method for evaluating therapy, it represented a move toward a more appropriate philosophy of science. As most psychologists are taught in their graduate, if not undergraduate, research classes, psychological science does not prove anything, it supports it. "Validated" approaches were often understood as being a "proven" approach.
The ESTs represented a very narrow view of science heavily biased toward quantitative research and what Elkins referred to as "short-term, linear therapies" (such as Cognitive-Behavioral, Interpersonal Psychotherapy, and other short-term, technique-based therapies). The representatives of many other types of therapy rightfully were very upset by this system and its biases, especially as it became political and many advocated that other types of therapy should be considered unethical.
There were several strong counter-movements. First was the empirically supported relationships, which advocated that it really was the therapy relationship accounting for most of the change in therapy. They looked at therapist and qualitative aspects of the therapy relationship connected to therapy change. Second, the empirically supported principles looked at broader features of the therapy relationship that contributed to change, including many relationship factors. Finally, Division 32 of APA (Humanistic Psychology) developed a set of standards of the practice of humanistic psychology rooted in a mixture of theory and research. While these approaches made some headway, the ESTs remained dominant.
The introduction of Evidence-Based Practice in Psychology (EBPP) was the first significant challenge to the ESTs that began to really see some change. Ron Levant, who was the primary champion of EBPP, warned that if a broad definition of EBPP was not clearly established, it would regress to being another label for the ESTs. Many, it seemed, tried to push for this to occur, but overall it seems that the broader understanding of EBPP began to dominant in the APA.
EBPP is rooted in three primary evaluative factors: 1) Research, 2) Clinical Experience and Expertise, and 3) Consideration for Individual Differences. For a therapy to be truly evidence-based, it should have support in all three categories. Here is where it is easy to demonstrate that the APS position, while claiming to be more rigorous, is actually much less. According to APS, only a narrow definition of criteria 1 is necessary for it to be "empirically validated," whereas the EBPP, increasingly supported by members of the APA, states this is insufficient in demonstrating therapeutic effectiveness. Let me briefly discuss each of these criteria before concluding with an illustrative example.
Research is understood broadly in EBPP and can include quantitative research, qualitative research, single-case design, public health and ethnographic research, and meta-analytic studies, to name a few. In this regard, it allows for a broad, in-depth analysis of therapy from multiple research methods to be used. This is much more rigorous than a narrowly defined research, or "scientific," agenda.
Clinical experience and expertise adds that evidence-based practice also takes into consideration the perspective of expertise in the field and the peer-review process. It is not good enough to be supported by research, it must also be supported by clinical experience and expertise. Practitioners should regularly be reflecting on the therapy process and effectiveness, seeking appropriate consultation, and consulting the professional literature (including research and scholarship). Here is another place where the rhetoric of APS clearly falls short. In attacking the position frequently supported by APA, PsyD programs, and professional schools, they appear to be attacking the scholar-practitioner model, which is increasingly being associated with EBPP. Several articles in the public media and scholarly literature have claimed that this model advocates for clinical judgment over science. As noted in a previous blog, either they do not understand this model or are intentionally misrepresenting it for political gain. Instead, it is quite clear that the scholar practitioner model and EBPP advocate for clinical judgment and science. In their argument, they refer to a survey in which many therapists indicated they rely on clinical judgment more than science. Again, this is clearly a straw-man argument that holds no weight. Clinical judgment is always informed by science. Many who say they use clinical judgment over science are saying that just relying on science, without also including knowledge based in experience, is dangerous. Science is too often blind to context; this is where it needs experience and a broader understanding of clinical judgment.
Consideration for Individual Differences is the final component of EBPP. This indicates that it takes into consideration individual differences, cultural differences, and other forms of difference. I would advocate that this also implicitly, if not explicitly, means different values systems. I have already regularly advocated that the APS position represents one value system and is antagonistic to other value systems. Its approach to diversity is to research the effectiveness for particular groups. For example, it examines whether Cognitive-Behavioral Therapy is effective in dealing with depression in African American males between the age of 20 and 30. However, it does not take into consideration the individual differences within this group (i.e., individual difference criterion of EBPP) and only considers effectiveness in terms of symptom reduction, not necessarily in consideration of common cultural values of this group. Clearly, this limitation is one that cannot be adequately addressed by a narrowly defined science, demonstrating its inferiority to an evidence-based approach.
EBPP has become the most influential outcome research approach in professional psychology and for good reason. It addresses the limitations of the APS position, which clearly lacks sufficient rigor, and it also addresses the problem of psychotherapeutic free-for-all (i.e., allowing therapists to do whatever they want). It provides adequate containment against abuses of third-party payors and the general public while also allowing for sufficient flexibility to adjust to individual and group needs and differences.
Several things can be quickly attained by the recent APS position by their language. First, they return to the language of "validated" and "proven" in their literature. This makes a strong statement about their philosophy of science, which is outdated. It is interesting to note that they are claiming to advocate for progress, a moving forward to a more scientific-based approach; however, in reality, they are advocating for a regression to an out-dated approach to outcome research that is less rigorous, not more.
Let me close with an example to illustrate the important deficiencies of the APS approach. In a narrowly-defined scientific-based approach, the therapist appeals to science for their decision making, often lending to a step-by-step approach, or a system in which if A occurs, one does B. This sounds nice and simple, but how many clients want a therapist that appeals to their manual in how to respond? According to the APS position, expert therapists who have been successfully practicing therapy for many years should defer to narrowly understood research on clinical decisions. They would advocate that a technician who has mastered the techniques in the laboratory should be just as effective as the master clinician with years of experience. The weaknesses of this argument are evident. First, nearly all master practitioners still engage in the literature and are informed by science and their experience. However, the experience is critical in responding when what presents in therapy is not the typical, textbook client issue. When things do not go as they ought, this is when the expert clinician is able to adapt while the technician must consult more research, or maybe conduct more research. Clearly, most clients want the scientifically-informed expert over the scientifically-restricted therapist.
History is an invaluable teacher. If we look to history to understand the current debate on outcome research, we can easily see the limitations, problems, and unfounded rhetoric in those who advocate for a narrowly-defined scientific approach. Even the narrow view of science should, and must, have a voice. But it should not be the only voice or the determinant of psychotherapy. EBPP at its best represents a truly rigorous and comprehensive evaluation of therapy outcomes.