Many will find this topic unimportant in their everyday work. It is intended to correct a distortion with practical consequences in the future. A growing number of clinicians reject the current idealization of evidence-based practices (EBPs). We know the work of psychotherapy is harder than using validated techniques. It is psychotherapy that needs a champion, not the widely celebrated EBPs.
Let us start with definitions. EBPs are therapies shown by research to be effective. Who can oppose that? Therapists might, especially as they understand the popular branding of EBPs. It is largely an endorsement of the techniques of the validated therapy. This is rooted in the biases of the medical model. For example, gall bladders are removed in a specific way, regardless of the surgeon.
Therapy techniques are isolated and idealized in line with the medical model, while clinicians are treated as mostly generic. To be fair, proponents of EBPs offer a rebuttal to this. They note EBPs are typically defined with an appreciation for clinical expertise and the needs of each patient. Is that not a flexible understanding of clinical work? It misses the point. This is about social symbols and social forces.
Evidence-based practice is only partly about real clinical work. It has become the mark of being serious about science. It is often embraced by those who know little about science. When a validated practice like cognitive behavioral therapy (CBT) is extolled, the focus is on therapeutic technique in isolation. Digital products based on CBT have seized the spotlight for these EBP discussions.
Is there any harm in providing clinical products based on proven techniques? To the contrary, it is a valuable addition to the services our field offers. Several of these digital products are less expensive, more accessible, and effective at reducing clinical symptoms. Their practical value is not in question. The problem is that they support a distorted view of therapy. Such views matter.
CBT is commonly idealized as the most validated therapy by those promoting digital health tools. Yet its research results are comparable to other major therapies. The product marketing spin ignores this. Also, some CBT experts support this technical focus by suggesting that results will improve with increasing fidelity to prescribed techniques. Research suggests otherwise.
The distortion of research is the least of it. Minimizing the critical need for psychosocial interventions is worse. The idealization of technique not only diminishes the importance of the therapist, but it also falsely casts therapy as a product of the medical model. Choose the right pill or EBP and all is well. In reality, therapy is a psychosocial solution. The therapy relationship is both crucial and subjective.
The EBP idealization is frustrating for therapists working with people with complex and chronic problems. They know patience and flexibility are paramount in their work, and fidelity to guidelines can conflict with that mindset. Few therapists like the term eclectic, but it captures an opposition to embracing a single therapeutic model. It restores the importance of trusting intuition and judgment.
The issue here is not how clinicians reflect on their work. The problem is non-clinicians simplifying and venerating the medical model. People with little understanding of psychotherapy want an unrealistic level of certainty. They seem to think all EBPs are equally impactful. They would have us believe the success of antibiotics is the norm. Psychotherapy is highly effective, but not like taking an antibiotic.
The idealization of EBP is misleading for promoting the wrong ideals. Psychosocial solutions like therapy are just as valuable as those emanating from the medical model. The psychosocial model will always have a role in healthcare, even with ongoing triumphs emanating from the medical model. The problem is that our EBPs are being promoted as a validation of the medical model, not the psychosocial model.
There are strange bedfellows in the EBP world. Researchers studying EBPs are pleased to mingle with medical colleagues in academia and have their guideline-driven, DSM-based solutions seen as products of the medical model. Purveyors of digital products want to transport the medical model aura into the world of commerce. They all minimize the psychotherapist who is the real champion of change.
This is not harmless. Could a cost-driven healthcare system one day insist on inexpensive digital products or providing sanctioned practices only? Many remember the early days of managed behavioral healthcare. Clinicians had to complete treatment plans identifying the therapy being provided. CBT was most common. It was seen as structured and time limited. The worst thing to call yourself was eclectic.
A lesson can be learned from the endurance of CBT as a gold standard. It wears the crown well, even if it is undeserved. CBT is both a useful therapy and an ideal symbol of the medical model. It seems quite objective, hardly a messy, subjective therapy. Yet like every other psychotherapy, it is a potent example of the psychosocial model. This is important, particularly for people making a living in this messy world.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.
