April 8, 2019
From:
Vinodha Joly, LMFT
Psychotherapy and Consultation
3015 Hopyard Rd, Suite M
Pleasanton, CA 94588
To:
The California Board of Behavioral Sciences
1625 N. Market Blvd S-200
Sacramento, CA 95834
Dear Members of the Board,
Re: Request to Treat Misleading Claims of “Evidence-Based Psychotherapy” as False Advertising.
Many in the field of psychotherapy, including practitioners and marketing personnel, are currently using the term “evidence-based therapy” to refer to something quite different from what someone might otherwise assume. It is, therefore, misleading and problematic. I am requesting this board to treat such incorrect and misleading claims as false advertising.
The American Psychological Association (APA) Task Force on Evidence-Based Practice (2006) defines Evidence-Based Psychotherapy Practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”
A treatment qualifies as an empirically supported treatment (EST) based on successfully replicated, randomized control trial (RCT) studies. The APA Task Force on Evidence-Based Practice (2006) clearly delineates the differences between EST and Evidence-Based Psychotherapy Practice (EBPP – shown expanded in the quoted text):
“It is important to clarify the relation between Evidence-Based Psychotherapy Practice and empirically supported treatments (ESTs). Evidence-Based Psychotherapy Practice is the more comprehensive concept. ESTs start with a treatment and ask whether it works for a certain disorder or problem under specified circumstances. Evidence-Based Psychotherapy Practice starts with the patient and asks what research evidence (including relevant results from RCTs) will assist the psychologist in achieving the best outcome. In addition, ESTs are specific psychological treatments that have been shown to be efficacious in controlled clinical trials, whereas Evidence-Based Psychotherapy Practice encompasses a broader range of clinical activities (e.g., psychological assessment, case formulation, therapy relationships). As such, Evidence-Based Psychotherapy Practice articulates a decision-making process for integrating multiple streams of research evidence—including but not limited to RCTs—into the intervention process.”
Proponents of mainly brief and manualized therapy models have appropriated the label "evidence-based" based solely on outcome research using RCTs. It is being widely asserted that these models are scientifically proven and superior to other forms of psychotherapy, which is a false statement (Shedler, 2015). It is also being used to exclude other psychotherapy models that have a different value-base from being considered legitimate forms of therapy. In other words, ESTs are claiming the term “evidence-based” therapy, when in reality, the term Evidence-Based Psychotherapy Practice refers to a more comprehensive concept.
So what does this Evidence-Based Psychotherapy Practice look like?
“How to improve psychotherapy outcome? Follow the evidence; follow what contributes to psychotherapy outcome. Begin by leveraging the patient's resources and self-healing capacities; emphasize the therapy relationship and so-called common factors; employ research-supported treatment methods; select interpersonally skilled and clinically motivated practitioners; and adapt all of them to the patient's characteristics, personality, and worldview. This, not simply matching a treatment method to a particular disorder, will maximize success." (Norcross and Lambert, 2011, p.13).
Classifying an entire group of therapists as using “empirically supported treatments” is problematic. It is even more misleading and erroneous to classify these therapists as "evidence-based" or not simply based on the model or label those clinicians self-identify with. For example, a study published in the Journal of Consulting and Psychology reports that only half of the clinicians claiming to use CBT use an approach that even approximates to CBT (Waller et al, 2011). Few clinicians adhere to a pure model or school of thought, and virtually none adhere to a script. Most models employ common techniques, and all are based on the underlying principles of a healing therapeutic relationship.
Diagnosis-specific interventions and ESTs are not equivalent to Evidence-Based Psychotherapy Practice. Critchfield and Knox (2010) discuss how therapists who are trained to simply implement ESTs have a relatively rigid skill set of limited applicability; they lack the conceptual skills necessary for the practice of true Evidence-Based Psychotherapy.
The recent court ruling against United Behavioral Health* established that:
1. The standard of care in our mental health profession is not limited to the alleviation of the presenting symptoms (or a DSM diagnosis), but the treatment of the underlying conditions of the symptoms.
2. The standard of care requires treating patients until they have obtained the benefits they can obtain, and treatment duration can neither be fixed nor specified in advance.
This rules out many ESTs from even meeting the standard of care for our profession, as most patients do not seek therapy for a single issue that can be treated in isolation. Moreover, two patients can present with similar symptoms (e.g., anxiety) but have different personalities, experiences and circumstances, and will therefore respond differently to treatment. Therefore, a patient’s treatment cannot be determined by their symptoms (or DSM diagnosis) alone. The empirical support for many ESTs (which is based on symptoms/disorders and RCTs and doesn’t take into account the personal and interpersonal variables inherent in therapy) is therefore flawed. The term “empirically supported” in the ESTs for psychotherapy is itself a misuse of the language and a misleading claim, now appropriating an even more definitive term “evidence-based” simply to exclude certain orientations that don’t fit well into the RCT-based model.
Third party health care and insurance companies are thus misusing false claims and labels of “evidence-based” practice in psychotherapy. This has the effect of favoring therapists who simply implement ESTs over therapists who have the clinical skills and expertise to actually practice Evidence-Based Psychotherapy. Clinicians who rigidly adhere to a single model or protocol (irrespective of whether that model/protocol is an EST), who are not relational, or who are unable to assess and formulate a case and flexibly adapt their methodologies/treatment to a specific client, are not following true Evidence-Based Practice, and are not meeting the standard of care for our profession.
False claims of “evidence-based” practice are ultimately hurting the consumers of psychotherapy services by misleading them. I request this Board to treat all such false and misleading claims of “evidence-based” practice as false advertising.
Thank you.
Sincerely,
(Vinodha Joly, LMFT)
*[1] Wit, et al., v. UBH, Alexander, et al., v UBH, United States District Court, Northern District of California, 2019
Full Article and References: Investigating False Claims of Evidence-based Psychotherapy at https://www.therapyroute.com/article/investigating-false-claims-of-evidence-based-psychotherapy-by-vinodha-joly-lmft
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The above letter was sent to the California Board of Behavioral Sciences. This letter may be used as a sample to draft a letter to your own state’s licensing board.
Please see reply received from the Board of Behavioral Sciences in the Comments section.