From:

Vinodha Joly, LMFT

Psychotherapy and Consultation

3015 Hopyard Rd, Suite M

Pleasanton, CA 94588

June 16, 2019

To Whom It May Concern:

Re: Request to Treat Lyra Health’s Misleading Claims of “Evidence-Based Psychotherapy” as False Advertising and Discriminatory against Therapists with a Different Value Base.

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. The specific claims by Lyra Health of providing “evidence-based psychotherapy exclusively” is particularly problematic, as these claims not only hurt the consumers of psychotherapy by misleading them and restricting their choices, but it is also discriminatory by explicitly excluding psychotherapy models that have a different value-base from being considered legitimate forms of therapy.  We request you 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, when in reality, the term Evidence-Based Psychotherapy Practice refers to a more comprehensive concept.  It is being widely asserted that these EST models are scientifically proven and superior to other forms of psychotherapy, which is a false statement (Shedler, 2015). For example, Lyra Health misleadingly asserts on its website “Only 20% of therapies are proven to work. Lyra's top providers only use these evidence-based methods.” , while in fact, the RCTs behind the depression and PTSD guidelines being used by Lyra Health demonstrate that the "recommended" treatments fail most patients most of the time! Specifically, two-thirds of patients who receive the "highly recommended" treatments for PTSD still have PTSD after treatment. Seventy percent of patients who receive the "recommended" treatments for depression do not improve or they relapse quickly. Therefore, statements such as “proven to work” are clearly false and misleading.

In addition, the policies of Lyra Health explicitly discriminate against psychotherapy models that have a different value base and that don’t solely focus on symptom reduction. For example, the selection criteria of Lyra Health explicitly exclude psychotherapists who work from an attachment-focused orientation (e.g., Emotional Focused Therapy) even though attachment theory models are based on decades of scientific research and study. Moreover, since Lyra Health claims to use only certain methods/models that it labels as “evidence-based” exclusively, attachment-oriented therapists are excluded from joining Lyra Health, even if these therapists are also skilled and trained in the “evidence-based” models being promoted by Lyra Health. An excerpt of their “evidence-based” claims is shown below:

"Unfortunately, accessing good care is shockingly difficult. Among therapists in health plan networks, just 10% are accepting new patients and exclusively using evidence-based techniques (treatments clinically proven to work). It’s hard enough finding someone to talk to and even harder finding a great therapist with the right expertise for your needs. It’s no surprise that six out of seven people do not receive effective care.

What makes this outcome particularly sad is that effective treatments exist. Short-term interventions like cognitive behavioral therapy (CBT) have been applied to a wide range of problems and are proven to reduce symptoms of depression, anxiety, stress, pain, and insomnia. With CBT, patients identify specific goals and then learn new skills, new ways of thinking, and new behaviors to improve their lives. CBT has been studied in hundreds of clinical trials and consistently delivers impressive results, usually after only 2-3 months. CBT, among other evidence-based therapies, including Acceptance and Commitment Therapy (ACT) and Dialectical Behavioral Therapy (DBT), and the Gottman Method, can be life-changing." (Ebersman, 2018, May 7)

The above marketing pitch is deconstructed as an example of simplistic and misleading “evidence-based” claims in Shedler (2015) and detailed below:

1.          "Evidence-based techniques (treatments clinically proven to work)" and "CBT has been studied in hundreds of clinical trials and consistently delivers impressive results, usually after only 2-3 months." CBT interventions have been shown in RCT studies to be effective (albeit with very small gains) in the short-term. However, these results do not necessarily translate directly to practice in real-life. Using the results of RCT trials alone to state that a therapist who utilizes only CBT interventions (or interventions from other models that have been, or will be, added to this coveted "evidence-based" list) will be more effective is erroneous and problematic. Simply being studied in hundreds of clinical trials does not make a model more effective.

2.          "Accessing good care is shockingly difficult" and "It’s no surprise that six out of seven people do not receive effective care" taken in its context implies "if it is not an "evidence-based” treatment, it is not good, i.e., therapies not in the "evidence-based" list are inadequate and ineffective.”

3.          The statement "[it is] even harder finding a great therapist with the right expertise for your needs." stated in its context, equates clinical expertise with simply being skilled in certain “evidence-based” techniques. This conclusion marginalizes quality practitioners with clinical expertise, especially in specialized areas of focus, such as developmental trauma and dissociative disorders. The practice of psychotherapy is much more complex than simply following a list of techniques for a particular disorder or symptom list.

4.          Making a claim of "exclusively using evidence-based techniques" is absurd in practice. Everything that is said or happens in therapy has to be considered an intervention or technique (e.g., sitting in silence with the client). That would imply "sitting in silence" has to be studied by an RCT study with different contexts/variables before an "evidence-based" practitioner can do so.

5.          Few clinicians adhere to a puritan model or school of thought, and certainly do not adhere to a script. Most models employ common techniques (such as identifying false/negative beliefs) and all are based on the underlying principles of a healing therapeutic relationship. 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). This doesn't necessarily make such CBT therapists more or less effective than those who practiced what was used in the RCT studies, but shows the problems of classifying an entire class of therapists as "evidence-based" or not, simply based on the model or label clinicians self-identify with.

6.          A rich array of factors contributes to successful therapy (the patient, the therapist, the setting and the therapeutic relationship, to name a few) and not just the treatment method (Marzillier, 2014).

7.          Diagnosis-specific interventions and ESTs are not equivalent to true 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 and lack the conceptual skills necessary for the practice of true Evidence-Based Psychotherapy Practice.

What does true 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)

The recent court ruling against United Behavioral Health* established that:

1.     The standard of care in our mental health profession is not simply the treatment of mental health symptoms (or a DSM diagnosis), but treating the underlying (and often complex) 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 short-term 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 such as Lyra Health are thus misusing false claims and labels of “evidence-based” practice in psychotherapy in both advertising to consumers and in recruiting psychotherapists for their network. 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 by healthcare companies such as Lyra Health are ultimately hurting the consumers of psychotherapy services by misleading them, and discriminating against other psychotherapists from being considered legitimate providers. We request you 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

This letter may be used as a sample to draft a letter to your state and federal governing agencies as well as state and national level professional organizations.