Evidence-based Practice: Thinking Outside the Box


Evidence-based Practice: Thinking Outside the Box

EBP.  The acronym has been around since the 1990s. Back then managed care companies began to appear on the health care scene, along with a perception that the public needed protection from medical interventions that weren’t substantiated by sound empirical research.  And thus the concept of EBP—evidence-based practice—was born.  It quickly migrated into the world of psychotherapy and has since changed the playing field through the impetus of employers and funding sources.


True EBP demands controlled studies to support a treatment method’s claim of effectiveness.  Such studies feature a double-blind design (the researchers don’t know what treatment condition each researchee has been assigned to, and the researchees don’t know what treatment condition they’ve been assigned to either) and a statistical analysis of results rather than anecdotal reports or observations.  Unfortunately, not many mental health treatment methods can fit into the specific parameters of solid EBP study designs.  CBT (cognitive-behavioral therapy) is one golden exception in that its methodology pairs nicely with empirical research efforts.  Not surprisingly, CBT emerged as the gold standard in EBP mental health care.


Now consider this: at the same time CBT was being hailed as the champion treatment method in psychotherapy, advances in clinical neuroscience were beginning to point to the significance of subcortical (read: non-cognitive) factors in emotional re-regulation and affect tolerance.  Bruce Perry, Allan Schore, Dan Siegel, Bessel van der Kolk, and others have since led the way in challenging cognition’s supremacy in the treatment of emotional distress.  Currently the world of psychotherapy is shifting from a cognition-focused practice to an experience-focused practice because experience invokes activity in subcortical brain structures that are directly implicated in the affective dysregulation associated with trauma, anxiety disorders, mood disorders, and head injury.  When action-based interventions are posed and guided by a professional who has substantial knowledge and skills in the provision of experiential therapy, it’s possible to re-regulate dysregulated areas in the client’s brain—even without cognitive processing.


But back to our story of EBP.  Not only do many experiential therapies lack a considerable body of empirical studies supporting their effectiveness, they also don’t lend themselves quite so nicely to the parameters of strict quantitative research to begin with.  To add to that, not too many experiential therapists are hired to produce outcome data anyhow.  I’ve been wanting to do such research since my undergraduate days at the University of Wisconsin-Madison, but to date no one has made research a part of my job description other than to offer verbal encouragement of my desire to do research!  Sigh.  And thus I have not found myself in a position to contribute toward the small but growing pool of art therapy outcome studies.


For those who are wondering what those studies have found, the Research Committee of the American Art Therapy Association maintains a bibliography of relevant outcome research.  While some of the studies involved are single-subject, quasi-experimental, and/or qualitative in nature, they still serve as a basis for raising awareness of art therapy/art-based treatment methods and for promoting further inquiry about their use.  In the meantime, there’s a counterculture movement against EBP in the mental health field, and it’s being fueled by practitioners of all types who find fault with quantitative study designs that fail to take into consideration the fact that many complexities involved in the therapeutic process don’t fit neatly into measurable/observable boxes.  See the American Psychological Association’s stance on evidence-based practice for a point of view that recognizes the importance of a client’s characteristics, culture, and preferences when implementing treatment rather than making the client conform to the mold of an empirically supported method.


With that in mind, consider the harrowing tale of an art therapist who worked at a children’s shelter in a Texas city that shall not be named.  She was informed by her supervisor that the facility was shifting to the provision of verbal CBT as its only form of therapeutic intervention because of its status as an EBP.  The art therapist was thus restricted to providing verbal CBT to abused, neglected children who most likely had even less prefrontal cortex mastery over impulses and emotions than their non-abused, non-neglected, same-age peers.  The supervisor apparently didn’t know that art therapy can be practiced from a cognitive-behavioral perspective, nor did he seem to know anything about child development and the brain or the effects of trauma on the child brain.  (He also didn’t know much about the limitations of his position; he stripped the “AT” from the “LPC-AT” on the art therapist’s name badge as if he had been appointed to do so by the Texas State Board of Examiners of Professional Counselors, but I digress.)  The art therapist left for a better-paying job where she was respected for her expertise and contributions to the affective re-regulation of emotionally disturbed youth.  I guess you could say that things worked out for her, but how did verbal CBT work out for the abused and neglected children she had to leave behind at the shelter?


It’s important to provide treatment that rests on foundational theory, technique, and training.  This is what separates clinicians who are trying to reinvent the wheel, as seems to be the case with the Association for Creativity in Counseling division of the American Counseling Association, from clinicians who can attest to the underpinnings of their approach and methods, as is the standard among art therapists.  But are effective treatments limited to those that fit into rigorous quantitative studies?  And can the results of these studies be generalized to all clients—even the ones who would not have met the criteria for being included in these studies?  Generally speaking, the answer is no.  To paraphrase the American Psychological Association, evidence-based practice that places clients into one-size-fits-all boxes for the convenience of implementing treatment is NOT best practice.  EBP can present us with a great package, but sometimes we have to think outside the box in order to provide effective service.


With appreciation for the important work you do,

Megan May 2012

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