Evidencebased Therapy Some Warnings

There are a number of points and warnings about the evidence-based approach that we would like to flag up, whilst mindful of the fact that these points (and others) will also be considered in many of the subsequent chapters.

• Any EBT can be done ineffectively. Just because a practitioner claims to be doing an EBT this does not guarantee that the therapy is being carried out effectively. Ineffectiveness can, of course, arise for a variety of reasons that may relate to therapist factors, client factors, the therapeutic relationship, the manner of the intervention, and factors outside of therapy such as negative life events. The lessons of the NIMH collaborative depression programme discussed earlier (Elkin, 1994) showed that there was considerable variation in the way that cognitive behaviour therapy was carried out across the three sites at which the eight therapists were based, despite the extensive training and ongoing supervision of the therapists by a leading therapist (see Shaw & Wilson-Smith, 1988). These 'site' differences can be more accurately interpreted as individual therapist differences.

• Any 'non-evidence based' therapy can be carried out effectively. Think of your favourite non-EBT and somewhere there is a practitioner who is doing the therapy very effectively. On average, the evidence base tends to show that doing something is better than doing nothing at all; that is, only rarely is a therapy shown to be worse than the control condition (though there have been one or two exceptions to this rule, as in the case of doing interpersonal therapy with drug/alcohol problems). The fact that the evidence base highlights the importance of the therapeutic relationship irrespective of therapeutic model emphasises the fact that sometimes the therapeutic relationship may be enough to bring about positive change (Okiishi et al., 2003). Ultimately, we are all in the business of psychotherapy and thereby share much in common (Power, 2002), although we often criticise most those we are closest to.

• All therapists have treatment failures no matter how effective they are. While many therapists hide in embarrassment from such failures there is often as much to be learned from failure as there is from treatment successes. Freud's (1905) famous treatment failure, the case of Dora, provided him with the opportunity to develop the concept of transference to include both negative as well as positive transference. The careful consideration of such failures can be used to explore the limits of any therapeutic system and its attendant theoretical premises (Foa & Emmelkamp, 1983). The evidence also shows that therapeutic benefits may continue after the end of therapy, that even though a therapeutic intervention may appear to be a failure or non-beneficial immediately post-treatment, sometimes benefits continue to develop. A dramatic example of such gains was documented in a recent study of cognitive behavioural therapy versus interpersonal therapy for bulimia; preliminary findings based on post-treatment data showed a significant advantage of cognitive behavioural therapy over interpersonal therapy, but follow-up data showed continued gains in the interpersonal therapy condition such that by 18 months both treatments were equally effective (Agras et al., 2000). These findings further emphasise the need for long-term follow-up data before firm conclusions can be reached about the impact of therapy. The main point is that therapies and therapists can have powerful effects on clients, both for good and for bad. A further example of this can be seen in the divisive debate about false memories and therapy (Davies & Dalgleish, 2001); the evidence suggests that some vulnerable individuals may be prone to the creation of false memories of experiences such as sexual abuse or alien abduction under the influence of therapy, just as other individuals may recover true memories of repressed abuse (Power, 2001). The careful evaluation of evidence is necessary in therapy just as it is in the comparison between therapies.

• The issue of therapy efficacy versus therapy effectiveness has been highlighted in a number of recent discussions (for instance, Bower, 2003). To reiterate the main points: studies of therapy efficacy are typically RCTs carried out in specialist research centres by the originators of a specific variety of therapy. In contrast, studies of therapy effectiveness refer to how clinical practitioners work with therapy in everyday practice. In order to understand therapy process and outcome, it is essential to have information for both efficacy and effectiveness; thus, major limitations occur, as summarised earlier, in the interpretation of therapy efficacy data because of the highly selective inclusion and exclusion criteria for participants that do not reflect everyday clinical practice; because of therapist allegiance effects, especially in earlier RCTs in which some therapists apparently carried out treatments that they did not believe in (for example, behaviour therapists claiming to do psychoanalytic psychotherapy); and because of the need to address issues such as subjects dropping out, longer term follow-up, and the importance of adaptations of therapy (for example, number of sessions, spacing of sessions, and integrative content) in everyday situations. There is now a considerable drive to establish effectiveness studies, for example, through the coordination of practice research networks (for example, Barkham & Mellor-Clark, 2003), which establish networks of practitioners who then use common assessment tools and methods with which to evaluate their routine clinical practice.

• It is now well-recognised that therapists do not always do what they claim to be doing, hence the need for supervision, taping, and review of therapeutic interventions when these are to form part of the evidence base. An interesting addendum to this observation comes from a study reported by Goldsamt et al. (1992), which consisted of a content analysis of a video produced to illustrate the therapeutic approaches of Beck (Beckian cognitive therapy), Meichenbaum (Meichenbaum's form of cognitive-behavioural therapy) and Strupp (psychodynamic therapy). In this video, these three well-known therapists each interview the same patient, named 'Richard', in order to illustrate their therapeutic approaches. The results of the content analyses showed unexpectedly that Meichenbaum and Strupp were more similar to each other than they were to Beck, rather than finding the predicted similarity between Beck and Meichenbaum; thus, whereas Meichenbaum and Strupp both tended to focus on the patient's impact on other people, Beck focused more on the impact that other people had on the patient. The moral is, in re-emphasis of what has long been well known in the therapy literature, that the purported differences in therapy should not be based on what therapists say they do but rather on what they actually do; the contrast can be considerable (cf. Sloane et al., 1975).

These five points are meant to illustrate that reading the evidence base for psychological therapies is far from straightforward and is a more complex process than many would wish.

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