The Fallacy of Evidence-Based Treatments

February 26, 2008

Just when the stranglehold of scientific materialism appeared to finally loosen its grip on professional psychology, the once distant murmurs of so-called “evidence-based” treatments now grow closer and louder. The subject was hotly debated at the recent American Psychological Association convention in Honolulu. Legislation requiring evidence-based treatments has allegedly been submitted to state and federal lawmakers. As a result, the freedom enjoyed by practicing psychotherapists may soon be threatened.

Two specific problems with professional psychology become highlighted by these recent developments. The first consists of the professions’ persistent but misguided efforts to force psychotherapy into some empirical-analytic model. This represents what contemporary philosopher Ken Wilber (2000) terms the “reductionistic frenzy” or the “flatland” that has characterized the Western world since the enlightenment. From this point of view, humans are treated as if they have no interiors. The second flaw, a most ironic one since psychologists so often face it, consists of denial. Our profession avoids confronting the true impetus behind these evidence-based efforts: They are motivated by money, pure and simple, and not by any lofty ideals about providing the most effective psychological treatments.

Beginning with the first concern, psychologists have understandably long sought conventional underpinnings for their work, like that found in scientific materialism, because the human mind is so overwhelmingly complex. As even biological materialists would admit, there are literally more neural connections in the central nervous system than stars in the universe. And the mind becomes incredibly more complex when considered in its many contexts. These include biology in the broader sense (general state of health, nutrition, and age), culture (rituals, ethics, values and meaning) and social systems (the techno-economic base, social institutions and physical structures). A patient’s subjective troubles always emerge from this combination of inter-related biological, cultural, and social factors.

The post-enlightenment period bolstered our understanding of these contextual factors, mostly because for the first time in a millennium and a half these three areas (corresponding to science, art, and morals), all of which had previously been dominated by the Church, became differentiated. These fields subsequently flourished. But where the Church once dominated, science now does. Science has attempted to colonize, dominate and marginalize all other forms of knowing and being. Its methods, namely empirical-analytic ones, excel at analyzing and understanding phenomena in an exterior and objective manner; they fail miserably in the understanding of interior events, such as human subjectivity, which can be seen only through introspection and interpretation.

Lightly armed with their experience and their theories, psychotherapists help their patients, sometimes using applied theory, sometimes warmth, sometimes whatever their own practice has shown to be best suited for the situation. And each human encounter, as practicing psychotherapists know, is unique. Of course psychotherapists want to be effective. They should certainly learn about research on what makes psychotherapy work. They should study the many across-theory psychotherapeutic techniques, such as interpretation, confrontation, support, boundary maintenance – all in the service of building self-awareness and autonomy – that help patients. But they should also understand the limits of science, and honor the centrality of introspection and interpretation when working with their patients. They need to not only be comfortable with ambiguity but see it as part of the sine qua non of the psychotherapy process.

In contrast, and following in the scientific materialist path, the evidence-based treatments seek to condense the complexity of psychotherapy into specific interventions tailored for specific categories of psychopathology. Psychologists might some day need to quickly categorize their patients’ difficulties into a few sleek diagnoses and then apply, with the proficiency of a technician, a brief number of pseudo-empirically validated interventions. That would be it. Treatment completed. Ironically, mental disturbances indeed fall into certain relatively distinct categories that involve associated symptoms, i.e. neuroses with anxiety, depression, obsessions, and borderline conditions with identity diffusion, impulse control and substance abuse disorders, etc. However – and this is a big however – these categories may not be even remotely compared to the more objective, biological types of categories found in medicine.

Consider, as one small example, the differences between an individual with appendicitis consulting a physician and one with “depression” presenting to a psychologist. The contextual factors noted above, i.e. cultural and social forces, are relevant in the case of the medical patient but much, much less so than in the case of psychological disturbances. The physician makes a series of algorithmic decisions, finds the inflamed appendix, and refers to the surgeon for the curative appendectomy. The general state of health of the patient, the level of prior nutrition, age, social status, etc., will all affect this process. In the final analysis, however, inflamed appendixes have much more in common across humans, by many orders of magnitude, than do “depressions.”

When a patient presents with “depression,” the algorithmic trees followed by psychologists are anything but orderly and predictable. One “depression” might be characterized by excessive fatigue, hypersomnia and malaise. It may have no discernable psychosocial precipitant. Another “depression” might be characterized by intense agitation, weeping, and hyposomnia. The symptoms might have been clearly elicited by the patient’s learning of his or her child’s terminal cancer diagnosis. The variants of “depression” are literally endless.

It is certainly possible – and the evidence-based treatments will do this – to cull from the complexity of the wounded human mind certain specific features. For example, the complexity of the two “depressions” described above could be reduced to some pattern in the results of a few standardized tests and psychosocial histories. These patients could then receive a systematized program of “treatment.” The effectiveness of that “treatment” could then be measured by post-tests of the same standardized measures. But no one could be possibly fooled by the oversimplification and even dissociation (from other aspects and contexts of the mind) inherent in such an approach.

Consider, as another analogy, a large city damaged by a significant earthquake. Like human beings, cities also have great complexity. They have varying degrees of vulnerability, i.e. differing geological factors, population density, quality of building construction, etc. Earthquakes strike with uneven force. Therefore, different parts of a city will be differentially affected. An evidence-based approach to repairing earthquake damage might proceed by measuring the earthquake’s impact on, say, one city block, and then make repairs only there. To then pronounce the city as effectively repaired would be patently ridiculous. By implication, if not by direct pronouncement, evidence-based treatments offer just such fallacious declarations.

The second problem with professional psychology’s pursuit of evidence-based treatments occurs in its ignorant dissociation from the raw financial motivation behind them. Psychotherapists sell a service, perhaps best described as a type of emotional, cognitive and social transformation. Because “treatment” consists of a highly trained person focusing their direct attention on another person for a considerable period of time, psychotherapy is expensive. Many of the more troubled members of our society, for example those with substance abuse problems which complicate active clinical syndromes embedded in personality disorders (which often develop in problematic social contexts) require a great deal of such “direct attention.” Assessing where such attention must be directed first, whether to the individual or the family, and whether to begin addressing the individual or familial psychodynamics, is extremely complicated and, ultimately, costly. The price tag of then proceeding down these paths in any depth accelerates rapidly—a real economic concern.

Financial resources available for psychological services are limited, whether they originate from individual, societal, insurance or governmental sources. Other solutions must and can be found, from more public support for nonprofit psychotherapy and teaching clinics to limiting numbers of (but not regulating the nature of) psychotherapy sessions covered by insurance. But in working to control costs for psychotherapy, the profession must be wary of other economic forces such as, most notably, the profit motive driving the health insurance industry. The primary beneficiaries of the evidence-based treatment approaches will be insurance companies, not patients. Not surprisingly, managed care companies are the major proponents of such structured interventions.

If our profession ultimately succumbs to the demand for these sterile, procedural, “evidence-based” approaches, it should only do so with full knowledge of their outright betrayal of the human subject and their basic financial motivation. The proliferation of evidence-based treatments will ultimately weaken, not strengthen, our profession. They will result in the public viewing professional psychology as just another flatland institution, like the food processing industry, selling limited non-nutritious services that emphasize efficiency and profit over real service. The profession should, instead, continue in its dedication to enhancing the mental health, with all of its endless complexity, of those they serve. It should support psychotherapy – that most challenging, dynamic, complex and creative of all healthcare interventions – dedicated to help but unencumbered by rigid, pseudoscientific controls.

References

Wilber, K. (2000). The Theory of Everything. Boston: Shambala.

By Alan Karbelnig, Ph.D.

(Dr. Karbelnig, a past Member of the CPA Board of Directors and current Chair of the Ethics Committee of the San Gabriel Valley Psychological Association, practices psychoanalytic psychotherapy and forensic psychology in South Pasadena, California.)

Published as:

Karbelnig, A. (2005). The fallacy of evidence-based treatments. The California Psychologist,
January/February 38: (1):11-13.

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