Evidence-Based Practice: The Limits
This is a recent comment I made on a forum on the difficulties with working inside a Evidence Based Practice regime. The original author was questioning how to work with the empathic methods he found so valuable:
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The system of mental health
Patrick, if I'm understanding you correctly it isn't that you doubt the methods that you work with – which are very much like the methods I work with – but rather that these methods are not endorsed my Medicaid.
Very briefly, there seems to be a similar system here in Australia. The fees of psychologists who use CBT and other EBP techniques are rebated to the client largely or fully by the federal government if the treatment is endorsed by a doctor.
Many of us here need to work outside this system. This means we only see clients who can manage our fees from their own pockets. Once consequence is that the fees of psychologists have risen to levels which I contend are opportunistic; given that the government pays a fixed part of the clients hour, it sees they say ‘why not raise my fee?' This means that the out of pocket amount for seeing a psychologist seem to be approaching what a psychotherapist would charge anyway.
Our umbrella organisation continues to fight for our inclusion in the scheme – a probably fruitless battle, given the cuts to it – but in the meantime all we can do it is try to match out-of-pocket fees, research treatment methodologies effectiveness and inform our potential clients, do excellent work and keep picking up the disaffected who have tried CBT psychology and find it doesn't work as well as empathic approaches.
CBT
I actually use CBT to a limited degree. I find it useful, when sensitively embedded in an empathic setting, as a diagnostic tool to understand how things like anxiety affect my clients and how what they do to mange it only makes it worse. I very rarely, and again, only within the bounds of empathic relationship, use it as part of the treatment.
Ultimately, a broken system of treatment cannot prevail. Either the system of treatment will collapse, or EBP will evolve into something has has long-term effectiveness, or our good work will be recognised as being equal. In the meantime – Read. Think. Study. Question. Feel – and Work.
I don't know the system that you work under but ultimately I don't know if any of us individually can have the energy to do more than to strive for excellence each hour with each individual in this, our chosen field.
– Tim Hill
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This is a book that I had on my bookshelves for some time, but I was quite reluctant to read.
I had been given it as a gift, and I had flicked through it but I wasn't much impressed — it seemed like a book which was quite superficial and seem to advocate approach which I wasn't particularly comfortable with, namely a cognitive and behavioural approach. So it sat on my bookshelf for more than a year.
When I started to read it I wished I had picked up years ago; in fact I wish I knew about it when I was doing my training. Although the book is written from the perspective of psychiatry and is meant for everyday reader, it gives invaluable information that will help every psychotherapist. In essence, it is a broad overview of mental illness and psychopharmacology. Each of its 21 chapters is devoted to a particular aspect of mental illness such as anxiety, mood and depression, mind and body, eating disorders, suicide and self-harm, psychiatric medication, personality disturbances, psychosis, and alcohol and drugs. It explains each one of these in clear language, gives examples and also makes comparisons between the different disorders.
Here's a brief quote from the book about obsessive personalities;
People with obsessive personalities are typically orderly, and punctual, dutiful and conformist to a degree that limits their capacity to respond to situations that call for flexibility or compromise. They display a rigid perfectionism that interferes with their ability to complete anything. Rarely do their achievements or those of others measure up to their required ideal standards. While obsessional qualities may be advantageous and socially desirable in particular circumstances, their moralising and inflexibility inevitably leads to difficulties. Their preoccupation with rules, procedures and social order overrides the pleasure of accomplishment or the company of others. They are often emotionally cold and judgment.(p140)
See? Concise, clear, informative and understandable.
Inevitably, Dr. Bloch’s recommendations for treatment tend towards the cognitive and behavioural, but he talks about the place of long-term psychotherapy as well — he just doesn't think it's that effective for many of the common disorders such as anxiety.
Summary
An informative and interesting book with basic and useful information about a wide range of psychological and psychiatric issues. Recommended.