Obtaining consensus in psychotherapy: What holds us back?

Goldfried, M.R.
American Psychologist
2018

Abstract

Although the field of psychotherapy has been in existence for well over a century, it nonetheless continues to be preparadigmatic, lacking a consensus or scientific core. Instead, it is characterized by a large and increasing number of different schools of thought. In addition to the varying ways in which psychotherapy has been conceptualized, there also exists a long-standing gap between psychotherapy research and how it is conducted in actual clinical practice. Finally, there also exists a tendency to place great emphasis on what is new, often rediscovering or reinventing past contributions. This article describes each of these impediments to obtaining consensus and offers some suggestions for what might be done to address them.

Here is an excerpt:

There are at least three problematic issues that seem to contribute to the difficulty we have in obtaining a consensus within the field of psychotherapy: The first involves our long-standing practice of solely working within theoretical orientations or eclectic combinations of orientations. Moreover, not agreeing with those having other frameworks on how to bring about therapeutic change results in the proliferation of schools of therapy (Goldfried, 1980). The second issue involves the longstanding gap between research and practice, where many therapists may fail to see the relevance to their day-to-day clinical practice and also where many researchers do not make systematic use of clinical observations as a means of guiding their research (Goldfried, 1982).2 The third issue is our tendency to neglect past contributions to the field (Goldfried, 2000). We do not build on our previous body of knowledge but rather rediscover what we already know or—even worse—ignore past work and replace it with something new. What follows is a description of how these three issues prevent psychotherapy from achieving a consensus, after which there will be a consideration of some possible steps that might be taken in working toward a resolution of these issues.

The article is here, behind a paywall.

When Evidence Says No, But Doctors Say Yes

David Epstein
ProPublica
Originally published February 22, 2017

Here is an excerpt:

When you visit a doctor, you probably assume the treatment you receive is backed by evidence from medical research. Surely, the drug you’re prescribed or the surgery you’ll undergo wouldn’t be so common if it didn’t work, right?

For all the truly wondrous developments of modern medicine — imaging technologies that enable precision surgery, routine organ transplants, care that transforms premature infants into perfectly healthy kids, and remarkable chemotherapy treatments, to name a few — it is distressingly ordinary for patients to get treatments that research has shown are ineffective or even dangerous. Sometimes doctors simply haven’t kept up with the science. Other times doctors know the state of play perfectly well but continue to deliver these treatments because it’s profitable — or even because they’re popular and patients demand them. Some procedures are implemented based on studies that did not prove whether they really worked in the first place. Others were initially supported by evidence but then were contradicted by better evidence, and yet these procedures have remained the standards of care for years, or decades.

The article is here.

10 years of mindlines: a systematic review and commentary

By Sietse Wieringa and Trisha Greenhalgh
Implementation Science 2015, 10:45
doi:10.1186/s13012-015-0229-x
Published: 9 April 2015

Abstract

Background

In 2004, Gabbay and le May showed that clinicians generally base their decisions on mindlines—internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines. We considered how the concept of mindlines has been taken forward since.

Methods

We searched databases from 2004 to 2014 for the term ‘mindline(s)’ and tracked all sources citing Gabbay and le May’s 2004 article. We read and re-read papers to gain familiarity and developed an interpretive analysis and taxonomy by drawing on the principles of meta-narrative systematic review.

Results

In our synthesis of 340 papers, distinguished between authors who used mindlines purely in name (‘nominal’ view) sometimes dismissing them as a harmful phenomenon, and authors who appeared to have understood the term’s philosophical foundations. The latter took an ‘in-practice’ view (studying how mindlines emerge and spread in real-world settings), a ‘theoretical and philosophical’ view (extending theory) or a ‘solution focused’ view (exploring how to promote and support mindline development). We found that it is not just clinicians who develop mindlines: so do patients, in face-to-face and (potentially) online communities.

Theoretical publications on mindlines have continued to challenge the rationalist assumptions of evidence-based medicine (EBM). Conventional EBM assumes a single, knowable reality and seeks to strip away context to generate universal predictive rules. In contrast, mindlines are predicated on a more fluid, embodied and intersubjective view of knowledge; they accommodate context and acknowledge multiple realities. When considering how knowledge spreads, the concept of mindlines requires us to go beyond the constraining notions of ‘dissemination’ and ‘translation’ to study tacit knowledge and the interactive human processes by which such knowledge is created, enacted and shared. Solution-focused publications described mindline-promoting initiatives such as relationship-building, collaborative learning and thought leadership.

Conclusions

The concept of mindlines challenges the naïve rationalist view of knowledge implicit in some EBM publications, but the term appears to have been misunderstood (and prematurely dismissed) by some authors. By further studying mindlines empirically and theoretically, there is potential to expand EBM’s conceptual toolkit to produce richer forms of ‘evidence-based’ knowledge. We outline a suggested research agenda for achieving this goal.

The entire article is here.

Drug Addiction Seen as 'Moral Failing,' Survey Finds

By Robert Preidt
HealthDay Reporter
Originally posted on October 3, 2014

People with drug addiction are much more likely to face stigma than those with mental illness because they're seen as having a "moral failing," according to a new survey.

The poll of more than 700 people across the United States also found that the public is less likely to approve of insurance, housing and employment policies meant to help people with drug addiction.

The study results suggest that many people consider drug addiction a personal vice rather than a treatable medical condition, according to the Johns Hopkins Bloomberg School of Public Health researchers.

The entire article is here.

Evidence based medicine is broken

By Des Spence
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g22 (Published 3 January 2014)
Cite this as: BMJ 2014;348:g22

Evidence based medicine (EBM) wrong footed the drug industry for a while in the 1990s. We could fend off the army of pharmaceutical representatives because often their promotional material was devoid of evidence. But the drug industry came to realise that EBM was an opportunity rather than a threat. Research, especially when published in a prestigious journal, was worth more than thousands of sales representatives. Today EBM is a loaded gun at clinicians’ heads. “You better do as the evidence says,” it hisses, leaving no room for discretion or judgment. EBM is now the problem, fueling overdiagnosis and overtreatment.

The entire article is here.

Evidence-Based Medicine and the Practicing Clinician

Finlay A. McAlister, Ian Graham, Gerald W. Karr, Andreas Laupacis
Journal of General Internal Medicine
Volume 14, Issue 4, pages 236–242, April 1999 (and still relevant today)

Abstract

OBJECTIVE: To assess the attitudes of practicing general internists toward evidence-based medicine (EBM—defined as the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions) and their perceived barriers to its use.

DESIGN: Cross-sectional, self-administered mail questionnaire conducted between June and October 1997.

PARTICIPANTS: Questionnaires were sent to all 521 physician members of the Canadian Society of Internal Medicine with Canadian mailing addresses; 296 (60%) of 495 eligible physicians responded. Exclusion of two incomplete surveys resulted in a final sample size of 294.

MAIN RESULTS: Mean age of respondents was 46 years, 80% were male, and 52% worked in large urban medical centers. Participants reported using EBM in their clinical practice always (33, 11%), often (173, 59%), sometimes (80, 27%), or rarely/never (8, 3%). There were no significant differences in demographics, training, or practice types or locales on univariate or multivariate analyses between those who reported using EBM often or always and those who did not. Both groups reported high usage of traditional (non-EBM) information sources: clinical experience (93%), review articles (73%), the opinion of colleagues (61%), and textbooks (45%). Only a minority used EBM-related information sources such as primary research studies (45%), clinical practice guidelines (27%), or Cochrane Collaboration Reviews (5%) on a regular basis. Barriers to the use of EBM cited by respondents included lack of relevant evidence (26%), newness of the concept (25%), impracticality for use in day-to-day practice (14%), and negative impact on traditional medical skills and “the art of medicine” (11%). Less than half of respondents were confident in basic skills of EBM such as conducting a literature search (46%) or evaluating the methodology of published studies (34%). However, respondents demonstrated a high level of interest in further education about these tasks.

CONCLUSIONS: The likelihood that physicians will incorporate EBM into their practice cannot be predicted by any demographic or practice-related factors. Even those physicians who are most enthusiastic about EBM rely more on traditional information sources than EBM-related sources. The most important barriers to increased use of EBM by practicing clinicians appear to be lack of knowledge and familiarity with the basic skills, rather than skepticism about the concept.

The entire study is here.

Thanks to Ed Zuckerman for this research article.

Bamboozled by Bad Science

The first myth about "evidence-based" therapy

Published on October 31, 2013 by Jonathan Shedler, PhD in Psychologically Minded

Media coverage of psychotherapy often advises people to seek "evidence-based therapy."
Few outside the mental health professions realize the term “evidence-based therapy” is a form of branding. It refers to therapies conducted by following instruction manuals, originally developed to create standardized treatments for research trials. These "manualized" therapies are typically brief, highly structured, and almost exclusively identified with cognitive behavioral therapy or CBT.

Academic researchers routinely extoll the “evidence-based” therapies studied in research laboratories and denigrate psychotherapy as it is actually practiced by most clinicians in the real world. Their comments range from the hysteric (“The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment.”–Professor Walter Mischel, quoted in Newsweek) to the seemingly cautious and sober (“Evidence-based therapies work a little faster, a little better, and for more problematic situations, more powerfully.”–Professor Steven Hollon, quoted in the Los Angeles Times).

The entire blog post is here.

Dangers found in lack of safety oversight for Medicare drug benefit

By Tracy Weber, Charles Ornstein and Jennifer LaFleur
ProPublica
Originally published: May 11, 2013

Here is an excerpt:

But an investigation by ProPublica has found the program, in its drive to get drugs into patients’ hands, has failed to properly monitor safety. An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive for their patients. Federal officials have done little to detect or deter these hazardous prescribing patterns.

Searches through hundreds of millions of records turned up physicians such as the Miami psychiatrist who has given hundreds of elderly dementia patients the same antipsychotic, despite the government’s most serious “black box” warning that it increases the risk of death. He believes he has no other options.

Some doctors are using drugs in unapproved ways that may be unsafe or ineffective, records showed. An Oklahoma psychiatrist regularly prescribes the Alzheimer’s drug Namenda for autism patients as young as 12; he says he thinks it calms them. Autism experts said there is scant scientific support for this practice.

The entire article is here.

Is It Ethical For Doctors To Prescribe Placebo?

By Alice Walton
Forbes
Originally published on March 22, 2013

A new British study out in the journal PLOS ONE is stirring up a lot of debate, as it gives some estimates on the number of doctors who are giving patients placebo to treat their various conditions. It finds that a resounding 97% of the 783 doctors surveyed admitted to giving patients some sort of placebo in their practice. But it would be misleading to say that doctors are giving patients sugar pills or saline injections at the drop of a hat – there are different kinds of placebos, and, as the survey found, doctors have different feelings about when each should be used. Not surprisingly, so does the public.

“Pure” placebos are indeed sugar pills or saline injections with no therapeutic value (aside from that stemming from the psychological effects – more on this later). This “pure” variety was used by about 12% of the general practitioners at some time in their careers. Among these doctors, there were various motivations, including the wish to generate psychological treatment effects, to calm patients, to appease patients’ wish for a treatment, and to treat “non-specific complaints.” Half the doctors only told their patients something vaguely promising, like “this therapy has helped many other patients.” About 25% told their patients that the treatment “promoted self-healing,” and less than 10% revealed that the treatment was actually placebo.

“Impure” placebos, on the other hand, are therapies for which there is no strong evidence that they work for a given problem – for instance, the use of antibiotics to treat a virus, off-label uses of medications, or probiotics for diarrhea. Impure placebos also include lab tests or physical exams that are given simply in order to reassure patients. This type of placebo was much more common, with 97% of doctors reporting their use at least once across their career, and 77% reporting “frequent” use, i.e., at least once per week.

The entire story is here.

The entire study, Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners, is here.

Psychiatry's identity crisis - Original letter

The Lancet, Volume 379, Issue 9823, Page 1274, 7 April 2012

Last week, the American Psychiatric Association issued a press release highlighting an ongoing decline in the recruitment of medical students into the specialty—at a time when the numbers of practising psychiatric professionals in the USA is falling. Various reasons are proposed, including the short-term nature of placements (usually just 4 weeks); the sheer breadth of an evolving specialty, which is drawing students towards newer areas such as clinical neuroscience; and concerns that psychiatry is not as lucrative as other specialties.

(cut)

Psychiatrists, first and foremost, are clinicians. Evidence-based approaches should be at the core of the psychiatrist and non-clinical members of any mental health team.

The entire piece is here.