Staff Perspective: And, If the EBT is Ineffective? What Then?

Staff Perspective: And, If the EBT is Ineffective? What Then?

In recent times, there has been a significant push to validate treatment approaches using the rigor of scientific research.  This welcomed addition to the field of clinical psychology has been great for the field and has met with much success.  A number of evidence-based treatments (EBTs) have been scientifically researched and proven effective (efficacious) in treating several clinical disorders.  For example, Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye Movement Desensitization (EMDR) have been rigorously studied and determined to be efficacious in the treatment of post-traumatic stress disorder (PTSD).  There are evidenced-based treatments for depression (CBT-D), insomnia (CBT-I), anxiety, substance use disorders, schizophrenia, obsessive/compulsive disorders, the list goes on.

With regards to EBTs (as well as in seminars and presentations related to such treatments), there is considerable discussion about the successful application of the protocol for X% of individuals (and for some EBTs, the maintenance of gains months after treatment has ended for X% of those for whom the initial protocol was effective).  What is rarely, if ever, discussed is what happened with the Y% of participants for whom the treatment protocol was ineffective (i.e., given that those individuals were selected into the study because they possessed and/or were afflicted with the same clinical symptoms and diagnoses as participants for whom the treatment protocol was effective).  A huge question begs to be answered here; what happened with those participants?!  That is to say, if the EBT was ineffective for them (as the researcher(s) states), what treatment did they get?  Were they simply told to “go home” because the “evidenced-based treatment doesn’t seem to work for you.”  Given the ethical issues that are involved, it is highly unlikely that the participants for whom the protocol(s) were ineffective were simply dismissed from treatment with no consideration for their emotional/psychological health and well-being.  However, the question remains to be answered, “What DID happen?” And, how successful (and/or effective) was the clinical intervention that was undertaken with those participants/patients?

There are at least two good reasons for this discussion. Firstly, it can be argued that patients for whom the EBT does not work are the same patients that we see chronically in an outpatient setting.  It makes sense (at least on the surface) that patients for whom the EBT protocol was effective leave the clinic having been “cured” (i.e., having experienced a significant decrease in symptom presentation to the point of not needing continued therapeutic sessions); whereas, patients for whom the EBT protocol was ineffective continue to come seeking therapeutic relief from their symptoms.  They are the chronic patients, the long-term patients, the “difficult” patients, the ones the therapist struggles with in his/her efforts to deliver an effective clinical resolution that is appropriate to the patient’s needs (i.e., addresses the PTSD, Depression, Anxiety, etc. symptom complaints).  These patients cannot be ignored and we ALL are doing “something” with them. 

Therein lies my second good reason for why this is an important discussion to have, “we ALL are doing something with them.”  So, what is that?  What are we doing?  I have yet to have a discussion with a fellow clinician who has said, “You know, [insert name of EBT here] did not work for my patient, so instead, I did [insert what they did here].”  So, why doesn’t this conversation happen for…say, 3 or 4 out of every 10 PE or CPT cases, and so forth and so on?  Given that the data states that 30-40% of patients will not have an effective outcome with PE, CPT, etc., I do not know the answer to the question. In my own experience, the phenomenon occurs for a number of reasons.

  • The clinician does not wish to be known for ‘not’ using an evidence-based treatment. 
  • The clinician does not wish to admit that when they did use it, it was ineffective.
  • The clinician is concerned that because it was ineffective, he/she will somehow be blamed for the failure of the protocol to be effective.

The bottom line here is that we NEED to be talking about it.  It is great when we can get into a discussion about the effectiveness of an EBT; however, we must be discussing EBT failures and what the next clinical step should be for the sake of patients for whom the EBT was ineffective as well as the sake of our clinical and ethical professionalism.

Speaking for myself, the discovery of an EBT being ineffective with a particular patient leads me back to basic clinical intervention processes known to decrease distress with patients in general. This might include a more extensive psychoeducational intervention related to the symptom presentation.  It might include more intensive work on cognitive processes or behavioral processes and/or psychoanalytical processes as appropriate for the set of presenting symptom complaints and/or the determined diagnosis(es).  

Anthony McCormick, Ph.D. is a licensed clinical psychologist with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, MD. Located at the Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, he provides behavioral health treatment interventions aimed at resolving the clinical issues and mental health concerns of military service members with a focus on deployment related diagnoses.