During my time working with the military and military providers, I’ve often been surprised, sometimes stupefied, by the resistance mental health providers have with implementing evidence-based treatments, especially ones that are “newer” to them, regardless of the wealth of research supporting their efficacy with patients. I’ve heard every reason from “that research doesn’t mean it works with Service members” to more honest anxiety about using something unknown to them. My all-time favorite reason came from a colleague who was referring one of her long-time patients to our residents for trauma treatment; this colleague admitted she knew how to conduct the evidence-based treatment herself, but she “didn’t like to.” I found there wasn’t much I could say at the moment, except to let her transfer her well-established patient to another provider for appropriate care. I’ve even had energetic conversations with well-respected clinicians who strongly contend that this “trend” to manualized care and depending on research to determine psychological treatment is dead wrong. Frustration and confusion, needless to say, often follows such evidence at how hesitant many established mental health providers seem to be at trying something new and perhaps unfamiliar, even if the treatment is well-proven through research.
On the flip side, there are times I hear my graduate students in frustrated conversations about why seasoned providers aren’t using newer and sometimes more proven treatments for various conditions, especially PTSD in our military population. In one of these recent conversations, a student was discussing the journal article by Scott Lilienfeld and colleagues (cited below), which discusses provider resistance toward evidence-based practice, reasons for it, and potential remedies. This prompted me to look to the article to better clarify their argument, as well as my own opinions on the topic. What I found was an article that I feel should be read by every practitioner and educator in mental health. This well-organized article gives both an understanding of resistance as well as reasons why providers should push through it. The authors point out that providers usually aren’t all-or-none in their resistance, oftentimes accepting some, if not many, aspects of evidence-based care, but remaining guarded toward others. They argue that resistance “typically reflects neither ignorance nor anti-intellectualism” but seems to be rooted in part by misunderstanding about “what EBT does and does not entail” (p. 4). This is what I too have observed with the providers both in my clinic and those I interact with externally. To me, it seems like much of the anxiety about using evidence-based treatments is linked to the belief that we are somehow taking the art out of therapy and demanding that a cookie-cutter approach is applied to everyone. This is fundamentally untrue, and providers I’ve spoken with seem to be much more accepting once this is explained. Even manualized treatments leave much room for provider judgements (to include choosing with the patient which treatment to go with), as well as allowing for the art and individual style of the provider to come through. I believe all mental health providers can agree that there has to be room in any treatment approach to adapt to the individual nature of the patient and their experiences. But that doesn’t mean research data should not have a role in our treatment decision making processes.
Going back to the discussion I was listening in on with my graduate students, one argument that surfaced had to do with ethical and unethical care. While it’s somewhat entertaining to hear how much students studying for licensure exams love directly quoting the ethics code by heart, I was struck with both the serious points they brought up and those I offered in exchange. Is it really unethical to not offer treatments that are more soundly supported by research, and if a “newer” treatment demonstrates proficiency does that really mean an “older” treatment that may have less research is really ineffective? The discussion expanded to consider if it is more ethical for a provider to continue with a treatment they are personally more comfortable and proficient with instead of using a treatment they are not comfortable with. It was an interesting point, and not one I initially knew where I stood. But after further reflection and rereading the Lilienfeld article, I contend that as a profession we are ethically and morally bound to keep up with the literature and obtain new training and supportive consultation as needed to become comfortable with unfamiliar treatments. After all, none of us would want to go to a cardiologist who had ignored the last 30 years of clinical advancements. Why should our profession be that different? As providers, we are responsible to know how to evaluate new research and apply it when appropriate. But we should never assume this means turning off our clinical perceptions and experiences. We need to always keep in mind that the best interest of the patient in front of us comes first. We should work with them to choose treatment plans that both reflect the individual nature of the patient and keep in mind the evidence-supported options and how they can be applied to the specific circumstances.
Lilienfeld, S., Ritschel, L.,Lynn, S., Cautin, R., and Latzman, R. (2013). Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies. Clinical Psychology Review, 33:7, 883-900.
Dr. Debra Nofziger is a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology. She currently holds the CDP position at Brooke Army Medical Center in San Antonio Texas.