Gary Bloom

March 29, 2021

Evidenced Based Practice

(This is an excerpt from a book I wrote on how to have career in the mental health field. I unpublished it because it would need to be revised to stay current.)

Evidenced-Based Practice

“Is advertising a psychotherapy as ‘evidence supported,’ any less vacuous than ”Pepsi’s the one“?”
—James Coyne, PhD

The inspiration for evidenced-based practice in mental health treatment came out of the success of evidence-based medicine (EBP) and its offspring in other healthcare. But in research, mental health treatment is not like any other healthcare. Cancer patients don’t get better while on a waiting list. Heart disease patients don’t get better while on a waiting list. Diabetes patients don’t get better while on a waiting list. In contrast, some mental health system clients, who are suffering sufficiently to rate an insurance-reimbursable DSM diagnosis, do get better while on a waiting list. Which brings me to how healthcare treatment research is done.

To put a drug on the market, a pharmaceutical company has to provide sufficient evidence that the drug is efficacious. To be considered as a reimbursable therapy treatment, most insurance companies now require that counseling meet the same requirement. Efficacious does not mean what you think it means. It means better than nothing. It does not mean better than reading the Dalai Lama. It does not mean better than consuming a McDonalds Double-Mindfulness burger. It just means better than nothing. The requirement for mental health practitioners to get reimbursed for their work is to use an approach that’s better than nothing. And it’s even worse than it sounds. Gaming the system in research for both medications and counseling is standard operating procedure. This should not come as a surprise: research in pharmaceuticals is almost always paid for by the producing pharmaceutical company. Research in psychotherapy is usually done by the practitioners using the approach being studied. 

Aside from outright bias, there are other reasons EBP is messy for counselors: 

First, it requires a disease model. Insurance companies won’t pay for relationship issues unless they’re translated into a cluster of individual symptoms. Your clients will not be having marital difficulties, they will be depressed: the insurance company requires a number of depressive symptoms. In the bizarre world of psychiatry, every day is opposite day, so decades of failed research has led to the foregone conclusion that depression is caused by a genetic predisposition. Your clients will not be allowed to just be bored with school. Even if they can play a video game or Dungeons and Dragons for hours on end, they'll still be diagnosed with Attention Deficit Hyperactivity Disorder. 

Second, you must create concrete goals with a timeline for achieving them. If you’re inclined towards a psychodynamic or person-centered approach, you may not be comfortable with concrete goals. If you’re a systems-oriented therapist, you may not be comfortable with individual rather than relationship goals. 

Third, you must justify your work to health care insurance managers who will almost assuredly have less knowledge than you. After learning how the real world of reimbursement looks, you might acquire those concrete symptoms of depression and anxiety so beloved by re-imbursers.