Tuesday, September 12, 2006

More Complaining about Evidence-Based Treatment

The most recent edition of the National Psychologist contains two articles concerning evidence-based treatment. Unfortunately, the online edition hasn't been updated yet and the articles are only out in hard copy.

For those of you who are not of the cognoscenti, evidence-based treatment is simply treatment with a clear research base. The research establishes that certain procedures are helpful for certain types of problems. My previous post describes an evidence-based treatment for OCD.

The first article, by Thomas Habib, opens with a bizarre story. Apparently a managed care network, Managed Health Network, wants to establish a category of, what Habib calls, an "elite clinician." I'm not sure if it's Habib's words or theirs'; I couldn't find it on their web site. Essentially, this elite clinician would be someone who has been trained in and practices evidence-based treatment. I assume that these elite clinicians would be given priority in referrals.

Habib is worried about the perceived deadly combination of managed care and evidence-based treatment. He states,

No one is against evidenced based practices. As mentioned above, how this goal was pursued and the disregard of how this might strait jacket psychology and be misused by mangled care is the problem.

"Mangled care" is an obvious shot at managed care. Certainly somewhat deserved, but then, our hands aren't entirely clean, either. There have been far too many clinicians who weren't good at getting change, but were very good at keeping clients in therapy for extended periods of time.

Managed care credentialing for clinicians doing evidence-based treatment is silly. From experience, I know this will fail, because it won't save MHN any money. Back in the 1980's, when managed care blew into Pennsylvania, I spent an incredible amount of time on the phone with "care managers," who would authorize treatment for my clients. Once I learned what they wanted to hear, it was no problem to get sessions authorized. I got to know a lot of care managers by name and we'd chat about our families before getting down to business. But, eventually, telephone authorizations became too expensive, and most of my telephone friends had to get other jobs. Now, my secretary fills out a page, I add the diagnosis, and sign it. Bingo! Another 10 sessions.

So, let me assure you, Dr. Habib. This will end with a whimper, and you'll be left with a mild bit of bureaucracy. Nothing to get excited about. Managed care isn't going to hurt you with evidence-based treatment requirements because it's too expensive to do so.

But, is evidence-based treatment a "strait jacket?" Absolutely not, and the second article illustrates my point clearly. Surprisingly the author, Frank Dattilio, also thinks he's attacking evidence-based treatment. He should really know better, as he has extensive training and publication in cognitive-behavior therapy. In his article, he tells the story of Corey, a young psychiatrist completing his fellowship. Corey brought him a tape of a therapy session, of which he was very proud. Dattilio viewed the tape and said,

Much to my dismay, the same things kept cropping up repeatedly during the course of the session--a dry, robotic type of interaction that almost appeared as though it was scripted.

At the end, Corey said to me, "So what do you think?" I was speechless. Before I had a chance to say anything, he interrupted me by saying, "I think it's classic cognitive-behavior therapy. I don't believe I left one thing out."

"Well, there is one thing that is missing," I replied. Corey looked at me perplexed, "What did I forget?" "You!" I exclaimed, "You, the therapist is missing."

It's a wonderful story, and a great cautionary tale to young therapists, who, unsure of themselves, want to retreat into "techniques." Since the 1950's, we've known the quality of the therapeutic relationship has a strong effect on therapeutic outcomes. Wampold (2001) has a good review of the data. Maintaining a good relationship with the client, being empathic and supportive, is part of any evidence-based treatment. Just look at Beck, Rush, Shaw, and Emery (1979).

The sad thing is that we continue to argue about evidence-based treatment even though we consider psychology to be a science. If psychology is a science, we believe the data. If psychology is a science, we opt first for treatments that the data shows are worthwhile. No one expects us to give up our clinical judgment and our empathy in the process. Being empathic and supportive is just another evidence-based therapy.

All psychotherapies are like seeds. They cannot grow into a beautiful flower without the fertile soil that the humanity of a good therapist provides. Clinicians do not need to fear evidence-based therapies.


Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Dattilio, F. M. (2006). Evidence based treatment may be too confining. National Psychologist, 15(5), 23.

Habib, T. A. (2006). A profession in search of legitimacy. National Psychologist, 15(5), 14.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Earlbaum Associates.

Wednesday, September 06, 2006

Obsessive-Compulsive Disorder

A good summary of psychotherapy for OCD, written by Bradley Riemann, appeared in the Psychiatric Times last month. The article opens with this observation:

Obsessive-compulsive disorder (OCD) is a common and debilitating condition. In many cases, it can come to dominate a person's behavior and cognitive processes, creating great anxiety. It typically affects all aspects of an individual's life, including school performance, occupational responsibilities, and family and social interactions.
Although the television show "Monk" strives for laughs about it, there is no humor OCD. It can be absolutely debilitating. The worst thing about it is that the client knows his or her behavior is irrational, but can't stop doing it.

The heart of treatment for OCD is exposure and ritual prevention. There is typically a feared situation, which is followed by some form of ritual to reduce the fear. For example, a client may go to the bathroom and then compulsively wash his hands for the next 20 minutes. Treatment is straightforward.

First, the client begins with a mildly anxiety-provoking response. For example, he might go into a public bathroom and touch the sink. This exposure creates anxiety. Normally, the client would reduce the anxiety by hand washing. Instead, the handwashing response is prevented. The client waits for the anxiety to drop, which it always does. The procedure is repeated until there is no more anxiety. Then, the client moves on to a more anxiety-producing stimulus, such as a toilet seat.

This procedure has two effects. First, the anxiety is extinguished by a process called habituation. Recall learning to drive. At first, you were quite anxious. As you drove repeatedly, you became less anxious. Through repeated exposure, you habituated to driving.

Second, the client learns an important lesson. Anxiety always goes away. If you tolerate anxiety for a period of time, it always goes away. This gives the client tools for dealing with other compulsive behaviors.

Psychotherapy for OCD is critical. Riemann cites research indicating that antidepressant medications can reduce symptoms of OCD by about 1/3, so medication alone won't provide full relief. Unfortunately, our office procedures are not always sufficient for good treatment. For exposure and response prevention to be truly effective, a person with OCD needs intensive treatment, usually outside the office. Treatment centers are being established in order to meet this need.

Sunday, September 03, 2006


It worked!!!
(I think...)

Here we go....

I just spent yesterday and this morning removing a Trojan horse from my wife's computer. It was easy enough to identify the infected file. I just couldn't delete it, the sneaky devil. I finally figured out that starting the computer in Safe mode would let me delete it. It worked.

Anyway, always a glutton for punishment, I'm now going to revise my blog to take advantage of the new features in Blogger Beta. I figure there are three possible outcomes: (a) It can transfer; (b) my computer can wind up dented in the street; or (c) I can page furiously through Albert Ellis's book, Anger: How to live with it and without it.

Since the first outcome is the least likely, I'm hoping for the third outcome....