Category Archives: EST (Empirically Supported Treatment)

What’s Wrong with Empirically Supported Treatments?

Psychologists in the field of psychotherapy like to engage in debates about scientific proof. Oftentimes this leads to arguments about which therapy has achieved the status of an “empirically supported treatment”…

An empirically supported treatment is a therapy that has been proven to work for a particular mental health condition. If you have received a diagnosis of social anxiety disorder, for example, an empirically supported treatment would be one that has been found to reduce social anxiety with a reliability higher than that of no treatment or an alternative treatment.

So what’s wrong with that?

To answer that question, we have to dig a little deeper…

The Mechanics of Empirically Supported Treatments:

The mindset that underlies the movement toward empirically supported treatments and the scientific quest for proof is a mechanistic one.

Therapy is perceived as a set of procedures the therapist “administers” to the client in order to achieve some predictable result.

For this to work, the therapist must agree to deliver interventions according to certain fixed procedures that show “fidelity” to the specific treatment that is being tested. The therapist, in other words, must simply become the tool or vessel for the treatment.

The client on the other hand must be reduced to the passive recipient of the “treatment”. It is not even clear that their subjective experience really matters. What matters is the “end result” or effect that the treatment produces. The client is, in other words, just a set of mental and physiological reactions that can be manipulated or caused in some predictable way.

In short, the philosophical underpinnings of the movement towards empirically supported treatments are mechanistic: The client becomes an object in the causal chain of action and reaction that makes up the physical world, and the therapist becomes the engineer who figures out how to induce change in the object.

Empirical proof in this model is found through observing or measuring mechanical changes in the client who after treatment may or may not feel anxious anymore, may or may not report feeling depressed, or may or may not function better in their relationship.

This kind of proof separates cause (treatment) and effect (results) and looks to some external reality for validation that the treatment has had a positive effect.

Why Therapy is not a Mechanical Process of Change:

In reality therapy is an interpersonal process where the therapist learns from the client, just as much as the client learns from the therapist.

The therapist will often entertain multiple hypotheses about the dynamics that could explain the client’s difficulties, but these can be overturned, altered, or refined based on what the client shares and how the client reacts to certain interventions.

The assumption that the therapist unilaterally administers treatment as some engineer aiming for a predictable result, is therefore flawed. Therapy is about learning, not about producing.

The sign of a good therapist is not the ability to be true to a certain therapy modality, but his or her ability to deviate and change course in response to what they learn from the client and jointly discover through the therapy itself.

This also means that the therapist cannot be guided by specific goals or predefined interventions, because what a client wants or needs, and what would be effective, changes depending on the moment and the context of each interpersonal encounter and each specific interaction.

Oftentimes what is therapeutic about therapy is precisely that it overturns previous knowledge and makes new possibilities and hypotheses appear.

A problem or disorder is thus not some “static” thing like a tumor or a bad tooth, but a temporary stopping point on a journey toward a much more complex understanding of various life issues that inevitably end up becoming the real “object” of the therapy.

Evidence of Change in Psychotherapy:

One of the biggest compliments I have gotten from a client was someone who told me, “the longer I keep coming here, the more uncertain I feel about what my problem really is”.

This client had initially defined their problem as a specific anxiety disorder, but was coming to the realization that anxiety is really shorthand for a host of unique and highly personal life experiences. It is not a “disorder” that calls for the administration of a specific empirically supported treatment, but a very personal sign of other life issues or problems which the person has yet to confront.

Good therapy helps clients dislodge themselves from preconceived notions of their problems and helps them discover needs and desires they were not aware of from the outset.

This also means that the empirical proof we are after is not some preconceived end goal to be measured only at the conclusion of the therapy.

When therapy goes well, goals and priorities change, problems get overturned, and new issues become salient. This dynamic process of change has to be allowed to unfold according to its own rhythm and logic, and should not be hijacked by a preconceived agenda or a heavy-handed attempt to steer the therapy in a predetermined direction.

The change in this kind of therapy is not external to the therapy, to be validated only by measurements or observations after the fact. Instead it happens as an immediate experience of something resonating in the here and now that changes the client’s view of themselves in a very real and irrefutable way.

This kind of therapy is not about fitting a client into a machine-like production of change, but about facilitating a personal journey where the benefits lie in the discoveries made on the journey itself.

Dr. Rune Moelbak

About me: I am Rune Moelbak, Ph.D., a clinical psychologist in Houston, Texas. I treat people, not problems. To read about my views on therapy, visit my “about me” page, where you can also schedule a therapy appointment.

 

The McDonald’s Approach to Therapy: Why Empirically Supported Treatments are Not the Way to Go…

Let’s take a rich experience of a real world therapy interaction, considered by both therapist and client to have meaning, intensity, and benefit.

The client is free to go where he or she may, to enter into new territory of emotion and thought, and to follow new leads and surprises uncovered through the therapeutic interaction…

The therapist is free to learn from a multitude of signs emitted by the client – consciously and unconsciously, verbally and nonverbally – indicating where the client might need to venture next, where the pain might be, and where truth has yet to emerge…

The course of therapy is free to be determined by the mutual input from both client and therapist and to take situational factors into account such as timing and the presence and absence of a variety of factors in the present moment, informing an organic intuition of where to go next…

Now compare this to a therapy where the client is given instructions of what to talk about and how to talk about it in a way that that has been determined in advance, and where the same instructions are being applied uniformly to each and every client regardless of specific circumstances and needs.

…to a therapy where the therapist is not free to follow his or her moment-to-moment intuitions or to adjust interventions on the basis of attunements to the importance of the timing and context of the situation.

…to a therapy where the course of therapy is determined not by client and therapist, but by a schedule that specifies what conversations or activities need to take place, when and for how long they need to be done, and in what order they must be accomplished.

The latter form of therapy, which I would call “therapy as technology” or “therapy as mass production”, has one benefit which the richer, more organic, and more tailored therapy does not: It is simplistic and rigid enough to lend itself well to the requirements of a scientific study that demands that an inflexible set of interventions be “administered” uniformly to a large number of clients that have been grouped in advance into uniform “categories”.

It is this set of restrictions, imposed on an otherwise rich, complex, and organic process, that is needed in order to prove what specific interventions can be said to be effective for which specific “type of problem” or which specific “category of client”.  If an effect is found that is greater than the effect of a chance encounter, as evaluated by some yard stick that is uniformly assumed to represent a good outcome, then the therapy in question is deemed to be “empirically supported” (EST) and to have earned the stamp of scientific proof.

Some therapists treat people as if they were “categories of problems” rather than unique individuals

The problem, as you can see, is that to get the stamp of approval, a series of operations had to be performed intended to simplify the richness of an actual flexible, organic, and complex therapy interaction. The intensity and meaningfulness of an experience evolving gradually between therapist and client had to be straight-jacketed and turned into a “technology” (a predefined set of procedures). Therapy had to become a machine-like process, the therapists had to become machine-operators, and clients, well… they had to be treated with the uniformity of “stock”, losing their individuality and autonomy completely in the process.

So let’s dispel the myth that empirically supported treatments are in fact superior forms of treatment. Let’s not fall into the trap of assuming that scientific proof is always the hallmark of the gold standard of treatment.

A uniformly produced McDonald’s hamburger, mass produced and mass-consumed, may have been found to be effective at reducing hunger, but it is not a superior hamburger of that accord. It cannot compete with a hand-crafted premium burger tailored exactly to the needs of each client.

I am not against scientific proof, but when we have to distort reality to make it conform to the needs of our scientific methods, we are committing tomfoolery in the guise of science and are contributing to a lowering of our standards rather than a bettering of our collective destiny.

Therapy is a complex relationship, not a science-based technology, and no scientific study will ever be able to question that fact…