Why I don't Practice "Evidence Based" Therapy

Time and time again, I’m doing good work with a client until their medical provider intervenes and tells them that CBT (Cognitive Behavioral Therapy) is the only thing that works. Then the client comes to me, feeling duped, and asks why we are not doing CBT. I can’t even count the number of times a client’s primary care doctor or even their psychiatrist has undermined the therapeutic relationship or gains made by poisoning the minds of individuals into thinking that there is only one kind of therapy that works. **Disclaimer, sure, CBT is in fact right for some people, but it is certainly not the only therapy in which we have “evidence.” **

If there was any real care coordination happening, a medical provider might actually consider getting a release signed and calling the therapist to try and gain understanding of their patient and the rationale behind their treatment since prescribers lack training in therapeutic methods.

The first thing to understand is that therapy is such a unique experience with so many variables, it is extremely difficult to research. It cannot be replicated from person to person. There are so many flaws in the way psychiatric research is conducted, it’s amazing any of it becomes trusted. Drug companies are often the ones funding psychiatric research. Did you know that the drug giant Pfizer is responsible for the questionnaire (PHQ-9) you fill out at the doctor’s office when they screen you for depression? This is the trusted screening tool by medical professionals for depression and it’s brought to you by the makers of Prozac in order to sell you Prozac. Did you also know that the folks doing research on psychiatric disorders and treatments are academics and not clinicians who actually treat people? Most have never treated a patient. Let that sink in.

Just as your depression may be more complex than a simple questionnaire, your treatment may need to be as well. We may have a lot of evidence for CBT — only because it’s a treatment that’s easier to study than other therapeutic modalities due to it’s manualized nature — but the “evidence” is that it’s been studied at all — not necessarily that it has remarkable outcomes. It’s also more often studied these days because CBT fits into the insurance model of doing business that dictates how many sessions you can have and how fast you “should” be healing from trauma. But again, the people studying this stuff aren’t practicing in the field. One of the most shocking things about “evidenced based” therapy is that it’s really just a marketing term that’s been misunderstood.

Decades of research (by practicing clinicians dating back to Freud) on what’s called the “therapeutic alliance” has shown that it’s not actually the type of therapy that matters, but the quality of the relationship between client and therapist that determines a positive therapeutic outcome. These outcomes have been consistent and replicated over diverse patient groups and studied by a variety of methods.

If you’ve benefitted from manualized treatment like CBT, I am genuinely happy for you and there are times when I do prescribe it for people. When I take a new client, I take in all the complexities of their humanness and think deeply about what type of treatment I think will be most beneficial (and if that’s CBT I refer them out for that). I spend an hour with clients, doctors spend 10 minutes. So how could they know what type of therapy is right for someone with complex psychological needs?

The bottom line is this: We need to look at both sides of the evidence, think critically about it, ask who is conducting the research by what methods and for what purpose.

So yeah, I don’t practice what physicians refer to as “evidence based” therapy, but I do practice critical thinking.