The debate over evidence-based practice (also known as empirically-supported treatment) in psychology is contentious and polarizing. Evidence-based practice, as defined by the APA, is “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences.” The debate over evidence-based practice can be summarized as follows:
Proponents of evidence-based treatment argue that clinical psychologists are scientists, that psychotherapy is (or should be) based upon scientific theory, and therefore therapists must use the best available scientific evidence in their practice of psychotherapy. They argue that the public must be protected from therapies which are not evidence-based, as such therapies may be ineffective or harmful.
Opponents of the evidence-based practice movement argue that psychotherapy is an art rather than a science, and that the essence of what they do – the “human element” – cannot possibly be manualized or subjected to clinical trials. Opponents are typically therapists who practice relationship- or insight-oriented approaches. They see their work as diametrically opposed to the principals of evidence-based practice.
I understand and appreciate the arguments of the opponents, and I do believe they have some valid points. However, I have established my professional identity as a strong proponent of evidence-based treatment.
When you visit a physician for an illness and she prescribes a medication, you can safely assume that the medication has been FDA-approved for your particular illness, that it is likely to be effective, and that it is unlikely to seriously harm you.
Imagine the following scenario: Drug A was used to treat Illness X twenty years ago. Then, ten years ago, clinical studies showed that Drug B is significantly more effective than Drug A in treating illness X. A physician, Dr. Dolittle, continues to prescribe Drug A for Illness X because he really believes it works, and because he was taught that Drug A works well when he was a medical student 20 years ago. Dr. Dolittle does not inform his patients that Drug B exists, because he doesn’t believe it will work for them and he has no experience with it.
The scenario described above would not happen in medicine, would it? And if it did happen, Dr. Dolittle would be reprimanded by the medical board and may have his license revoked.
Believe it or not, this scenario happens in psychology all the time. Most people outside the field would be shocked to learn that the majority of psychological treatment out there is NOT evidence-based.
I have seen patients who underwent years of psychodynamic therapy for severe depression, without getting any better, without being told about cognitive-behavioral therapy (CBT) and without being referred to a psychiatrist for a medication evaluation. I have seen patients with anxiety disorders whose psychiatrists have prescribed multiple medications for them, never once referring them for psychological treatment, without ever mentioning that CBT at least as effective, if not more so, than medication for most anxiety disorders. I have seen patients who suffered from eating disorders for many years, who have seen many therapists, who have had multiple stints in residential treatment and have taken numerous medications, but were never restored to their ideal body weight and never provided with the support they needed to eat properly. And finally, a substantial portion of my case load is comprised of teenagers with eating disorders who have experienced months or years of ineffective, non-evidence-based treatment. The families of these teenagers were never informed about Family-Based Treatment (FBT), which is the only empirically-supported treatment for adolescents with eating disorders. Their parents discovered FBT on their own through desperate late-night internet searches.
These patients are pleasantly surprised to see how quickly and dramatically they improve with evidence-based treatment. They are also angry that they were not provided with, or at least informed about, effective treatment from the start. I believe that all patients and their families deserve to be fully informed about the range of different treatment options available to them, including evidence-based treatment. I do believe that there is a place for non-evidence based treatment, but patients and families should know from the outset what they are getting.
Evidence-based practice is not about using treatment manuals verbatim, or only relying upon randomized clinical trials. Treatment manuals are necessary for research and dissemination, but they are not intended to be followed verbatim with every patient in the real world. Manuals don’t treat patients – they merely provide a guide and a plan of action which may be revised and altered as needed for each unique patient. The basic principles and techniques of the treatment are the brick and mortar; the details of each room can and should be tailored to the individual.
Clinical psychology is a science, but it is not as precise as the so-called “hard sciences” like physics or mathematics. The brain is too intricate; human behavior too complex to be boiled down to immutable formulas. There is, and always will be, room for intuition, creativity, spontaneity, and that intangible “human element” that cannot be manualized or subjected to laboratory research. But the evidence base is there, so we owe it to our patients and to our profession to use it. Otherwise, we are no better than Dr. Dolittle.
I remain somewhat ambivalent..
As a scientist I am, of course, in favour of evidence-based treatment for illness of any type. But in terms of the evidence base for FBT, the major caveat is the way that ‘treatment efficacy’ has been measured: using EDE. The limitations of EDE as a measure of treatment efficacy in treatments where patients are under strict surveillance is something I have discussed here:
http://extralongtail.wordpress.com/2012/03/23/thinking-in-eating-disorders-logical-or-irrational/
Furthermore, the few clinical trials of treatments for AN suggest that FBT is no better longer term than adolescent focused therapy.
On a personal level, I would not have found FBT helpful and it wouldn’t have worked for my family. I have lovely parents, and there is no way that my parents ’caused’ my AN; however, FBT doesn’t work for every family.
On the contrary, what I found helpful ultimately was to be treated by a professional who viewed me as a whole person and with whom I established a strong therapeutic relationship. I didn’t have just AN alone, but co-morbidities that fed into the illness. I agree with your statement: “The brain is too intricate; human behavior too complex to be boiled down to immutable formulas [formulae].” Sometimes the older ‘Drug A’ may work better than ‘Drug B’.
I will add to my comment above by saying that the best evidence in support of FBT for many families is not the clinical trials data, but the families who themselves (including the individual with the ED), who have come through it successfully.
extralongtail,
What is the evidence that FBT is no better long term than adolescent focused therapy? I have not seen those clincial trials.
Anonymous, see: http://www.ncbi.nlm.nih.gov/pubmed/21532979
Dear extralongtail,
I don’t read that paper as showing that FBT is no better long term than adolescent focused therapy (AFT). In fact, the paper is not an individual study, but a review of other studies, none of which, to the best of my knowledge, compared FBT with AFT.
On the other hand, after that paper was published, the author, James Lock, reported on an RCT comparing FBT with AFT at both end of treatment and at follow-up during the next year. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038846/?tool=pmcentrez It showed that FBT was superior to AFT at both the 6 and 12 month follow-up times.
I’m not aware of any reported trials showing that AFT is superior to FBT, either short- or long-term. AFT might be better for some people, but we can only speculate.
Hi Anonymous
I do not dispute that FBT works for some people, perhaps depending upon what triggered their ED initially, and how their ED manifested. But the evidence suggests that there are non-responders. And non-responders may benefit from a different treatment strategy.
Nevertheless, I do criticise the use of EDE as a tool for assessing recovery from AN, and in particular, restricting AN without significant body image issues (as I had). EDE is biased towards fat-phobic EDs. Furthermore, FBT involves very close surveillance of a child with AN, which means that they cannot engage in ED behaviours. To recover long term, a person needs to be able to manage their ED on their own, which means identifying triggers, recognising and acknowledging that one has an ED, and actually desiring recovery.
By commenting on Dr Ravin’s post I am not stating that I am opposed to FBT. Rather, I am stating that it is not suited to every patient with AN and that more traditional treatments, or novel treatments may be more helpful to non-responders.
I would like to bring the discussion back to the original issue.
The statement was made that “Furthermore, the few clinical trials of treatments for AN suggest that FBT is no better longer term than adolescent focused therapy.”
As a parent, I read the scientific literature and conclude that my kid has the best probability of long term recovery with FBT, not AFT. Nobody has claimed FBT is effective 100% of the time, but neither is AFT. The point is that FBT gives the highest probability of a good outcome. To say that the “clinical trials” “suggest” no advantage for FBT over AFT is to misrepresent the current scientific literature, as there is no clinical trial showing equal outcomes, long term, between the two approaches.
Anonymous
If you feel that FBT is the best option then use it. Please be assured that I am NOT criticising FBT negatively. I am actually criticising the tools used to assess its efficacy in clinical trials, which (I feel) oversimplify a complex illness. I know of a number of families for whom FBT has worked well (hence my second comment above). But I also know families for whom FBT hasn’t worked.
There are few clinical trials of specific treatments for AN, which is hardly surprising because there are some who doubt whether an illness as complex as anorexia nervosa can be explained by a unified, brain-based theory that can be treated primarily via a single approach. The few trials of FBT conducted to date suggest that some people don’t benefit from it. Those individuals may benefit from alternative treatments, and I was one such individual.
I wish you and your family the best of luck with FBT.
To summarize: the only scientific experiment testing FBT against AFT showed that, 12 months after end of treatment, 49% of the FBT patients were fully recovered, while only 23% in the AFT group were. In addition, only 15% of the patients in the FBT group needed to be hospitalized during the course of treatment, while 37% of those in the AFT arm became so seriously ill that hospitalization was necessary.
This experiment shows a clear advantage for FBT over AFT, both in terms of avoiding medical instability and long term recovery.
I think everyone is entitled to their own opinion, but not everyone is entitled to their own facts. The statement that “the few clinical trials of treatment for AN suggest that FBT is no better longer term than AFT” is incorrect as a question of fact. While it is possible that some people might conceivably do better with AFT than with FBT, but there is no support in the clinical trials for that opinion, and it is dangerous and misleading to state otherwise.
Anonymous, I have read the study and noted how ‘full remission’ and ‘partial remission’ have been assessed – i.e. using % ideal body weight adjusted for age and sex, and Total EDE within 1 SD of normal.
The point I am making is that for families who are able to cope with the pressure of FBT, of course there will be an apparent improvement in outcome – because FBT includes such close surveillance of the patient and forbids engagement in ED behaviours. So if the patient is asked how many times, over a given period of time, they engaged in certain ED-related behaviours, of course they will score lower with FBT, because they have not been permitted to engage in those behaviours (and for good reason). AFT works on the patient changing their own mind and way of thinking. So my criticism relates to the tools used to assess remission, which are largely behavioural and focused prominently on weight and shape concerns. AN is more complex than a ‘body image disorder’ with behaviours undertaken to modify body image.
I am not promoting AFT. Neither am I being negatively critical of the process of FBT. What I am suggesting is that researchers examine the tools they use to assess recovery. Ultimately, a person with AN needs to be able to look after themselves and to live their life without constant surveillance. They need to be able to make healthy choices of their own accord.
You write: “While it is possible that some people might conceivably do better with AFT than with FBT, but there is no support in the clinical trials for that opinion, and it is dangerous and misleading to state otherwise.”
My answer to this point is that there are very, very few clinical trials comparing various treatments for AN. The Lock and LeGrange trials are relatively short-term. As I mentioned earlier, I am not attempting to promote AFT over FBT, or to promote AFT at all. What I am attempting to do, and which doesn’t seem to be getting through to you, is to critique the FBT studies from a different angle and to question how the efficacy of treatment is assessed.
Extralongtail,
I agree with you that the outcome measures used in these studies are not ideal. I also agree that there is far too little research on effective treatments for AN. We definitely need longer-term follow-up studies. It would be helpful to know how patients fare 5, 10, or 15 years after completing treatment. Anonymous is correct, though, in his assertion that the little data we have indicate that FBT is superior to AFT at 6 and 12 months post-treatment.
Your responses to this post suggest that you favor individual therapy because it helps patients cope with AN on their own and helps them change their own thought processes, whereas patients who do FBT not taught to cope on their own, but are merely complying because they aren’t allowed to engage in ED behaviors. This is an inaccurate assessment of FBT. Phase 2 of FBT is all about gradually helping the patient eat on her own as she demonstrates readiness, and Phase 3 is all about helping her resume life as a normal, independent adolescent. So FBT most definitely does teach patients to cope with AN on their own.
Thanks for your response Dr Ravin.
I actually DON’T favour any particular approach to the treatment of AN, because I believe that every person is an individual with a unique set of difficulties and a unique experience of life.
My main reason for commenting on your blog post was not to criticise FBT itself, or to elevate one therapy beyond another. It was to discuss evidence-based science, which is the topic of this blog post. I made most of my comments objectively (rather than subjectively), critiquing the research methodology and not the therapeutic approach. I have witnessed young people recover well from AN via FBT, and I have also witnessed people recover well using very different approaches. I am not in the least opposed to FBT, but as a research scientist I am interested in research design and data interpretation. As a former sufferer of AN, I am interested in the way that AN is conceptualised and understood.
Extralongtail,
Yes, I understood that you were critiquing the methodology. I agree that it is very important that we, as scientists, continue to look at research evidence objectively and critically as you have done. I value your input both as a scientist and as a recovered sufferer. Keep commenting!
Switching to a separate issue, there is one difference between FBT and AFT that I think is often overlooked. In AFT, as described in the Lock and leGrange study cited above, the professional holds separate meetings with the parents and with the sufferer. In FBT, on the other hand, all meetings include the sufferer and his or her parents. In my opinion, this is a healthier approach, as it respects
open communication and minimizes the risk of misunderstandings.
Thanks Anonymous, and Dr Ravin for the discussion! I don’t think there’s a ‘right’ or ‘wrong’ in any of this. AN is an enigmatic illness that difficult to understand from everyone’s point of view. I am keen to see data from more research studies using different research designs. However, I am inclined to think that just as autism experts say: “once you’ve seen one person with autism you have seen [only] one person with autism” – perhaps the same applies to AN (?).
“Family-Based Treatment (FBT), which is the only empirically-supported treatment for adolescents with eating disorders. ” – Family support will bring tremendous help for victims of eating disorder, specially for young adults. Great article. Thanks for sharing!