Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

What does evidence-based psychotherapy really mean?

Steven Reidbord, MD
Conditions
August 28, 2019
Share
Tweet
Share

When a mental health clinic, online referral service, or private practice offers “evidence-based” psychotherapy, that certainly sounds like a selling point.  It suggests solid science supports the therapy offered — and that competing services lack this support.  But what does this phrase really mean?

“Evidence-based medicine” first appeared in the medical literature in 1991.  It cast doubt on physicians’ clinical intuition and anecdotal experience, reminding them that science should guide medical practice.  (The term was new, the warning was not.)  Acceptable scientific evidence included clinical epidemiology, bench research, published case reports, and so on.  However, the randomized controlled trial (RCT) soon emerged as the gold standard, the best evidence that a treatment works.

In a RCT, subjects who all suffer the same disease are randomly assigned either to the treatment under study, or to a control group.  The latter receives an inactive placebo, or sometimes an active comparison treatment.  Ideally, RCTs are “double-blind”: neither the subjects nor those rating them know who is in which group.  This minimizes psychological effects such as confirmation bias, where both researchers and subjects tend to rate more improvement where they expect to see it.  If the treatment group then fares better on average, this is taken as strong evidence of treatment efficacy.

RCTs are powerful tools — with limitations.  Best for studying a single treatment applied to a single disease, the method becomes impractical when studying patients with multiple or ill-defined conditions, or when assessing treatments with nuanced variations.  It can be hard to find a suitable placebo or comparison treatment, and sometimes it proves impossible to create double-blind conditions.  For a variety of reasons, there is still an important role for evidence aside from RCTs.

In the field of psychotherapy, the paradigm in the first half of the 20th century was psychoanalysis and its offshoots.  Its prominence was largely due to intellectual elegance and compelling case reports, not RCTs.  But by mid-century, critics began questioning the broad claims of psychoanalysis.  New medications and psychotherapies were introduced.  And in 1980, psychiatry’s Diagnostic and Statistical Manual was revised.  It would thereafter define mental disorders not narratively, but by symptom criteria.  With the right set of symptoms, a patient would “meet criteria” for one or more diagnoses.

Drug developers and the newer schools of therapy, especially cognitive-behavioral therapy (CBT) and short-term structured therapies, were eager to prove they could reduce these symptoms and, by definition, relieve psychiatric disorders.  Many RCTs were done, and indeed these studies showed, on average, that symptoms were reduced.  This led to FDA approval for the medications, and to “evidence-based” claims for the therapies.

Yes, CBT and other symptom-focused therapy is “evidence-based.”  But that’s only part of the story.  Left unsaid is that a great deal of scientific evidence finds traditional, psychoanalytically based therapy effective as well.  This includes group studies using standardized measures — even RCTs — as well as patient satisfaction surveys, a myriad of case reports, and other lines of evidence.  Although there are fewer RCTs of analytic therapy than CBT, often the amount of improvement (the statistical “effect size”) is greater in the former.

“Evidence-based” also glosses over why people seek therapy.  Many hope to decrease concrete symptoms: to feel less anxious, to have a brighter mood, to sleep more soundly.  Here the evidence supporting CBT and similar treatments is very solid.  But others are motivated by vague complaints that arise only in the context of close relationships.  Or by a lack of meaning in life.   Or by unwitting self-sabotage.  Not uncommonly, they really can’t say what is wrong.  No RCTs exist for such problems, as there is no diagnostic group to randomize, no concrete symptoms to treat.

It reflects a fundamental misunderstanding — or false advertising — to promote “evidence-based psychotherapy” for these sufferers.  There is no such evidence, if by that we mean RCTs.  Yet if evidence is more broadly construed, as it was in the original conception of “evidence-based medicine,” it is psychoanalytic therapy, not CBT, that is supported by far more evidence.

“Evidence-based therapy” has quickly become an empty phrase that slights the competition.  The evidence is real, but its relevance often is not.  This false narrative has misled insurers, government agencies, and many patients into believing certain approaches to psychotherapy are inherently superior when they are not.

Cognitive, highly structured, symptom-focused therapies certainly help many people.  Psychoanalytic therapies, and other therapies that rely on depth and relatedness, do as well.  The best choice for an individual depends on factors unique to that person, starting with his or her presenting complaints and preferences.  It may or may not be relevant that a particular therapeutic approach works against specific symptoms as tested in RCTs.  “Evidence-based” is mostly sales-talk, not a blanket scientific endorsement.  All mainstream psychotherapy is evidence-based.

Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.

Image credit: Shutterstock.com

ADVERTISEMENT

Prev

The story of a hospital collapse and how small towns were devastated

August 28, 2019 Kevin 1
…
Next

3 lessons learned from the deep end of the pool

August 29, 2019 Kevin 0
…

Tagged as: Psychiatry

Post navigation

< Previous Post
The story of a hospital collapse and how small towns were devastated
Next Post >
3 lessons learned from the deep end of the pool

ADVERTISEMENT

More by Steven Reidbord, MD

  • Incurable psychiatric disorders: Should we offer palliative care or medical aid in dying?

    Steven Reidbord, MD
  • How drug prices are manipulated

    Steven Reidbord, MD
  • Which is better: Psychotherapy using video or in-person while wearing masks?

    Steven Reidbord, MD

Related Posts

  • Considering the recent setbacks of evidence-based medicine

    Kenneth Lin, MD
  • How to ace your medical school interviews: evidence-based tips

    Dilshan Pieris
  • Want to crush USMLE Step 1? Here are some evidence-based study tips.

    David Griffin, MD
  • The expanding role of specialists in value-based care

    Martin Lustick, MD
  • Lessons from the meeting of different value-based concepts

    Joshua Liao, MD
  • Behavioral health providers face challenges in value-based care

    Martin Lustick, MD

More in Conditions

  • One injection dropped LDL by 69 percent. Should we celebrate?

    Larry Kaskel, MD
  • Does cycling hurt male fertility?

    Martina Ambardjieva, MD, PhD
  • How community and buses saved my retirement

    Raymond Abbott
  • How changing your self-talk can transform your entire life

    Faust Ruggiero
  • Why your clinic waiting room may affect patient outcomes

    Ziya Altug, PT, DPT and Shirish Sachdeva, PT, DPT
  • The ethical crossroads of medicine and legislation

    M. Bennet Broner, PhD
  • Most Popular

  • Past Week

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Why your clinic waiting room may affect patient outcomes

      Ziya Altug, PT, DPT and Shirish Sachdeva, PT, DPT | Conditions
    • The backbone of health care is breaking

      Grace Yu, MD | Physician
    • How new loan caps could destroy diversity in medical education

      Caleb Andrus-Gazyeva | Policy
    • Why transplant equity requires more than access

      Zamra Amjid, DHSc, MHA | Policy
    • The ethical crossroads of medicine and legislation

      M. Bennet Broner, PhD | Conditions
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • How doctors can think like CEOs [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why your health care dashboard isn’t working and how to fix it

      Dave Cummings, RN | Policy
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • A surgeon’s testimony, probation, and resignation from a professional society

      Stephen M. Cohen, MD, MBA | Physician
    • One injection dropped LDL by 69 percent. Should we celebrate?

      Larry Kaskel, MD | Conditions
    • Locum tenens: Reclaiming purpose, autonomy, and financial freedom in medicine

      Trevor Cabrera, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Why your clinic waiting room may affect patient outcomes

      Ziya Altug, PT, DPT and Shirish Sachdeva, PT, DPT | Conditions
    • The backbone of health care is breaking

      Grace Yu, MD | Physician
    • How new loan caps could destroy diversity in medical education

      Caleb Andrus-Gazyeva | Policy
    • Why transplant equity requires more than access

      Zamra Amjid, DHSc, MHA | Policy
    • The ethical crossroads of medicine and legislation

      M. Bennet Broner, PhD | Conditions
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • How doctors can think like CEOs [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why your health care dashboard isn’t working and how to fix it

      Dave Cummings, RN | Policy
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • A surgeon’s testimony, probation, and resignation from a professional society

      Stephen M. Cohen, MD, MBA | Physician
    • One injection dropped LDL by 69 percent. Should we celebrate?

      Larry Kaskel, MD | Conditions
    • Locum tenens: Reclaiming purpose, autonomy, and financial freedom in medicine

      Trevor Cabrera, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

What does evidence-based psychotherapy really mean?
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...