On Evidenced Based Therapy

Ever since I have been doing this work, there has been a preference in the mental health field, as well as in our culture, for therapy practices that are based in what can broadly be called “evidence based techniques.”

What does this mean? It sounds like an obvious choice. If you were to choose a doctor who admittedly practiced medical techniques that were not based in evidence, your loved ones might certainly hold an intervention. You probably definitely want a therapist who is practicing a kind of therapy that has been proven to work.

And that is the real purpose for this term- to indicate a focus on results. Evidence based techniques have been empirically proven in countless peer-reviewed studies to deliver results, and in a timely manner. An example of these techniques might be Cognitive Behavioral Therapy (CBT), which is sort of the gold standard of evidence based therapeutic techniques. Another one, particularly popular in Seattle due to its origins here, is Dialectical Behavioral Therapy (DBT), which has been proven to be one of the most effective therapies for those struggling with Borderline Personality Disorder among other mental health issues.

Insurance companies and mental health clincis love evidence based techniques because they provide measurable results. It only makes sense right? When you are paying for someone to go to therapy, you’d like to know they are making progress and eventually going to finish treatment. And since there are only two people allowed in the treatment room, it would be nice for them to have some sort of indication that actual therapy is happening and progress is being made. Evidence based techniques supposedly provide that reassurance.

But there is still a problem with designating these techniques as evidence based and leaving other techniques out, and that is the relational factors in any treatment duo. In fact, Relational, or Interpersonal Therapy might be the epitome of what kind of therapy we are not talking about when we talk about evidence based techniques.

What is Relational or Interpersonal therapy? The late interpersonal therapist, Stephen A. Mitchell said that it was therapy with the central principle that “the relationship is curative.” There are a thousand explanations for what this therapy includes but simply put, it is therapy practiced from the perspective that the relationship itself is healing, not the technique.  

But this might include all kinds of different techniques. This is often why relational therapists call themselves “psychodynamic.” It isn’t that they don’t understand CBT or DBT or so-called evidence based techniques, it’s that they understand that the relationship is more important than the technique.

But what about research? Is there no scientific accountability for those practicing relational therapy? Well this is yet another problem with labeling certain techniques as evidence based. There is research about Relational Therapy. In fact, Relational Therapy along with Cognitive Behavioral Therapy have similar test results when used to treat depression. So it has been scientifically indicated to be successful.

But it’s hard to study relational therapy because it’s hard to measure a relationship. Conversely, the “evidence” that supports those other techniques is difficult to measure apart from the relationship. For example, your therapist may be a cognitive behavioral therapist, but you still have a relationship with them, and that relationship is incredibly significant in your treatment.  If it wasn’t, cognitive therapy would just consist of handing a workbook to a client and telling them to work through the chapters on their own.  So when our data indicates that Cognitive Behavioral Therapy works, it’s not so easy to say that the technique worked apart from the relationship. And until we have robots that practice therapy, it will be difficult to say.

So what does that mean for how we should choose our therapists? Well, it means that we should probably pick someone who fits, based on their personality and how we connect with them, not based on what proven techniques they use. And for some people, they will fit better with a Cognitive Behavioral therapist. The therapy will focus more on goals and modifying behaviors, but the relationship will still be important. Some people will fit better with a Relational/Interpersonal therapist. The therapy will focus more on relational patterns and understanding the Self, but there will still be important goals.

In the end, the hope is transformation. And whether or not that transformation is through hard goal-oriented step work, or whether or not it is through abstract relational analysis and dialogue, transformation, and the contexts that it takes place in, are beyond immeasurable.