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Taking Stock of "Evidence-Based Therapy"

Psychotherapy is more art and craft than hard science.

Key points

  • Evidence-based practice in the field of psychotherapy is a term for therapy models where results can be studied.
  • Psychology is not rooted in science the same way physics or mathematics are.
  • The pendulum on evidence-based practice may have swung too far.

"Evidence-based practice (EBP)" in the field of psychotherapy is a term for therapy models that can be studied under tightly controlled and highly selective treatment arrangements.

Samuel Regan-Asante/Unsplash
Source: Samuel Regan-Asante/Unsplash

Studies exclude complex patients to mitigate confounding variables, factors that complicate determinations of causal effect. Results of many controlled studies do not generalize because, in the real world, complexity and comorbidity are the norm, not the exception.

The author C.S. Lewis quipped in 1970 that much of science is nihilistic because it is “all the apparatus of thought busily working in a vacuum."

Conflicts of Interest

“EBP” has become a means to secure a greater slice of the valuable managed care market. Still, intellectual conflicts of interest are even more dangerous than financial conflicts of interest because they are insidious rather than obvious, and far more pervasive (Frances, 2019).

Psychotherapy Research Is Rife with Hype

James Coyne (2014), who taught critical thinking in health psychology at University Medical Center in the Netherlands, warned:

"[Psychotherapy] randomized controlled trials are underpowered, yet consistently obtain positive results by redefining the primary outcomes after results are known. The typical RCT is a small, methodologically flawed study conducted by investigators with strong allegiances to one of the treatments being evaluated. Which treatment is preferred by investigators is a better predictor of the outcome of the trial than the specific treatment being evaluated. Many positive findings are created by spinning a combination of confirmatory bias, flexible rules of design, data analysis and reporting and significance chasing. Many studies considered positive, including those that become highly cited, are basically null trials for which results for the primary outcome are ignored, and post-hoc analysis of secondary outcomes and subgroup analyses are emphasized. Spin starts in abstracts and results that are reported there are almost always positive."

Tim Gouw/Unsplash
Source: Tim Gouw/Unsplash

Psychotherapy Is a Craft Based on Soft Science, Not a Technology Based on Hard Science

Scientists who study oceans know about waves but can hardly predict the behavior of a particular wave. Still, they know a great deal about the tides, about the forces that influence and participate in the larger oceanic ecology. An average surfer would be reticent to speak of oceanic ecology, yet a good surfer knows a great deal about waves.

The behavioral sciences do not deal in anywhere near the absolutes of mathematics or physics, where studies of cause and effect are more realistically isolated into forces and impacts. The method with which so much of science calculates and intervenes is through a reasoning predominantly of the quantitative sort. Yet we who surf the ultra-complex, qualitative multiverse of mind and behavior continue to be pressed to demonstrate empirical bases for our actions.

There are obstacles inherent to psychotherapy research. It is more art and craft than science. Dr. Allen Frances (2019), chair emeritus of Duke's School of Psychiatry and Behavioral Sciences and former chair of the DSM-IV task force, cautioned, "Many naturally great therapists have turned into mediocre clods once they started studying psychotherapy theory and tried to do it by the book."

 Anders Norrback Bornholm/Unsplash
Source: Anders Norrback Bornholm/Unsplash

Research Has Its Place

Though many practitioners, including myself, prefer more modest terms like "evidence-informed," there are good reasons we should continue expanding research in and implementation of promising practices. Guild cadres of therapists studying and honing niche research-based methods is a worthy investment.

I see a couple of clear benefits:

  1. Research-backed therapy interventions delivered by trained therapists offer increased efficacy in treating certain disorders (Wampold, 2001; Roth & Fonagy, 1997; Nathan & Gorman, 1998).
  2. When we emphasize the need for evidence-informed skill sets, we elevate in value and priority the need for consistently effective therapeutic treatment with clients, including our knowledge about what works and with whom (Norcross, 2002).

It Is Time to Take Stock

Donald Berwick, a Harvard-based quality improvement expert noted for employing evidence-based methods in the field of medicine, wrote in 2005 that we had “overshot the mark” and turned evidence-based practice into an “intellectual hegemony that can cost us dearly if we do not take stock and modify it." The same is true for the field of psychotherapy.


Berwick, D. M. (2005). Broadening the view of evidence-based medicine. Quality and Safety in Health Care 14, 315–316.

Coyne, J. (2014, June 10). Salvaging psychotherapy research: A manifesto. Retrieved from…-

Edwards, B. G. E. (2018). The empathor's new clothes: When person-centered practices and evidence-based claims collide. In M. Bazzano (Ed.), Re-visioning person-centred therapy: Theory and practice of a radical paradigm. Oxfordshire, England, UK: Routledge.

Frances, A. [@AllenFrancesMD]. (2019, May 24). I've seen many naturally great therapists turned into mediocre clods once they started studying #psychotherapy theory & tried to do [Tweet]. Twitter.

Frances, A. [@AllenFrancesMD]. (2019, July 4). My experience with 1000's experts: 'Intellectual Conflict Of Interest' is more dangerous than 'Financial' because it's insidious rather than obvious [Tweet]. Twitter.

Frances, A. [@AllenFrancesMD]. (2019, July 12). I never trust post-hoc analyses. If you torture a data set long & hard enough, it will confess to almost [Tweet]. Twitter.

Frances, A. [@AllenFrancesMD]. (2019, July 19). Noble effort by @GoldfriedMarvin to integrate #psychotherapy/base it on research. Inherent Obstacles: 1)It's more art & craft than science [Tweet]. Twitter.

Frances, A. [@AllenFrancesMD]. (2019, July 5). Psych providers are so slow to adopt "evidence based practice" bec the evidence is weak & the practices dont generalize [Tweet]. Twitter.

Frances, A. [@AllenFrancesMD]. (2019, July 6). Evidence Based Practice" has degenerated into branding hype & makes a promise it cant keep. I prefer more modest "evidence [Tweet]. Twitter.

Frances, A. [@AllenFrancesMD]. (2019, July 6). Inconvenient truths re "evidence based practice": 1)Highly selected research patients dont resemble real patients 2)Results of simple randomized trials dont [Tweet]. Twitter.

Lewis, C. S. (1970). Meditation in a toolshed. In W. Hooper (Ed.), God in the dock: Essays on
theology and ethics
(pp. 212-215). Grand Rapids: Eerdmans Publishing Company.

Nathan, P. E., & Gorman, J. M. (Eds.). (1998). A guide to treatments that work. London: Oxford University Press.

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York, NY: Oxford University Press.

Roth, A., & Fonagy, P. (1997). What works for whom? A critical review of psychotherapy research. New York: Guilford Press.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum.