Can we talk about what evidence-based psychotherapy is?

Evidence-based therapy is about more than choosing a technique or modality with research behind it. Research on the technique or modality matters, but not without looking at the significance of the therapeutic relationship and the research into why some therapists consistently get better outcomes than some other therapists.

Evidence-based practice therefore involves more than applying findings from research. It also involves clinical expertise and attention to the person—their circumstances, preferences, values and their own understanding of what they hope to change or achieve through therapy. For me, research informs my practice, but so does what I have learned through clinical experience and from paying close attention to the people I work with and reading the works of experienced clinicians like Nancy McWilliams. McWilliams has written extensively about psychotherapy, and I find her thinking about psychological health particularly useful because it asks us to consider more than psychopathology. When reading research or discussing research, I think it is important to keep our eyes on what psychological health is and how we achieve it.

This video featuring McWilliams talking about ‘what the good life is’ is worth watching as we think about researching outcomes of psychotherapy focusing on what humans want rather than symptom reduction. In the video, McWilliams outlines ten concepts of mental health: Safety, Self-Continuity, Agency, Self-Esteem, Resilience, Self-reflection & Mentalization, Self & Community, Vitality, and Acceptance. McWilliams in particular refers to research focusing on change, but she states that acceptance is important as psychotherapists often help people accept what cannot be changed.

As humans, I think we are also deeply individual, and not reducible to clusters of symptoms. Some research necessarily focuses on symptoms because they are easier to define and measure, whereas aspects of psychological health such as agency, vitality, meaning and acceptance can be more difficult to operationalise.

Alongside research, there is clinical knowledge that has developed over decades through clinical practice, training and supervision. For me, this needs to be kept in mind when we look at research and when we implement research critically in our day-to-day practice.

Why I pipe up about discussing evidence-based practice

The internet and social media platforms have a ‘swell’ of information about what evidence-based therapy is and who provides it. CBT and EMDR are often presented as the evidence-based or gold standard therapies, but what evidence-based therapy means is often not explained.

I wrote this reflection because I thought people who land here would like to know how I use research and what type of research informs my practice. I invite other clinicians to do the same and explain a bit more about where they are coming from when they say the therapy they do is evidence-based.

In writing this, it is my hope you might also ask of any therapist you consider seeing (or are seeing now) what they mean when they say they offer evidence-based therapy. I also give you a little insight into what informs my practice and how I grapple with the construct of evidence-based therapy.

How do mental health professionals learn about research?

How mental health professionals learn about research and evidence-based practice varies. Counsellors do not all come to research and evidence-based practice with the same education in statistics or research methods, and some come to find research in roundabout ways outside their training institutions and universities.

For me, despite doing an undergraduate degree in psychology and two subjects in Research Methods & Statistics, I was never exposed to research on what constitutes efficacious therapy beyond manualised therapy and techniques. Instead, I slogged away at things like how to do factor analysis on the Big Five personality traits, and I wrote a literature review on finger length and testosterone and a research report involving statistics on something so nonsensical I cannot remember it anymore. The type of work I really loved doing in my undergraduate was a literature review on the multiple aetiologies of Major Depressive Disorder. It allowed me to look at the different causes of depression, such as environment, childhood trauma, nutrition and more. I hope those doing postgraduate psychology degrees are exposed to a wider variety of research about what helps people get better and what matters to clients rather than what I experienced in my undergraduate psychology degree.

However, I am not sure about this given that psychologist and researcher Jonathan Shedler writes about the lack of education for psychologists in this area—dare I say the same lack perhaps exists for counsellors (?). You can read more on his website and on Substack, where you can find his jargon-free articles about therapy as well. The journal paper by Shedler that I find most useful is The Efficacy of Psychodynamic Psychotherapy, which reviews research on the effectiveness of psychodynamic psychotherapy (The paper can be downloaded as a PDF from his website):

 ‘The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings’.

The therapist effect in therapy vs the technique

Another exposure to something that made me curious was an article by Scott D. Miller called How Psychotherapy Lost Its Magick. It was the first time I read anything elaborating on something related to the therapist effect in psychotherapy rather than the single effect of the particular technique used, such as CBT or EMDR, which are some of the most researched therapies. You will find Miller’s article at Psychotherapy Networker, but you have to sign up to access it.

Miller's article piqued my interest because it highlighted research suggesting that differences between therapists could not be explained simply by the particular technique being used. If you are curious to read more about this type of research, perhaps peruse the thesis by Australian psychologist Daryl Chow called The study of supershrinks: development and deliberate practices of highly effective psychotherapists. Daryl is also an experienced clinician and author who writes about life, not just research!

So, now you know about some of the research that informs my practice. What I really want to leave you with is the notion that a therapist can miss the mark and not provide good therapy and still use a so-called evidence-based technique.

Finally, I hope you might ask your next therapist what informs and inspires their work. If you ask me what inspires me, there is the research, but there is also poetry, and nothing captures human suffering, joy and grief or other human experiences like poetry!

Hence, I will end this reflection with the words of Irish poet David Whyte from Consolations II, on the word “Care”, which reminds me of something important about the work of therapy:

…restoring our sense of being cared for or deserving to be cared for is also one of the timeless and often dramatic necessities of human life.