Attending to the Omissions: A Historical Examination of Evidence-Based Practice Movements.

Abstract

Evidence-based practice and empirically supported treatment movements are potent forces that affect the practice of psychology today and have the potential to mandate the types of treatments psychologists conduct. The histories of these movements reveal that certain aspects of therapy valued by psychologists have been ignored. It is shown that the evidence-based movements (a) overemphasize treatments and treatment differences and (b) ignore aspects of psychotherapy that have been shown to be related to outcome, such as variation among psychologists, the relationship, and other common factors. It is important that psychologists understand the development of these movements so that they can be critical consumers of research and can effectively influence the future course of events. The practice of psychology is increasingly being affected by the systems that pay for psychological services. As a field, psychology has responded to these pressures by demonstrating that various psychological treatments are based on empirical evidence, which in turn has led to attempts to mandate the types of treatment provided by psychologists. However, many practitioners have resisted the efforts by managed care and some academic psychologists to alter their practice. In contentious contexts, it is often helpful to understand where things originated and to be cognizant of the forces that furthered various aspects while limiting others. The purpose of this article is to provide a historical perspective of the development of the evidence-based practice movement, highlighting the omissions that have occurred so as to enable psychologists to advocate more effectively in the debates that are shaping practice. This perspective will strengthen our role as scientistpractitioners in the broadest sense. History and progress are constructed and defined by events and choices made. Foucault (1965) termed the social sciences, including psychology and medicine, as the human sciences to emphasize and highlight the fact that they are constructed through the actions and choices of various actors. Looking backward through the lens of progressivism, a seemingly inevitable march toward enlightenment is revealed. The occasional blemish (e.g., in the social sciences, the eugenics movement) is either ignored or characterized as an anomaly. This retrospective approach typically leads to an enthusiastic embrace of contemporary events as steps forward; critics are characterized as nostalgic and anachronistic at best or pessimistic and obstructionist at worst. However, a reasoned examination of history, noting the omissions as well as the events, is critical if one is to have a balanced contextual understanding of current trends. When one looks at contemporary scientific developments in the mental health field, two movements predominate: evidence-based practice (EBP), which originated in the United Kingdom, and empirically supported treatments (ESTs), which originated in the United States (where appropriate, we consolidate them together under the rubric of evidence-based movements). In this article, we present both a retrospective and a prospective examination of the evidence-based treatments, elucidating the changes that have occurred and revealing how progress shaped the omissions. In this way, the costs as well as the benefits of EBP can be properly assessed from the perspective of psychological practice.

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