Shortcomings of Evidence-Based Practice: Part One | Psych Central Professional
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These days, more and more, the concept of evidence based practice is training mental health workers to put the cart before the horse. Setting up strict fidelity measures to replicate success grossly underestimates the impact of local culture on an individuals’ life. In particular, the widespread practice of CBT for “psychosis” with its set of strict fidelity measures, runs the risk of doing damage in place of really needed work. Unfortunately, there is rarely longitudinal studies on treatment failures that examine the negative impact of mental health politics and damage that can be done during treatment failures. Often times, big egos and manifest destiny desires of theorists that don’t respect the limits of their work continue to be promoted by administrators. I contend that the cultural art of human connection and the need for psychotherapists to learn more through authentic experiences is not and will never be fully captured in research.
My beef with therapy that follows strict theoretical fidelity measures started twenty-seven years ago when I was first hospitalized at age seventeen for anorexia in Salvador Minuchin’s clinic. My family was to receive a best practice Structural Family Therapy performed with the highest of fidelity measures with one-way mirrors and expert consultation. I was expected to gain a half pound a day or my family would be viewed as a failure. I would later learn that 6000 calories a day would not anatomically gain me a half pound a day. In therapy I kept making this point but the team was instructed to ignore me when I was oppositional. In other words, I was to lose my voice in the family system if I behaved that way. We went through intense and traumatic experiences as a family including my father being encouraged to bully me into eating. While he later did many things that worked, I was not able to conceptualize my rage and started to throw up indiscriminately. I had no idea what we were supposed to do, only that we were failing at an impractical expectation.
In working my way through my Master’s level education I did some extra reading on Salvador Minuchin. I learned that he was an Argentinian, Israeli Army guy who developed his theory for people of the “slums.” Going after psychosomatic problems like eating disorders and juvenile diabetes was a way for him to penetrate middle class markets and prove that his work was manifest destiny universal. This way students could learn that they could use his theory with anyone.
When I reflect on this, it tickles me. All those years ago Minchin was dealing with two aristocratic Quaker families who were in many ways the highest of authorities on being anti-authoritarian. My father, a Quaker school principal; my grandfather, an Ivy League administrator; being trained to insert military structure so Minuchin could prove that his ideas were universal. But the results of this simple mismatch were lasting. My family on all sides weren’t used to being told they were failures. None of us took kindly to that news and what essentially ensued was a thirteen year emotional cut-off.
When, thirteen years later, in a political thriller against the powerful housing authority of a major US city, I finally descended into a two year schizophrenia. Reunification as a prodigal son didn’t go very well. Suddenly I, considering myself a whistle-blower, found society hell-bent on incarcerating and making me accountable for being a eugenic failure. And my only remaining supporters, my long-lost family agreed. My father did what he could to get me to stay an extra nine months on the most chronic of back-wards; and later to prevent me from having a car.
The car thing became a hard way to be treated, when, six months after the three month hospitalization, I was only able to find a minimum wage job with a two hour bike/train commute while in “psychosis.” A car was key to enable me to grow out of this situation. After ten months, I was finally able to manipulate my mother into helping me. And with a car I did improve my job performance, start back on medications and eventually escape the grasp of a company that I was later able to confirm really did cooperate with a local mob boss, just as I thought.
Though most Master’s-level clinicians of my era learned that multiculturalism was important, we also learned that if you chose a best practice orientation like Minuchin’s Structural Family Therapy, or CBT and apply the concept across cultural divides and you were okay. In those days we were not taught to study the cultural ethos within which the best practice was created and translate it through ourselves while considering the cultural experiences of the subject. I certainly was not blessed with such thoughtfulness from any of the mental health providers I came into contact with. I am now left to wonder what would have happened if I received the treatment of Minuchin’s primary competitor Bowen who worked with Midwestern, white-bread schizophrenic families.
I once heard an aggressive professional teacher angrily favor Minuchin, emasculating Bowen as being over protective. This particular teacher flew in from another state, and never disclosed his Afrikaners background. It kind of made me chuckle when he yelled at me for making an insubordinate point, although perhaps a significant portion of the room was with him. I believe this highlights the need for any mental health worker to first define themselves culturally and then assert themselves locally in this increasingly multicultural society. In my opinion, a good theorist like Minuchin did this. By all reports, he interacted well with his local consumer base.
The positive thing I got from my Minuchin experience was a fondness for the inner-city community that supported me during my hospitalization. I started to listen to rap music and found that people who came from different backgrounds (particularly of African American and Puerto Rican descent) could really see who I was. I was touched by their humanity in contrast to the private school community I was raised in where I would eventually return to face stigma. It stands to be noted that there is a silver lining in this longitudinal study of my failure at Minuchin’s clinic. Just as I was coming to see insulated, Caucizoidal academia as a world where the cheaters got ahead and did less work, the eating disordered unit that saved me from Minuchin drained the college fund. Because after two stints there, the ghetto was the only place I could afford to live, it all worked out. I moved to Camden New Jersey and studied sociology and the neighborhood through working.
This brings me to take a peek at the massive funding for early intervention strategies for “psychosis” that are based on high fidelity to a best practice that was initially constructed to help an Ivy League nerd (Albert Ellis) overcome his awkwardness and get a date. Watching this practice applied to where I work in Shy Town kind of tickles me. Initially, I was not selected for the local implementations of the project. I wrote a thank you letter schooling the project on the demands of the locale. Later, when actually considered for a position, I could not bring myself to submit to the high level of fidelity measures I would be required to submit to. I have spent the last eight years using my lived experience to lead groups on “psychosis” in the heart of Shy Town. Led by the most institutionalized community members I have created my own theory based on what many community members face on the ground.
I think it is time for administrators to wake up and limit the relevance of evidence based strategies. Step inside a state hospital backward, or prison and you get a pretty good sense of where all the good intentions of counseling theorists and administrators may well lead you. I think that most other survivors of these environments will tell you that they did not get much support from a theory in that squalor. Speaking for myself, I was only helped by people who threw the theory away and treated me like a human being. And believe me we clients can tell when people are treating us like a statistic, like we are one of their “folks.” That is not helpful.