A Psychotherapist Reflects on Shortcomings of Evidence-Based Practice: Part One

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 individual’s 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.

Unfortunately, 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 27 years ago when I was first hospitalized at age 17 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.

Impractical Expectations

I would later learn that 6,000 calories per 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 apparently developed his theory for people of the “slums.”

Going after psychosomatic problems like eating disorders and juvenile diabetes was a way for him, in my opinion, 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 notion, 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 13 year emotional cut-off.

A Psychotherapist Reflects on Shortcomings of Evidence-Based Practice: Part One