Psychoanalytic Psychotherapy

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Evidence-Based Practice: Issues for Psychotherapy

Martin Milton

To cite this article: Martin Milton (2002) Evidence-Based Practice: Issues for Psychotherapy,
Psychoanalytic Psychotherapy, 16:2, 160-172, DOI: 10.1080/14749730210133429

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Psychoanalytic Psychotherapy (2002)
Volume 16, No. 2, 160–172

EVIDE NCE -BASE D PRACTICE : ISSUE S F OR

PSYCHOTHE RAPY

MA RTIN MILTON

SUM M ARY
This paper attempts to review both the frequently discussed
‘objective’ factors in evidence-based practice as well as the
more subjective factors facing psychotherapists engaged in
this debate. The contention is that greater familiarity with
the issues will allow us to inform and structure this debate
in a more appropriate manner than if we allow those from
other disciplines to structure it for us.

INTRODUCTION
Readers of this journal will be familiar with the attention that is currently
being paid to the concept of evidence-based practice (EBP). Readers are also
likely to have views on the strengths and limitations of this approach and
on what constitutes ‘evidence’. These positions are also evident in the
literature (Roth and Fo nagy 1996, Owen 2001).
W hile the concept of EBP addresses some of the desires that psycho-
therapists have for their patients’ best interests, it is also one that requires
thorough consideration, as the notion of ‘evidence’ is not a straightforward,
unambiguous, clear notion (Newnes 2001, Spinelli 2001). This dimension of
the evidence-based debate therefore often fosters a level of anxiety, confusion
and ambivalence that is not well attended to in the literature nor in health
service policy.
This paper reflects on the current literature about evidence-based practice
and attempts to include attention to the impact of this organizational dis-
course on the profession of psychotherapy and its practices, and on psycho-
therapists themselves.

Psychoanalytic Psychotherapy ISSN 0266-8734 print/ISSN 1434-9734 online

© 2002 The Association for Psychoanalytic Psychotherapy in the NHS
http://www.tandf.co.uk/journals
DOI: 10.1080/14749730210133429

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THE MEANI NG OF RE SEARCH

EBP has clear links to a scientist-practitioner model of practice, as well as
calls to accountability. A simplified and well-intentioned understanding of
the term draws our attention to the notion that where there is research
evidence for a given therapy this approach should be used first (Department
of Health 2001b). This is a concept that many psychotherapists will have
sympathy for, and they will feel that this ethos is embedded within their
everyday practice. However, it is in the attempts to operationalize this term,
in calls to develop ‘lists’ of empirically validated therapies that some psy cho-
therapists experience the greatest anxiety. It seems that part of this anxiety
is in relation to ‘Research’ and how decisions are made with regard to what
is valid and what is not. At the centre of this confusion is the concept of
‘evidence’. It is interesting to note that while this may be experienced as a
contemporary ‘threat’ to psychotherapy – it has a long history. Indeed,
Jones drew our attention to this very issue almost half a century ago when
he wrote:

M ediocre spirits demand a science of a kind of certainty which it

cannot give, a sort of religious satisfaction. Only the real, rare, true
scientific minds can endure doubts which are attached to all our
knowledge. I always envy the physicists and mathematicians who can
stand on firm grounds. I hover, so to speak, in thin air. M ental
events seem to be immeasureable and probably always will be so
(Jones 1957, p.418).

At this current point in time, it is not only mathematicians and physicists

who seek certainty ; it is a current socio-cultural preoccupation and pervades
all aspects of our lives, including health service policy . At times, this seems
to be completely at odds with the awareness that the psychotherapist has,
from day to day , moment to moment experience of the fluid, moving nature
of personal meaning in the therapeutic encounter. The juxtaposition of these
two perspectives draws our attention to the chasm that still exists between
human reality and empirical certainty.
This conundrum is central to the EBP debate and the role of research.
W hile health service documents outline the usefulness of a hierarchy of
evidence with the randomized-controlled trial (RCT) as the ‘gold standard’
(Department of Health 1996, 2001a, b, Roth and Fonagy 1996) when thinking
at a populations level, the psy chotherapist has a different focus. Ours is the
consideration of what this ‘evidence’ means for the client we sit with session
after session and the psy chotherapeutic project that has been engaged in.
As well as an ethical discourse about appropriate therapy for particular
patients, this chasm also results in dilemmas with regard to organizing
services that meet the demands of EBP, yet are still relevant to the unique
and very personal psy chotherapeutic journeys that are undertaken by ‘mere’

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individuals. The impact of this on services and psychotherapists will be

considered later in this paper.
Rather than just apply ing science to practice within a politically set
schedule, a true call to EBP is a rather more complex (and, might I add,
exciting) issue. At epistemological and service levels, the call to EBP requires
us to reconsider the research that we have undertaken and to consider a
range of evidence and research methodologies to ensure that they are relevant
and appropriate to the task before us (Department of Health 1996, Sandler
et al. 2000, M ilton 2001).
The usefulness of RCTs is not an issue here, as RCTs enlighten psycho-
therapy with respect to epidemiology and a degree of response to ‘treatment’.
W hat is worth considering is the predominance that such an approach
should have, as it cannot account for individual experience and the evolving
and ongoing co-construction of meaning. Despite the best efforts of some
of our technocrats, we may never be able to technologize existence and to
develop complete certainty . Another interesting and related question is the
relationship that traditional, quantitative methodologies based on modernist
assumptions can have on other research findings – formal research such as
that undertaken by qualitative researchers (Dennis et al. 1994, Howe 1996)
as well as those which are informal yet highly educative and more sociological
(Newnes 2001) for example biography and literature.
This raises the question of what these other forms of research would
look like and what sort of evidence would they generate? It is also interesting
to consider the impact that other research methods and questions might
have on psychotherapists’ abilities to warm to and focus on empirical
research.

APPROPRI ATE M ETHODOL OGI ES AND ‘ HOW TO DO I T’

To jump models briefly – it is self-evident that structural engineering and
chemistry will generate different research questions and require different
forms of inquiry. It is of course also evident that the materials used in an
engineering project will have a chemical composition and the chemist will
eventually be required to attend to the structural implications of their
compounds. The point of invoking such a metaphor has, as its intention,
the aim to clarify a point by way of novel and different meaning. In terms
of psychotherapy , the appropriateness of research and the evidence it gener-
ates is dependent upon an understanding of the nature of the relevant
discipline and the aim of the research. Thus, psychotherapists (like engineers)
are right to be cautious about adopting research methodologies directly
from medicine or elsewhere before critically evaluating their ability to remain
true to the psychotherapeutic aim and ethos. One of the particular concerns
is the difficulty in developing models of research and human science that
recognize an appropriately attuned exploration (Spinelli 2001).

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As with schools of engineering and chemistry, different psychotherapies

are based on different assumptions and practices and may therefore require
different approaches to research. A definition of psychoanalysis (PA) that
limits PA to the intrapsychic (Green 2000) will offer different views on the
nature of appropriate research as opposed to another understanding that
might privilege the internal or intersubjective. Yet both of course are relevant
to the work of most psychotherapists when engaged in psychotherapeutic
work with the complex personalities humans are blessed (or burdened) by.
Another way of thinking about this is to examine current Department
of Health policy. Those within psychotherapy recognize the difficulties in
finding appropriate methodologies with which to explore the effects of
interpretative and insight-oriented psychotherapies. Indeed this difficulty
has led to a lack of research in some areas. Despite the fact that this is a
difficulty for psychoanalytic and systemic therapies in particular, it should
not be taken to suggest that there is evidence against the usefulness of these
psychotherapies. The Department of Health recognizes this, and its publica-
tion is littered with comments such as ‘Other psychotherapeutic approaches
have not been systematically reviewed/evaluated’ (Department of Health
2001a, p.24).
This awareness has implications for our stance to evidence and requires
us to be cautious about the definitions of science, research and evidence
that we adopt. M uch research undertaken in the health services is seen to
be ‘quick and dirty’ research in order quickly to explore a question and
offer information to stakeholders. W hile at times this is useful, psychother-
apists have learnt that ‘quick and dirty’ may not do service to science nor
to psychotherapy . As a corollary, we should also recognize that, as in
psychotherapy, a difficulty may not need an extensive analysis, when a
concise, time-limited response will suffice. The issue of deciding which
approach to take requires consideration of the question, anticipated outcome
and contextual realities.
One issue to note when considering appropriate research strategies is
the distinction between hypothesis generation and hypothesis proving. RCTs
are often useful at illuminating, supporting and challenging our assumptions
about the general impact of our work. However, in order for psychotherapy
to be in a position to undertake such efforts at validation, we require
attention to the hypothesis-generation phase of any research project. This
is captured in the concepts of ‘innovative practice’, ‘case series evaluation’
and ‘theory development’ – all of which have legitimate positions within
the cycle of research recognized by the Department of Health (1996).
W hile attending to some slightly different issues, Fonagy addresses the
complexity of this situation when he notes the place of clinical work:

The empirical basis of psychoanalysis is the clinical situation. The

laboratory does not provide its empirical base and as the theory is

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not based on laboratory findings it cannot be either disproved or

validated by them (Fo nagy 1982, p.127).
Fo nagy’s point is important, as it again notes the chasm that can occur
between academic research and clinical practice. If these two highly import-
ant domains are to usefully inform each other and generate fruitful dialogue
(rather than deny or attack) we need some kind of bridging potential.
Wallerstein outlines the qualities of what such a bridge might look like
when he states:
Research that is simultaneously faithful both to the highly subjectiv-
istic and complex data of the psychoanalytic consulting-room and
the so-called objective canons of the empirical scientific enquiry.
That should be, after all, the heart of what we call psychoanaly tic
research (Wallerstein 2000, p.28).
The notion of ‘psychoanalytic research’ is important here, as by invoking
such terms and working to include these in the EBP debate we may be in a
position to clarify questions that will enlighten our therapeutic practices,
and to give thought to the methods we might develop to explore them –
without having to fall into the narrow confines of traditional and rather
static quantitative methodologies, pre- and post-therapy explorations, and
the like. The advantages of course are that by having both a research and a
practice eye, both endeavours may be enriched. This is a point made in the
literature.
There is room for a form of psychoanalytic research that is more
systematic than what we presently do, and more rigorous, but which
is not based on, as it were, extra-psy choanalytic data (Sandler et al.
2000, p.134).
These thoughts bring us to the crucial issue – if psychotherapy recognizes
the limitations of some of the more orthodox approaches to research,
what alternatives can it suggest? Some responses to this question seem to
have argued the case for alternative methods to be used. Other responses
have challenged the focus of the whole EBP debate and suggested alternat-
ive foci.
Alternative methodologies suggested include that mainstay of psychoana-
lytic and psychotherapeutic research – case-study methodologies (Sandler
et al. 2000). In some respect these have a clear place in official EBP as a
manifestation of innovative practice and case-study evaluation (Department
of Health 1996). As well as health targets on a population level, health
service policies also support the psychotherapist in a personalized approach
to psychotherapy through the activities of personalized assessment and
decision-making on the specifics of each individual’s need (Department of
Health 2001a, b). As case studies are so individually responsive to particular

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therapies, they have the potential to be used to illuminate factors in the

therapeutic process as well as client characteristics. As with RCT methodolo-
gies, they also have limitations – one being that by taking a case-study
approach the psychotherapist is not able to take a stance that their findings
are generalizable at a population level and, of course, the presence of the
author’s subjectivity has both great advantages and its own difficulties.
In addition to their legitimacy as a research enterprise in their own
right, case studies can also be used in other qualitative methodologies as
the data for further and alternative analyses (M itchell and Brownescombe
Heller 1999, M ilton 2001). M ethodologies such as Discourse Analysis
(DA), Grounded Theory, Thematic Content Analysis and Interpretive
Phenomenological Analysis can all use a single case study or series of case
studies to explore issues relevant to psychotherapy and the questions that
EBP asks us to consider. Diamond (2001) uses DA on stored transcripts
from the Psy chological Therapies R esearch Centre to review the ‘to-and-fro’
of therapeutic sessions in order to explore the manner in which unconscious
mechanisms manifest themselves in psychody namic work and the issues that
this raises for psychotherapy practice and provision.
Other methodologies can, of course, be used independently of case study
work. Of course the methods outlined above will all be able to offer
interesting and unique perspectives on the question of useful and ethical
practice and can be tailored to consider particular models of psychotherapy,
specific population groups and issues related to therapist practices.
As mentioned above, those involved in the EBP debate have often
thought critically and creatively about the issues involved, and a comple-
mentary position has been recognized. This is the notion of practice-based
evidence (PBE) (Barkham and M ellor Clark 2000, Carroll and Tholstrup
2001). As well as EBP making demands on those in the clinic, PBE attends
to how research might be tailored to meet explicitly the agenda of those
involved in the psychotherapeutic enterprise. This approach has only
recently been invoked in the psy chotherapy literature and therefore requires
further development, including the development of guidelines and criteria
for what PBE would look like. In principle it uses the evidence of the
psychotherapeutic process itself to assist clinicians and service providers to
evaluate the service. Such a stance values local and idiographic evidence as
well as the nomothetic evidence available from RCT research.
As well as recognizing the efforts of those in the clinic and those in the
academy, it is very useful when those charged with policy development
collaborate in this debate, as contextual factors are important. W hile clini-
cians and researchers are aware of what Target calls ‘feasible research’ (1998,
p.79) it is important for this to be discussed with all the ‘stakeholders’ so
that the value of what is possible is recognized, and the desire for unrealistic
answers is recognized and worked through by all involved. It is also import-
ant to locate research within systems that have the required support. It is

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not possible for heads of psy chotherapy departments to undertake research

of the RCT type and thus it is appropriate to leave such large-scale research
within government-sponsored academic departments with access to multi-
site samples. This type of research needs well-resourced posts with adequate
support. It would also be appropriate to consider the type of work that can
occur in single-handed practices, local psychological therapies services and
poorly-resourced psychotherapy services. In these services, clinicians often
undertake their own literature reviews (for in-house consumption or to add
to published literature in more accessible journals and newsletters) and of
course case studies are obviously relatively easy to undertake. In addition,
honorary therapists very often need to undertake service-related research
for their training. In addition, Trust requirements for audit can be useful in
examining the relationship between practice and the literature.

POSSI BL E GA I NS
If it is possible to protect (or limit) psychotherapy from the problems of
the rational/traditional empiricist assumptions of a knowable truth – and if
it is possible to enrich science with a respect for what psychotherapy can
do, what does psychotherapy gain? How does psychotherapy as a discipline
and its practitioners and clients benefit from this effort?
In this respect, the arguments are many and varied. Some have suggested
that properly targeted and executed research has the potential to enrich our
therapeutic work and in particular make the psychotherapeutic enterprise
more relevant to contemporary existence. In addition, where psy chotherapy
takes advantage of a range of research methodologies we are able to ensure
that we explore questions from a range of perspectives and may thereby
avoid some of the ‘false causal connections which may be read into a case
history or the story of a therapeutic intervention’ (Target 1998, p.81). As
well as the ‘in-session’ benefits that may accrue when we undertake and use
appropriately-targeted research, there are also advantages to be gained for
the relationship between those within psychotherapy and those on the
outside.
One benefit that is immediately apparent is to confirm to others – service
commissioners and of course patients – that our efforts to assist people
result in benefit rather than harm. There is already a body of evidence that
we can draw upon to assert this, but the greater our body of evidence the
more useful it can become. For useful references see Fonagy (1999) and
M ilton (1996). In psychoanalysis we might refer to work with:

• adults (Weber et al. 1985a, b, Wallerstein 1989, Bateman and Fonagy

2001)
• couples (Heller and Gore 1995)
• groups (Ganzarain and Buchele 1990, Sigrell 1992)

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• children and adolescents (M oran and Fonagy 1987, Lush et al. 1991,
M oran et al. 1991, Fonagy and Target 1994, 1996)
• short- and long-term work (M itchell and Brownescombe 1999).
There is also evidence that dynamic psy chotherapy is useful for:

• personality disorders (Waldinger and Gunderson 1984, Woody et al.

1985)
• depression (Barkham et al. 1994, Shapiro et al. 1994)
• eating disorders (Garner et al. 1993)
• anxiety disorders if there is comorbidity, particularly personality dis-
order ‘where evidence for the use of dy namic techniques exists’ (R oth
and Fonagy 1996, p.144).
As well as such broad recognition of the benefits of psychotherapy, there
is also evidence of the nature of the benefit experienced by patients in
psychotherapy. Authors in the field note that there are broad benefits from
psychoanalytically oriented work and suggest that these take the form of :
reduced somatic symptoms or problems, more satisfying and loving
relationships, greater capacity to cope with life and its problems, less
use of medication, fewer GP visits, fewer episodes of violence or self-
harm, less offending behaviour, and more time spent in employment
and fewer difficulties at work (M itchell and Brownescombe Heller
1999, p.40).
In addition to these, it is also apparent that effective psychotherapy can
provide economic benefits as well – after working through difficult issues
and gaining insight into their concerns many people use fewer Health Service
resources in terms of fewer trips to Accident and Emergency departments,
lower reliance on medication and visits to GPs, etc. (M itchell and
Brownescombe Heller 1999).

ANXI ETIES ABOUT ATTACK

So far, this paper has addressed some of the issues in the literature with
regard to psychotherapy and evidence-based practice. At this point, I want
to return to the point made in the opening section and give voice to some
of the more dynamic aspects of the EBP debate.
It is interesting to note that many practitioners across the psychothera-
peutic professions are (at best) sceptical about the role of formal research
in psychotherapy. In fact, there seems to be a reluctance to undertake
research once core training is complete (M ilton 2001) and even to read
up-to-date research reports regularly. In this climate of research awareness
it might be interesting to consider this in line with notions of avoidance
and denial.

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W here therapists do engage in the EBP debate there is often a degree of

anxiety evident about it (M ilton 2001). Some have gone further than to
express scepticism or anxiety , and construct the call to EBP as an attack on
themselves and their profession as is witnessed in the language of the
following comment:

Overvaluation of ‘Research’ often goes together with an undervalu-

ation, or devaluation, of the research with which we engage in our
psy choanalytic work. And if this Research (with a capital R) is
privileged within psychoanaly sis, we will, in order to placate and
propitiate our enemies from without, succeed in destroying psycho-
analysis from within. I believe this to be a ‘real’ (not just a fantasized)
danger! (Brenman Pick 2000, p.109).

These anxieties may develop for a number of reasons. Some initial

possibilities include a lack of familiarity with research and its potential and
a lack of research training (Target 1998, M ilton 2001). The limitations of
research methodologies that confine their attention to symptom checklists
and the ‘manualisation of treatment’ may also influence this (Target 1998).
As indicated by Brenman Pick (2000), it may also be related to a realistic
appraisal of the power and function of what Foucault termed the ‘psy-
complex’ (Fo ucault 1995). In foucauldian terms, the mental health sy stems
and professions such as psychiatry, psychology and psychotherapy function
as regulators of social interactions, and thus he draws our attention to their
joint powers. The EBP agenda is just one manifestation of this system, with
benefits and dangers.
As well as an ‘objective’ reading of the EBP literature, it is interesting to
note a tone of moral superiority that is woven through it. This tone attempts
to discredit the psychotherapeutic project and/or individual practitioners
who are not able to quote indices of behavioural change. This is evident in
the Government rhetoric about ‘unqualified/bad practitioners’, ‘bad apples’
and ‘do-gooders with no training’. It is interesting that a tone such as this
seems to ignore the high quality of work that does occur, the level of skill
that exists, and also the goodwill that the NHS relies on.
These dynamics need our attention, as left unattended they threaten to
spoil the potential for creative thought that originally drew so many psy cho-
therapists into the field. Reflection on this issue is not just a task for
psychotherapists on their own – if EBP is going to reach its potential to
assist the profession of psychotherapy in creating fruitful and ethical thera-
peutic encounters, it needs to be an inclusive debate. W ithout this, there is
potential for splitting at all sorts of levels – research from practice and
commissioners from providers with all the disruptive and destructive poten-
tial that this has.

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CONCL USIONS
This paper has noted both objective and subjective issues involved in the
current evidence-based practice debate that is central to the provision of
public-sector health care. As is often quoted in our literature, this issue is
filled with uncertainty and lower limits of knowability than may be the case
in other areas. The challenge facing those that provide such services is again
a similar one – to engage with what we do know and what we do not know
in a thoughtful and ethical manner with the best interests of our clients in
mind. This aim may infuse both our stance to the practice of psychotherapy
as well as research and service development. The challenge also requires us
to generalize what we know from psychotherapy (e.g. about staying with
uncertainty and aiming for collaborative, engaged and attuned discussions)
to our relationships outside the consulting room with colleagues at all levels
of service organization.
Statements such as this, ‘noble’ as they may be, do little to assist clarifica-
tion of how we might proceed in the dual (and challenging) task of the
evidence-based project, at the same time as providing the services already
so stretched. M y own thoughts are that the curiosity that often drives us as
psychotherapists is something that can easily be turned to the research
endeavour. However, clinicians and researchers alike have to challenge the
prevailing rhetoric about the only useful or informative research being RCT-
ty pe approaches. As outlined above, this is of course a useful strategy , but
local services are simply not equipped or resourced to undertake this type
of research. M uch more feasible (and to many , much more interesting)
approaches to research are those that draw on the well-honed skills used by
psychotherapists every day: collaborative, qualitative approaches that value
the attunement to the client’s world of meaning. Grounded theory research
of clients’ understanding of characterological change through long-term
insight-oriented therapy, interpretive phenomenological analysis research of
clients’ understanding of specific difficulties, discourse analytic research as
to the presence of socio-political material in clients’ narratives and its rela-
tionship to distress and recovery , are just some projects that come to mind
and may be feasible within most psychotherapy services with nothing more
than some time available from the continuing professional development
‘allowance’.
W hatever strategies services take, and these will be different depending
on local demographics, level of resource and interest of those involved, the
skills of psychotherapists should be capitalized upon to help us to take our
disciplines forw ard as broadly and as richly as is possible in an effort to
help those we seek to help. An additional outcome might be that therapists
could be re-vitalized in their passion for their chosen fields.

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Dr M artin M ilton
Consultant Counselling Psychologist and Psy chotherapist
Hedgecock Centre, Barking Hospital, U pney Lane, Barking, IG11 9LX

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