What is Evidence-Based Practice in Mental Health?

I want to talk about the importance of what we in the mental health field call “evidence-based practice” or “evidence-based medicine,” and why it differs from talking to somebody about your problems. To do that, I’d like to take you back to a time when I was seriously questioning my career choices:

I was a year or two into graduate school, sitting in a classroom ahead of a course in research methodology, when my professor posed a question to all of us in the room.  As a way of introducing the topic of “evidence-based practice,” he asked the group of aspiring psychologists: “What makes your service any different from a hairdresser or barber?”  We all chuckled a bit, but as psychologists do, our professor let the question linger for a moment in Socratic fashion.

He went on, “Think about it. In short order, patients will come to you, sit in a chair, and talk about what’s bothering them for 30 to 60 minutes.  They will get something off their chest, gain some insight into their problems, and leave their chair feeling better about themselves.  Many people go to their hairdresser or barber for 30 to 60 minutes, sit in a chair, talk about their problems for a bit, and leave their chair feeling better about themselves, but with a new haircut.  Are these services really that different?”

All of us looked nervously at each other, thinking “of course they’re different,” but all hesitated to answer the rhetorical question with a convincing response. I began to think about the years of my life I spent studying as an undergraduate, preparing for standardized tests, the hours spent in research labs and preparing for graduate school interviews.  The essays, letters of recommendation, and research on graduate programs. Should I have just traded all of that for some hair clippers? The inclination to search Amazon to price out grooming kits hit quickly.

The answer to the question is evidence-based practice. I understand the inclination to seek out psychotherapy because someone “wants to talk about their problems,” and to be sure there’s a safe space to process their thoughts and feelings during stressful times in their life.  However, psychotherapy has additional benefits above and beyond providing that space to air your concerns.

What is Evidence-Based Practice in Mental Health?

Evidence-Based Practice (EBP) is a systematic approach to mental health treatment that uses the available evidence accumulated through decades of rigorous peer-reviewed research, and how that knowledge is applied to improve patients lives.

For example, when a patient comes to meet with a therapist, the therapist will first do an assessment to see what the person’s collection of symptoms looks like and whether it fits an established mental health diagnosis. Based on that diagnosis, psychotherapists can then select interventions that have been shown to be effective for people who have symptoms like the patient’s. This is one of the ways that we can have confidence that what we do in our therapy visits is more likely to be effective than just giving someone space to “talk about their problems.”

Components of Evidence-Based Practice in Mental Health

As important as it is to use the available evidence to assist in selecting an intervention that can be helpful to patients, clinicians also consider the unique aspects of the patients they work with as well.  We can think of the factors that contribute to evidence-based care as a “three-legged stool.” In this approach the clinician uses

1. The available research to select an intervention that can help the problem
2. The clinician’s own judgment and clinical training
3. The patient’s preferences, values and culture

Each of these factors is important in promoting the best outcome for patients seeking care.

Using the Scientific Method in Evidence-Based Practice in Mental Health

There’s value in looking at evidence-based practice in psychotherapy through the lens of the scientific method. In short, this suggests that psychotherapy should be like the way a scientist would address problems in their field via

1. Observation
2. Generating hypotheses
3. Testing these hypotheses with experiments
4. Analyzing the data and forming conclusions

Many patients come into therapy because they believe that something’s changed for the worse, or they recognize they need assistance in an area related to mental health (observation).  An intake assessment can help begin to unravel what might be contributing to and maintaining that problem (generating hypotheses). The therapist would then use the existing evidence base to select an intervention that has been effective for others with similar symptoms (testing via experimentation), and measure what effect this intervention has on their mood, anxiety, and/or behavior (analysis).  This cycle is repeated until the patient is satisfied with the outcome.

Effective Evidence-Based Therapies in Mental Health

There are decades of research looking into talk therapy options that are effective for a wide variety of mental health conditions. You may have heard of treatment options like Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Interpersonal Psychotherapy, Exposure Therapy and many others. These treatments give psychotherapists a blueprint on what actions might help the people we work with feel better.

Cognitive Behavioral Therapy (CBT)

CBT is one of the most widely researched and supported psychotherapies. In short, CBT aims to better understand the relationship between a person’s thoughts, their actions, and the way they feel, as all of these concepts are interrelated. In response to certain events in their life, a patient recieving CBT is going to be asked to monitor the conclusions they draw, what they do, and how they feel to identify how they might modify any of these factors to feel better.

Dialectical Behavior Therapy (DBT)

DBT is another kind of cognitive-behavioral approach which was originally developed for borderline personality disorder but is now applied to a range of other conditions. DBT places an emphasis on emotional regulation (how well we cope with and ‘come down’ from intense emotions), distress tolerance, interpersonal effectiveness and mindfulness strategies to help address clinical problems.

Acceptance and Commitment Therapy (ACT)

ACT is another established psychotherapy approach which combines use of behavioral strategies with mindfulness approaches. In contrast to CBT which often focuses on “restructuring” or changing the perspective one might have, ACT uses a more mindfulness based approach of acceptance of some of the difficulties in life and the pain that sometimes results.  The result is a treatment that is less focused on symptom reduction as much as an acceptance for life on its terms.

Interpersonal Therapy (IPT)

IPT was originally developed as a treatment for depression but has since been modified to treat a range of other conditions. The focus in IPT is on a central interpersonal problem and not necessarily symptoms of mental health directly. This could be the grief of losing a loved one, or a change in one’s role (e.g. having a new baby, retirement, graduation), conflict in a relationship or a lack of social satisfaction. The aim is to attempt to resolve the main interpersonal problem which often results in improvement.

Exposure Therapy

Exposure therapy is an approach often used in anxiety disorders including panic disorder, many phobias, OCD, and social anxiety. Its philosophy is relatively straightforward in that avoiding the things that make a person anxious worsens anxiety in the long-term. Improvement comes when the person can “face their fears” and have a space to be able to process what they learn when they’ve done so. Patients are guided through a series of “exposures” to their feared situations and helped to form new conclusions that help reduce their anxiety.

Behavioral Activation

Behavioral activation is often used for depression and focuses more on a person’s behavior that might be contributing to their mood. Many who are depressed often report not having the energy or interest to do activities they normally find enjoyable. In behavioral activation, the goal is to help overcome some of the obstacles that stand in the way of participating in these activities. In part because of its focus on behavior and less on abstract thoughts, this can be a particularly useful intervention for youth in encouraging them to engage in meaningful activities.

Benefits and Challenges of Evidence-Based Practice in Mental Health

There are a number of advantages in seeking out evidence-based care. Using evidence-based practices helps ensure that the help we’re providing is more likely to be helpful than just giving someone a space to “talk about their problems.” It is a crafted intervention that is tailored to the patient and aims to be

1. Safe – Having studies demonstrating how patients improve and, importantly, are not made worse, by the interventions we use is one of the ways we can promote better outcomes for our patients.
2. Consistent – While no two therapists will administer these interventions in the exact same way, someone receiving CBT from one provider will likely see many of the same interventions and approaches used from other CBT providers. This consistency to the tools that work help increase confidence in the efficacy of our treatments.
3. Cost-effective – For most conditions, therapy doesn’t need to be an indefinite endeavor. Established treatment protocols can help identify timeframes in which we can usually expect people to improve, reducing the amount of services required and supporting patients on an as-needed basis once they’re feeling better.

Conclusion: Embracing Evidence-Based Practice for Better Mental Health Outcomes

In the end, no, therapy and a good haircut aren’t the same thing. While both might leave you feeling better, only one is backed by decades of research, careful assessment, and clinical expertise. Evidence-based practice is used to help increase our confidence in the therapy that we deliver. It helps us practice in a way that is safe, ethical, effective, and respectful of your time. While it does rely on established interventions, these approaches can and should be tailored to fit the needs of the individual seeking help, so you can receive treatment that is not only effective but unique to your presenting concerns.

Let Rittenhouse Psychiatric Associates Listen and Help You

When we at Rittenhouse Psychiatric Associates identify as an academically minded practice, it’s because many of our providers are or have been faculty at local academic institutions who themselves have contributed to the body of literature we use to help our patients. It’s through this lens that I and others in our practice view the work that we do, which helps our patients feel better and improve their ability to function.

Schedule an appointment with Rittenhouse Psychiatric Associates today to begin your journey to better mental health.

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