Concerns and issues that have emerged with the evolution of evidence-based practice

Until a few years ago, if you were a post-menopausal woman, you could expect to receive hormone replacement therapy to treat or prevent distressful symptoms and to protect you from cardiovascular disease. However, in a classic study from the Women's Health Initiative, hormones were shown to actually increase the likelihood of heart disease and stroke (Rossouw et al., 2002). Careful collection and assessment of the evidence changed the recommendations in this field yielding non-hormonal interventions aimed at symptomatic relief, being now the first line of treatment. Few would argue about the value in this instance of healthcare professionals being able to identify “what works” and being appropriately trained to practice accordingly.

Parallel to the trend of general medicine which has emphasized the essential importance of identifying and implementing effective care (Sackett et al., 1996), mental health has made similar strides (Drake et al., 2001; Reynolds, 2000). Specifically, the development of evidence-based practice has had profound impact on the field and contributed to the identification, development and dissemination of effective interventions which have proven to improve outcomes. While we believe that the evidence-based movement is a necessary development, and one we support (Roe et al., 2007), like many social, political and scientific developments, it is not without its risks or unintended consequences. We are well aware that we are not the first to raise concerns, nor do we suggest that our concerns are exhaustive or that we hold the solutions. It is not our intention to turn back the clock or suggest nostalgia for another time but rather explore three of those risks and hope to stimulate discussion and raise awareness of some of the difficulties we perceive.

The first concern we see is that an emphasis on evidence and measurement naturally inclines persons to study outcomes that can be most easily observed and hence risk developing models, which are lopsided or at least not sufficiently attentive to some of the most human and important aspects of the matters at stake. Specifically, we suggest that there is a risk within the evidence-based movement towards the development of models of psychopathology and dysfunction which are driven by a focus on distinct phenomenon and processes which can quickly be observed as present or absent. For example, if we want to study whether an intervention is effective, it is relatively simple to ask whether persons who received the treatment experience a reduction in symptoms or learn a new skill. While symptoms and skills are undoubtedly important, there is a risk of neglecting the fact that recovery involves a range of processes that are not necessarily a sum of discrete skills or experiences (Crawford et al., 2011). To move towards recovery may be to experience oneself more fully as an agent in the world (Davidson & Roe, 2007). It may also mean to synthesize and develop more complex ideas about oneself and others which are not a matter of being correct or asserting a specific belief. Meaning making is not just present or absent but is to varying degrees adaptive, complex and flexible (Bolton, 2012). It is not a matter of forming a singularly correct perception of something nor is it reducible to a set of correct perceptions. Meaning making is instead a synthesis of a broad range of discrete perceptions into a personal account of a set of life events (Lysaker et al., 2012). Thus, one challenge for the evidence-based movement and research is the development of ways to study and conceptualize complex matters without over emphasizing phenomenon which are simpler to measure and thus ignoring the highly synthetic activities which allow people to share the meanings they have and are making of their lives.

Another risk we see is a potential misunderstanding about the nature of human communication. Efforts to concretely manualize intervention and increase fidelity have naturally resulted in a focus on content or the particular types of things service providers should say or teach under particular circumstances. With this, however, there may be a tendency for those providers to become less sensitive to meanings of interactions with service users that can only be intuited in the moment. Of course, manuals are intended to guide and are not scripts. Nevertheless, there is a danger that an increasing emphasis on the general content of speech as the critical treatment ingredient may neglect the reality that identical statements can have very different meanings – both on the part of providers as well as service users. The physical and social context, relationship with the provider and/or assessor, to say nothing about the geographical and cultural setting and even the immediate mood of the person at a given moment, can all have profound impact on the actual meaning of the same words and their ultimate therapeutic effect. One possible result then is that clinical and rehabilitative interactions may become increasingly less sensitive and possibly do not show sufficient regard for the personal meanings that psychological and social problems and successes have for the service user.

Finally, we are concerned that the evidence-based movement has created a new social structure. Specifically in the face of the waves of incoming evidence from new studies and the need to integrate that information within a body of older studies, more and more expert panels seem to have sprung up in essence to serve as arbiters of evidence. Examples of this include committees offering definitive interpretations of what research has legitimately determined, formulas for comparing the validity of conclusions from different studies, as well as decisions about which instruments should be included in research assessment batteries. While certainly expert opinions are to be valued, there is a risk here of committee work deciding what constitutes legitimate evidence, replacing the role of service providers and service users as individuals who must make their own sense of information. Also of concern are directives that service providers and researchers should follow the decisions of such panels, decisions which are likely subject to the same extraneous socio-political factors that generally have been observed to influence most committee work. Within these groups as in other groups, decisions may be made on the basis of the prestige of a method or fashionableness of a particular at that moment all leading to the danger of curtailing original thought and opportunities for serendipitous discovery.

In sum, the evidence-based practice movement is clearly an important development in the evolution of the allied mental health field. As with most efforts at social, political and scientific advancement, the advance, solution or cure often has side effects. In this editorial, we have suggested three potential risks that have emerged with this movement: the oversimplification of outcome in terms of discrete improvement, the oversimplification and reduction of human communication to a point where meaning may be lost and the creation of limiting social structures. It is likely, none of these challenges is insurmountable but each should be foremost in the consciousness of our field if we are to make use of emerging research, avoid stagnation and prevent the loss of deep human understanding of suffering and resilience.