Evidence-Based Treatment and Clinical Flexibility

I want to talk today about a frustration that I have with rigid adherence to manualized and “evidence-based” treatment approaches in psychotherapy.

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Clients often ask me about medication options for their diagnosis. Although I don’t prescribe, for many, I am the first person they talk to when they are considering psychotropic medication, so I give them some educational materials and help them make the best choice for themselves. Probably the most common question I get is, “What will happen if I take X medication?” My answer is, “I know what X medication tends to do, but we won’t know for sure how it will affect you until you take it.”

The FDA does studies on thousands of people when approving medications to get a good idea of how that med interacts with the human brain, but the problem we run into is that each of us has a unique brain chemistry. The FDA did not do a study on how each medication affects my unique brain chemistry. That’s why a lot of people have to try a few different medications and doses before figuring out what works for them, and it’s why I am not able to say what will definitively happen when someone starts a new medication. We need to keep this same thing in mind when it comes to therapy.

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There seems to be a tendency to view “evidenced-based” therapy as somehow infallible when the same principles hold true. I might know that peer-reviewed literature has shown that a certain intervention tends to help a certain symptom or diagnosis, but when a client comes to me for therapy, it is highly unlikely that anyone studied how that individual will respond. No matter how good the evidence backing is, we need to remember that each client is an individual who might respond differently. Not to mention, no matter how well-versed I am in an intervention, therapists aren’t standardized either, so the way I present it will not be identical to the experimental conditions.

I am all for keeping a toolbox of evidence-based interventions on hand, but I need to know when to pull from it and when to leave that toolbox closed. We need to come to our clients with a spirit of curiosity, asking, “What do you think of this approach?” or “Does this fit your experience?” rather than, “I know what will help you. Do it this way and you will get better.” Frankly, if strict adherence to a manualized approach were completely effective, I would have been replaced with AI by now.

Stay educated. Keep your therapy toolbox up-to-date with interventions that have backing. But, more than anything, be flexible and be open to feedback from clients. We might be “experts” in mental health, or in their diagnosis, but they are the only expert on themselves.

Published by Dr Marschall

Dr. Amy Marschall received her Psy.D. from the University of Hartford in September 2015. Her clinical interests are varied and include child and adolescent therapy, TF-CBT, rural psychology, telemental health, sexual and domestic violence, psychological assessment, and mental illness prevention. Dr. Marschall presently works in the Child and Adolescent Therapy Clinic at Sioux Falls Psychological Services in Sioux Falls, South Dakota, where she provides individual and family therapy and psychological assessment to children, adolescents, and college students. She also facilitates an art therapy group for adolescents and college students with anxiety and depression. Dr. Amy Marschall is certified in Trauma-Focused Cognitive Behavioral Therapy and Telemental Health.

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