Two experiences I had that took place roughly 25 years into my clinical work combined to effectively dismantle my strict allegiance to the primacy of “empiricism” as it was taught to me, and rigorous use of “evidence-based practices” as I had been trained. I’ll discuss those two experiences down below.
But a few years before that, I had begun to soften after hearing challenges to empiricism and EBP’s from some advanced and credible sources. Ironically, part of what started to soften me was that these challenges used objective scrutiny.
I eventually started quoting a number of these newer challenges while providing formal, professional continuing education lectures. Here are a few of them:
- “Why should addiction treatment be held to a relapse-free standard of remission?”
- With any other disease when a treatment is effective, later removed, and the result is relapse – that is considered a demonstration that the treatment was effective, not ineffective.
- “What about practice-based evidence?”
- Does a surgeon who has done 10,000 of the same procedure have anything valuable to say about the illness, the course of care, or getting better?
- “Residential addiction treatment is too cookie-cutter.”
- But what’s more cookie-cutter than a CBT manualized protocol?
- We are better at identifying and counting behavior than we are at measuring intrapsychic change processes.
- And so, CBT “wins”.
- “If you need surgery, or a plumber, do you want the seasoned one? And why?”
- Is experientially-based knowledge a thing? And, is it considered valuable (as academically-derived knowledge and empirically-based knowledge already are)?
Here are the two experiences I had. They happened close together in time.
One of those experiences was reading an article1 that someone handed me. It was a critique of the “evidence-based practice movement”. And to me it was a splendid piece of logic.
General challenges in the paper included key questions like:
- Which proposed studies get funded and why?
- Why and when are null-findings published or not published?
- Do we find what is, or what we measure?
The paper also included more specific challenges to research concepts and methods, such as noting:
- over-emphasis of prescriptive technique (vs other practices)
- setting aside of non-diagnostic characteristics of the person (aspects of the person as a person)
- lack of real-world inclusion criteria for who gets studied (very tightly controlled)
- lack of real-world clinical settings within which research is conducted
- emphasis on symptom suppression (rather than aiming toward wellness, for example)
- lack of attention to cultural factors
- lack of attention to family system factors, and
- a generally mechanistic world view.
The other experience was listening to Lee Feldman on a few occasions, the last of which was him speaking to me in an un-interrupted monologue of 3 full hours. Listening for those 3 hours went by very quickly, and the impact of that experience is with me to this very day. What did Lee talk about? “Spy satellites, cream of mushroom soup, and eating a peach.”
Lee gave me permission to share these publicly. He taught them to me in the order I will present below. He started with a seemingly strange and irrelevant topic, but by the end I was captivated. Listening to him was transcendent and sublime.
Spy satellites. Lee told of working for the Department of Defense (DOD) and being the one to write an algorithm for complex decision making based on a wide variety of data inputs. The purpose of the algorithm was to prioritize photographic opportunities of satellites (versus other factors like the lifetime of the satellite, the life of the battery, and what it took to recharge the battery, etc.). He pointed out that the algorithm worked perfectly unless and until “policy” matters were added as variables, even when corrected as weighted variables. The look on Lee’s face when he said, “policy” made it clear that he meant something quite problematic for the essence of the decision making process.
- Lee discussed how the field of complex decision making could be applied to our field. Listening to him describe that application was a “wow”.
Cream of mushroom soup. Next, he told of a company that approached DOD for help in keeping the flavor of soup consistent. I was incredulous that such a problem existed and that a company would approach DOD for the solution. The company said the list of ingredients and cooking methods could be controlled but the flavor profile for some ingredients would change across seasons of the year (such as the flavor of milk vs the greenness of grass and when the grass is eaten). The company said the master soup makers check the flavor of the almost-finished industrial vat of soup and ask for certain ingredients to be added at the end to keep the flavor consistent. The company said master soup makers are aging out and none of the younger people want to go into apprenticing as master soup makers. Lee said when DOD heard this they said, “That’s a Lee Feldman problem” and gave him the project because of his work in complex decision making.
Lee told me how his project team tried to use behavioral observation, interviewing, and other techniques to pull the competency and skill out of the master soup makers and transform all of that into an algorithm for automation or that others could use. Lee’s final advice to the company was: “Continue to apprentice master soup makers”. He told me the state of the art of behavioral neuroscience could not replace those highly skilled and seasoned chefs.
- Listening to Lee, at that point all I could think about was the clinical supervision of counseling, and the clinical supervision of clinical supervision. And that was exactly how Lee applied the lesson.
Eating a peach. Lastly, Lee taught me the word “qualia” and said it was the plural form of a word for individual experiences of human consciousness.
He asked me if I had ever eaten a peach. When I said “Yes” he told me to imagine trying to convey that experience (the flavor, the feel, how I experienced it, etc) using only words to someone who had never eaten one. Lee said qualia could not be transmitted in words from one person who had the experience, to one who did not.
It is profound to consider Lee’s input to me that:
- No experience a person has is truly shared or identical in a literal qualitative sense.
- Each of us is an individual, and each of us lives a life of qualia that are not the exact same as anyone else.
- Our individual differences as people also come from the total accumulation of all the experiences of our lives; qualia add up within us and we differ accordingly.
- We can’t really, exactly, share our unique experiences in the form of mere words.
And so, back to stark empiricism and evidence-based practice.
All of this leaves me with various questions. Here are some of them:
- What do we measure, and why?
- Are we able to identify and measure the most important variables? Would it even matter if we could?
- What is it like for someone to be them?
- Shall we meet and treat the total person? Or shall we merely apply a protocol in order to stop a problem that we (the clinicians and researchers) happen to notice?
Reference: 1 Marquis, A., Douthit, K. Z. & Elliot, A. J. (2011). Best Practices: A critical yet inclusive vision for the counseling profession. Journal of Counseling & Development. 89: 397-405.
Suggested Reading: Freedman, N, Hurvich, M, Ward, R., Geller, J. D. & Hoffenberg, J. (2011). Another Kind of Evidence: Studies on internalization, annihilation anxiety, and progressive symbolization in the psychoanalytic process. Karnac Books, Ltd., London.