Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies☆
Introduction
As Charles Dudley Warren, and later Mark Twain, quipped, “Everyone complains about the weather, but nobody does anything about it” (Platt, 1989, p. 22). The same can be said about the modal attitude of clinical psychologists toward the negative views of many of their colleagues toward evidence-based practice (EBP), especially the component of EBP requiring clinical decision-making to be anchored in rigorous scientific evidence (Gambrill, 1999, Spring, 2007).
Most academic clinical psychologists are aware that a sizeable proportion of their practitioner and researcher colleagues, not to mention their graduate students, are skeptical of EBP's insistence that research data inform clinical decisions. Indeed, as we will discover (see “Psychologists' attitudes toward evidence-based practice: survey data”), these perceptions are rooted at least partly in reality, as survey evidence suggests that doubts about EBP among clinical psychologists are hardly rare (Baker, McFall, & Shoham, 2008). Yet most advocates of EBP prefer to either ignore the negative attitudes of many of their colleagues and students toward EBP, or to dismiss these attitudes as reflections of ignorance or anti-intellectualism. Still others view the resistance to EBP dichotomously, perceiving psychologists as either “for” or “against” EBP when in fact much of this resistance reflects discomfort with only certain aspects of scientifically-based approaches to clinical decision-making.
The field of clinical psychology's widespread neglect of resistance to EBP is potentially dangerous, as such resistance may inadvertently fuel the continued popularity of unscientific or even pseudoscientific interventions (see Lilienfeld et al., 2003, Thyer and Pignotti, 2013). Specifically, practitioners who do not recognize the underlying reasons for EBP may fail to appreciate how readily they can be fooled by ineffective or harmful treatments. In addition, the neglect of psychologists' resistance to EBP may hamper the effectiveness of ongoing efforts to disseminate evidence-based therapies to practitioners (see Herschell et al., 2004, Siev et al., 2009, for discussions of barriers to dissemination).
In this manuscript, we (1) examine the principal sources of resistance to EBP among clinical psychologists and allied mental health professionals (e.g., social workers, counseling psychologists, counselors, psychiatrists, psychiatric nurses); (2) outline the essential role of EBP in clinical education, training, and practice; and (3) propose constructive remedies for addressing resistance to EBP. We argue that this resistance typically reflects neither ignorance nor anti-intellectualism, although some of it is rooted in misunderstandings about (a) human nature and (b) what EBP does and does not entail.
Section snippets
Goals of the article
Our intended audience is broad, and encompasses all individuals who are skeptical of the central premises underlying EBP, especially graduate students and practitioners. We also address our article in part to instructors who wish to combat unwarranted skepticism of EBP among their students and to practitioners and researchers who wish to combat unwarranted skepticism of EBP among their colleagues. Hence, our central arguments apply with equal force to students, practitioners, teachers, and
What is evidence-based practice?
The movement toward EBP has its roots in medicine (Sackett et al., 1996, Straus et al., 2010). EBP began to gather momentum in the 1990s, when a growing cadre of physicians argued that medical practices needed to become more firmly grounded in scientific evidence. Over the past decade, EBP has gained increasing traction in clinical psychology, social work, and allied disciplines (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006, Kazdin, 2008).
Resistance in psychotherapy: an analogy
In their training, psychotherapists are routinely taught that client resistance, especially when expressed repeatedly, should not be ignored or dismissed (Shea, 1998). They are further taught that if therapists do not address resistance explicitly, it is likely to recur in various guises, potentially impeding the effectiveness of treatment. In addition, trainees often learn that not all resistance is inherently pathological, and that some resistance may reflect understandable reservations
Mental health professionals' attitudes toward evidence-based practice: survey data
A modest but burgeoning body of survey data offers valuable insight into mental health professionals' attitudes toward EBP and more broadly, the inclusion of scientific evidence in treatment selection. These findings are valuable, as they afford us a panoramic view of the landscape of resistances that advocates of EBP confront. On balance, these data yield a mixed picture, but suggest that many practitioners view EBP with at least some degree of suspicion. Like Safran, Abrue, Ogilvie, and
First source of resistance: naïve realism
In the bulk of the remainder of the manuscript, we delineate six major sources of resistance to EBP among psychologists and students. The first major source of resistance we address is what psychologists, following philosophers, have termed naïve realism (Ross & Ward, 1996). Naïve realism, also called common sense realism or direct realism, is the erroneous belief that the external world is exactly as we see it. This belief is deeply embedded in our intuitions. A host of phrases in everyday
Second source of resistance: myths and misconceptions regarding human nature
A second source of resistance to EBP is the widespread acceptance of deep-seated myths and misconceptions regarding human nature, some of which are held by psychologists themselves (Lilienfeld, Lynn, Ruscio, & Beyerstein, 2010). Many of these false beliefs are propagated by the media, the popular psychology industry, and in some cases, self-proclaimed leaders in the psychotherapy field. In still other cases, they may be imparted to practitioners and students during their education and clinical
Third source of resistance: the application of group probabilities to individuals
The classic distinction between nomothetic and idiographic approaches to understanding human nature (Maher & Gottesman, 2005) has long been one of the flashpoints of confusion and contention in clinical psychology (Dawes et al., 1989, Meehl, 1954). EBP relies primarily on nomothetic findings, which strive to extract universal or quasi-universal laws that apply to all or most individuals within the population. Yet the everyday task of the practitioner is necessarily idiographic: Practitioners
Fourth source of resistance: reversal of the onus of proof
One of the core tenets of science is that the burden of proof rests on the proponents rather than the skeptics of assertions (Saks, 2002). Science is inherently a conservative enterprise, because most novel ideas are wrong (Sagan, 1995). Hence, science imposes a heavy burden on the advocates of new assertions, including untested treatments. As Dawes (1994) observed, this epistemic burden can be summarized in terms of the motto of the state of Missouri: “Show me.” That is, it is up to developers
Fifth source of resistance: mischaracterizations of what EBP is and is not
Another source of resistance to EBP stems from misunderstandings and misrepresentations of what EBP entails (see Bohart, 2002, Wachtel, 2010, for examples). In some published works and workshops, EBP has been characterized in an inaccurate or even caricatured fashion (Gallo and Barlow, 2012, Gibbs and Gambrill, 2002). Several of these misconceptions partly reflect thoughtful and understandable reservations concerning EBP and may even contain a kernel of truth, but are oversimplified. Because
Sixth source of resistance: pragmatic, educational, and attitudinal obstacles
A final major source of resistance to EBP comprises a host of pragmatic, educational, and attitudinal obstacles encountered by many psychologists, especially those working in practice settings. We delineate the primary obstacles here, although our list is surely not exhaustive (see also Gallo and Barlow, 2012, McHugh and Barlow, 2012, Stewart et al., 2012, for useful discussions). Because our emphasis is on barriers to the initial acceptance of the premises of EBP, not to the adoption of EBP
Conclusion: constructive recommendations for addressing resistance to EBP
In this article, we have contended that resistance to EBP is both widespread and understandable. The resistance is widespread in that it is displayed by sizeable minorities of practicing psychologists (e.g., Chambless & Stewart, 2007; Pignotti, 2009) and perhaps clinical psychology graduate students (Luebbe et al., 2007). The resistance is understandable in that it stems from several deep-seated sources, such as naïve realism and misconceptions regarding human nature and group probabilities,
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The authors thank Jackie Larson and Kristy Pitts for their valuable help with references.