Best practices: a critical yet inclusive vision for the counseling profession.
Driven by the growing demand for proof of service effectiveness, the EST and EBP movements have deeply affected counseling and other mental health professions, influencing the type and quantity of services that are reimbursed by third-party payers, practiced in agencies and other counseling settings, and included in educational curricula (Norcross, 2002). Within the counseling community, these developments have generated important and impassioned debate concerning the relative appropriateness and value of the BP movement, with positions ranging from avid support (Sexton, as cited in Marotta & Watts, 2007) to ardent opposition (Hansen, 2006). In this article, we provide a brief summary of the EST movement; review accompanying issues and criticisms; and discuss the implications of BPs for the long-term survival of various dimensions of counselor identity, including multiculturalism, developmentalism, social justice, and a holistic wellness perspective. Ultimately, our aim is to further clarify a balanced and inclusive conception of BP that we hope helps to reconcile contemporary pressures to provide evidence-based services with counselors' need to feel confident that they can retain their core values while serving clients in the most effective manner possible.
* Overview of the BPs Controversy
Proponents of EBPs claim that a problem of accountability is created by the "institutionalization of untested psychological theory as fact" (Sexton, as cited in Marotta & Watts, 2007, p. 493) as well as the lack of standardization in clinical practice (O'Donohue & Fisher, 2006). Scholars promoting EBPs further contend that implementing standards of evidence is a critical means of ensuring the quality and reliability of counseling services. Although providing some form of evidence for the effectiveness of the services a counselor delivers is undoubtedly a laudable goal and an ethical imperative for some scholars, other scholars have argued on conceptual, cultural, and methodological grounds against the criteria that have been used to define evidence and designate EBPs (Atkinson, Bui, & Mori, 2001; Seligman, 1995; Westen, Novotny, & Thompson-Brenner, 2004). It has been further argued that the EST and EBP movements represent an attempt to legislate a narrow, medicalized approach to counseling research and practice that relies excessively on traditional experimental research methods and easily measured outcomes, as well as places undue emphasis on treatment models at the expense of factors such as the "person of the counselor," the counseling relationship, and clients' nondiagnostic characteristics (Hansen, 2006; Wampold, 2001). Scholars of varying theoretical orientations (Hansen, 2006; West & Bubenzer, as cited in Marotta & Watts, 2007; Norcross, 2010) have further cautioned that once proclaimed "best," institutionally dominant forms of knowledge and practice will marginalize alternative (namely, humanistic, constructivist, and multicultural) theoretical perspectives and therapeutic modalities, to the detriment of the counseling profession. These scholars fear that interventions that are privileged as "evidence-based" will largely determine what treatments are reimbursed, funded for further research, taught in practitioner education programs, and subsequently implemented. Thus, although EBPs are noble in their intention, they have the potential to dominate the therapeutic landscape; eclipse more nuanced, complex, and individualized intervention strategies; and be misused (Norcross, 2010).
Although diverse opinions on the subject have promoted fruitful discussion, there is a growing recognition of the need to overcome polarized depictions of BPs and to advance a more integrative and finely tuned view of both their contributions and limitations (Marotta & Watts, 2007). We note similar threads of commentary relating to other global and controversial trends within the mental health field, including Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnosis (Ivey & Ivey, 1998), psychopharmacology (Ingersoll & Rak, 2006; King & Anderson, 2004), and psychiatric genetics (Douthit, 2006), in which scholars trained in the counseling tradition have sought to incorporate advantageous aspects of these research and practice trends while remaining wary of potential distortion and misuse. In the case of BPs, a clear and cohesive conceptual framework for BPs can help align the efforts of researchers to produce, and practitioners to apply, research that can meaningfully inform counseling services delivered in diverse, real-world clinical contexts. On the other hand, in the midst of ideological and market pressures that may threaten core counseling values, it is important for counselors to be critical consumers of existing EST research and EBP guidelines. We believe that such critical reflection and continued discussion about the formulation and implementation of BPs will go a long way toward ensuring that service quality and client welfare, rather than vested institutional interests, drive the BPs endeavor in the counseling field.
* Issues and Criticisms Related to the EST Movement EST Criteria
In 1995, Division 12 (Society of Clinical Psychology) of the American Psychological Association formed the Task Force on Promotion and Dissemination of Psychological Procedures, which was charged with the task of outlining the criteria necessary for a treatment to attain the title "empirically validated treatment" (later changed to "empirically supported treatment"). It was decided that EST criteria require the following:
1. Comparison with a no-treatment control group, alternative treatment group, or placebo (a) in a randomized control trial, controlled single case experiment, or equivalent time-samples design and (b) in which the EST is statistically significantly superior to no treatment, placebo, or alternative treatments or ... is equivalent to a treatment already established in efficacy, and power is sufficient to detect moderate differences.
2. These studies must have been conducted with (a) a treatment manual or its logical equivalent; (b) a population, treated for specified problems, for whom inclusion criteria have been delineated in a reliable, valid manner; (c) reliable and valid outcome assessment measures, at minimum tapping the problems targeted for change; and (d) appropriate data analysis. (Chambless & Hollon, 1998, p. 18)
One of the major controversies involved in the EBP movement concerns the use of treatment manuals, which, as noted, are mandatory for a treatment to obtain EST status. Standards pertaining to the content of treatment manuals have not been precisely operationalized; as a result, their content has ranged from specific session-by-session prescriptions to broad principles of practice (Chambless & Hollon, 1998), although they typically include a protocol outlining the goals, mechanism, and sequencing of interventions (Sexton, as cited in Marotta & Watts, 2007). From a research standpoint, manualization is necessary in order to ensure that subjects within a particular group receive the same experimental treatment. It is possible to forego use of a treatment manual in the case of a relatively simple treatment intervention that is clearly described in the Method section of the article in which it is being reported (Chambless & Hollon, 1998). There has been speculation, however, that manualized attempts to minimize variation within treatment groups may also tend to diminish the role of clinical judgment on the part of individual counselors (Westen et al., 2004). Accordingly, reservations about the potential constraints of manual-driven intervention on the clinician's judgment, intuition, and creativity are major sources of resistance to the use of treatment manuals (Beutler, 2000). A closely related concern is that "manualized treatment may restrict flexibility in the adaptation of the treatment approach to specific aspects of the client's personality and circumstances" (Edwards, Dattilio, & Bromley, 2004, p. 589; Norcross, 2010). The counseling profession, in particular, is challenged by the typical omission from manualized interventions of diversity considerations and developmental frameworks, as well as wellness- and strength-based strategies. Being highly client-specific, these dimensions of counseling process tend not to fit neatly into a standardized protocol.
Despite the many concerns raised regarding manualized treatment, we recognize that rather than being the cookbook caricatures that are often portrayed, manuals are increasingly complex constructs that allow for some flexibility in treatment implementation and require training and clinical skill to apply effectively (Chambless & Hollon, 1998; Edwards et al., 2004). Thus, the contention that simply because a treatment is manualized it will be mechanical and unresponsive to client needs seems unjustified (Sexton, as cited in Marotta & Watts, 2007). Likewise, creating a treatment manual or describing one's counseling methods with adequate description to allow for replicability and treatment fidelity across therapists is a basic research design issue that, even if difficult, could be accomplished by practitioners using some of the humanistic approaches without undue constriction of the counselors in those traditions. Nonetheless, the notion that there may be an inherent danger in rigid adherence to manualized guidelines appears to be a legitimate concern, particularly in light of the finding that training in manualized treatment was associated with "deterioration in certain interpersonal and interactive aspects of therapy" (Henry, Strupp, Butler, Schacht, & Binder, 1993, p. 434).
Perhaps the most common criticism of EST research is that its methodology and resulting conclusions lack relevance to actual clinical practice. The core issue in this relevancy debate is the difference between efficacy and effectiveness. The term efficacy indicates that a treatment has demonstrated a successful outcome (in statistical comparison to another treatment or control group) in stringently controlled experimental research designs. The principal example of such a controlled research design, which is also the standard design in EST research, is the randomized clinical trial (RCT). In the RCT, which is borrowed from the Food and Drug Administration's method of evaluating prescription drugs, subjects meeting highly specific inclusion criteria (usually a single DSM-IV-based Axis I diagnosis having no comorbidity; American Psychiatric Association, 1994) are randomly assigned to treatment, alternative, or control groups. In contrast to efficacy, the term effectiveness denotes how a given approach actually works in naturalistic settings, where the many variables that were controlled in efficacy studies cannot be as well controlled. A very frequent criticism of EST protocols is that in the process of ensuring scientific precision (which demands an internally valid experimental design), the external validity of the research--how applicable or generalizable the findings are to the real conditions of clinical practice--is sacrificed (Marquis & Douthit, 2006). These limitations on clinical (as distinguished from statistical) significance led Seligman (1995), in a seminal work on the topic, to conclude that "the efficacy study is the wrong method for empirically validating psychotherapy as it is actually done, because it omits too many crucial elements of what is done in the field" (p. 966).
Seligman (1995) listed and described various characteristics of counseling as naturally practiced that are typically absent in efficacy studies. For example, naturalistic therapy is usually not of a prefixed duration, and is self-correcting (counselors will alter or abandon an approach that is not working as opposed to continuing to adhere to manualized guidelines). Furthermore, clients with multiple concerns and/ or comorbid diagnoses are the norm in clinical practice, in contrast to the participants in efficacy/EST studies who are required to have only one diagnosis (Westen et al., 2004). In addition, naturalistic counseling is almost always geared toward clients' overall improvement, as opposed to the emphasis on treating specific DSM symptoms that characterizes most EST studies (Seligman, 1995). Naturalistic effectiveness also involves the long-term success of the treatment approach. A critical shortcoming of EST research is that the bulk of the observed therapeutic effects represent acute treatment response, as opposed to longer term improvement or recovery. In their meta-analytic review of more than 30 EST studies, Westen and Morrison (2001) noted that very few EST studies reported follow-up data, and for empirically supported treatment of generalized anxiety disorder and depression, data suggest "sustained efficacy rates of 25%-30% over 12-24 months," which are "poor by almost any standards" (p. 887).
Another source of controversy is alleged theoretical bias. The majority of ESTs are characteristically short-term cognitive-behavioral therapies (CBTs; see O'Donohue & Fisher, 2006, pp. 12-13), leaving longer term psychodynamic, experiential, existential-humanistic, and constructivist approaches largely excluded from large-scale empirical validation studies. This is a matter of concern to the extent that this theoretical exclusivity is substantially unrepresentative of the theoretical diversity of many counselors with considerable clinical expertise. We posit that rather than reflecting actual properties of greater effectiveness, the preponderance of CBTs in the EST literature is more likely due to the notion that the values (objectivism, reductionism) and features (structured, symptom focused, relatively short term) of CBTs more readily lend themselves to typical EST methodology (Marquis & Douthit, 2006; Slife, Wiggins, & Graham, 2005). Although some non-CBT approaches have also been manualized (Busch, Milrod, & Sandberg, 2009; Henry et al., 1993), by focusing on the struggles underlying symptoms--as well as on more subjective, less concrete outcomes--dynamic, humanistic, and constructivist approaches require greater ambiguity and flexibility and are thus more difficult to standardize than are CBTs. In addition, the EST outcome criteria, which tend to focus on rapid reduction of symptoms (usually as assessed by clinicians), are more compatible with some therapies than with others (Messer, 2004; Wampold & Bhati, 2004). We in no way mean to discount the importance of ameliorating symptoms. Yet, this is far from the only aspect of "outcome," which also encompasses clients' sense of satisfaction, wellness, and progress and includes such factors as enhanced insight, increased self-esteem, a stronger sense of personal identity and agency, and emotional awareness (Messer, 2004). Instead of the methodological range of EST inquiry expanding to include these content and process aspects of counseling (which are difficult to study using traditional empirical/experimental methods), they generally have been dismissed as expendable in outcome research. Consequently, entire approaches that emphasize these comparatively more subjective dimensions of human experience do not commonly earn the status "empirically supported," not because they are inherently less effective but because of the methodological logistics (Marquis & Douthit, 2006; Slife et al., 2005).
Conceptual and Empirical Criticisms
In seeking to establish which psychological treatments are most appropriate and effective to address particular DSM disorders ("specific treatment for specific disorders"; Hansen, 2006, p. 155), the EST movement appears to make several important assumptions. First, it assumes that a DSM diagnosis is the best indicator of the appropriate treatment, thereby suggesting that diagnoses reliably and validly characterize client problems and are sufficiently homogenous so as to warrant the same treatment across cases. As noted, however, real-world clients usually present with multiple clinical issues spanning more than one diagnostic category. Furthermore, clients and their concerns are heterogeneous along numerous dimensions bearing on counseling strategy, including personality factors, developmental dynamics, and subjective meanings, as well as the sociocultural and environmental conditions in which they have developed or presently live. Thus, the EST framework reduces client problems to a diagnosis and implies that the same intervention should be pursued regardless of etiology or the client's myriad nondiagnostic characteristics and circumstances. Westen et al. (2004) asserted that it is only for certain clearly circumscribed problems (such as specific phobias or posttraumatic stress disorder following a single traumatic experience) that these EST assumptions concerning diagnosis may be appropriate.
Another cardinal assumption made by the EST movement is that the treatment itself is the primary determinant of outcome, in that the component strategies and techniques (or "ingredients") characterizing the given approach (such as cognitive restructuring in CBT) differentially target and alleviate the pathology associated with particular disorders, an assumption known as the specificity hypothesis (Hansen, 2006; Wampold & Bhati, 2004). However, empirical research has failed to validate the notion that such distinctive elements are the operative factors in producing client change (Wampold, 2001). Quite oppositely, research has suggested that "common factors" shared across different theoretical approaches account for the bulk of client change (Lambert, 2003). In a landmark quantitative review, Lambert (2003) concluded that of all the factors involved in positive therapeutic outcomes, extratherapeutic (client related) factors are responsible for the largest portion of outcome variance (40%), followed by common factors (30%), expectancy/placebo effects (15%), and specific techniques or interventions (15%). Furthermore, and likely because of the very complexity of client concerns, multiplicity of change processes, and common elements across therapeutic approaches, meta-analytic review of comparative outcome research spanning 40 years has contradicted the notion that any major school of therapy is significantly more effective than another; rather, it has attested to the overall outcome equivalence of established (bona fide) therapeutic approaches (Wampold, 2001). Nevertheless, the empirical evidence supporting the efficacy of such bona fide non-CBT therapies (including certain psychodynamic, humanistic, and family therapy approaches) is typically excluded from EST consideration because it derives from studies that have not used the approved RCT methodology or "have not targeted one specific DSM-based disorder" (Messer, 2004, p. 582). Scholars have also asserted that the variance attributable to the specific therapist appears to considerably exceed the variance attributable to the form of treatment (Wampold, 2001; Wampold & Bhati, 2004). This observation implies that the focus of psychotherapy research would be better placed on identifying effective therapist behaviors and interactions rather than investigating which treatment is better (Norcross, 2010). Thus, although we agree that no psychotherapy should be exempt from the provision of supporting evidence, we believe it is important to note that empirical research itself suggests that the focus on the "correct" treatment--in contrast to integrating research-supported treatments with the "person of the counselor," the client's nondiagnostic characteristics, and the therapy relationship--is misplaced.
* Institutional and Professional Consequences
Postmodern philosophy has illuminated the ways in which forms of dominant knowledge and meaning are partially contingent on the social and institutional systems of power in which they arise (Gergen, 1982), a phenomenon readily apparent in the EST arena. In addition to the methodological feasibility constraints discussed previously, dynamic, existential-humanistic, constructivist, and contextual approaches face obstacles to EST status associated with institutional access. Funding streams for inordinately expensive RCTs are typically directed to schools of medicine in large research universities, and thus it is not surprising that forms of psychotherapy most closely aligned with the medical model of diagnosis and prescriptive intervention are able to garner more investigatory interest. Conversely, segments of the research community that embrace a critical, postmodern philosophical orientation and support more holistic and contextual approaches to counseling traditionally attract far fewer funding dollars and are unlikely to be competitive for large RCT grants. Such bias begs the question as to whether certain widely touted interventions such as CBTs are actually the "best" treatments for a particular psychological problem or, alternatively, are the treatments most likely to have been the focus of large-scale research efforts (Marquis & Douthit, 2006).
Of grave political concern is how managed care companies, government policy makers, and other insurance providers are increasingly using lists of ESTs and EBPs to dictate what treatment approaches will be approved and reimbursed (Edwards et al., 2004; Norcross, 2002). In addition to economic constraints, rhetorical suggestions of greater scientific validity and therapeutic superiority create professional and educational incentives to voluntarily embrace evidence-based treatments. As a result, dynamic, existential-humanistic, constructivist, and contextual approaches face possible institutional obsolescence, and even more sobering is the prospect that treatments not designated as an EST or EBP may one day become the subject of malpractice suits (Sanderson, 2003).
* Implications and Concerns Related to Core Counseling Values
Various scholars have argued that the EST movement is rooted in a research culture of quantitative empiricism as well as a medicalized conception of counseling process emphasizing diagnosis and prescriptive technique (Hansen, 2006; Marquis & Douthit, 2006; Wampold, 2001). Although such contentions have been disputed (Sexton, as cited in Marotta & Watts, 2007), they raise important concerns pertaining to counselor identity and values. Hansen (2006) contended that "as in medicine, counselors become expert technicians who implement BP guidelines, and ... clients are reduced to disorders" (p. 157). Certainly, on an individual basis, the pursuit of a given EST therapy (e.g., a CBT approach) need not imply a distinctly medicalized formulation that views the client's problems only in terms of pathology. However, on the systems level, and as currently constructed, EST directives necessarily elevate the importance of diagnosis in assessment, because it is considered to be the basis on which the appropriate evidence-based treatment is selected. Clearly, this is a matter of particular importance to counselors, who are wary of the potential of a diagnosis to impose adverse institutional consequences as well as to promote a disempowering psychopathological view rather than an empowering developmental orientation to client distress (Ivey & Ivey, 1998). Furthermore, the question arises as to whether such an ordained role for diagnosis and prepackaged, time-limited treatment would, however unintentionally, make it more difficult--although not impossible--for counselors to explore the subjective dimensions of client concerns as well as each client's sensibilities regarding change strategies.
Another concern related to counseling values stems from the criticism that ESTs may lack appropriateness and effectiveness with culturally diverse populations and may undermine efforts toward greater multicultural competence in counseling (Atkinson et al., 2001). From its inception, the EST initiative has paid minimal attention to issues of cultural relevance, beginning with a failure to report the racial/ethnic characteristics of research subjects (Doyle, 1998; La Roche & Christopher, 2008). Available data indicate that the large majority (approximately 85%) of EST research subjects have been European American, reflecting an underrepresentation of minority groups (Doyle, 1998). In addition, clinical populations and recruited research subjects may differ on a host of other diversity dimensions. Quite simply, with the exception of a few behaviorally oriented family systems approaches, such as multisystemic therapy, the efficacy of ESTs with racial, ethnic, and other cultural minority groups has not been substantiated (Atkinson et al., 2001 ; La Roche & Christopher, 2008). Although effective multicultural helping largely hinges on "compatibility of [the client's and counselor's] beliefs about the causes of, and solutions to, psychological problems" (Atkinson et al., 2001, p. 569), such beliefs are highly culturally contingent. Sue and Sue (1999) stressed that traditional counseling approaches that dominate lists of ESTs typically bear the imprint of Western, European American, and middleclass values privileging individual autonomy and satisfaction over the interpersonal harmony and collective responsibility emphasized by many other cultural groups. Consequently, the multicultural competencies endorsed by the Association for Multicultural Counseling and Development emphasized that "culturally skilled counselors ... are not tied down to only one method or approach to helping" (Arredondo et al., 1996, p. 70), suggesting the possibility of conflict between such requisite flexibility and the adherence to protocol demanded by ESTs.
Multicultural competence is closely linked to social justice concerns (Constantine, Hage, Kindaichi, & Bryant, 2007), including marginalization and inequalities related to poverty, race, ability, sexual orientation, gender, and so on, as well as the corresponding goals of client empowerment and systemic change. However, given the preponderance of CBTs, EBPs for DSM disorders are overwhelmingly individually, rather than ecologically oriented, generally resulting in minimal attention to contextual and sociopolitical influences on clients' mental health. In summary, the various philosophical inclinations of EBPs seem to present considerable dilemmas for the counseling profession, which has historically stood at the forefront of the field in expounding the significance of cultural diversity and social-systemic conditions to client concerns and the practice of professional helping (Constantine et al., 2007).
* Toward an Inclusive Vision of BPs in the Counseling Profession
In light of the problems associated with narrow approaches to EBP, we are highly encouraged by the support within the counseling field for a "generous and inclusive understanding of best practices--one that allows for multidimensional and multimethod perspectives" (Marotta & Watts, 2007, p. 501), and we elaborate on various aspects of this understanding as follows. It is clear that one of the greatest barriers to a more inclusive vision of BPs is the ideological dissension between modern and postmodern positions. Advocates of EBP have criticized what they view as an extreme relativist stance applying to both the individual and cultural, "in which few if any general principles are viewed as applying to the uniqueness of each case" as well as theoretical views, in which "all perspectives are held to have equal value" (O'Donohue & Oser, as cited in O'Donohue & Fisher, 2006, p. 6). Conversely, postmodernist scholars (Hansen, 2006; Slife et al., 2005) decry the extreme universalist attempt to mandate particular approaches to knowledge and practice alleged to be "objectively" superior, as if free of the subjectivities and limitations outlined previously. We propose a more balanced position, holding that although certain practices may be appropriately judged to be more useful, and thus better than others, the validity of these determinations is highly contingent on the degree of freedom from epistemological, theoretical, and institutional bias. As we discuss further, a more inclusive and equitable system of BPs would ask different types of questions; incorporate diverse research methodologies; and, ultimately, consider client characteristics and counselors' clinical expertise as well as the aforementioned conventionally conceived empirical evidence.
Expanding Lines of Inquiry: Empirically Supported Relationships
As noted previously, investigating and prescribing theoretically narrow treatments based on uncomplicated Axis I, DSM-IV (American Psychiatric Association, 1994) diagnoses is of limited use, particularly given that most clients have comorbid diagnoses and most clinicians practice in a theoretically integrative or eclectic fashion (Beutler, 2000; Marquis, Tursi, & Hudson, 2010). An alternative line of inquiry would "focus more on understanding the basic principles and strategies of change than on theoretically linked techniques" (Beutler, 2000, p. 1002), thus marking a shift away from establishing ESTs and toward identifying those aspects of treatment that are empirically informed (Westen et al., 2004). Empirically informed principles and strategies would examine the dynamics of and interactions between variables involving the client, practitioner, and treatment context in addition to the treatment model (Beutler, 2000). Relationship factors, for example, compose a particularly important set of variables that have been almost entirely ignored in EBP guidelines to date. Seeking to remedy this critical omission, a large research undertaking has used extensive meta-analytic reviews in an attempt to discern the various aspects of empirically supported relationships (Norcross, 2002, 2010). Some of the principal findings include robust empirical support for the alliance, empathy, goal consensus, and other forms of collaboration as elements of effective relationships. Support was also garnered for tailoring the therapeutic strategy (e.g., level of directiveness) to client characteristics, including level of reactance, internalizing/externalizing coping style, treatment preferences, and stage of(readiness for) change (Norcross, 2010). Such meta-analyses serve as an example of how understanding the transtheoretical nuances of the counseling relationship, an aim that speaks to the heart of the counseling profession, can potentially provide a vehicle for enhancing actual counseling services. More inquiry into relationship factors and other aspects of counseling process that are more difficult to assess than behavioral outcomes could provide important therapeutic insights currently eclipsed by the focus on more easily measured outcomes.
Methodological Pluralism: What Counts as Evidence?
One of the most important and controversial questions concerning EBP is, What constitutes valid and sufficient evidence? Despite the fact that the term scientific is often interpreted to mean empirical or experimental, in its true sense, the term encompasses a much wider range of investigative approaches applied systematically according to criteria for valid methodology and evidence (Slife et al., 2005). Many of the criticisms and limitations of EST research have resulted from the excessive weighting of RCTs in the evaluation of evidence (Edwards et al., 2004). Although experimental designs are appropriate for certain research questions, there are many viable methodological alternatives that illuminate different aspects of clinical problems and the therapeutic change process (Marquis & Douthit, 2006). These alternative methodologies are better suited to measuring various outcomes that are essential to a comprehensive understanding of counseling process (e.g., the treatment response of an individual, the success of an agency service program).
One constructive methodological development in recent years is the increased attention to the need for naturalistic outcome research (American Psychological Association, 2005), which measures the effectiveness of counseling services as delivered in actual practice settings and thus provides the external validity lacking in well-controlled, yet artificial, efficacy studies. These naturalistic effectiveness studies offer a financially and methodologically viable means of studying service outcomes in organizational treatment settings and can be used to demonstrate results to funders, consumers, or other third parties (Granello & Hill, 2003). Readers are referred to Granello and Hill (2003) for an overview of the design and implementation of such research.
In addition to relying excessively on efficacy research, Edwards et al. (2004) convincingly argued about EBP inquiry's "failure to recognize the significance of case-based research in the process of building clinical knowledge" (p. 589). Case-based research includes both intensive narrative case studies and quantitative single-case experiments. The latter, commonly known as n = 1 (or interrupted time series) research designs, allow for systematic analysis of outcome in individual clinical cases by collecting and comparing data during baseline and intervention conditions (Sharpley, 2007). Although there are indeed important limitations to case research, it offers numerous benefits, including more detailed illumination of the component effects of therapeutic process over time and a greater relevance to naturalistic conditions (Edwards et al., 2004; Messer, 2004). In short, case research provides a means of expanding the evidence base of the counseling discipline (Sharpley, 2007) as well as sharing and applying scientifically grounded clinical knowledge (Messer, 2004).
A truly comprehensive system of BP investigation would also use qualitative research methods. The particular nature of the inquiry should guide the methodological considerations rather than having an inquiry that is fundamentally methodologically driven. Thus, if practitioners are interested only in a person's observable symptoms and behaviors, then a narrow form of empiricism is justifiable. If, on the other hand, internal dynamics such as self-concept, meaning, and life narratives are the subjects of study, then qualitative research methods are more suited to the task. Simply because a method is qualitative, and in certain respects more "subjective," does not mean it is not a rigorous method capable of a considerable degree of reliability within communities competently trained to work with these forms of inquiry (Marquis & Douthit, 2006).
Different epistemologies and methodologies, each of which has strengths and limitations, complement rather than contradict one another (Marquis & Douthit, 2006). Therefore, appropriately matching a pluralism of methodologies to specific investigative questions (Slife et al., 2005) will help advance the profession's understanding of counseling process and outcomes far more than will reliance on one narrowly defined form of empiricism. Ultimately, drawing on diverse methods of inquiry has the potential to expand the scope of what may be studied and thus discovered, enhance the applicability of research findings to real counseling situations, and "level the playing field" such that historically excluded epistemologies and theoretical models can contribute to BP knowledge.
Rethinking the "Best" in BPs
In identifying the purpose of BP investigation, McGowan (2003) referred to the attempt to answer "one or more aspects of Gordon Paul's famous 1967 question, paraphrased as: What works best for this particular client with this particular problem with this particular counselor in this particular setting?" (p. 387). McGowan's conceptual framework calls for a system of inquiry whose parameters and objectives transcend the narrow and somewhat misleading EST concern with the best treatment for a particular diagnosis. As stated in a recent American Psychological Association (2005) report, "ESTs start with a treatment and ask whether it works for a certain disorder or problem under specified circumstances," whereas "[EBP] starts with the patient and asks what research evidence ... will assist the [practitioner] to achieve the best outcome" (p. 6). This systematic pursuit of empirically informed counseling may be the enduring contribution of the EST and EBP movements, one that is vitally necessary for the counseling profession. However, a growing chorus of voices seeks to remind us that counseling is both an art and science, each of which is irreducible and invaluable to effective practice. Accordingly, there is a growing recognition that EBP needs to account and allow for the experience, judgment, and expertise necessary to "apply these scientific principles to the complexity of lives and ... find creative and new ways of making them relevant and workable" (Beutler, 2000, p. 1006). Clinical expertise, as a repository of cumulative knowledge and experience, would thus appear to be a valuable source of BPs recommendations (Marotta & Watts, 2007; Norcross, 2010).
In working toward an inclusive vision of BPs in counseling, we recommend taking a page from a recent report on EBP produced by the American Psychological Association (2005), which defined EBP as "the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences" (p. 5). Whereas the EST movement has tended to focus almost exclusively on "best research," a truly comprehensive and well-rounded formulation of BPs would rest on all three pillars of EBP (best available research, clinical expertise, and a consideration of clients' nondiagnostic characteristics). Constructing and applying BPs in this manner will help researchers and practitioners to overcome false dichotomies and instead promote complementary admixtures of individual and universal data as well as scientific and humanistic perspectives (Messer, 2004). In other words, the person of the counselor, client characteristics, and the therapeutic relationship act in concert with ESTs to determine effectiveness; thus, promulgating BPs without consideration of these other variables is incomplete and misleading (Norcross, 2010).
Finally, it is important to recognize that however promising, EBP is still a youthful enterprise that will require much more development and refinement (Garcia, as cited in Marotta & Watts, 2007). O'Donohue and Fisher (2006) presented a list of no less than 20 open questions concerning EBP. Therefore, it seems imperative to avoid hasty declaration of certain practices as best, lest the profession restricts rather than expands clinical knowledge by prematurely foreclosing on alternative perspectives and approaches. Ultimately, it is our hope that BPs in counseling will continue to be circumscribed as a rigorous but broad-based concept seeking the integration of evidence from methodologically diverse and practically relevant research that considers clinical expertise, a responsiveness to personal and cultural differences, and an appreciation for clients' voices. Such an inclusive BP endeavor, bold in its objectives yet cautious in its conclusions, can encompass both modernist and postmodernist contributions and inform the profession of counseling to the benefit of its clients.
* Summary and Implications
We have attempted to communicate a balanced vision of BPs for the counseling profession, one that recognizes both its strengths and limitations. Although we recognize the need for evidence and accountability with regard to the quality and effectiveness of the counseling services counselors provide, we also see a need to remain critical of the pitfalls ensuing from the assumptions and narrowly focused methodology underlying traditional EST research and corresponding EBP directives. The take-home message is that counselors, counselor supervisors, counselor educators, and the American Counseling Association can each play important roles to ensure that BP conclusions are both sound and impartial.
What might this sound and impartial vision look like in practical terms? We suggest that counselors and supervisors pursue (aided by the Best Practices section of the Journal of Counseling & Development) research that can fruitfully inform practice yet retain a healthy skepticism of institutionally dominant EBP findings. For example, bear in mind the critical differences between centering research on diagnoses and treatments rather than on clients, counselors, and the therapeutic relationships and strategies they cocreate, as well as the multicultural imperative to avoid a one-size-fits-all approach. We urge counselor educators to take a more active role in performing and promoting smaller scale research (such as quantitative single-case experiments and qualitative intensive single-subject case studies) that affords a more nuanced appreciation of how BPs are pertinent to counseling values such as diversity, social justice, and developmental and holistic wellness considerations. Finally, we recommend that the American Counseling Association lead the helping professions in encouraging insurance and other third-party providers to recognize the limitations and false guarantees of ESTs (especially the relative lack of evidence for their effectiveness with diverse groups), as well as advocating for more theoretically and methodologically inclusive BPs that also take into account clinical expertise and client differences. In the face of dominant ideologies, market pressures, and vested institutional interests, counseling professionals need to work in concert to ensure that BPs are being constructed and applied in a manner that will genuinely serve each client's well-being.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychological Association. (2005). Report of the 2005 Presidential Task Force on Evidence-Based Practice. Washington, DC: Author.
Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalization of the Multicultural Counseling Competencies. Journal of Multicultural Counseling and Development, 24, 42-78.
Atkinson, D. R., Bui, U., & Mori, S. (2001). Multiculturally sensitive empirically supported treatments--An oxymoron? In J. G. Ponterotto, J. M. Casas, L. A. Suzuki, & C. M. Alexander (Eds.), Handbook of multicultural counseling (2nd ed., pp. 542-574). Thousand Oaks, CA: Sage.
Beutler, L. E. (2000). David and Goliath: When empirical and clinical standards of practice meet. American Psychologist, 55, 997-1007. doi: 10.1037//0003-066X.55.9.997
Busch, F. N., Milrod, B. L., & Sandberg, L. S. (2009). A study demonstrating efficacy of a psychoanalytic psychotherapy for panic disorder: Implications for psychoanalytic research, theory, and practice. Journal of the American Psychoanalytic Association, 57, 131-148. doi: 10.1177/0003065108329677
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7-18. doi: 10.1037//0022-006X.66.1.7
Constantine, M. G., Hage, S. M., Kindaichi, M. M., & Bryant, R. M. (2007). Social justice and multicultural issues: Implications for the practice and training of counselors and counseling psychologists. Journal of Counseling & Development, 85, 24-29.
Douthit, K. Z. (2006). The convergence of counseling and psychiatric genetics: An essential role for counselors. Journal of Counseling & Development, 84, 16-28.
Doyle, A. B. (1998). Are empirically validated treatments valid for culturally diverse populations? In K. S. Dobson & D. D. Craig (Eds.), Empirically supported therapies: Best practice in professional psychology (pp. 93-103). Thousand Oaks, CA: Sage.
Edwards, D. J. A., Dattilio, F. M., & Bromley, D. B. (2004). Developing evidence-based practice: The role of case-based research. Professional Psychology: Research and Practice, 35, 589-597. doi: 10.1037/0735-7028.35.6.589
Gergen, K. J. (1982). Toward transformation in social knowledge. New York, NY: Springer-Verlag.
Granello, D. H., & Hill, L. (2003). Assessing outcome in practice settings: A primer and example from an eating disorders program. Journal of Mental Health Counseling, 25, 218-232.
Hansen, J. T. (2006). Is the best practices movement consistent with the values of the counseling profession? A critical analysis of best practices ideology. Counseling and Values, 50, 154-160.
Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of Consulting and Clinical Psychology, 61, 434-440. doi: 10.1037/0022006X.61.3.434
Ingersoll, R. E., & Rak, C. F. (2006). Psychopharmacology for helping professionals: An integral exploration. Pacific Grove, CA: Brooks/Cole.
Ivey, A. E., & Ivey, M. B. (1998). Reframing DSM-IV: Positive strategies from developmental counseling and therapy. Journal of Counseling & Development, 76, 334-350.
King, J. H., & Anderson, S. M. (2004). Therapeutic implications of pharmacotherapy: Current trends and ethical issues. Journal of Counseling & Development, 82, 329-336.
Lambert, M. J. (2003). Psychotherapy outcome research: Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldstein (Eds.), Handbook of psychotherapy integration (pp. 94-129). New York, NY: Basic Books.
La Roche, M., & Christopher, M. S. (2008). Culture and empirically supported treatments: On the road to a collision? Culture & Psychology, 14, 333-356. doi: 10.1177/1354067X08092637
Marotta, S. A., & Watts, R. E. (2007). An introduction to the Best Practices section in the Journal of Counseling & Development. Journal of Counseling & Development, 85, 491-503.
Marquis, A., & Douthit, K. Z. (2006). The hegemony of "empirically supported treatment": Validating or violating? Constructivism in the Human Sciences, 11, 108-141.
Marquis, A., Tursi, M., & Hudson, D. (2010). Perceptions of counseling integration: A survey of counselor educators and supervisors. Journal of Counselor Preparation and Supervision, 2, 61-73.
McGowan, A. S. (2003). New and practical sections in the Journal of Counseling & Development: Information for the prospective author and the readership. Journal of Counseling & Development, 81, 387-388.
Messer, S. B. (2004). Evidence-based practice: Beyond empirically supported treatments. Professional Psychology: Research and Practice, 35, 580-588. doi: 10.1037/0735-7028.35.6.580
Norcross, J. C. (2002). Empirically supported therapy relationships. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 3-32). New York, NY: Oxford University Press.
Norcross, J. C. (2010, May). Psychotherapy relationships that work II: Evidence-based practice and practice-based evidence. Paper presented at the meeting of the Society for the Exploration of Psychotherapy Integration, Florence, Italy.
O'Donohue, W. T., & Fisher, J. E. (2006). Introduction: Clinician's handbook of evidence-based practice guidelines: The role of practice guidelines in systematic quality improvement. In W. T. O'Donohue & J. E. Fisher (Eds.), Practitioner's guide to evidence-based psychotherapy (pp. 1-23). New York, NY: Springer.
Sanderson, W. C. (2003). Why empirically supported psychological treatments are important. Behavior Modification, 27, 290-299. doi: 10.1177/0145445503027003002
Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports" study. American Psychologist, 50, 965-974. doi:10.1037/0003-066X.50.12.965
Sharpley, C. F. (2007). So why aren't counselors reporting n = 1 research designs? Journal of Counseling & Development, 85, 349-356.
Slife, B. D., Wiggins, B. J., & Graham, J. T. (2005). Avoiding an EST monopoly: Toward a pluralism of philosophies and methods. Journal of Contemporary Psychotherapy, 35, 83-97. doi: 10.1007/ s10879-005-0805-5
Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd ed.). New York, NY: Wiley.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum.
Wampold, B. E., & Bhati, K. S. (2004). Attending to the omissions: A historical examination of evidence-based practice movements. Professional Psychology: Research and Practice, 35, 563-570. doi: 10.1037/0735-7028.35.6.563
Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69, 875-899. doi:10.1037/0022-006X.69.6.875
Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631-663. doi:10.1037/00332909.130.4.631
Andre Marquis, Kathryn Z. Douthit, and Ari J. Elliot, Department of Counseling and Human Development, University of Rochester.
Correspondence concerning this article should be addressed to Andre Marquis, Department of Counseling and Human Development, University of Rochester, Warner School, PO Box 270425, Rochester, NY 14627-0425 (e-mail: firstname.lastname@example.org).
|Printer friendly Cite/link Email Feedback|
|Author:||Marquis, Andre; Douthit, Kathryn Z.; Elliot, Ari J.|
|Publication:||Journal of Counseling and Development|
|Date:||Sep 22, 2011|
|Previous Article:||Counseling Muslim Americans: cultural and spiritual assessments.|
|Next Article:||Use of Ifa as a means of addressing mental health concerns among African American clients.|