Manuals don't treat patients

One of the unfair and unfounded raps on "evidence-based" care is that it means people have to live out of a book. That's like saying a clinical trial of penicillin is unreasonably limiting the use of antibiotics. Evidence-based means guided by well-gathered data and not tradition and myth. Will there be innovations and critique? Of course: that's how science works.

No one is asking that clinicians be forced to offer treatments they find inappropriate, or that they practice out of a book. Research does have to be done 'by the book' to assure consistency, but no reasonable person thinks that's the end of the clinician's job. That is a misunderstanding of what "evidence based" is supposed to mean. Those who feel threatened by being asked to be trained in evidence-based approaches are missing the point: improving their own skills and effectiveness.

But there is another mistake about evidence-based practice that June Alexander addressed yesterday in her blog: clinical skill and belief matter.
You can have a good, evidence-based treatment in theory, but if the therapist does not believe in it 100 per cent, it won’t work. ‘ED’ is smart and therapists need to be smarter. Allow one iota of doubt to appear – a facial expression can be enough to sow the seed of doubt – and ‘ED’ will grab it and magnify the doubt a million times over.


  1. June is so right, and I should probably comment on her blog as well as here. Not only does the therapist have to believe in what he or she is doing, he or she has to be well supported both by fellow clinicians (no good the therapist saying one thing if the nurse doing the weighing or the doctor in charge of the medical matters says another) and by the system around him or her. It's perfectly possible, although not particularly desirable, to practice from a dreary clinic with peeling wallpaper and the world's smallest waiting room, but if the phone system doesn't work or the secretarial support isn't there to send letters out in a timely manner parents are going to have an awful lot of difficulty believing that this is best practice care.

  2. A manual, while it can be seen as cut and dry, sets standards. It is a road map. It's up to the therapist to bring the human, caring element to it. A manual assures that certain procedures are implemented. As I work in the schools, all I can think of it our state standards for students (and now teachers as well). These standards, which are publicly available, try to inform all of what the expectations are and how to go about meeting them. They try to assure some uniformity of approach between professionals and expectations of the final outcome among recipients. They aren't perfect, and they change as we learn more, but they are the best we have got. It is still up to the teacher to put them into practice and each person has their own unique personality and style.

    I'd rather have that road map than none.


  3. It makes sense to try the evidence based approach first and if it doesn't work, then care can be more individualized. Plain and simple. It may not always work, but it should be assumed to be the best option at the starting gate. For now anyway. As we go along, there will be more information about those who don't respond to the first treatment and better types of evidence based care.

    But as a parent who was given evidence based care as a desperate plan B, only to find that it worked, I am a little bothered that it wasn't given to us at first. I always wonder if she has brain damage from some of the things that happened in the first round. Not to mention all the other things that were lost along the way.


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