Michelle Dean

The Illusion of “Evidence-Based” Practices

Posted by Michelle Dean, Sep 20, 2010 13 comments


Michelle Dean

Michelle Dean

As cited in the Green Pages: Does the intense federal focus on “evidence-based” practices results in a premature dismissal or disregard for therapeutic practices that are beneficial to many populations?

Let’s face it, value placed on evidence-based practices is not just because of federal funding but a cultural bias that values scientific method, in an attempt “to prove” or “validate” what is real. The economic origins of this long-standing bias are beyond the scope of this blog but none-the-less the question remains: How does art therapy fit in this model?  Well, not so well due to its very symbolic nature.  And why should it?

Although there have been great efforts to promote and conduct evidence based treatment (EBT) and research in art therapy, it may be said that art therapy (or any therapeutic relationship for that matter) is a symbolic process, which is embedded in a relation-based therapeutic practice. So when symbols or people in a relationship are taken out of context they lose their meaning. For example, it would be like taking two people in love and removing one person in the couple and plopping them down with someone else and expecting the same amorous feelings – this is clearly absurd.  Sociologist, Durkheim discusses the advantages of being in a relationship as a reduced risk factor to suicide. However, when an art therapist is actually working with a patient, the statistical risk factor is far less important than the qualities and meaning of the relationship. And it is those relationship qualities that are so elusive to measure.  Elkins debunks the validity of empirically supported treatments, by uncovering the insidious economic gains for the insurance and pharmaceutical companies. And Seife points out, in his soon to be released text, Proofiness: The Dark Arts of Mathematical Deception, “Our society is now awash in proofiness. Using a few powerful techniques, thousands of people are crafting mathematical falsehoods to get you to swallow untruths”. Who is to say that what is being conveyed by the statistics of EBT are even measuring what they are claiming?

Although objective observation may be desirable in evidenced-based therapies, it is not truly possible in this relational, creative, and symbolic context. One cannot remove the therapist, or be replace by another, as no two therapists are the same person.  And the artwork that emerges in the session does so because of the surrounding conditions: time, place, therapist, and other numerous clusters of factors, some easily definable other not so. The observer or researcher cannot ever truly remove himself or his biases from the equation.  Gilfoy, states EBT’s are a modernist concept, which “[…] seeks universal absolutes that derive from a single narrative trajectory that assumes its truths are superior to others”. Scientific Methodologies do have their place in hard-science but to reduce or generalize results to patient care or other symbolic manifestations in a therapeutic context or in turn to deny services or payment for services because they do not fit neatly in this economically driven method, may actually do more harm than good; one could even argue, they are unethical in practice due to their deception.  So although art therapy may not fit neatly into the current psychological trend of EBT, it does not mean that its significance is lesser or that its benefits are not profound.

“Promising practices” is a concept, which has only begun as a means to document and highlight the effectiveness of the relationship, the interaction achieved in multidisciplinary treatment, and a host of creative, symbolic, and environmental factors, which may be a more reasonable way to inform support for a soft-science practice such as art therapy. In the meantime, without question, the real underlying drive and pervasive use of a data measurement is used to attract funding and monies.  How else might one draw  economic viability for the work of art therapists, without losing sight of the importance of the symbolic nature of the work?

References:

Web

Documents

  • Durkheim, E. (1979). Suicide: A study in sociology. New York: The Free Press.
  • Gilfroy, A. (2006). Art therapy, research and evidenced-based practice. London: Sage Publications.
  • Seife, C. (2010). Proofiness: The Dark Arts of Mathematical Deception. New York: Viking Adult.
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13 responses for The Illusion of “Evidence-Based” Practices

Comments

Marc says
September 21, 2010 at 11:46 am

Attempting to quantize art therapy or anything that resides in the mental realm, is difficult. I don't think there is a person alive who would argue that dreams are something we all experience - yet if challenged to prove that they "exist," no one could. Likewise, how does one quantify love, hate, anger, sadness, etc.?

After the September 11 attacks on the World Trade Centers, an entire nation was congruent in feeling anger and sadness over what had happened: Yet, even among 330 million people, any scientist would be hard-pressed to find proof that those feelings were, "real".

As a patient of art therapy, an artist and a true believer in the significance of symbolism in life, the call for evidence-based therapies, to me, feels like pressure from the Insurance and Pharmaceutical industries to further quantize and label the therapeutic process so that patients can be diagnosed, categorized, sold policies, sold pharmaceuticals and be billed accordingly.

There are benefits to a using a scientific approach in any field. Measurable data allows the community to study problems, understand the challenges and improve solutions.

That being said, evidence-based practice sounds more like lab work than it does the humane, compassionate and personal attention that most therapy patients seek. Considering how much of the therapeutic process deals with emotions, EBT seems to have little to do with healing and much more to do with paperwork and profits.

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September 21, 2010 at 3:45 pm

This reply is to Michelle and Marc
To say that EBP is an illusion or lab work is as weak an argument against it as those that insist we must have evidence based outcomes if we are to be given "our place in the sun".
There is no question that the therapeutic relationship can not be quantified. And it is a major aspect of every therapeutic process. That said, I must also say there are certain aspects of art therapy that can be quantified, documented with legitimate research measures and reported.
I have published case studies that are anecdotal and I have published studies citing data analysis supporting or not supporting sound hypothesis. Examples- case studies in my books (found on Amazon.com); articles listed on my web site. published results of the normative study of my assessment (new book on Amazon); a research project with the school of nursing, at FAU in Boca I conducted 12 art therapy sessions with 20 depressed seniors as a control group for 3 groups: walking in a japanese garden. having guided imagery in the garden and art therapy at the college. There was a depression scale and statistical results and I also evaluated my group's images with my assessment criteria. (in process of writing this up)
The poinmt I am making is that this is ALL art therapy. And we need it all to define this unique and remarkable profession. Having discussions about the importance or imossibility of EBP or outcomes does not help us. I repeat it is all important and we need to define when, Marc's words, we do some lab work and when in Michelle's words, it may be an illusion to apply it.
And for the record, what we do need, is leadership that will make us recognized as a credible profession - not a sub-something of another discipline.

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James Hawking, MD says
September 22, 2010 at 8:28 pm

Thank you, Dr. Levick, for isolating some of the key points that are being missed here. My wife is an art therapist, so I have an interest in this area and her work.

This may seem harsh, but those of you who believe that phenomenological or grounded research studies are going to show evidence of art therapy's effect seem to be avoiding the real issues. Since my wife and I review the literature for art therapy research on a regular basis, where are all these doctoral dissertations [the "rich" ones, full of data] that Mrs. Phillips and others are referring to? In reality, the types of doctorates that many art therapists have apparently obtained from institutes yield "projects of excellence". They have not really turned out any major research contributions that have supported the field in a meaningful way.

I really want to see art therapy become recognized as a valid treatment; I am on your side. But when conversations digress to the same old conversation about "you cannot measure the richness of what happens between client and therapist" or the impact of art on health, you are simply avoiding what needs to be accomplished. Or perhaps you do not understand some of the ways research is conducted, that good research on mental health practices comes from both qualitative and quantitative measures.

Thank you Dr. Levick for sharing your research; other doctors on this discussion, what did your doctoral dissertations contribute to moving the field of art therapy ahead? I am very curious to read more now.

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September 23, 2010 at 12:46 pm

Levick, M.F. (1980) Group dynamics of dependency and counter- dependency manifested in drawings of graduate art, movement and music therapy students.In The Arts in Psychotherapy. New York: Ankho International. 7, . 87 - 96.

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September 23, 2010 at 1:27 pm

Dr. Hawkins,
I wrote a reply, ending with the reference above and now note that only this reference appears.
I am writing again to clarify what I said and share more.I hope this will not disappear.
I do appreciate your thoughts and agree with your wishes for more art therapy research. I do not think the therapeutic relationshiup can be analyzed quantitatively. I do think qualitative research in this area can be employed and should be encouraged. In fact, this is included in my paper (in process)about group art therapy with depressed seniors. Two years later, some members still check in with me.
I do wish more medical doctors would recognize the contributions art therapists could offer woking with their patients. Coincidentally, my husband is a retired oncologist,but during our years in Phila.,he and his partners referred patients, and sometimes their families to me. And some of my art therapy students did their internships working with their hospitalized patients. A wonderful experience that lead to thesis projects.
Your comments reminded me of the research I did in 1980. While this work was conducted with students I taught in a core course in the Creative Arts Therapy Program at Hahnemenn U (now Drexel U), the impact the (professor)had on dependence/counter-dependency responses manifested in the graphic imaages of each group was hypothesized and analyzed. The reference is above.

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Christine Ruberti says
September 21, 2010 at 11:35 am

I think finding viability in the field of art therapy while preserving its symbolic nature is a good question to contemplate. The identity of the art therapist may also relate to the question. How do we describe art therapy to other people and how to we define ourselves in the profession? There is the role of the artist and the role of the therapist.

Art therapy as an alternative therapy as its benefits in its more personal, client centered approach. It has been known to feel more natural, and less clinical than standard medical practice. More recently, art therapy can viewed as a modality that can support more standard medical practices. It can provide rich information that can serve as a clue or a puzzle piece in determine a client’s pathology and for treatment planning.

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September 21, 2010 at 9:52 pm

Michelle! I am so glad to find your blog and so very glad you have initiated this discussion. I am not an Art Therapist. I am a Licensed Professional Counselor who happens to use some of the creative arts in my practice. But, of course, this discussion of EBT is relevant to all of us in the mental health professions.

I so appreciated Joan and others' reminders that there are many types of evidence that support the use of the creative arts and depth therapies. It's just that many who preach that EBT is "the way" choose to place different values on those streams of evidence that are not so easily quantified. Call me crazy but it seems that once again the "hard sciences" have set the rules and the "softer sciences" are silly enough / scared enough / gullible enough to play by them.

Like you and Mandy have suggested, we should be focused on a THIRD WAY of seeing and reframing this issue rather than picking sides.

Again, so pleased to find your blog tonight. I'll be passing the URL along to my colleagues and putting you in my feed reader.

Tamara G. Suttle, M.Ed., LPC
http://www.AllThingsPrivatePractice.com
http://www.TamaraSuttle.com

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September 21, 2010 at 9:06 pm

There is worthy research that has been done and much more that can and needs to be done for art therapy. I must agree that the research methods Joan mentions: narrative, phenomenological, and qualitative are better suited for the work of art therapy and provide a fuller picture of the multi-faceted experience. There is no argument that there are benefits to the hard-sciences as they apply to those things they can best measure, such as chemistry. But when there is an attempt to measure a cup of milk with a yardstick, there is a problem.

To clarify, I am advocating for a deeper grounding in the knowledge of the fields of art, human relations, symbolic function, and psychological processes as well as many other related fields for art therapy research and practice. Thus, by doing so, produce research, which employs methods that best fit the work instead of trying to participate blindly in a smoke and mirrors game to falsely “secure a place in the sun”. This I believe would be energy better spent.

Respectfully submitted,
Michelle

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Terry Tibbetts says
September 23, 2010 at 2:19 pm

I am an art therapist who is often disappointed in the defensiveness of those in our field who disparage EBT. In reading this discussion thread, however, I am also struck by the lack of knowledge that most responders appear to have regarding the formalized outcome of the EBT "debate." Read Porter & Turner, "Taking Charge: An Introductory Guide to Choosing the Most Effective Services for the Mental, Behavioral, and Emotional Health of Youth Within a System of Care" (2006). The document clearly delineates "evidence-based interventions" from "effective practices."

While art therapy would not be defined as an EBT/EBI for lack of sufficient evidence (despite the outstanding work of Dr. Levick and others in this area), is art therapy an "effective practice?" Absolutely - "treatment interventions that families and service providers believe can help youth and their families but generally have not gone through repeated studies by clinical researchers...An example of an effective practice is systemic family therapy, in which the entire family is treated, as opposed to just the youth. It is considered an effective practice because many families, youth, and health professionals describe it as an intervention that works." (p. 3)

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Mandy says
September 21, 2010 at 5:17 pm

As a current undergraduate student pursing Art Therapy as a future career, I have found myself stumbling upon this debate throughout my college career. I now find myself stuck in between the Psychology aspect of the practice as well as the Fine Arts aspect of it. We are offered the choice to either major in Psychology with a concentration in Art Therapy, or to major in Fine Arts with a concentration in Art Therapy. Being a psychology major at a school that heavily relies on research based practices, I cannot argue that I have seen the value that evidence based research provides. However, I do not believe that we are always going to have the answers to everything. In fact, I'm absolutely sure of it. I do agree that for what we are able to measure (i.e. physiological & behavioral measures) that it could greatly benefit the Art Therapy field and the clients that are served in it. Currently, I work as an activities assistant in a nursing home with patients that have Alzheimers and other forms of Dementia. I am able to witness the calming effects that art has on the patients, but sometimes, I do find myself wondering: to what extent could creative therapies benefit this population?

Being a very spiritual person, I know there are feelings and emotions that just cannot be quantified, and I have witnessed these such emotions through my own artwork. However, I am also a very daring person who has a desire to change the world, and if that means proving to those in the psychology world that are not convinced of the beneficial values of Art Therapy, then I believe it can happen. If research is what they want to see, I think it's possible to offer as much as we can, even though the true spiritual and emotional value that art is able to provide can never be measured.

This debate alone has been very frustrating for me, especially since I have Psychology, Fine Arts, and Art Therapy teachers all at the same time with completely different views. Needless to say, I feel slightly inferior to posting my opinion due to my confusion. While I still have much to learn, I believe that all creative therapies deserve to be valued and respected, even if that means allowing Art Therapy to preserve the symbolic quality of its practice.

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September 20, 2010 at 10:27 pm

What an excellent discussion. While recognizing the limitations of requiring "evidence based" practice, I also think we need to expand what constitutes "evidence" and realize there are valid academic research approaches that are not completely statistically based or scientific in the oldest meanings of that word. I am referring to narrative, phenomenological, grounded, and other forms of research that are accepted for doctoral research and as producing "evidence", albeit from differing theoretical perspectives. Being boxed into a purely "scientific" corner will never address the rich outcomes and evidence that truly exist in our field. Some "evidence based" data is merely patient satisfaction or outcome data, and art therapists could produce volumes of that if we took the time.

Taking the time is another issue in a very practice and applied field such as ours, with a small cadre of researchers at most. Most art therapists are practicing clinically and in community, educational and medical settings and are not researchers per se. A rich area to discuss and thanks for opening this up.

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September 22, 2010 at 9:33 pm

I am not suggesting abandoning all art therapy research qualitative or otherwise, the blog entry was addressing the sentence stated in the Green Paper: “Does the intense federal focus on ‘evidence-based’ practices results in a premature dismissal or disregard for therapeutic practices that are beneficial to many populations?” It seems to me, there is an over-valuation of EBT, or an almost Svengali effect, and that as a culture, there is a bandwagon mentality due to fear of lack of funding or economic gains (i.e., join or be left out or another popular, polarized view: You are either with us or against us). I am urging great caution in becoming overly polarized or over-investing in the current EBT movement, with the promise of the making ourselves “real” or as Myra stated, “our place in the sun”, my concern is that there is too much one-sidedness and a real loss of the symbolism and the cultivation of the therapeutic relationship that is at the heart of what we do as clinicians. Research and clinical practice are not one in the same, but there obviously is overlap in some places; some research methods lending themselves more or less to this overlap seem desirable for a more balanced representation. If we remain centered in a multitude of methods that may better meet our research needs, we will not lose the essence of our unique and multi-faceted identity.

NB: My blog post was not in anyway intended to be a criticism of any art therapy research that has been, is, or will be done; it was a piece about not getting swept away in an over-valuation of EBT and current cultural values, and begins to allude to the insidious shadow in this culture value.

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Megan Van Meter says
September 20, 2010 at 5:17 pm

Thanks for addressing this, Michelle! Last fall I was blessed to be at a conference for school psychologists and hear one of the presenters, who primarily addressed EBT to an EBT-hungry crowd, remind everyone that there are also highly effective forms of treatment that don't fit into the EBT study methodologies. She added that just because no "EBT data" exists on these treatments doesn't mean the treatments are ineffective. If only more people were aware of this.

Although I would push for more empirical research in the field of art therapy for obvious reasons, I would also have to question the institutions and mental health practitioners who insist that nothing is valid until it can be backed by strong stats. This sounds a little like fear talking...as though a set of numbers is a security blanket that excuses a therapist from having to develop a strong intuitive skill set/good clinical judgement and excuses administrators from having to trust the capabilities of the clinicians who work for them. An art therapist friend of mine had been working at a children's shelter for years when a new supervisor came along and decided that only verbal cognitive-behavioral therapy, an EBT, would be used with the children and that my fried would no longer bear the title of art therapist or be allowed to provide art therapy services (apparently the supervisor never realized that art therapy can be provided from a cognitive-behavioral perspective). Fortunately my friend soon found work elsewhere, but the children at the shelter got stuck with verbal cognitive-behavioral therapy because the supervisor felt comfortable with the stats behind it. A sad story indeed.

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