Does diagnosis matter?
What about the treatment approach?
Applying particular therapeutic methods to specific psychiatric diagnoses is the considered by many a “best practice”–the core of what some label, “empirically-supported” (EST) or “evidence-based psychological treatments” (EBPT).
Now, imagine a place where diagnosis and prescriptive protocols are not required or even considered essential to clinical practice. A place where practitioners are free–even encouraged–to focus on helping people in whatever way works. More on that in a moment.
In the meantime, consider a study just out in the Journal of the American Medical Association (JAMA). Back in 2004, the lead author coined the term, “psychological treatments,” arguing that the future of the field depended on creating a formulary of “psychological treatments…matched to specific forms of pathology.” The impact of this idea on clinical practice is nothing less than staggering. Around the world, practice guidelines and funding for services are based on and restricted to methods applied to specific psychiatric diagnoses.
Participants in the newly released study either were treated with an approach specifically designed for their particular diagnosis or a generic alternative. The results? No difference in outcome at termination or 6-month follow-up! Said another way, diagnostic-specific protocols did not improve the effectiveness of treatment. In their place, the authors promote “transdiagnostic treatment protocols”–a term, I know you will be hearing more about in the future. No need to be confused (or impressed) by the sophisticated sounding name. Given decades of research showing all psychological approaches work equally well, this new one is, if nothing else, is a perfect example of “boldly charging forward into the past.”
The truly revolutionary implication of this study is not mentioned by the researchers: neither psychiatric diagnosis or diagnostic-specific treatments improve the outcome of psychological care. That was the promise. It failed.
Bottom line: it’s time to move on.
That’s exactly what psychologist Birgit Valla has done. The leader of a large, community mental health center in Stange, Norway, Birgit publically announced neither she or her staff would employ psychiatric diagnoses or standardized treatment protocols.
Was she brave or foolhardy? For sure, she had the weight of evidence on her side as well as an unwavering commitment to delivering effective services. Still, she was soon accused of failing to follow the “standard of care.” An investigated was started. Sanctions and a withdrawal of funding were threatened.
What happened next? Watch the interview to find out!
That’s it for now. Until next time,
Scott
Scott . Miller, Ph.D.
Director, International Center for Clinical Excellence
“If you persist in telling the truth, eventually you will be found out”. Oscar Wilde.
Thanks Scott and Birgit. Truly inspiring.
Hello Rob! And Hello Scott.
Birgit said:
“Before I knew what I was going to do. Now I don’t know what I’m going to do.” Lord save me from certainty!
This attitude, apart from being consistent with Lao Tzu’s principles, also comports with Rønnestad & Skovholt’s ideas on therapist reflexivity. They describe the reflexive therapist as someone who has developed the capacities of:
* Cognitive complexity
* Tolerance of ambiguity
* Openness to experience
* Process unpleasant and uncomfortable emotions
I’d say the first three at least are the very things the manualized approach tries to eliminate!
Julian
Professional and personal courage demonstrated. The headwinds of ideology and dogma are stiff, indeed.
Thank you Scott and Birgit, I have a few comments:
1) If it were not for an enlightened Health Minister in Norway, however brave you are you will probably of had to conform to the current constraints of “best practice” around the world and would not have been allowed to continue to practice…I believe.
2) Neuro-Linguistic Programming has advocated this way of working for 40 years. Academics back then said it would die out within a decade because of its cult like status and lack of standardisation, however, it is still with us and you can see why and how it represents what Birgit talks about at this link and short description:
3) NLP has to this day had push back from academic psychologists and clinicians, as indeed Birgit had in the year long investigation. The difference seems to be because NLP practitioners largely work outside the system, they do not have the pressure mental health practitioners have upon them to track their results. The answer NLP practitioners often give is “I know it works because I continue to have clients refer me and I see it working”. Their emphasis is often therefore on maintaining their business.
Thank you once again for an interesting story. With best wishes, Bruce
Thank you. What a refreshingly honest and vulnerable interview. So many take-aways about what it means to honour and empower the client – rather than the ‘system’.
Wow… I remember having lunch with David when I was a postdoc back in 2004, and we were all talking about psychological treatments back then. This is fascinating…
Lovely to hear this hopeful report from Norway. Now the rumour is spread… There is a ghost coming around, you can help people – help themselves – if you focus on the feed-back, not on the so called instruments…
Good luck, carry on and
Thank you for Inspiring !!
halsning fra Sverige // Jan
Intriguing and challenging at the same time. But very encouraging; I can imagine a time when simply being engaged with another person’s (ie., client’s) life issues in a professional sense and working with them rather than ‘on’ them will be recognised as a valid way to work.
Activity based funding? bah! Humbug!
Wow! Just watched your video, “Brave or Foolish.” It hit the nail on the head.
Fortunately, I’m a sole provider and do not take insurance so diagnosis is rarely an important consideration in helping others. Instead of evidence-based practice, I believe we should focus on “outcome-based practice” using the ORS an SRS.
For several years, I have been convinced that the ORS and SRS are absolutely crucial to providing effective services and for increasing My skill as a therapist. I totally agree, it’s not my agenda but the client’s needs that should guide therapy. This keeps me humble and achieves lasting positive outcomes for each individual.
Congratulation to you Birgit and your team!
Someone needs to say it out so that others can follow.
You are not alone in being naiv enough to think that helping people is more important than finding out a name for the problem that fits in to a system of diagnosis.
And yes it is important to work with clients feedback and results witch means that we have to be brave enough to look at ourselves, reflect and get out of our comfort zone!
Fantastic intervju, gave me lots of energy!!!
“Ever tried? Ever failed? No matter. Try again. Fail again. Fail better and successfully.”
(Beckett featuring FIT)
Hi Birgit and Scott
Great interview….inspiring….courageous….creative.
Thanks a lot
Thomas Villiger / CH
Scott – 1) at the Menninger Clinic in Topeka, Kansas we spent hours learning to administer the Rapaport Diagnostic Test Battery to the patient over three two hour test sessions: Wechsler, Rorschach, TAT – this battery was very helpful in understanding the patient and in treatment planning. The problem is not with diagnosis – but how diagnosis is conceptualized and carried out. — 2) The British psychoanalyst Wilfred Bion said, “Begin each session without desire, memory, or understanding” – a way for the therapist/analyst to enter into the session with an open frame of mind or reference. – Ira
When I talked to a psychologist on staff at U of MN counseling center in Twin Cities, I was told that they made a similar change in their work with university students.
Birgit,
I loved your interview, thanks! I am a psychotherapist, and have followed what you are suggesting — to follow the client’s lead, rather than the instruments — for decades. in my last workplace, i had to do this work “subversively”, as the agency was caught up in “evidence-based practice”, and was always coming up with more forms to fill out during the therapy hour.
I learned my approach in the 1970’s from Carl Rogers, who demonstrated in a compelling way that it’s the therapeutic alliance that matters, not the particular style of the psychotherapist. he also was primarily responsible for empowering the client as the driver of the therapeutic process. i had the honor of meeting Carl towards the end of his career. i’m sure he would be delighted with your work. Thanks.
Just to clarify that the JAMA article compared treatments for anxiety disorders. The total treated was just over 200 patients. This really cannot be generalized to the treatment and outcomes of all psychological concerns and issues.