Sunday, June 3, 2012
Mental Health Mantras versus Evidence-based Treatment: A Clash of Attitudes?
Several days ago I was at a meeting of the board of a non-profit child mental health group, and a discussion ensued which was both predictable in its attitudes and suggestive of behind-the-scenes beliefs in mental health and social services circles.
The discussion began when I brought up some concerns about bad advice to parents-- for example, a couple of things I’ve mentioned on this blog, like the idea that babies must be made to crawl, and the idea that instead of spanking one can put nasty tastes like Tabasco sauce on children’s tongues. I tried to float the idea that the group might publicly oppose such advice. But in fact I knew that this very pleasant, kind, energetic, well-trained, intelligent group of colleagues would not agree to any such thing, and sure enough they didn’t.
Several people carefully explained their reasoning to me.
One recommended that we should speak only in positive terms and about the right way to do things. If something negative must be mentioned, it should be more than balanced by a discussion of positive ideas.
Another member of the group suggested that when we object to an idea, we should not say that it’s wrong, but present it as an alternative point of view and describe our own views in the same way.
A third member gave the opinion that “talking about it gives it life” -- that we give energy to mistaken ideas by discussing them at all, and need to ignore them and emphasize better ideas.
Now, these were all attitudes that I have met many times before, and two of them stem from educational principles. Teachers are reminded again and again not to begin by telling students what is NOT true, but to focus on what is true, and to deal with common mistakes later if at all. In teaching and in behavior modification, professionals are advised to withhold reinforcement for undesirable behavior, to “catch them being good” and to reward desirable performance rather than calling attention to undesirable actions. These two ideas have to do with the best way to get a message across and to influence other people.
The third idea is not so much about how to persuade, but about moral conduct. Considering other people’s views as genuine alternatives to our own, however much we disapprove of them, can be morally right and even intellectually productive. It’s also possible that we can be more persuasive if we do not waste time arguing about whether a belief is totally unacceptable, or offending by our attitudes people whose co-operation we need.
As a general rule, these mantras of mental health and of social services apply pretty well to real life. Most people appreciate it if we “accentuate the positive” and treat their views as worthy of respect.
But what if there are beliefs and practices that are actually wrong and demonstrably harmful—or even wrong and harmless, but a waste of time and resources? Adults who molest children often have excellent rationales for what they do and believe they do no harm; should we treat their claims as just “a different point of view”? And if the molesters are in the wrong and should be stopped, why does the same reasoning not apply to less sensational harmful behavior and beliefs?
I understand very well that sermonizing and shouting about issues is less persuasive than cheerful proselytization of better methods. However, I believe it is a mistake to fail to point out to professionals working in mental health and social services that some ideas may be attractive but are nevertheless unsupported by reason or evidence.
I am especially concerned about these issues because I wonder whether they are behind the reluctance of many mental health and social services professionals to stress evidence-based treatments-- interventions whose effectiveness has been supported by several well-designed empirical studies. It was not long after the concept of evidence-based treatment came into mental health circles that the principle of an evidentiary foundation began to be diluted into “evidence-based practice”, in which “practice wisdom” and patient preferences were given equal weight with evidence of effectiveness, and the very definition of evidence-based treatment became so blurred that it came to mean little more than that a study had been done.
What’s the connection with my colleagues who want to stick to the positive, ignore the negative, and frame rejection of a treatment as an opposing point of view? You can’t consider the evidence basis of an intervention unless you are willing to say that the treatment was more or less effective than another treatment or than no treatment. You can’t assess any treatment accurately unless you pay attention to adverse events-- cases in which harm seems to have been caused by the treatment itself. In order to examine and report on the effectiveness of a method, you must be willing to talk about whether it worked as well, better, or worse than another method, not just about how good it was. You must be willing to talk about failures or adverse events, not to assume that they will go away if you don’t mention them. And you must be able to marshal and describe all the facts of your data and analysis as they support a considered opinion which is by no means simply a “point of view”.