Evidence and Non-Evidence Based Treatment Options

profiletashrifie
Handbook_of_Evidence-Based_Practice_in_Clinical_Ps..._----_Part_I_Overview_and_Foundational_Issues.pdf

4

Limitations to Evidence-

Based Practice

THOMAS MAIER

The promotion of evidence-based medicine

(EBM) or, more generally, of evidence-based

practice (EBP) has strongly characterized

most medical disciplines over the past 15 to 20

years. Evidence-based medicine has become a

highly influential concept in clinical practice,

medical education, research, and health

policy. Although the evidence-based approach

has also been increasingly applied in related

fields such as psychology, education, social

work, or economics, it was and still is pre-

dominantly used in medicine and nursing.

Evidence-based practice is a general and

nonspecific concept that aims to improve

and specify the way decision makers should

make decisions. For this purpose it delineates

methods of how professionals should retrieve,

summarize, and evaluate the available empir-

ical evidence in order to identify the best

possible decision to be taken in a specific

situation. So EBP is, in a broader perspective,

a method to analyze and evaluate large

amounts of statistical and empirical infor-

mation to understand a particular case. It is

therefore not limited to specific areas of sci-

ence and is potentially applicable in any field

of science using statistical and empirical data.

Many authors often cite Sackett, Rosenberg,

Muir Gray, Haynes, and Richardson’s (1996)

article entitled “Evidence-based medicine:What

it is and what it isn’t” as the founding deed of

evidence-based practice. David L. Sackett (born

1934), an American-born Canadian clinical

epidemiologist, was professor at the Department

of Clinical Epidemiology and Biostatistics of

McMaster University Medical School of Ham-

ilton, Ontario, from 1967 to 1994. During that

time, he and his team developed and propagated

modern concepts of clinical epidemiology.

Sackett later moved to England, and from 1994

to 1999,he headed the NationalHealth Services’

newly founded Centre for Evidence-Based

Medicine at Oxford University. During that

time, he largely promoted EBM in Europe by

publishing articles and textbooks as well as

by giving numerous lectures and training

courses. David Sackett is seen by many as the

founding father of EBM as a proper discipline,

although he would not at all claim this position

for himself. In fact, Sackett promoted and elab-

orated concepts that have been described and

used by others before; the origins of EBM are

rooted back in much earlier times.

The foundations of clinical epidemiology

were already laid in the 19th century mainly by

French, German, and English physicians sys-

tematically studying the prevalence and course

of diseases and the effects of therapies.

As important foundations of the EBM-

movement, certainly the works and insights

of the Scottish epidemiologist Archibald

(Archie) L. Cochrane (1909–1988) have to be

c04 18 April 2012; 19:44:27

55 Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

mentioned. Cochrane, probably the true

founding father of modern clinical epidemi-

ology, had long before insisted on sound epi-

demiological data, especially from RCTs, as the

gold standard to improve medical practice

(Cochrane, 1972). In fact, the evaluation of

epidemiological data has always been one of

the main sources of information in modern

academic medicine, and many of the most

spectacular advances of medicine are direct

consequences of the application of basic epi-

demiologicalprinciplessuchas hygiene,aseptic

surgery, vaccination, antibiotics, and the iden-

tification of cardiovasular and carcinogenic risk

factors. One of the most frequent objections

against the propagation of EBM is, “It’s nothing

new, doctors have done it all the time.”

Rangachari, for example, apostrophized EBM

as “old French wine with a new Canadian

label” (Rangachari, 1997,p. 280) alluding to the

French 19th century epidemiology pioneer

Pierre Louis, who was an influencing medical

teacher in Europe and North America, and to

David L. Sackett, the Canadian epidemiologist.

Even though the “conscientious, explicit and

judicious use of the current best evidence in

making decisions about the care of individual

patients”(Sackettetal.,1996,p.71)seemstobea

perfectly reasonable and unassailable goal, EBM

has been harshly criticized from the very begin-

ningof its promotion(Berk&Miles Leigh,1999;

B. Cooper, 2003; Miles, Bentley, Polychronis,

Grey, and Price, 1999; Norman, 1999; Williams

& Garner, 2002). In 1995, for example, the edi-

tors of The Lancet chose to publish a rebuking

editorial against EBM entitled “Evidence-based

medicine, in its place” (The Lancet, 1995):

The voice of evidence-based medicine has

grown over the past 25 years or so from a

subversive whisper to a strident insistence that

it is improper to practise medicine of any

other kind. Revolutionaries notoriously exag-

gerate their claims; nonetheless, demands to

have evidence-based medicine hallowed as

the new orthodoxy have sometimes lacked

finesse and balance, and risked antagonising

doctors who would otherwise have taken

many of its principles to heart. The Lancet

applauds practice based on the best available

evidence–bringing critically appraised news

of such advances to the attention of clinicians

is part of what peer-reviewed medical journals

do–but we deplore attempts to foist evidence-

based medicine on the profession as a discip-

line in itself. (p. 785)

This editorial elicited a fervid debate carried

on for months in the letter columns of The

Lancet. Indeed, there was a certain doggedness

on both sides at that time, astonishing neutral

observers and rendering the numerous critics

even more suspicious. The advocates of EBM

ontheir partactedwith great self-confidence and

claimed noless than to establish a new discipline

and to put clinical medicine on new fundaments;

journals, societies, conferences, and EBM

training courses sprang up like mushrooms;

soon academic lectures and chairs emerged;

however, this clamorous and pert appearance of

EBM repelled many. A somehow dogmatic,

almost sectarian, tendency of the movement was

noticed with discontent, and even the deceased

patron saint of EBM, Archie Cochrane, had to

be invoked in order to push the zealots back:

How would Archie Cochrane view the

emerging scene? His contributions are

impressive, particularly to the development

of epidemiology as a medical science, but

would he be happy about all the activities

linked with his name? He was a freethinking,

iconoclasticindividualwithahealthycynicism,

who would not accept dogma. He brought an

open sceptical approach to medical problems

and we think that he would be saddened

to find that his name now embodies a

new rigid medical orthodoxy while the real

impact of his many achievments might be

overlooked. (Williams & Garner 2002, p. 10)

THE DEMOCRATIZATION

OF KNOWLEDGE

How could such an emotional controversy

arise about the introduction of a scientific

56 Overview and Foundational Issues

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

method (Ghali, Saitz, Sargious, & Hershman,

1999)? Obviously, the propagation and refusal

of EBM have to be seen not only from a

rational scientific standpoint but also from

a sociological perspective (Miettinen, 1999;

Norman, 1999): The rise of the EBM move-

ment fundamentally reflects current develop-

ments in contemporary health care concerning

the allocation of information, knowledge,

authority, power, and finance (Berk & Miles

Leigh, 1999), a process becoming more and

more critical during the late 1980s and the

1990s. Medicine has, for quite some time, been

losing its prestige as an intangible, moral

institution. Its cost-value ratio is questioned

more and more and doctors are no longer

infallible authorities. We do not trust doctors

anymore to know the solution for any problem;

they are supposed to prove and to justify

what they do and why they do it. These

developments in medicine parallel similar

tendencies in other social domains and

indicate general changes in Western soci-

eties’ self-conception. Today we are living

in a knowledge society, where knowledge

and information is democratized, available and

accessible to all. There is no retreat anymore

for secret expert knowledge and for hidden

esoteric wisdom. The hallmarks of our time

are free encyclopedic databases, open access,

the World Wide Web, and Google©. In the

age of information, there are no limitations for

filing, storage, browsing, and scanning of

huge amounts of data; however, this requires

more and more expert knowledge to handle it.

So, paradoxically, EBM represents a new

specialized expertise that aims to democratize

or even to abolish detached expert knowledge.

The democratization of knowledge increas-

ingly questions the authority and self-

sufficiency of medical experts and has deeply

unsettled many doctors and medical scientists.

Of course, this struggle is not simply about

authority and truth; it is also about influence,

power, and money. For all the unsettled doc-

tors, EBM must have appeared like a guide for

the perplexed leading them out of insecurity

and doubt. Owing to its paradoxical nature,

EBM offers them a new spiritual home of

secluded expertise allowing doctors to regain

control over the debate and to reclaim

authority of interpretation from bold laymen.

For this purpose, EBM features and empha-

sizes the most valuable label of our time that is

so believable in science: science- or evidence-

based. In many areas of contention, terms like

evidence-based or scientifically proven are

used for the purpose of putting opponents on

the defensive. Nobody is entitled to question a

fact, which is declared evidence-based or

scientifically proven. By definition, these

labels are supposed to convey unquestioned

and axiomatic truth. It requires rather com-

plex and elaborate epistemological reasoning

to demonstrate how even true evidence-based

findings can at the same time be wrong,

misleading, and/or useless.

All these accounts and arguments apply in

particular to the disciplines of psychiatry and

clinical psychology, which have always had a

marginal position among the apparently

respectable disciplines of academic medicine.

Psychiatrists and psychologists always felt

particularly pressured to justify their actions

and are constantly suspected to practice

quackery rather than rational science. It is

therefore not surprising that among other

marginalized professionals, such as the general

practitioners, psychiatrists and psychotherapists

made particularly great efforts over the last

years to establish their disciplines as serious

matters of scholarly medicine by diligently

adopting the methods of EBM (Geddes &

Harrison, 1997; Gray & Pinson, 2003; Oakley-

Browne, 2001; Sharpe, Gill, Strain, & Mayou,

1996). Yet, there are also specific problems

limiting the applicability of EBP in these

disciplines.

EMPIRICISM AND REDUCTIONISM

In order to understand the role and function of

EBP within the scientific context, it may be

Limitations to Evidence-Based Practice 57

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

helpful to give a brief overview of the theo-

retical backgrounds of science in general.

What is science and how does it proceed?

Science can be seen as a potentially endless

human endeavour that aims to understand

and determine reality. Not only are physical

objects matters of science, but also immate-

rial phenomena like language, history, soci-

ety, politics, economics, human behavior,

thoughts, or emotions. Starting with the Greek

scientists in the ancient world, but progress-

ing more rapidly with the philosophers of

the Enlightenment, modern science adopted

defined rules of action and standards of rea-

soning that delineate science from non-

scientific knowledge such as pragmatics, art,

or religion. Unfortunately, notions like sci-

ence, scientific, or evidence are often wrongly

used in basically nonscientific contexts caus-

ing unnecessary confusion.

The heart and the starting point of any

positive science is empiricism, meaning the

systematic observation of phenomena. Scien-

tists of any kind must start their reasoning with

observations, possibly refined through sup-

portive devices or experimental arrangements.

Although positive science fundamentally

believes in the possibility of objective per-

ception, it also knows the inherent weaknesses

of reliability and potential sources of errors.

Rather than have confidence in single obser-

vations, science trusts repeated and numer-

ous observations and statistical data. This

approach rules out idiosyncratic particularities

of single cases to gain the benefit of identifying

the common characteristics of general phe-

nomena (i.e., reductionism). This approach of

comprehending phenomena by analytically

observing and describing them has in fact

produced enormous advancements in many

fields of science, especially in technical dis-

ciplines; however, contrasting and confusing

gaps of knowledge prevail in other areas

such as causes of human behavior, mind–body

problems, or genome–environment inter-

action. Some areas of science are apparently

happier and more successful using the classical

approach of positive science, while other dis-

ciplines feel less comfortable with the reduc-

tionist way of analyzing problems. The less

successful areas of science are those studying

complex phenomena where idiosyncratic fea-

tures of single cases can make a difference, in

spite of perfect empirical evidence. This

applies clearly to medicine, but even more to

psychology, sociology, or economics. Medi-

cine, at least in its academic version, usually

places itself among respectable sciences,

meeting with and observing rules of scientific

reasoning; however, this claim may be wishful

thinking and medicine is in fact a classical

example of a basically atheoretical, mainly

pragmatic undertaking pretending to be based

on sound science. Inevitably, it leads to con-

tradictions when trying to bring together

common medical practice and pure science.

COMPLEXITY

Maybe the deeper reasons for these contradic-

tions are not understood well enough. Maybe

they still give reason for unrealistic ideas to

some scientists. A major source of misconcep-

tion appears to be the confused ontological

perception of some objects of scientific inves-

tigation. What is a disease, a disorder, a diag-

nosis? What is human behavior? What are

emotions? Answering these questions in a

manner to provide a basis for scientific reason-

ing in a Popperian sense (see later) is far from

trivial. Complex objects of science, like human

behavior, medical diseases, or emotions, are in

fact not concrete, tangible things easily acces-

sible to experimental investigation. They are

emergent phenomena, hence they are not stable

material objects, but exist only as transitory,

nonlocal appearances fluctuating in time. They

continuously emerge out of indeterminable

complexity through repeated self-referencing

operations in complex systems (i.e., autopoietic

systems). Indeterminable complexity or deter-

ministic chaos means that a huge number of

mutually interacting parameters autopoietically

58 Overview and Foundational Issues

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

forma system, renderingany precise calculation

of the system’s future conditions impossible.

Each single element of the system perfectly

follows the physical rules of causality; however,

the system as a whole is nevertheless unpre-

dictable. Its fluctuations and oscillations can be

described only probabilistically. In order to

obtain reasonable and useful information about

a system, many scientific disciplines have

elaborated probabilistic methods of approach-

ing their objects of interest. Thermody-

namics, meteorology, electroencephalography,

epidemiology, and macroeconomics are only a

few such examples. Most structures in bio-

logical, social, and psychological reality can be

conceived as emergent phenomena in this sense.

Just as the temperature of an object is not a

quality of the single molecules forming the

object—a singlemoleculehas notemperature—

but a statistic description of a huge number of

molecules, human behavior cannot be deter-

mined through the description of composing

elements producing the phenomenon—for

example, neurons—even if these elements are

necessary and indispensable preconditions for

the emergence of the phenomenon. The char-

acteristics of the whole cannot be determined by

the description of its parts. When the precise

conditions of complex systems turn out to be

incalculable, the traditional reaction of positive

science is to intensify analytical efforts and to

compile more information about the compon-

ents forming the system. This approach allows

scientists to constantly increase their knowledge

about the system in question without ever

reaching a final understanding and a complete

determinationofthefunctionofthesystem.This

is exactly what happens currently in neurosci-

ences. Reductionist approaches have their

inherent limitations when it comes to the

understanding of complex systems.

A similar problem linked to complexity that

is particularly important is the assumed com-

parability of similar cases. In order to under-

stand an individual situation, science routinely

compares defined situations to similar situ-

ations or, even better, to a large number of

similar situations. Through the pooling of large

numbers of comparable cases, interfering

individual differences are statistically elimi-

nated, and only the common ground appears.

The conceptual assumption behind this pro-

cedure is that similar—but still not identical—

cases will evolve similarly under identical

conditions. One of the most important insights

from the study of complex phenomena is that

in complex systems very small differences in

initial conditions may lead to completely dif-

ferent outcomes after a short time—the so-

called butterfly effect. This insight is well

known to natural scientists; however, clinical

epidemiologists do not seem to be completely

aware of the consequences of the butterfly

effect to their area of research.

FROM KARL POPPER TO

THOMAS S. KUHN

Based on epistemological considerations, the

Anglo-Austrian philosopher Karl Popper

(1902–1994) demonstrated in the 1930s the

limitations of logical empiricism. He reaso-

ned that general theories drawn from empiri-

cal observations can never be proven to be

true. So, all theories must remain tentative

knowledge, waiting to be falsified by contrary

observations. In fact, Popper conceived the

project of science as a succession of theories to

be falsified sooner or later and to be replaced

by new theories. This continuous succession of

new scientific theories is the result of natural

selection of ideas through the advancement of

science. According to Popper, any scientific

theory must be formulated in a way to render it

potentially falsifiable through empirical test-

ing. Otherwise, the theory is not scientific:

It may be metaphysical, religious, or spiritual

instead. This requires that a theory must be

formulated in terms of clearly defined notions

and measurable elements.

Popper’s assertions were later qualified as

being less absolute by the American philoso-

pher of science Thomas S. Kuhn (1922–1996).

Limitations to Evidence-Based Practice 59

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

Kuhn, originally a physicist, pointed out that in

real science any propagated theory could be

falsified immediately by contrary observations

because contradicting observations are always

present; however, science usually ignores or

even suppresses observations dissenting with

the prevailing theory in order to maintain the

accepted theory. Kuhn calls the dissenting

observations anomalies, which are—according

to him—always obvious and visible to all, but

nevertheless blinded out of perception in order

to maintain the ruling paradigm. In Kuhn’s

view, science will never come to an end and

there will never be a final understanding of

nature. No theory will ever be able to integrate

and explain consistently all the observations

drawn from nature. At this point, even the

fundamental limitations to logical scientific

reasoning demonstrated by Gödel’s incom-

pleteness theorems become recognizable (cf.

also Sleigh, 1995). Based on his considerations,

Kuhn clear-sightedly identified science to be a

social system, rather than a strictly logical and

rational undertaking. Science, as a social phe-

nomenon, functions according to principles of

Gestalt psychology. It sees the things it wants to

see and overlooks the things that do not fit.

In his chief work The Structure of Scientific

Revolutions, Kuhn (1962) gives several

examples from the history of science support-

ing this interpretation. It is in fact amazing to

see how difficult it was for most important

scientific breakthroughs to become acknowl-

edged by the contemporary academic estab-

lishment. Kuhn uses the notion normal science

to characterize the established academic sci-

ence and emphasizes the self-referencing

nature of its operating mode. Academic teach-

ers teach students what the teachers believe is

true. Students have to learn what they are taught

by their teachers if they want to pass their

exams and get their degrees. Research is mainly

repeating and retesting what is already known

and accepted. Journals, edited and peer-

reviewed by academic teachers, publish what

conforms with academic teachers’ ideas. Soci-

eties and associations—headed by the same

academic teachers—ensure the purity of doc-

trine by sponsoring those who confirm the

prevailing paradigms. Dissenting opinions are

unwelcome. Based on Kuhn’s view of normal

science, EBP and EBM can be identified as

classical manifestations of normal science. The

EBP helps to ensure the implementation of

mainstream knowledge by declaring to be most

valid what is best evaluated. Usually the cur-

rently established practices are endorsed by the

best and most complete empirical evidence;

dissenting ideas will hardly be supported by

good evidence, even if these ideas are right.

Since EBP instructs its adherers to evaluate the

available evidence on the basis of numerical

rules of epidemiology, arguments like plausi-

bility, logic consistency, or novelty are of little

relevance.

AN EXAMPLE FROM RECENT

HISTORY OF CLINICAL MEDICINE

When in 1982 the Australian physicians

Barry Marshall and Robin Warren dis-

covered Helicobacter pylori in the stomachs

of patients with peptic ulcers, their findings

were completely ignored and neglected by

the medical establishment of that time. The

idea that peptic ulcers are provoked by an

infectious agent conflicted with the prevail-

ing paradigm of academic gastroenterology,

which conceptualized peptic ulcers as a

consequence of stress and lifestyle. Although

there had been numerous previous reports of

helicobacteria in gastric mucosa, all these

findings were completely ignored because

they conflicted with the prevailing paradigm.

As a consequence Marshall and Warren’s

discovery was ignored for years because

it fundamentally challenged current scien-

tific opinion. They were outcast by the

scientific community, and only 10 years later

their ideas slowly started to convince more

and more clinicians. Now, 25 years later, it

is common basic clinical knowledge that

60 Overview and Foundational Issues

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

Helicobacter pylori is one of the major causes

of peptic ulcers, and eradication therapy is

the accepted and rational therapy for gastric

ulcers. Finally, in 2005 Barry Marshall and

Robin Warren gained the Nobel Price for

their discovery (Parsonnet, 2005).

BENEFITS AND RISKS OF

EVIDENCE-BASED PRACTICE

The true benefits of EBP for patients and

society in terms of outcomes and costs have

not been proven yet—at least not through

sound empirical evidence (B. Cooper, 2003;

Geddes & Harrison, 1997). Nevertheless, there

is no doubt that the method has a beneficial

and useful potential. Many achievements of

EBP are undisputable and undisputed, hence

they are evident.

Owing to the spread of methodical skills in

retrieving and evaluating the available epi-

demiological evidence, it has become much

harder to apply any kind of obscure or

idiosyncratic practices. The experts’ commu-

nity, as well as the customers and the general

public, are much more critical toward

pretended effects of treatments and ask for

sound empirical evidence of effectiveness

and safety. It is increasingly important not

only to know the best available treatment, but

also to prove it. The EBP is therefore a helpful

instrument for doctors and therapists to justify

and legitimate their practices to insurance,

judiciary, politics, and society.

Furthermore, individual patients might be

less at risk to wrong or harmful treatment due to

scientific misapprehension. Of course, common

malpractice owing to inanity, negligence, or

viciousness will never be eliminated, not even

by the total implementation of EBP; however,

treatment errors committed by diligent and

virtuous doctors are minimized through careful

adherence to rational guidelines.

In general, clinical decision-making paths

have become more comprehensible and

rational, probably also due to the spread of

EBP. As medicine is in fact not a thoroughly

scientific matter (Ghali et al. 1999), continuous

efforts are needed to enhance and renew

rationality. The EBP contributes to this task

and helps clinicians to maintain rationality in a

job where inscrutable complexity is daily

business. In current medical education, the

algorithms of EBP are now instilled into stu-

dents as a matter of course. Seen from that

perspective, EBP is also an instrument of dis-

cipline and education, for it compels medical

students and doctors to reflect continuously all

their opinions and decisions scientifically

(Norman, 1999). Today EBP has a great

impact on the education and training of future

doctors, and it thereby enhances the uniformity

and transparency of medical doctrine. This

international alignment of medical education

with the principles of EBP will, in the long run,

allow for better comparability of medical

practice all over the world. This is an important

precondition for the planning and coordination

of research activities. Thus, the circle of nor-

mal science is perfectly closed through the

widespread implementation of EBP.

GENERAL LIMITATIONS TO

EVIDENCE-BASED PRACTICE

It has been remarked, not without reason,

that the EBP movement itself has adopted

features of dogmatic authority (B. Cooper,

2003; Geddes et al., 1996; Miles et al., 1999).

This appears particularly ironic, because EBP

explicitly aims to fight any kind of orthodox

doctrine. The ferocity of some EBP adherents

may not necessarily hint at conceptual weak-

nesses of the method; rather, it is more likely

a sign of an iconoclastic or even patricidal

tendency inherent to EBP. Young, diligent

scholars, even students, possibly without any

practical experience, are now entitled to criti-

cize and rectify clinical authorities (Norman,

1999). This kind of insurgence must evoke

resistance from authorities. If the acceptance

of EBP among clinicians should be enhanced,

Limitations to Evidence-Based Practice 61

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

it is advisable that the method is not only

propagated by diligent theoreticians, but

mainly by experienced practitioners.

One of the first and most important argu-

ments against EBP is reductionism (see earl-

ier, Welsby, 1999). Complex and maybe

fundamentally diverse clinical situations of

individual patients have to be condensed and

aggregated to generalized questions in order to

retrieve empirical statistical evidence. Import-

ant specific information about the individual

cases is inevitably lost owing to this general-

ization. The usefulness of the retrieved evidence

is therefore inevitably diluted to a very general

and dim level. Of course, there are some fre-

quently used standard interventions, which are

really based upon good empirical evidence

(Geddes et al., 1996).

EXAMPLES FROM CLINICAL

MEDICINE

Scabies, a parasitic infection of the skin, is

an important public health problem, mainly

in resource-poor countries. For the treatment

of the disease, two treatment options are

recommended: topical permethrin and oral

ivermectin. Both treatments are known to be

effective and are usually well tolerated.

The Cochrane Review concluded from the

available empirical evidence that topical

permethrin appears to be the most effective

treatment of scabies (Strong & Johnstone,

2007). This recommendation can be found

in up-to-date medical textbooks and is

familiar to any well-trained doctor.

Acute otitis media in children is one of the

mostcommondiseases,oneofthemaincauses

for parents to consult a pediatrician, and a

frequent motive for the prescription of antibi-

otics, even though spontaneous recovery is

the usual outcome. Systematic reviews have

shown that the role of antibiotic drugs for the

course of the disease is marginal, and there is

no consensus among experts about the

identification of subgroups who would poten-

tially profit from antibiotics. In clinical prac-

tice, in spite of lacking evidence of its benefit,

the frequent prescription of antibiotic drugs is

mainly the consequence of parents’ pressure

and doctors’ insecurity. A recent meta-analy-

sis (Rovers et al., 2006) found that children

youngerthan2yearsofagewithbilateralacute

otitis media and those with otorrhea benefited

to some extent from antibiotic treatment;

however, even for these two particular condi-

tions, differences were moderate: After 3–7

days, 30% of the children treated with antibi-

otics still had pain, fever, or both, while in the

control group the corresponding proportion

was 55%. So,the available evidence to guide a

clinicianwhentreatinga childwith acuteotitis

media is not really significant and the decision

willmostlydependonsoftfactorslikeparents’

preferences or practical and economical

considerations.

Evidently, clinicians choosing these inter-

ventions do not really need to apply the algo-

rithms of EBP to make their decisions. They

simply administer what they had learned in

their regular clinical training. The opponents

of EBP rightly argue that the real problems in

clinical practice arise from complex, multi-

morbid patients presenting with several ill-

nesses and other factors that have to be taken

into account by the treating clinician. In order

to manage such cases successfully there is

usually no specific statistical evidence avail-

able to rely on. Instead, clinicians have to put

together evidence covering some aspects of the

actual case and hope that the resulting treat-

ment will still work even if it is not really

designed and tested for that particular situ-

ation. Good statistical evidence meeting the

highest standards of EBP is almost exclusively

derived from ideal monomorbid patients, who

are rarely seen in real, everyday practice

(Williams & Garner, 2002). It is not clear at

all—and far from evidence-based—whether

evidence from ideal cases can be transferred to

62 Overview and Foundational Issues

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

more complex cases without substantial loss of

validity.

Another argument criticizing EBP points at

an epistemological problem. Because the EBP

operates retrospectively by evaluating what

was done in the past, it cannot directly con-

tribute to developing new strategies and to

finding new therapies. The EBP helps to

consolidate well-known therapies, but cannot

guide researchers toward scientific inno-

vations. No scientific breakthrough will ever

be made owing to EBP. On the contrary, if all

clinicians strictly followed recommendations

drawn from available retrospective evidence

and never dared to try something different,

science would stagnate in fruitless self-

reference. There is a basically conservative and

backward tendency inherent to the method.

Although it cannot exactly be called anti-

scientific on that account (B. Cooper, 2003;

Miles et al., 1999), EBP is a classical phe-

nomenon of normal science (Kuhn, 1962). It

will not itself be the source of fundamental

new insights.

Finally, there is an external problem with

EBP, which is probably most disturbing of all:

Production and compilation of evidence

available to clinicians is highly critical and

exposed to different nonscientific influences

(Miettinen, 1999). Selection of areas of

research is based more and more on economic

interests. Large, sound, and therefore scien-

tifically significant epidemiologic studies are

extremely complex and expensive. They can

be accomplished only with the support of

financially potent sponsors. Compared with

public bodies or institutions, private com-

panies are usually faster and more flexible in

investing important amounts of money into

medical research. So, for many ambitious sci-

entists keen on collecting publishable findings,

it is highly appealing to collaborate with

commercial sponsors. This has a significant

influence on the selection of diseases and

treatments being evaluated. The resulting body

of evidence is necessarily highly unbalanced

because mainly diseases and interventions

promising important profits are well evaluated.

For this reason, more money is probably put

into trials on erectile dysfunction, baldness, or

dysmenorrhea than on malaria or on typhoid

fever. So, even guidelines based on empirical

evidence—considered to be the ultimate gold

standard of clinical medicine—turn out to be

arbitrary and susceptible to economical, po-

litical, and dogmatic arguments (Berk & Miles

Leigh, 1999). So, EBP’s goals to replace

opinion and tendency by knowledge are in

danger of being missed, if the relativity of

available evidence is unrecognized. The

uncritical promotion of EBP opens a clandes-

tine gateway to those who have interests in

controlling the contents of medical debates and

have the financial means to do so. Biasing

clinical decisions in times of EBP is probably

no longer possible by false or absent evidence;

however, the selection of what is researched

in an EBP-compatible manner and what is

published may result in biased clinical deci-

sions (Miettinen, 1999). One of the most

effective treatment options in many clinical

situations—watchful waiting—is notoriously

under-researched because there is no com-

mercial or academic interest linked to that

treatment option. Unfortunately, there will

never be enough time, money, and workforce

to produce perfect statistical evidence for

all useful clinical procedures. So, even in

the very distant future, clinicians will still

apply many of their probably effective inter-

ventions without having evidence about

their efficacy and effectiveness; thus, EBP is a

technique of significant but limited utility

(Green & Britten, 1998; The Lancet, 1995;

Sackett et al., 1996).

EXAMPLE FROM CLINICAL

MEDICINE

Lumbar back pain is one of the most frequent

health problems in Western countries. About

5% of all low back problems are caused by

prolapsed lumbar discs. The treatment is

Limitations to Evidence-Based Practice 63

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

mainly nonsurgical and 90% of acute attacks

of nerve root pain (sciatica) settle without

surgical intervention; however, different

forms of surgical treatments have been

developed and disseminated. Usually these

methods are considered for more rapid relief

in patients whose recovery is unacceptably

slow. The Cochrane reviewers criticize that

“despite the critical importance of knowing

whether surgery is beneficial for disc pro-

lapse, only four trials have directly compared

discectomy with conservative management

and these give suggestive rather than con-

clusive results” (Gibson & Waddell, 2007,

p. 1). They concluded:

Surgical discectomy for carefully selected

patients with sciatica due to lumbar disc

prolapse provides faster relief from the

acute attack than conservative management,

although any positive or negative effects on

the lifetime natural history of the underlying

disc disease are still unclear. (p. 2)

Surgical treatments of low back pain hold an

enormous commercial potential due to

the worldwide frequency of the problem. It

appears obvious that there are only a few

trials comparing conservative treatment

with surgery.

SPECIFIC LIMITATIONS TO EBP IN

PSYCHIATRY, PSYCHOTHERAPY,

AND CLINICAL PSYCHOLOGY

In psychiatry and psychotherapy, there is an

ambivalent attitude toward EBP. Attempting to

increase their scientific respectability, some

psychiatrists and clinical psychologists zeal-

ously adopted EBP algorithms (Geddes &

Harrison, 1997; Gray & Pinson, 2003; Oakley-

Browne, 2001; Sharpe et al., 1996) and started

evidence-based psychiatry. Others remain

hesitant or doubtful about the usefulness of EBP

in their field, and several authors have addressed

different critical aspects of evidence-based

psychiatry (Berk & Miles Leigh, 1999; Bilsker,

1996; Brendel, 2003; Geddes & Harrison, 1997;

Goldner & Bilsker, 1995; Harari, 2001; Hotopf,

Churchill, & Lewis, 1999; Lawrie, Scott, &

Sharpe, 2000; Seeman, 2001; Welsby, 1999;

Williams & Garner, 2002) with all of them

fundamentally concerning practical and scien-

tific particularities of psychiatry and clinical

psychology. Next, we shall try to clarify these

arguments.

The evidence-based approach to individual

cases is critically dependent on the validity of

diagnoses. This is an axiomatic assumption

of EBP, which is rarely analysed or scrutinized

in detail. If in a concrete case no diagnosis

could be attributed, the case would not be

amenable to EBP, and no evidence could

support decisions in such a case. If the diag-

nosis is wrong, or—even more intricate—if

cases labeled with a specific diagnosis are

still not homogenous enough to be comparable

in relevant aspects, EBP will provide useless

results.

EXAMPLE FROM PSYCHIATRY

According to DSM-IV, eating disorders are

classified in different categories: anorexia

nervosa (AN), bulimia nervosa (BN), binge

eating disorder (BED), and eating disorder

not otherwise specified (EDNOS). These

categories are clinically quite distinct and

diagnostic criteria are clear and easily

applicable. In spite of the phenomenological

diversity of the disease patterns, there is a

close relationship between the different forms

of eating disorders. In clinical practice,

switches between different diagnoses and

temporary remissions and relapses are fre-

quent. In the course of time, patients may

change their disease pattern several times:

At times they may not meet the criteria for

a diagnosis anymore, although they are not

completely symptom free, and later they may

relapse to a full-blown eating disorder again

or may be classified as having EDNOS.

64 Overview and Foundational Issues

c04 18 April 2012; 19:44:28

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

Corresponding to these clinical impressions,

longitudinal studies demonstrate that the sta-

bility of eating disorder diagnoses over time is

low ( Fichter & Quadflieg, 2007; Grilo et al.,

2007; Milos, Spindler, Schnyder, & Fairburn,

2005). Based on systematic evaluation of

the available evidence, however, treatment

guidelines give specific recommendations for

the different conditions (National Institute

for Clinical Excellence [NICE], 2004). For

patients with AN, psychological treatment on

an outpatient basis is recommended. The

treatment should be offered by “a service that

is competent in giving that treatment and in

assessing the physical risk of people with

eating disorders” (p. 60). For patients with

BN, the NICE guideline proposes as a pos-

sible first step to follow an evidence-based

self-help program. As an alternative, a trial

with an antidepressant drug is recommended,

followed by cognitive behavior therapy for

bulimia nervosa. In the absence of evidence to

guide the treatment of EDNOS, the NICE

guideline recommends pragmatically that

“the clinician considers following the guid-

ance on the treatment of the eating problem

that most closely resembles the individual

patient’s eating disorder” (p. 60). So even

though specific diagnoses of eating disorders

are not stable and a patient with AN might be

diagnosed with BN a few months later,

treatment recommendations vary consider-

ably for the two conditions. It becomes

obvious that different treatment recommen-

dations for seemingly different conditions

reflect rather accidental differences in the

availability of empirical evidence than real

differences in the response of certain condi-

tions to specific treatments. Hence, the guid-

ance offered by the guideline is basically a

rather unstable crutch, and of course, cogni-

tive behavior therapy or an evidence-based

self-help program might be just as beneficial

in AN or in EDNOS than it is in BN, even

though nobody has yet compiled the statis-

tical evidence to prove this.

What does the validity of a diagnosis mean?

The question concerns epistemological issues

and requires a closer look to the nature of

medical diagnoses with special regard to psy-

chiatric diagnoses. R. Cooper (2004) questioned

if mental disorders as defined in diagnostic

manuals are natural kinds. In her thoughtful

paper, the author concluded that diagnostic

entities are in fact theoretical conceptions,

describing complex cognitive, behavioral, and

emotional processes (R. Cooper, 2004; Harari,

2001). Diagnostic categories are based upon

observations, still they are strongly influenced

by theoretical, social, and even economical

factors. The ontological structure of psychi-

atric diagnoses is therefore not one of natural

kinds. They are not something absolutely

existing that can be observed independently.

Rather they are comprehensive theoretical

definitions serving as tools for communication

and scientific observation. Kendell and

Jablensky (2003) have also recently addressed

the issue of diagnostic entities and concluded

that the validity of psychiatric diagnoses is

limited. They analysed whether diagnostic

entities are sufficiently separable from each

other and from normality by zones of rarity.

They concluded that this was not the

case; rather, they concluded that psychiatric

diagnoses often overlap (R. Cooper, 2004;

Welsby, 1999), shift over time within the same

patient, and several similar diagnoses can be

present in the same patient at the same time

(comorbidity). Not surprisingly, diagnosis

alone is a poor predictor of outcome (Williams

& Garner, 2002). Acknowledging this hazi-

ness of diagnoses, one realizes these problems

when trying to match individual cases to

empirical evidence. When even the presence

of a correctly assessed diagnosis does not

assure comparability to other cases with the

same diagnosis, empirical evidence about

mental disorders is highly questionable

(Harari, 2001). Of course, limited validity does

not imply complete absence of validity, and

empirical evidence on mental disorders is

still useful to some extent; however, insight

Limitations to Evidence-Based Practice 65

c04 18 April 2012; 19:44:29

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

into the limitations is important and that

insight points out that psychiatric diagno-

ses represent phenomenological descriptions

rather than natural kinds. Several authors

have treated the same issue when writing

about the complexity of cases, the problem of

subsyndromal cases, and of single cases versus

statistical evidence (Harari, 2001; Welsby,

1999; Williams & Garner, 2002).

NONLINEAR DYNAMICS IN THE

COURSE OF DISEASES

It might be fruitful to look at evidence-based

psychiatry from another perspective and to

address the issues of complexity and nonlinear

dynamics. With regard to their physical and

mental functioning, humans can be conceptu-

alized as systems of high complexity

(Luhmann, 1995). This means that they cannot

be determined precisely, but only in a prob-

abilistic manner; however, probabilistic

determination is sufficient for most purposes in

observable reality. Human life consists fun-

damentally in dealing with probabilities.

Social systems and human communication are

naturally designed to manage complexity more

or less successfully. Medicine itself is a social

system (Luhmann, 1995) trying to handle the

effects of complexity (Harari, 2001), for

example, by providing probabilistic algo-

rithms for treatments of diseases. In most

situations, medicine can ignore the particular

effects emerging from the complex nonlinear

structure of its objects, although such effects

are always present. Only sometimes do these

effects become obvious and irritating, as for

example in fluctuations of symptoms in

chronic diseases, variations in response to

treatment, unexpected courses in chronic dis-

eases, and so on. Such phenomena can be seen

as manifestations of the butterfly effect (see

earlier). This insight questions deeply the core

principle of EBP that assumes that it is rational

to treat similar cases in the same manner

because similarity in the initial conditions will

predict similar outcomes under the identical

treatment. The uncertainty of this assumption

is particularly critical in psychiatry and psy-

chotherapy. In these fields similar appearance

is just a palliation for untraceable difference,

and this exact difference may crucially influ-

ence the outcome.

Addressing such problems is daily busi-

ness for psychiatrists and psychotherapists,

so their disciplines have developed special

approaches. Diagnostic and therapeutic pro-

cedures in these disciplines are much less

focused on critical momentary decisions, but

more on gradual, iterative procedures. Psy-

chiatric treatments and even more psycho-

therapy are self-referencing processes, where

assessments and decisions are constantly re-

evaluated. Instead, EBP focuses primarily on

decision making as the crucial moment of good

medical practice. One gets the impression that

EBM clinicians are constantly making critical

decisions, and after having made the right

decision, the case is solved. Maybe it is

because of this misfit between the proposals of

the method and real daily practice that many

psychiatrists are not too attracted by EBP.

EXAMPLE FROM PSYCHIATRY

The diagnosis of posttraumatic stress dis-

order (PTSD) was first introduced in the

third edition of the Diagnostic and Statis-

tical Manual of Mental Disorders (DSM-III)

in 1980. Before that time, traumatized

individuals were either diagnosed with dif-

ferent nonspecific diagnoses (e.g., anxiety

disorders, depression, neurasthenia) or not

declared ill at all. Astonishingly, the

newly discovered entity appeared to be a

clinically distinct disorder and the corre-

sponding symptoms (re-experiencing, avoid-

ance, hyperarousal) were quite characteristic

and easily identifiable. Within a short

time after its invention (Summerfield, 2001),

PTSD became a very popular disorder;

66 Overview and Foundational Issues

c04 18 April 2012; 19:44:29

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

clinicians and even patients loved the new

diagnosis (Andreasen, 1995). The key point

for the success of the new diagnosis was that

it is explicitly based on the assumption of an

external etiology; that is, the traumatic

experience. This conception makes PTSD so

appealing for the attribution of cause,

responsibility, and guilt is neatly separated

from the affected individual. PTSD allows

for the exculpation of the victim, a feature

that was particularly important when caring

for Holocaust survivors and Vietnam War

veterans. But what was almost proscribed

for some time after the introduction of PTSD

is now evidence-based: Preexisting individ-

ual factors play an important role in the

shaping of posttraumatic response. Whether

or not an individual develops PTSD after a

traumatic experience is not only determined

by the nature and the intensity of the

traumatic impact, but also by various

pretraumatic characteristics of the affected

individual. Furthermore, PTSD is not the

only posttraumatic mental disorder. A whole

spectrum of mental disorders is closely

linked to traumatic experiences, although

they lack the monocausal appearance of

PTSD. Anyway, the most frequent outcome

after traumatic experiences is recovery. In

the second rank of frequency comes major

depression. Borderline personality disorder

is fully recognized now as a disorder pro-

voked by traumatic experiences in early

childhood. Dissociative disorders, chronic

somatoform pain, anxiety disorders, sub-

stance abuse, and eating disorders are

equally related to traumatic experiences.

Not surprisingly, PTSD is often occurring as

a comorbid condition with one or more

additional disorder or vice versa. In clinical

practice, traumatized patients usually pre-

sent more complex than expected. This may

explain to some extent why PTSD was vir-

tually overlooked by clinicians for many

decades before its introduction, a fact that is

sometimes hard to understand by younger

therapists who are so familiar with the PTSD

diagnosis. At any rate, the high-functioning,

intelligent, monomorbid PTSD patient is

indeed best evaluated in clinical trials, but

rarely seen in everyday practice.

PTSD was right in the focus of research

since its introduction. Also from a scientific

point of view, the disorder is appealing

because it is provoked by an external event.

PTSD allows ideally for the investigation of

thehuman-environmentinteraction,whichisa

crucial issue for psychiatry and psychology in

general. The number of trials on diagnosis and

treatment of PTSD is huge, and the disorder is

now probably the best evaluated mental dis-

order. What is the benefit of the accumulated

large body of evidence on PTSD for cli-

nicians? There are several soundly elaborated

guidelines on the treatment of PTSD (Ameri-

can Psychiatric Association, 2004; Australian

Centre for PosttraumaticMentalHealth,2007;

NICE, 2005), meta-analyses, and Cochrane

Reviews providing guidance for the assess-

ment and treatment of the disorder. When we

look at the existing conclusions and recom-

mendations, we learn that:

� Debriefing is not recommended as routine practice for individuals who have

experienced a traumatic event.

� When symptoms are mild and have been present for less than 4 weeks after the

trauma, watchful waiting should be

considered.

� Trauma-focused cognitive behavior therapy on an individual outpatient basis

should be offered to people with severe

posttraumatic symptoms.

� Eye movement desensitization and repro- cessing is an alternative treatment option.

� Drug treatment should not be used as a routine first-line treatment in preference to

a trauma-focused psychological therapy.

� Drug treatment (Specific Serotonin Reuptake Inhibitors) should be considered

Limitations to Evidence-Based Practice 67

c04 18 April 2012; 19:44:29

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

for the treatment of PTSD in adults

who express a preference not to engage

in trauma-focused psychological

treatment.

� In the context of comorbid PTSD and depression, PTSD should be treated first.

� In the context of comorbid PTSD and substance abuse, both conditions should

be treated simultaneously.

These recommendations are obviously

clear, useful, and practical. They give real

guidance to therapists and do not leave much

room for doubts or insecurity. On the other

hand, they are basically very simple, almost

trivial. For trauma therapists, these recom-

mendations are commonplace and serve

mainly to endorse what they are practicing

anyway. The main points of the guidelines

for the treatment of PTSD could be taught in

a 1-hour workshop. The key messages of the

guidelines represent basic clinical knowl-

edge on a specific disorder as it has been

instructed in times before EBP. Through

their standardizing impact on the therapeutic

community, guidelines may in fact align and

improve the general service quality offered

to traumatized individuals, although this

effect has not yet been demonstrated by

empirical evidence.

The treatment of an individual patient

remains a unique endeavor where interper-

sonal relationship, flexibility, openness, and

cleverness are crucial factors. This challenge is

not lessened by evidence or guidelines.

REFERENCES

American Psychiatric Association. (2004). APA practice

guidelines. Treatment of patients with acute stress

disorder and posttraumatic stress disorder. doi:

10.1176/appi.books.9780890423363.52257

Andreasen, N. C. (1995). Posttraumatic stress disorder:

Psychology, biology, and the Manichaean warfare

between false dichotomies. American Journal of

Psychiatry, 152, 963–965.

Australian Centre for Posttraumatic Mental Health.

(2007). Australian guidelines for the treatment of

adults with acute stress disorder and posttraumatic

stress disorder. Melbourne, Victoria.

Berk, M., & Miles Leigh, J. (1999). Evidence-based

psychiatric practice: Doctrine or trap? Journal of

Evaluation in Clinical Practice, 5, 149–152.

Bilsker, D. (1996). From evidence to conclusions in

psychiatric research. Canadian Journal of Psychiatry,

41, 227–232.

Brendel, D. H. (2003). Reductionism, eclecticism, and

pragmatism in psychiatry: The dialectic of clinical

explanation. Journal of Medicine and Philosophy, 28,

563–580.

Cochrane, A. L. (1972). Effectiveness and efficiency:

Random reflections on health services. London, En-

gland: Nuffield Provincial Hospitals Trust.

Cooper, B. (2003). Evidence-based mental health policy:

A critical appraisal. British Journal of Psychiatry,

183, 105–113.

Cooper, R. (2004). What is wrong with the DSM? History

of Psychiatry, 15, 5–25.

Fichter, M. M., & Quadflieg, N. (2007). Long-term sta-

bility of eating disorder diagnoses. International

Journal of Eating Disorders, 40(Suppl.), 61–66.

Geddes, J. R., Game, D., Jenkins, N. E., Peterson, L. A.,

Pottinger, G. R., & Sackett, D. L. (1996). What pro-

portion of primary psychiatric interventions are based

on evidence from randomised controlled trials?

Quality in Health Care, 5, 215–217.

Geddes, J. R., & Harrison, P. J. (1997). Closing the gap

between research and practice. British Journal of

Psychiatry, 171, 220–225.

Ghali, W., Saitz, R., Sargious, P. M., & Hershman, W. Y.

(1999). Evidence-based medicine and the real world:

Understanding the controversy. Journal of Evaluation

in Clinical Practice, 5, 133–138.

Gibson, J. N. A., & Waddell, G. (2007). Surgical inter-

ventions for lumbar disc prolapse. Cochrane Data-

base of Systematic Reviews, Issue 1. Art. No.:

CD001350. doi: 10.1002/14651858.CD001350.pub4

Goldner, E. M., & Bilsker, D. (1995). Evidence-based

psychiatry. Canadian Journal of Psychiatry, 40,

97–101.

Gray, G. E., & Pinson, L. A. (2003). Evidence-based

medicine and psychiatric practice. Psychiatric Quar-

terly, 74, 387–399.

Green, J., & Britten, N. (1998). Qualitative research and

evidence based medicine. British Medical Journal,

316, 1230–1232.

Grilo, C. M., Pagano, M. E., Skodol, A. E., Stanislow,

C. A., McGlashan, T. H., Gunderson, J. G., & Stout,

R. L. (2007). Natural course of bulimia nervosa and of

eating disorder not otherwise specified: Five-year

68 Overview and Foundational Issues

c04 18 April 2012; 19:44:29

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

prospective study of remissions, relapses and the

effects of personality disorder psychopathology.

Journal of Clinical Psychiatry, 68, 738–746.

Harari, E. (2001). Whose evidence? Lessons from the

philosophy of science and the epistemology of

medicine. Australian and New Zealand Journal

of Psychiatry, 35, 724–730.

Hotopf, M., Churchill, R., & Lewis, G. (1999). Pragmatic

randomised controlled trials in psychiatry. British

Journal of Psychiatry, 175, 217–223.

Kendell, R., & Jablensky, A. (2003). Distinguishing

between the validity and utility of psychiatric diag-

noses. American Journal of Psychiatry, 160, 4–12.

Kuhn, T. (1962). The structure of scientific revolutions.

Chicago, IL: University of Chicago.

The Lancet. (1995). Evidence-based medicine, in its place

[Editorial]. Elsevier Science, 346, 785.

Lawrie, S. M., Scott, A. I., & Sharpe, M. C. (2000).

Evidence-based psychiatry—Do psychiatrists want it

and can they do it? Health Bulletin, 58, 25–33.

Luhmann, N. (1995). Social Systems. Stanford, CA:

Stanford University Press.

Miettinen, O. S. (1999). Ideas and ideals in medicine:

Fruits of reason or props of power? Journal of

Evaluation in Clinical Practice, 5, 107–116.

Miles, A., Bentley, P., Polychronis, A., Grey, J., & Price, N.

(1999). Advancing the evidence-based healthcare

debate. Journal of Evaluation in Clinical Practice,

5, 97–101.

Milos, G., Spindler, A., Schnyder, U., & Fairburn, C. G.

(2005). Instability of eating disorder diagnoses:

A prospective study. British Journal of Psychiatry,

187, 573–578.

National Institute for Clinical Excellence (NICE). (2004).

Eating disorders. Core interventions in the treatment

and management of anorexia nervosa, bulimia ner-

vosa, and related eating disorders. National clinical

practical guideline number CG9. London, England:

The British Psychological Society and Gaskell.

National Institute for Clinical Excellence (NICE). (2005).

Posttraumatic stress disorder (PTSD). The manage-

ment of PTSD in adults and children in primary and

secondary care. Clinical guideline 26. Retrieved from

www.nice.org.uk/CG026NICEguideline

Norman, G. R. (1999). Examining the assumptions of

evidence-based medicine. Journal of Evaluation in

Clinical Practice, 5, 139–147.

Oakley-Browne, M. A. (2001). EBM in practice: Psy-

chiatry. Medical Journal of Australia, 174, 403–404.

Parsonnet, J. (2005). Clinician-discoverers—Marshall,

Warren, and H. pylori. New England Journal of

Medicine, 353, 2421–2423.

Rangachari, P. K. (1997). Evidence-based medicine: Old

French wine with a new Canadian label? Journal of

the Royal Society of Medicine, 90, 280–284.

Rovers, M. M., Glasziou, P., Appelman, C. L., Burke, P.,

McCormick,D. P., Damoiseaux, R.A., . . . Hoes,A. W.

(2006). Antibiotics for acute otitis media: A meta-

analysis with individual patient data. The Lancet, 368,

1429–1435.

Sackett, D. L., Rosenberg, W. M. C., Muir Gray, J. A.,

Haynes, R., & Richardson, W. S. (1996). Evidence-

based medicine: What it is and what it isn’t. British

Medical Journal, 312, 71–72.

Seeman, M. V. (2001). Clinical trials in psychiatry: Do

results apply to practice? Canadian Journal of

Psychiatry, 46, 352–355.

Sharpe, M., Gill, D., Strain, J., & Mayou, R. (1996).

Psychosomatic medicine and evidence-based

treatment. Journal of Psychosomatic Research, 41,

101–107.

Sleigh, J. W. (1995). Evidence-based medicine and Kurt

Godel. Letter to the editor. The Lancet, 346, 1172.

Strong, M., & Johnstone, P. W. (2007). Interventions for

treating scabies. Cochrane Database of Systematic

Reviews, Issue 2. Art. No.: CD000320. doi: 10.1002/

14651858.CD000320.pub2

Summerfield, D. (2001). The invention of post-traumatic

stress disorder and the social usefulness of a psychi-

atric category. British Medical Journal, 322, 95–98.

Welsby, P. D. (1999). Reductionism in medicine: Some

thoughts on medical education from the clinical front

line. Journal of Evaluation in Clinical Practice, 5,

125–131.

Williams, D. D. R., & Garner, J. (2002). The case against

“the evidence”: A different perspective on evidence-

based medicine. British Journal of Psychiatry, 180,

8–12.

Limitations to Evidence-Based Practice 69

c04 18 April 2012; 19:44:31

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .

c04 18 April 2012; 19:44:31

Hersen, M., & Sturmey, P. (2012). Handbook of evidence-based practice in clinical psychology, adult disorders : Adult disorders. John Wiley & Sons, Incorporated. Created from ashford-ebooks on 2021-11-23 18:29:03.

C o p yr

ig h t ©

2 0 1 2 . Jo

h n W

ile y

& S

o n s,

I n co

rp o ra

te d . A

ll ri g h ts

r e se

rv e d .