If you pause for a moment and think about the phrase 'Evidence Based Practice' you will notice its rhetorical character. Imagine for a moment that a set of solicitors got together and called themselves the Evidence Based Lawyers. If you begin to try to argue with it you quickly find yourself labelled as someone who is against evidence and by inference someone irrational or dishonest. Somehow the phrase marks out a space within which a moral right has been established, and if you are not a part of it, then somehow you are in the wrong.
Check out the web site: according to the Centre for Evidence-Based Medicine "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."
The conscientious, explicit and judicious use of the best… By implication, anyone who wants to question it finds themselves already caught in the opposite: a careless, obfuscating, stupid user of the worst, evidently.
Evidence Based Anything is a rhetorical manoeuvre that is being used without reference to its history or its points of departure. It has been ripped away from the human beings whose job it should be to anchor it to reason and sensibility. For example, I recently heard someone claiming that EBM (shorthand for Evidence Based Whatever - the W and M are equivalent in this topsy-turvy world) include anthropology, case studies, and focus groups - well, yes everything is evidence based in that case and doesn't need a separate category. But, when the idea was first put forward it was really contrary to this - it was an attempt to resolve the problem of relying of subjective ideas, specifically that of opinion. Focus groups cannot constitute evidence other than of a set of opinions from a specific group of people at a given time on a particular question. And you might wonder who they are, and on what they base their opinion, because there is still a duty to make a good judgement on the basis of such evidence.
When an ideology gets going, it does tend to draw everything within its scope - this process removes what seems to them to be the tedious inconvenience of contradiction and argument, and it builds up the idea that those on the inside are right. This can create panic amongst those who find themselves excluded (especially if they are excluded from funds, from treatment, from presenting a paper at a conference) and cause a rush to join the In-Crowd. When people betray themselves in this way, they lose their bearings. This can lead to anxiety, and depression. It might also lead to aggression.
Ideologies tend towards totalising world-views because this is what 'underpins' the truth of what they say. It is the base upon which they depend. To be a strong base it will need at least three legs to stand on, each one supporting one of the others, and these need to be defended from argumentation. Because there is no real basis for truth in an ideology, the structure is inherently unstable, and will need constant reinforcement and policing.
Another consequence for the lack of real substance to bind the truth, is that people find themselves having to rely on hierarchical indicators for guarantees (titles like Professor, Sir, Lord, Your Highness, for example). It becomes more necessary to rely on the ethics of these individual's positions, or at least to hope they are not nincompoops, incompetents, or bullies.
At the recent conference, Psychological Therapies in the NHS (30 Nov, 1 Dec 2007 Savoy Hotel), we had the chance to witness some of the elements and some of the players putting them to work. A particularly clear example came from Louis Appleby (the mental health czar) who made a passionate appeal to the fact that today politics is based on evidence (Evidence Based Politics), so anyone who is against the politics must be against the evidence, and that anyone who is against the evidence must therefore be irrational. That being the case, he declared that those in opposition must not be allowed to stand in the way of progress (Evidence Based Citizenship?).
When Del Loewenthal (from Roehampton University) posed a question from the floor that pointed to the difference between consumerism and medicine, and between the aims of politicians and those of a practitioner. Ian McPherson (programme director of NIMHE), on the other hand, said that it was paranoid to think that Governments had different aims from anyone else (Evidence Based Diagnosis?).
The psychiatrists David Veale and David Clark both saw fantastic possibilities to link Evidence Based Therapies to the management programme of IAPT ('increasing access to psychological therapies'). Everyone using the new bureaucratised therapies would be asked to fill out an assessment form after each of their sessions, these would then be fed into a national database. In this way, they painted a picture of a perfect, complete data set of the progress of all mental cures evidenced by their new regime. In a single smooth move they obliterated the differences between practice, management, research, and politics and made it all into one, just like that.
Andrew Elder (a GP) pointed out from the floor that a great deal of mental distress was contained by GPs in their surgeries everyday. He did not talk about illness and cure, but about distress and containment, and was clearly talking from a different point of view. It seems somehow evident that this is an old idea, coming from a different millennium, so - good grounds to label him Old and thus ignore his point. Pity, it is a good one: he said it was more difficult to sustain the relational aspect of the GPs work under the conditions created by the new GP contracts and this undermined their ability to contain the anxiety of their patients. He added that changes in the educational structures also made it tricky to teach this to medical students. He was arguing that something was being excluded from the field - let's call it the human factor - something he believed to be of central importance to the effective practice of medicine. The human factor reminds us that humans are never simply objects. This isn't just a political or ethical point, there is a great deal of evidence to support it, or reason to believe it, or grounds to argue it, or history to learn from, or experience to count on...
It was already quite clear that any kind of debate was going to be tricky at this meeting not least because it came after the fact. Two weeks previously, the Government had announced a massive spending programme to support a national roll out of CBT in the NHS. The ideology that supports NICE, IAPT, and Evidence Based Mumbo Jumbo clearly shows its bias here by coming out in favour of this one kind of treatment on the question of mental distress. But the main reason for a lack of debate was the strangle hold already in place that effectively choked off any difference of opinion. This was stunningly demonstrated by Michael Rawlins, the Chairman of NICE, towards the end of the conference when he suddenly exploded in a spectacular show of personal power and shouted over the voices of dissent: "you've just been given the biggest pot of money! So shut up and stop whingeing!" I think it must also be noted that this man began his intervention with the remark that some people describe NICE as Stalinist - he thought he might take this as a compliment.
A lot of people who talked at this conference took the diplomatic precaution of preceding their comments by saying CBT is ok really. Usually their comments went something like: 'with a careful practitioner, CBT does not necessarily reduce the patient to an object and some people really have been helped'. Perhaps this is the difference between the CBT outside an ideology and the CBT inside one. But, wait a minute - if a practitioner can subvert the apparent objective uniformity of a national state funded experiment, shouldn't the thought police be told? After all, the data produced can no longer be considered objective. Jacques Barber?(Professor of Psychology in Psychiatry) was a little more specific, he said: 'we need more properly trained researchers: it will take a generation or two to turn them into proper CBT practitioners. The old-style say they do CBT, but really they'll never change - we will have to wait till they die out'.
At least he is prepared to wait.
Janet Low, 30 January 2008
Information from the conference is drawn from a set of 7 one-hour videos, which can be found on the internet.