Why Many Clinical Psychologists are Resistant to Evidence-Based Practice

Lilienfeld, S.O., Ritschel, L.A., Lynn, S.J., Cautin, R. L., & Latzman, R.D. (2013). Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies. Clinical Psychology Review, 33, 883-900.

Reviewed by Kate McKenna, MEd, MSEd, BCBA, LBA
Association for Science in Autism Treatment

The proliferation of the use of non-evidenced-based therapies is a persistent problem in the treatment of autism. It is perhaps easy to assume that resistance to the use of evidence-based practices (EBP) is based in ignorance or from a lack of respect for science and research. In this article, Scott Lilienfeld and his co-authors posit six reasons why clinicians may resist embracing a novel evidence-based strategy or evaluating the therapies they are using by scientific standards. Although this article is written about clinical psychologists, the discussion of resistance is relevant to any of us advocating for the use of evidence-based practices in our work with individuals with autism.

According to Lilienfeld et al. (2013), resistance to evidence-based practice is understandable. The fact that certain therapies are better supported by science than others place some clinicians in the position of informing patients that a particular therapy is misguided or ineffective. It may mean clinicians admitting that a therapy they are using is not backed by science and should be discontinued. Both situations can be uncomfortable and may impact relationships with colleagues and consumers alike.

The six reasons for resistance to evidence-based practice addressed in the article are:

naïve realism;
myths and misconceptions about human nature;
application of group probabilities to individuals;
reversal of the onus of proof;
mischaracterization of what an evidence-based practice (EBP) is and is not; and
pragmatic educational and attitudinal obstacles

These reasons for resistance are not mutually exclusive and may work together in the decision-making process of a clinician or therapist.

Naïve realism, also referred to as commonsense realism or direct realism, is the erroneous belief that the world is exactly as we see it. The danger of relying on naïve realism is that it leads people to trust in their own judgment, to misinterpret change when it occurs or to see change that in fact has not occurred. As Lilienfeld et al. (2013) point out, change following treatment is not the same as change because of treatment. Given the long duration of intervention, this faulty belief may be even more common in our work serving individuals with autism, particularly when the individual is receiving multiple interventions concurrently.

Scientific evidence often discredits strongly held myths and misconceptions about human nature and the motivations behind behavior. In clinical psychology, these myths could be related to the recovery of repressed memory, the primacy of early life experiences, or dream theory. These myths often are relied on as the rationale for the use of therapies that have been proven by research to be ineffective. The long held and erroneous belief that “Refrigerator Mothers,” by withholding affection and attention from their children, caused autism is a perfect example of this.

The application of group probabilities to individuals, the interplay of nomothetic and ideographic research, can impact the acceptance of evidence-based practice. EBP relies on nomothetic findings which extract universal laws that apply to most or all members of a given population. However, clinicians make therapeutic decisions based on ideographic factors, the unique characteristics of the client. The rationale that a client is a unique being, to whom these universal laws may not apply, in combination with naïve realism or deeply held misconceptions about human nature, may result in clinicians rejecting an evidence-based therapy because they focus on unique factors and minimize the common factors.

In science, the burden of proof lies with the proponents of a theory or intervention. The rigor of the scientific method is meant to provide proof of a functional relation between variables, in this case a therapy and positive change in the behavior and life of the client. However, in the case of many current pseudo-scientific therapies the burden of proof is reversed. Rather than accepting the responsibility of proving that the therapy is effective, proponents of nonproven therapies assert that the therapy should be considered effective until it is proven not to be. A good example of this within the autism community is facilitated communication. In fact, limited outcomes are often explained away as a function of an observer’s skepticism.

Mischaracterizations of EBPs are discussed in detail. EBPs are seen to take a one size fits all approach to therapy, stifling innovation and discouraging new theories and ideas. The reliance on the results of controlled studies results in practitioners ignoring other factors, such as personality or a client’s history, that may be important in therapy. Additionally, this reliance leads clinicians to ignore evidence from other sources that may speak to the efficacy of therapies that are not scientifically proven to be effective. Controlled studies are seen as artificial situations such that the results do not generalize outside of the study. The category of evidence-based practice is seen as unnecessary because all treatment could be equally efficacious, depending on the many variables that effect progress in treatment. Finally, EBP as a concept is limiting because much therapeutic change cannot be quantified, and human behavior is essentially impossible to predict.

More mundane factors that may prompt resistance to EBP are pragmatic, educational, and attitudinal obstacles. It takes time to contact current research literature, especially given the number of peer-reviewed journals in publication. Awareness that a therapy has been proven effective is not a substitute for in-depth experience and training, which can be time-consuming, inconvenient and expensive, reasons why clinicians may avoid exploring an EBP. The widening gap between scientific research and practice creates barriers to the use of EBPs. Clinicians in practice may feel that academic research lacks external validity due to methodological limitations or a study design that has little relevance to the needs of clients.

As a response to resistance the authors recommend that professional organizations, such as the American Psychological Association (APA) make outreach that bolsters the integration of science and practice to practicing clinicians a greater part of their mission. This outreach, which is at the core of the Association for Science in Autism Treatment’s (ASAT’s) educational efforts, may be of great benefit in the treatment of autism as the collaboration between educators and related service providers would be built on the common ground of using science to guide treatment decisions. The authors suggest practicing what we preach, in other words, using the research on attitude change to guide efforts to decrease resistance to the use of EBPs.

As the authors remind us it is difficult to create enduring changes in long held attitudes or opinions, which is important for us to remember as we act as proponents for the use of evidence-based practice in the treatment of autism. Advocacy for EBPs may be interpreted as striving to bring about unneeded change or it may seem like we are working to deny individuals access to other therapies that may appear to be better suited to enrich their lives. Differences in beliefs about what constitutes evidence can result in communication breakdowns and tensions between members of a treatment team, who may consider anecdotal reports of progress to be equally probative of a rigorous scientific study. As we seek to alter peoples’ thinking about EBPs, we are working against the strength of “informal” evidence, anecdotal reports of progress that appear believable but lack a functional relationship between therapy and behavior change. Misconceptions about EPBs, such as applied behavior analysis, contribute to the unwillingness of practitioners outside our field to consider their use. Our advocacy may be strengthened by considering the six reasons for resistance discussed in this article, as an understanding of what is contributing to an individual’s misapprehensive about EBPs may assist us in framing our position more effectively.

Citation for this article:

McKenna, K (2021). Review of Why many clinical psychologists are resistance to evidence-based practice: Root causes and constructive remedies. Science in Autism Treatment, 18(9).

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Review of Why Many Clinical Psychologists are Resistant to Evidence-Based Practice: Root Causes and Constructive Remedies