This morning while reading an article on civilians trying to find support for their Post-Traumatic Stress Disorder (I don’t have PTSD, but have an interest in how trauma gets laid down in the brain), I followed a link to “Where is the Evidence for ‘Evidence-Based’ Therapy?” by Jonathan Shedler, adapted from remarks he gave at a conference several years ago.
“Evidence-based therapy” has become quite the catchphrase. The term “evidence-based” comes from medicine. It gained attention in the 1990s and was, at the time, a call for critical thinking. It reflected the recognition that “we’ve always done it this way” is not a good enough reason to keep doing something. Medical decisions should reflect clinical judgment, patients’ values and preferences, and relevant scientific research.
But “evidence-based” has come to mean something very different in the psychotherapy world. The term has been appropriated to promote a particular ideology and agenda. It has become a code word for manualised treatment—most often, brief, highly-structured cognitive behavioural therapy (CBT). “Manualised” means the therapy is literally conducted by following an instruction manual. The treatment may be pre-scripted in a way that leaves little room for understanding patients as individuals.
Shedler’s goal here is to debunk just what “evidence-based” means in the realm of mental health, and it mostly seems to be something of a deceptive a marketing phrase, propped up by carefully choosing the question you’re answering and by limiting one’s definition of success to the short-term.
My interest here, of course, is that Applied Behavioral Analysis, too, is referred to as “evidence-based” treatment when it comes to autism, despite the anecdotal reports from older autistics who relate their childhood experiences of ABA as being somewhat torturous.
What’s clear to me from those anecdotes, especially in the context of Shedler’s look at the evidence for “evidence-based” treatments like Cognitive Behavioral Therapy in other contexts, is that what’s really needed are long-term, long-range studies of children who underwent ABA to determine its lasting effects, both inward and outward.
(I did not undergo ABA, as I was not diagnosed until midlife. I pay attention to the ABA discussion only tangentially, because of my own interest as an autistic adult in the matter of autistics and psychotherapy, since I question the degree to which traditional socially-performative approaches themselves can just be additional, problematic stressors which interfere with the therapeutic benefits.)
Older autistics tend to describe ABA less as any kind of treatment for autism than as a kind of treatment for the people around the autistic person. In effect, the argument goes, it simply forces the autistic person to suppress the outward-facing behaviors of being autistic. Left seemingly unaddressed (in large part, I suspect, because most of the evaluations are made by people outside the child, and not by the child themselves) is the degree to which this has a real beneficial inward effect upon the actually autistic individual. It does, however, make the people around the autistic more comfortable being around the autistic.
One thing I found interesting in Shedler’s analysis of things like CBT for cases like depression is this notion of how these treatments are “manualized”, scripted approaches. My limited understanding of ABA suggests it is similar in that regard, and so in this context partakes a little too much of the idea of the autistic as a kind of soulless automata. ABA, then, becomes just a kind of reprogramming.
(I don’t think my last therapist viewed me as an automaton, but as a proponent of Dialectical Behavioral Therapy, an offshoot of CBT, she did come across to me as if she simply had this checklist in her head that she was trying to plug me into, as quickly as she could. It’s why I only lasted three sessions, and am still trying to find a replacement.)
Is anyone monitoring the long-term impact of childhood ABA treatment upon autistics as they grow older and more self-aware? Do these studies already exist? If so, what questions are they asking about how to define success, and what are they showing? If such studies don’t exist, why don’t they?
While finishing up this post, I ran into CJ Eller’s “Metaphor Debt”, which gave me another way to think about this.
There is the common concept in software called technical debt. It is the implied debt of additional work caused by choosing the easier solution rather than the better one that would take more time and resources to complete.
The open questions, I guess, are whether or not ABA is just “the easier solution”, and, if so, what debts we—or, rather, the autistic kids—are incurring because the people around them didn’t instead choose what might be the better path.