6.3 Evidence-based practice
Imagine that, as a practitioner, you need to evaluate claims made for the success of a particular therapy. What would you want to know before you were prepared to accept the claims? Note down some ideas before reading on.
Box 11 sets out a framework of relevant questions for evaluating practice. You will notice a considerable overlap with the design considerations for an appropriately controlled and ethically sensitive experimental study. There are, of course, difficulties in applying rigorous experimental standards in the complex real-world setting we are considering here. But given what is at stake, sound theoretical grounding, valid claims about efficacy, and ethical procedures are necessary standards for practice. Rutter observes ‘It has become generally accepted that all of us, as clinicians, need to base what we do on solid empirical research findings’ (1999, p. 169). This approach, which is widely advocated in clinical psychology, is known as evidence based practice.
We will evaluate Bettelheim's and Welch's approaches in light of the criteria in Box 11, and refer back to them in subsequent discussion.
Box 11: Criteria for evaluating practical interventions
1 Theoretical rationale
Is there either a theoretical or a sound practical rationale for predicting success? For both Bettelheim's and Welch's approaches the answer would have to be ‘no’. As this course has shown, there is no evidence (research or otherwise) to suggest that autism is psychogenic in origin (in the sense that it arises from deep emotional conflict engendered by the child's social or familial environment), indeed there is extensive evidence for the role of other influences. In fairness, Bettelheim and Welch clearly believed in psychogenic causes for autism, and the overwhelming evidence favouring genetic and neuropsychological influences did not exist when they devised their therapies.
2 Methodological considerations
Do tests of the procedure employ a relevant group of participants?Participants involved in a proposed therapeutic procedure for autism/ASDs must be shown to have an appropriate diagnosis. Otherwise the fact that it succeeds says nothing about its application to autism. There was no evidence that Bettelheim employed widely accepted diagnostic criteria for autism. His participants may well have been emotionally disturbed, or have come from emotionally dysfunctional families, but this is not the same thing. Similarly, Welch explicitly offered her therapy for a wide category of childhood emotional disturbances. Since there was apparently no attempt to secure differential diagnoses for participants, it would be unjustified to draw any specific conclusions about effects on autism. This illustrates the benefits of systematic diagnosis following agreed criteria as outlined in Section 2.
Can reported successes clearly be attributed to the intervention as opposed to confounding factors or chance? Once again, neither Bettelheim nor Welch carried out their work in the kind of systematic way that would permit answers to these questions. For instance, no attempt was made to compare the efficacy of the therapeutic procedure with that of an alternative ‘control’ procedure
What are the criteria for success? e.g. does the effect last? Does it generalise to a range of situations or to individuals beyond the participants?Again, both Bettelheim's and Welch's work was flawed by the fact that success was based on the therapist's subjective evaluation of single cases, that there was no proper follow-up and no clear effects on the well-being of the children.
Can the intervention be carried out in an ethically acceptable way that does not cause distress to the child with autism or his/her family? Bettelheim's approach clearly raised serious ethical questions. Holding therapy is also ethically questionable. For instance, it advocates deliberately distressing the child in order that the parent can overcome emotional negativity, and persisting in holding even though this is disagreeable.
Most practitioners these days are extremely wary of therapeutic procedures that are presented as ‘cures’. Some effects of autistic spectrum disorders are seen as ‘life long’. However, there is much scope for improving the life situation of people with ASDs, employing sounder principles for intervention.
Evidence-based practice: An approach that advocates the importance of basing therapeutic practice on sound empirical evidence.
Psychogenic: Influence on the development of psychological problems that originates ‘in the mind’, rather than from known biological factors.