Put the Pencil Down… Sometimes

Executive Brief: Certain types of practice bases should be particularly familiar (by now) to therapists, namely: Evidence-Based Practice (EBP), Lived-Experience Informed Practice (LEIP), and Practice-Based Evidence (PBE). Contrary to the war being waged among some singleminded adherents, these frameworks are complementary when used appropriately (and not abused), and the arguments that diametrically pit them against one another are largely quackery.

Details…

I decided to write about this topic after attending Kelly Mahler’s interoception training, in which she reports that Lived-Experience Informed Practice [LEIP] and Evidence-based Practice [EBP] are “colliding”… at least in her environment.

That stress is a shame, as it is unnecessary.

She strictly blames EBP, and lauds LEIP for coming to the rescue; unfortunately, that is an orange flag for quackery, in that this is a straw argument, and the blithe appeal to this sort of trick detracts from an otherwise valuable training.

While she portrays this in terms of a fundamental incompatibility, no such diametric opposition exists at base: both LEIP and EBP are just tools. They are tools designed to serve different functions within a broadly shared domain.

Any tool can be used or abused; that is to say (in terms that are not as binary), every tool-like entity exists somewhere in the conceptual space defined in part by a continuum between its uses and abuses.

The use of EBP, LEIP, or of any other practice should include:

• the wants/needs of the person who will be benefitting from the therapy;

• the reliability (depth, breadth, and so on) of the various proficiencies of the team members making the recommendation (including the student/client/patient); and

• the best reliable information that is available at the time, relative to the type of practice (i.e., there is something good to be said for objectivity, subjectivity, and any other jectivity).

I understand that there are arguments that essentially devolve into harangues about the ultimate seat of authority and so on (i.e., as if only one type of person can ever have the correct answer in every type of situation), but there is no one primal source of authority when it comes to therapeutic practice.

EBP is a statistical/stochastic entity that holds across entire populations. LEIP is an entity that is applied by individuals, to individuals. PBE tries to hit a sweet spot between them, where individual cases are gathered into relatively controlled environments (in consistent ways). They are all risk analyses. They speak to likelihoods. Using any of these tools as proof instead of practice is an abuse of that tool.

So you can’t use EBP for LEIP, or PBE for EBP, and so on. Making those sorts of comparisons is a misleading endeavor, whether to suggest that they necessarily “collide,” or that one is the cure for fundamental limitations in the other. EBP resides more firmly in the space defined by objective pursuits, and LEIP is to be found in the neighborhood of subjectives. PBE tries to enhance EBP by drawing upon LEIP, and keep decisions informed by documenting replicable patterns in the interim. They all have value, and each of those kinds of information serve different purposes… to the extent that we keep them separate, anyway. They work together as well as faith and science can; that is to say, when no one tries to treat one as if it were the other.

EBP should not be used – as in Mahler’s anecdotes, or elsewhere – to tell someone that a certain approach has been proven to work for them individually, or really even for people similar to them. EBP doesn’t say that. It only says that to the degree that we can reduce the interference of some extraneous variables (to be able to refer meaningfully to a defined population in a defined environment), the risk of relying on that approach is such-and-so for a given person, explicitly depending largely upon how well any given person in a given environment matches the researched pattern.

No therapist should skip that bit about matching. In Mahler’s anecdote, the fragility resides in the practitioner who misused EBP, and not in the design or intent of EBP itself.

LEIP is also a risk analysis. It says that one person’s lived experience in a certain environment has been interpreted in one particular way by that individual. And if that pattern helps that person out, whether or not it reflects objective reality, then that has value for them, which is a very cool thing. LEIP does not intend for that pattern to be taken as informative about any other person (albeit it is regularly abused in just that fashion), nor to invalidate EBP for a population.

LEIP, EBP, and PBE all display variation among individual people. EBP addresses that by trying to establish reduced-variable populations. LEIP addresses that by definition of the approach (i.e., the recipient of the therapy chooses it based upon their individual lived experience). PBE tries to plot a course through the middle ground. These are not incompatible: LEIP should always be used to help to make informed decisions among various types of EBP (and/or to suggest a new approach), and just one of those ways is through PBE. That’s one reason for the continual arguing about ABA, antibiotics, floor time, chiropractics, oxygen for COPD, ivermectin for COVID, vaccines, facilitated communication, CBT, IQ scores, Laetrile, delayed echolalia, CBD, GLP, and so on; that is to say:

• EBP might show that a certain type of therapy tends to be associated with positive changes across a tested (and preferably controlled) population, or it might suggest that it is largely (or entirely) useless or even dangerous… which does not dictate that it must  necessarily display that same kind/degree of result with absolutely every single person. (Note that this is not the same thing as some other kind of science defining a certain type of therapy as being wholly horseshit… like Radithor.)

• LEIP might show that a certain approach happened to be associated with a positive change for one person (which has value), or that it was useless or dangerous for that one person… but it can’t really say whether that was a coincidence or not (so it might not be replicable, reliable, or safe); furthermore, a motivated pattern is not a collection of coincidences across multiple people. (An abuse of LEIP would be Eben Byers becoming psychologically addicted to Radithor and dissolving his skeleton in the pursuit of pain relief, all because he felt that the elixir was making him feel good.)

• PBE might find out that despite a lack of demonstrated usefulness across a controlled mass of people (or despite a general finding of uselessness in such studies), there might be some common factor (nonetheless) among a small group of people for whom a therapy was associated, and that shared factor might reveal a plausible mechanism for their unpredicted benefit (and so reduce the chance of pure coincidence).

These are broad caricatures (in the interest of brevity), but when they are each used for their designed intent, and not abused, then they are best friends; however, when a use of one is compared to an abuse of the other (as Mahler did), then what you get is a kind of a lie. That sort of mismatch is an amateur rhetorical trick (especially when supported only by anecdotal examples, whether that cherry-picked story is LEIP or EBP or PBE based).

A professional should treat an actual understanding of EBP as the most fundamental prerequisite for making authoritative-sounding statements about its (alleged) inherent failures, especially when claiming that any other practice is guaranteed to be more likely to provide a cure. Mahler does not have this understanding. I understand that her environment is traumatic; nonetheless, she is falsely scaring people away from a valuable source of information in their decision making.

That kind of ethos is what Wittgenstein might identify as ‘bad’.

I’m not really intending to sound all judgey here. Everyone has their own shit. But if we say that this therapist “simply didn’t know any better” than to use this sort of trick to promote their product, well, then they were acting in ignorance, and should not be trusted to promote themselves as an authority (about that topic, anyway).

And I’m pointing it out because people are being hurt, which tempers my kindness reflex.

Crucially, when a lie/trick is used specifically to validate a therapy and its related products, then that validation suffers, as does my estimation of the reliability of the person who resorted to that kind of a strategy. Yes, there is value in a significant chunk of what Mahler has to say, and I value her efforts in promoting those ideals, but unfortunately the entire structure is built upon (or wrapped around) a couple of kinds of untruth. So when that same person keeps talking about who their friends and clients are, and keeps using their influencer status (in effect) to slam EBP to increase their product sales, it feels gross.

Oh yeah, the reason for the title of the article…

Jesse Billow, an SLP from my grad cohort back in whenever, told me about a clinical advisor who was observing a therapy session. Jesse was trying to take consistent data while engaging with a child, and the supervisor told him, “Put the pencil down.”

I mean, taking data is great and all, but it’s not the highest priority, or the best tool for every purpose… otherwise you’ll end up with a sheet full of data that meticulously records how you failed to be useful when you were too occupied to interact with the person who is relying on your help.

[2023-02]

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