The case for practice-based evidence

'There is no evidence that using an evidence-based approach to health care actually improves outcomes, and plenty of anecdotal evidence that it doesn’t.'

This about sums up the attitude of the 'rejecters' – one of three classes of practitioner, whose astringent criticism of the new conventional wisdom of prevention science gets an airing in the latest edition of Clinical Child Psychology and Psychiatry.
 
In ”Improvers, Adapters and Rejecters — the link between evidence-based practice and evidence-based practitioners", Nick Midgley, a psychotherapist at the Anna Freud Centre, sets out the variety of attitudes to evidence-based practice current in his child mental health field.

At the extreme are those for whom the whole evidence-base practice (EBP) movement is based on 'an outrageously exclusionary and dangerously normative approach promoting dependency on pre-interpreted, pre-packaged sources'.

These are the group Midgley calls the 'rejecters'. For others, the ideals of evidence based practice are more valued, and the debate concerns how best to put them into practice.
 
Whether in medicine, education or mental health, the culture of evidence based-practice pervades almost every aspect of our public lives, he argues.

That such an approach should have become a universal impulse is a tribute to the work of the British epidemiologist Archie Cochrane and his 1972 critique of the medical establishment Effectiveness and Efficiency.

In that book, Cochrane argued that patterns of care in medicine were 'chaotic, individualistic, often ineffective and sometimes harmful,' largely due to the fact that medicine itself had not organized its knowledge “in any systematic, reliable and cumulative way”. Cochrane’s solution was evidence based medicine (EBM), the forerunner of the more wide-ranging evidence-based practice movement.
 
'At best, this development has led to a deeper understanding of "what works for whom" and a corresponding improvement in the provision of high-quality care,' Midgley writes. 'At worst, it has been a way of "rationalising" services by withdrawing funding for any forms of treatment that cannot be proven to work within the very restrictive definitions of ‘evidence’ used by many of the advocates of EBP.'

A convincing balance has still to be struck between two professional caricatures, he argues. One is of the enlightened practitioner, typified as someone who is always 'integrating individual clinical expertise with the best available external clinical evidence from systematic research' while taking into account client values, preferences and expectations. The other is of a born-again equivalent, whose dogmatism leads to assertions that 'children with X should be offered Y because the evidence-based guidelines say so'.