There is a good deal of concern these days that psychotherapy should be “evidence based”. This has led to a neglect of, for instance, psychoanalysis. I cannot help thinking that this development is a mistake. When I think of the kind of psychotherapy that I do, I am at a loss to understand what the “evidence” could be. For sure, there is evidence in every case, but it is never of the same kind from case to case. In case A it is success if the client is less sad and more cheerful. In case B it is success if the client is weeping and no longer smiling. In case C it is success if the client is more rational and realistic. In case D it is success if the client is more romantic and creative and has ceased to be so tightly logical. In case E it is success if the client is still alive. In case F it is success that the client has decided to sacrifice his life in an important cause. How can one find a criteria in all this that will demonstrate that such therapy is or is not effective? Whatever criterion one selects, is one not thereby going to be imposing upon the clientele an extrinsic value system that may have little or nothing to do with the meaning of their life?
The idea of evidence in psychology usually rests upon classifying clients according to their supposed syndromes which are then regarded as being on a par with medical ailments. This is a false move. A person’s psychology is not comparable with an infectious illness or a broken leg. In the latter case there is something like a physical entity for which some test can be administered, whereas in the case of psychology it is not at all the same. The various syndromes in the Diagnostic and Statistical Manual mostly do not correspond to entities of any kind. Furthermore, what appears to be at issue at the beginning of therapy may soon turn out to have been nothing more than a pretext. If the task were merely that of making sad people cheerful then entertainers could do a better job of it.
The imaginary entities categorised in the DSM are only collections of symptoms which do not always go together and mean different things in different individuals. Psychotherapy is not simply a matter of manipulating a person's mood. A chemical can do that, but it does not make the person's life more meaningful.
Since there is no test you can administer to identify the “disease”, nor is there any to identify the “cure”. Whatever one takes as evidence is spurious. Perhaps we use self-report or questionnaires, but these are, by definition, subjective so cannot really count as evidence.
Even when there is something objective to go by, it needs interpretation. A therapist sees a child who is school phobic. Later the child is attending school. We might take this as evidence that this therapist has a method that is effective in the treatment of school phobia. A person with a gun who frog marched the child to school each day might also have an effective method. This really has little or nothing to do with psychotherapy. Has this therapist made this child’s life more meaningful and constructive or has she merely made him docile and conformist? There is no way that our “evidence” can answer this question, yet this is the really important question. Whether the child attends school or not is a matter of social administration, not psychology and failure to attend might be for a thousand different reasons. There is no psychological entity called school phobia, only a legal one called non-attendance.
I am asked how I would treat a case of depression or of suicidal ideation. I do not “treat” such things, I relate to people. The melancholic mood of this client is not the same as that of that one. People consider suicide for all kinds of reasons, some noble, some less so. Is it wrong that a person commit suicide? Not always. Is it bad that a person is melancholic? Not necessarily. An evidence based approach assumes that certain conditions should be eliminated from human experience, but if Nature has given us a capacity for something, it is for a reason and we seek to abolish it at our peril.
We are told that such and such a type of therapy is good for treating such and such a condition, depression, say, or anxiety. Depression and anxiety are, however, natural parts of life that have meaning in the context of the particular person in his world. Simply persuading the person to be more cheerful or training them to be more relaxed does not honour the depth of meaning of the particular life. It is an instrument of social control, not a liberation for the human spirit. Social control is not therapy. At most, it is a form of education. Evidence based psychotherapy, in the normal sense of the term “evidence based”, is not really psychotherapy at all.
It is important that the psychotherapist have regard for evidence, but this is the evidence of the particular case, not statistical norms. I want to see evidence of what is happening in the life of my client and I seek to understand what it signifies in the deepest possible way, by which I mean, that I seek to know what it means in terms of the life trajectory of the person. Not all clients are moving in the same direction. Not all have the same life meaning. Not all manifest in the same way and what is good for one is not necessarily good for another.
Evidence based “psychotherapy” is like formula based literature: either completely nonsensical or cheap and rubbishy. No great literature is of this type and equally no real psychotherapy. "Evidence based" has become a slogan by which certain brands of therapy have managed to assert their dominance over others. These now dominant forms, however, are generally less subtle, less penetrating and less well adapted to the complaxity of the human condition. After all, one of the ways to become "evidence based" and so gain approval is only to do the kinds of thing from which statistics can easily be collected. Thus this trend leads to a general dumbing down of the psychotherapeutic art and its reduction to standardised interventions. This is the wrong way to go.