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.
Replies
Namo Amida Bu.
Yes.
I agree 'outside perspectives can help but also distract the empathic attention needed in each case.' The psychological model you described at ITZI in September comes to mind: Objective situation > Triggered action > Experiment > Learning > Completion. Life, medicine, therapy, relationship, friendship in a pure form, all these approaches remain art. In Buddhist Psychology the proof of a method might be whether the individual having encountered the intervention, moves closer to completion (empty mind, mirror mind as described by Dogen)?
Thank you. We all rely upon evidence, but evidence of what? It differs from case to case. Scientific evidence is generally a matter of aggregating results from many cases so as to yield a generalisation. Such generalisations are interesting and useful in the right context, but may be irrelevant to a given particular instance of therapeutic work. Knowledge of such outside perspectives can to some extent help to educate the intuition of the therapist, but she has to work with the specific case in front of her and there is always a danger that her knowledge of the outside perspective will distract from the empathic attention to the specific that is what is actually needed in each case. Therapy has, therefore, to be a creative art. Just as although a knowledge of the history and theory of art will probably be of interest to a painter the actual picture that he is painting today will not be an instance of anything that he has read in the book,so a given piece of therapy will not simply roll out a prescripted protocol. Real art will itself in some way and in some degree change the way that everything in the book is then construed. If there is nothing new, then it was not real. This is just as true of therapy as of any other art.
I agree Dharmavidya. Our reliance on hard evidence is not always helpful and can distract from what is relevant and meaningful to a specific individual. Failed scientific evidence is rarely published, brings bias and closes minds prematurely. Our need for evidence comes from a hunger to know what is true and what we can trust and have faith in. Evidence can certainly help with superficial understanding and learning but cannot quench the heart's deeper thirst. For example, knowing how many people died in car accidents every year can help a society find ways to make roads safer. We can then measure whether interventions are having an impact year on year. Deep learning works in a different way. Deep learning does not care about numbers, evidence, publications, money or status. What is of value, what touches the heart cannot easily be counted or measured but it can be experienced. We know this truth when we feel changed by music, poetry, art or love. The unseen exists and shapes us every day. The way things are operates independently of evidence or human comprehension. Deep learning requires periods of solitude and reflection to appreciate the dance between form/formless. After a period of reflection learning can be brought back, applied and tested in the reality of our lives and relationships. This process provides 'evidence' (learning and change) but not in the way we know it!
Sounds as though we are not so far apart really.
I have no problems with Carl Rogers. The therapist is important etc. I can't think of an 'off the shelf' therapy that works. I can though think of proven therapeutic interventions that when applied correctly work really well. They tried a computer programme called Beating the Blues, not very successful, not to be repeated, lacked the therapist touch. I can't remember when or who exactly developed a postal therapy, post the problem and advice and therapy is given by post was quite successful but not popular. Then there are Self Help books which many I suspect have found helpful and informative, perhaps we should include the Bible in this category, A.A. does. Finally we have the internet so God help us all but my guess is He has lost interest.
Interesting. This probably is where we disagree. I think that the characteristics of the therapist matter and that what might be called generic factors such as those identified by Carl Rogers, for instance, are more important than this or that procedure. I accept that in the case of very specific problems, like say, spider phobia, some of the methods developed by behaviourism do often work, but in all my time as a psychotherapist I have never once been asked to help a person overcome spider phobia, so maybe, to some extent, we are talking about different kinds of clients. If I have a client who comes and says "I have been hospitalised for schizophrenia twice and if it happens again I fear I will lose my job. Can you help me?" I do not have an off the shelf method that could be applied by anybody who followed the instructions. Rather I establish a rapport with that person and my ability to do so is a function of what I bring to that situation as a person as well as the authentic interest that I have in that person and their world.
To agree with the rapport angle would be to degrade the efficacy of therapeutic approach to personality, when in fact the real ingredient of successful evidence based 'outside' therapies rests in its repeatability regardless of therapist characteristics, although being genuinely interested helps.
David Brazier said:
I don't think that the therapy you did was dumb, Peter. I think if it was successful, that success will have been largely due to the rapport you achieved with your clients.
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