efficacy and outcome
Sitting in the pub the other night a friend invited me to consider that we don't ever really know whether we psychotherapists have helped our patients. (Curious how this kind of sentence only really works to convey its allegedly valid point if we put the 'know' in italics.) A desire for modesty, and reflection on the self-serving confirmation bias of therapists - reflection on how easy it is to tell a post-hoc narrative in which the good outcomes are a result of the therapy, the poor ones the result of the psychopathology or life circumstances, incline me to agree with him. (He told me too of a patient who shared with him the priceless 'When I'm doing better my psychiatrist tells me it's his drugs working; when I'm doing worse he says it's something I'm doing wrong. I can't win!' ) And yet...
The question touches for me on two other concerns. The first has to do with interventionism in the philosophy of science. The second to do with a distrust, by psychoanalytical psychotherapists, of outcome research, a distrust which often seems poorly reasoned but which yet may, I suspect, sometimes be on to something.
So here is a way of looking at therapeutic efficacy and outcome which sustains the idea that we don't really know whether we've helped someone. It is one in which the interactions in the consulting room - actually it really works best, for reasons that will become clear, if we call them 'interventions' - and the emotional relief of the patient - and it works best if this is thought of as an 'outcome' - are thought of as 'distinct existences'. Distinct existences that, we will now want to describe as, either actually or merely apparently in relation to one another. Now it becomes clear how we can get going with a picture of emotional therapeutics which renders its impact beyond anything that could safely, non-arrogantly, be said to be known.
So, yes, if we have to do with distinct causes and effects - with something brought by the therapist which is the intervention, and something now felt in and by the patient which is the effect of the intervention - then the appeal of maximal epistemic modesty - 'we can't ever really know whether what we do really helps them' - 'we can't ever really know whether or not our intervention works' - becomes evident.
But why would anyone think that that's (the 'workings of interventions') a good way to characterise the therapeutic encounter? It might ally nicely with a medical model (does the drug work or not?), but does it ally with what any of us really experience as patients of psychotherapy?
Actually there are situations in which something like this characterisation does seem apt. The occupational/behavioural therapy of a depressed person is an obvious example. 'Do you know, I really do feel better just going out and getting on with some work; I really didn't expect what she said to help but I do find myself feeling a lot better'. Even here, however, we have two things going on which I think need teasing apart. One is the non-psychotherapeutic boon of the recovery of self-sustaining meaning-making through work, world-engagement, etc. Good old behavioural recovery. Nothing to do with the unity of subject and subject in a therapeutic relationship, this. Rather the transmission of a guiding idea from the one to the other. The other is an existential and emotional shift - a recovery of trust in the cogent solicitude of the other (of the therapist that is) implicit in this situation of which the patient's mind is a part: the patient allows himself to hear what she is saying to him. And a recovery of trust in his own mind - a recovery in his ability to show himself meaningful solicitude.
On the whole, however, and especially when what we have to do with is psychotherapy proper, the medical model - by which I mean a model framed in terms of the distinct existences of intervention and outcome - hardly seems applicable. A better model would, I suggest, be face painting. Someone wants to get their face painted. So they go to a face painter. Here it would be daft to call the face-painting the intervention which has the effect of the person's face now having paint on it. The cause and the effect are not here two separate things: the cause is the painting on the face which is the same thing as the face being painted. Imagine someone saying 'But do you ever really know that it's your face-daubing that causes the face-being-daubed-ness of your client?' The correct answer is 'Yes mate I kinda do, but your talk of "causing" is flagrantly hyperbolic'.
'But', it will be objected, 'psychotherapy is hardly as sure an art as face painting'. 'It is this uncertainty, this difficulty, that gives our thoughtful scepticism its point'. Well. Yes. But. But we mustn't generalise from the difficulty of significant emotional change relative to facial hue change to the idea that when emotional change does happen it happens in a way that can be aptly modelled on the idea of interventions leading certainly or uncertainly to outcomes. Might it not rather be like going to see a dyspraxic face-painter? Four out of five attempted daubings miss their target, but the one that does: there's no question for this one that it might not be the daubing that causes (better: constitutes) the being daubed. No question of being immodest if we pretend to knowledge here.
It seems to me that it is perfectly clear enough, and no kind of unsafe inference - no kind of inference of any sort, for that matter - clear to both therapist and patient, when a therapy is alive, when it truly is functioning as a therapy. My patient is defended, emotionally cut off, irritable, stuck in his depressed or anxious state - and I make various attempts to 'get through to him'. And many of these backfire. But then I do - there we go - now he has that rush of tears, that relinquishment, that flowing up and out of openness, he settles into a meaningful relief or sadness, or he allows himself to feel his anger, his envy, his guilt. He relinquishes the suppression or involution of his anger. There is this lifting of his depression, in this moment. This cessation of depression now is not the cause of its ongoing cessation over the week. We're not inferring from one thing to another thing here either. To borrow an analogy from Squires' (1969) brilliant critique of causal theories of memory: the curtains being indigo today is not the cause of their being indigo tomorrow; it's just that nothing has intervened in the meantime. In this moment of therapeutic action both therapist and patient know perfectly well that this therapy, here, now, is working.
None of this is to say that outcome research is invalid. By all means find a description of therapist actions and beneficial patient reactions under which they manifest as external relata, and then ask about how consistent such relations are for this or that therapist, or perhaps even across therapists, for those using this or that model of therapy for example (although I think this is much harder to think sensibly about). We would be crazy to go and see a therapist whose outcome data, measured thus, was effectively at a chance level - who offered therapeutic relationships in which therapeutic moments were no more frequent than in any other waking hour of their patients' lives. But we would also, it seems to me, be crazy to try to use such outcome research to guide us in our practice - at least to the extent that it inclined us to a mode of therapeutic action which was all about doing things to our patients. We already know what is therapeutic. Sometimes we need to take courage. Sometimes we need to get better at challenging defences, discerning the extent of a patient's identification with his defences. Sometimes we can fail in our compassion. (Not fail in a technique of showing compassion, whatever that would be - but just fail ethically to meet our patients as people. We do this, sometimes, because we are human. And if you do it a lot you don't need a better model of therapy but rather something like a call to conscience, or some more therapy yourself to help with your projections.) But we do know, often enough, when it is working, that it is working. We were there. Not there as witnesses to an unsafely-inferred two-place relation, but participants in the midst of this unitary unfolding of the patient's emotional restoration.
The question touches for me on two other concerns. The first has to do with interventionism in the philosophy of science. The second to do with a distrust, by psychoanalytical psychotherapists, of outcome research, a distrust which often seems poorly reasoned but which yet may, I suspect, sometimes be on to something.
So here is a way of looking at therapeutic efficacy and outcome which sustains the idea that we don't really know whether we've helped someone. It is one in which the interactions in the consulting room - actually it really works best, for reasons that will become clear, if we call them 'interventions' - and the emotional relief of the patient - and it works best if this is thought of as an 'outcome' - are thought of as 'distinct existences'. Distinct existences that, we will now want to describe as, either actually or merely apparently in relation to one another. Now it becomes clear how we can get going with a picture of emotional therapeutics which renders its impact beyond anything that could safely, non-arrogantly, be said to be known.
So, yes, if we have to do with distinct causes and effects - with something brought by the therapist which is the intervention, and something now felt in and by the patient which is the effect of the intervention - then the appeal of maximal epistemic modesty - 'we can't ever really know whether what we do really helps them' - 'we can't ever really know whether or not our intervention works' - becomes evident.
But why would anyone think that that's (the 'workings of interventions') a good way to characterise the therapeutic encounter? It might ally nicely with a medical model (does the drug work or not?), but does it ally with what any of us really experience as patients of psychotherapy?
Actually there are situations in which something like this characterisation does seem apt. The occupational/behavioural therapy of a depressed person is an obvious example. 'Do you know, I really do feel better just going out and getting on with some work; I really didn't expect what she said to help but I do find myself feeling a lot better'. Even here, however, we have two things going on which I think need teasing apart. One is the non-psychotherapeutic boon of the recovery of self-sustaining meaning-making through work, world-engagement, etc. Good old behavioural recovery. Nothing to do with the unity of subject and subject in a therapeutic relationship, this. Rather the transmission of a guiding idea from the one to the other. The other is an existential and emotional shift - a recovery of trust in the cogent solicitude of the other (of the therapist that is) implicit in this situation of which the patient's mind is a part: the patient allows himself to hear what she is saying to him. And a recovery of trust in his own mind - a recovery in his ability to show himself meaningful solicitude.
On the whole, however, and especially when what we have to do with is psychotherapy proper, the medical model - by which I mean a model framed in terms of the distinct existences of intervention and outcome - hardly seems applicable. A better model would, I suggest, be face painting. Someone wants to get their face painted. So they go to a face painter. Here it would be daft to call the face-painting the intervention which has the effect of the person's face now having paint on it. The cause and the effect are not here two separate things: the cause is the painting on the face which is the same thing as the face being painted. Imagine someone saying 'But do you ever really know that it's your face-daubing that causes the face-being-daubed-ness of your client?' The correct answer is 'Yes mate I kinda do, but your talk of "causing" is flagrantly hyperbolic'.
'But', it will be objected, 'psychotherapy is hardly as sure an art as face painting'. 'It is this uncertainty, this difficulty, that gives our thoughtful scepticism its point'. Well. Yes. But. But we mustn't generalise from the difficulty of significant emotional change relative to facial hue change to the idea that when emotional change does happen it happens in a way that can be aptly modelled on the idea of interventions leading certainly or uncertainly to outcomes. Might it not rather be like going to see a dyspraxic face-painter? Four out of five attempted daubings miss their target, but the one that does: there's no question for this one that it might not be the daubing that causes (better: constitutes) the being daubed. No question of being immodest if we pretend to knowledge here.
It seems to me that it is perfectly clear enough, and no kind of unsafe inference - no kind of inference of any sort, for that matter - clear to both therapist and patient, when a therapy is alive, when it truly is functioning as a therapy. My patient is defended, emotionally cut off, irritable, stuck in his depressed or anxious state - and I make various attempts to 'get through to him'. And many of these backfire. But then I do - there we go - now he has that rush of tears, that relinquishment, that flowing up and out of openness, he settles into a meaningful relief or sadness, or he allows himself to feel his anger, his envy, his guilt. He relinquishes the suppression or involution of his anger. There is this lifting of his depression, in this moment. This cessation of depression now is not the cause of its ongoing cessation over the week. We're not inferring from one thing to another thing here either. To borrow an analogy from Squires' (1969) brilliant critique of causal theories of memory: the curtains being indigo today is not the cause of their being indigo tomorrow; it's just that nothing has intervened in the meantime. In this moment of therapeutic action both therapist and patient know perfectly well that this therapy, here, now, is working.
None of this is to say that outcome research is invalid. By all means find a description of therapist actions and beneficial patient reactions under which they manifest as external relata, and then ask about how consistent such relations are for this or that therapist, or perhaps even across therapists, for those using this or that model of therapy for example (although I think this is much harder to think sensibly about). We would be crazy to go and see a therapist whose outcome data, measured thus, was effectively at a chance level - who offered therapeutic relationships in which therapeutic moments were no more frequent than in any other waking hour of their patients' lives. But we would also, it seems to me, be crazy to try to use such outcome research to guide us in our practice - at least to the extent that it inclined us to a mode of therapeutic action which was all about doing things to our patients. We already know what is therapeutic. Sometimes we need to take courage. Sometimes we need to get better at challenging defences, discerning the extent of a patient's identification with his defences. Sometimes we can fail in our compassion. (Not fail in a technique of showing compassion, whatever that would be - but just fail ethically to meet our patients as people. We do this, sometimes, because we are human. And if you do it a lot you don't need a better model of therapy but rather something like a call to conscience, or some more therapy yourself to help with your projections.) But we do know, often enough, when it is working, that it is working. We were there. Not there as witnesses to an unsafely-inferred two-place relation, but participants in the midst of this unitary unfolding of the patient's emotional restoration.
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