So Does It Work?

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Is the sky blue? Is exercise good for you? Do politicians lie? One could say ‘yes’ to all of these ‘universal truths’ and be right . . . most of the time. But, like many questions that beg a one-word, absolute, black or white answer, some of the time that ‘yes’ would be wrong — or, minimally, too reductionist, unqualified, misleading.

The house research muse happened on a podcast recently somewhat invitingly entitled Does Psychotherapy Work? Right up there with is there a unified theory of everything?. At some very basic level, a simple ‘yes’ is a pretty compelling answer. However, like those days when it’s cloudy, daily workouts have inched towards ‘positive addiction’, or an elected official actually tells it like it is, the answer is, at the very least, more nuanced.

Evidence-based ______________. Fill in the blank as you will: programming, treatment, practice. The list stretches to the horizon. The current ‘buzz phrase’ has popped up across any number of disciplines, generally attached to an increased need for accountability, science-based ‘proof’, appropriate resource allocation, program efficacy. Gone are the days of reading the bumps on someone’s cranium, channeling Woody Allen as he sits with his analyst five days a week, exorcising evil spirits, and (dare I say it), intercessory prayer. Show me the beef have belatedly become the new watchwords. Demonstrated proof of effectiveness, controlled studies are the foundation of evidence-based intervention. Injecting bleach evidently doesn’t make the cut. Critical thinking over snake oil.

An essential companion to an evidence basis is measurement of outcome. I drop a glass of milk to the kitchen floor, the glass usually (in my case) breaks and the contents spill. I hit my thumb with a hammer and I feel something I describe as pain (and occasionally say some words). Pretty predictable, pretty reliable results. Basic physics and anatomy. Running these ‘experiments’ repeatedly isn’t going to produce a different outcome — ever. Certainty, though messy and painful, is assured.

Enter psychotherapy. The universe of ‘what constitutes psychotherapy’ has been being refined for well over a century. Study after study, meta analyses, and careful replications have created for practitioners a tool kit with a relatively reliable track record. Results not quite as predictable as losing grip of a glass or a misdirected hammer swing — but better than past life regression!

A metaphor or two. I use an iMac with two terabytes of storage; and just for convenience, I carry a one kilo backup buddy that lets me take my office on the road. And, once on said road, my interactive sat-nav stares back at me from the car’s dashboard. My Apple II+ with a brain now eclipsed by my watch and the comfortable satisfaction refolding a paper map are distant memories. I certainly have the equipment to do wonderful things (and rarely get lost!). But I’m 74. Despite fancying myself pretty tech-savvy, I sometimes reflect on my ‘facility’ with these marvellous ‘gadgets’. In short, great tools do not, on their own make for great results. After all my now sainted mother stored her potato chips in the stackable clothes dryer and never did get the hang of that VHS machine. The tool is necessary — but insufficient in the absence of some very essential conditions!

The most efficacious (I love the very sound of that word) of interventions, ever so thoroughly validated, are only as good as the practitioner into whose hands they fall. Only ‘work’ if they’re the right match for a presenting complaint; brought to one’s office by a client who’s willing to engage. And only produce measurable, long-term change when the ‘fix’ facilitates the development of a sustained practice. The caution of a revered mentor continues to echo in my mind: Insight without action is bullshit!

Back to outcome, the elusive challenge of measuring it — and, perhaps, in the bargain offering an answer to the question at the top of this piece. The sine qua non (another ‘flows trippingly off the tongue’ favourite!), of course is the ‘tool’, the treatment itself. And, for the sake of argument, let’s assume all credentialed practitioners are created equal and competent. Which means they’re all pulling the right screw driver out of the pouch for the job. We’ve stacked the therapeutic deck pretty favourably.

So I take out my ruler, stick it under my tongue for 30 seconds and note that my temperature is 10 inches (allowing for old technology and metrics). Hmm? Nothing wrong with the ruler; no problem with the protocol. Just a meaningless result. Welcome to the world of outcome measurement. Some age old issues remain. Principal amongst these: Are we measuring the right stuff? In a meaningful way? With a valid and reliable test? And, for good measure (in the spirit of same), repeatedly and over sufficient time?

Tests purporting to tap into the holy grail of psychotherapy abound, ranging from short and useless to long and unwieldy. The ‘quickies’ are widely employed and easily interpreted. And almost certainly measure your body temperature in units of length!

One or two rungs up the ladder are longer, better normed, less easily ‘fooled’ instruments. Mapping the course of change is usually possible with these — with two important riders. They are typically ‘self-report’ which brings along all manner of client-based biases — intended or no. And with these, the hobbling of comparing a therapeutic technique’s effectiveness across a client group (not just measuring one individual’s progress over time). One person’s ’28’ as it were, may be quite different from another’s — an ‘I feel pretty good’ versus ‘this is pretty much how I always am’. Still, better than ‘the ruler’.

Finally, the ‘gold standard’ instruments address most of the above concerns — but at a cost measured both in time (for completion) and dollars (expensive). Great information, reliably assessed. Just painfully impractical to administer repeatedly — not to mention client resistance (the ‘Oh God, not again’ dilemma).

So does psychotherapy work? Yes it does. . . sorta, kinda, probably, I guess — with good tools, skilled mechanics, right ‘gadget’ for the job, and committed customers with an eye for future maintenance. How do we know? Well. . . that’s the rest of the story, isn’t it.

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