By Seth Warren, Ph.D.
“Accountability” and Research on Psychotherapy Outcomes
I would like to continue the theme of my previous column on the future of psychoanalytic practice, but before I do, I would like to remind our members that my intention is to provoke conversation and dialogue on these matters. My belief is that our ideas develop, both in the clinical setting and in public forums such as our Newsletter, through participatory dialogue. I would like all our readers to feel encouraged to respond to what is published here by sending comments, thoughts, and replies, in whatever form, to our Editor, Mary Lantz.
The following comments are adapted from an article submitted for publication in the IARPP eNews, a digital publication of the International Association for Relational Psychoanalysis and Psychotherapy.
Different kinds of knowledge can contribute to our understanding of human experience, including research in various fields in both social sciences and natural sciences. But this use of research is very different from the notion that psychoanalysis as a clinical approach must be subjected to empirical studies modeled on research in the natural sciences in order to justify its claims, its knowledge, and its clinical applications.
In recent years growing chorus of psychoanalytic writers have suggested that the only way psychoanalysis can be “accountable” is by employing the kind of empirical research methods used more broadly within Western medicine and academic psychology. In some ways this movement has gained increased momentum as a result of a number of articles published by Jonathan Shedler, a psychologist/psychoanalyst who has convincingly argued that the view that psychoanalytically-oriented psychotherapy is not “evidence-based” is, itself, not evidence-based! He makes this argument by gathering together and analyzing a number of outcome studies demonstrating the efficacy of psychoanalytic psychotherapies. While we all may enjoy the support and encouragement such studies provide, it seems to me that important questions remain about the value and importance of quantitative empirical research in psychoanalysis.
This outcome research – very different from basic research in psychology and other fields – is directed at the goal of proving that psychoanalytic therapy “works,” that is to say, it does what it is intended to do. But what is such psychotherapy intended to do? What does it mean for a therapy to “work” from a psychoanalytic point of view? If we simply adopt the goals and purposes of a medical model framework, relying on a medical approach to diagnosis and symptom reduction, we abandon much of what is unique, essential and important in psychoanalysis, for the sake of good public relations, and the acceptance of organizations and institutions that do not necessarily care about psychoanalysis and its particular aims and goals.
Setting aside the enormous and important problem of therapeutic aims and goals, the more extreme “pro-research” psychoanalysts adopt a notion of accountability that arises in a particular historical and social context. Although this type of accountability is often framed by the evidence-based movement in moral and scientific terms, it arose largely in the economic, bureaucratic, and legal-administrative contexts of a modern capitalist society concerned with claims of efficacy for the purpose of marketing and liability. By this narrow definition of accountability, no human practice could make any claims to being accountable until the development of large-scale experimental studies and statistics – the type of empirical methods favored now by our current medical model and academic psychology. But this is obviously false; the argument that quantitative empirical research is the only way for any practice to be accountable relies entirely on this limited, historical definition of what it means to be “accountable.”
Doctors have always seen themselves as accountable to their patients, to provide the best possible care. The Hippocratic Oath, dating back perhaps 25 centuries, is the expression of accountability arising from a sense of moral responsibility. Prior to the advent of nomothetic research methods, people were personally accountable to one another, and practices arose and were displaced on the basis of experience and social contracts. The “evidence-based” view of accountability implies that practices are modified or rejected only because of the results of empirical research. This view fails to consider the mechanisms of theoretical or clinical progress that are based on dialogue, self-reflection, public discourse, personal integrity and openness, listening to patients, intellectual criticism and self-criticism, and other forces that act on our individual and collective knowledge and practices. Humans learn from experience and from one another. The antidote to dogma is openness, flexibility, acceptance of one’s limitations, and awareness of other points of view, as much as it is the refinement of scientific methods.
It is easy enough to understand why one might want to make stronger kinds of truth claims, but, as psychoanalysts know very well, wishing doesn't make it so. If psychoanalysts accept a greatly limited concept of “effectiveness” – one defined within a medical framework and required by quantitative empirical research methods – to be the only measure of the usefulness of what they do, the practice appears doomed. Even if one could design a “perfect” study showing psychoanalysis to be, for example, an effective treatment of depression – as effective for argument’s sake as antidepressant medication used as a control – we are still left selling an impossible product. We could claim that a clinical approach requiring three or five or more years of three weekly sessions costing many tens of thousands of dollars was “equivalent” to a treatment taking several months, a few visits to the psycho-pharmacologist and costing a tenth as much. What good is that? Psychoanalytic psychotherapists obviously believe that we offer something beyond symptom reduction. But the “more” we offer is precisely what quantitative empirical clinical studies do not – and cannot – observe. Ways of thinking about progress in a psychotherapy patient that might matter a great deal to a psychoanalytic therapist – such as the patient being more loving, feeling more alive, having more successful relationships, being ‘wiser’, experiencing affects more deeply and openly, being more creative, being more self-reflective, being less self-destructive etc. – are ignored or operationalized in ways that distort and greatly diminish their meaning. The evaluation of such aspects of clinical change requires acts of interpretation: a human interpreter with human limitations, a personality, a personal history, gender, clinical theories, language, culture, and experience. In short, the kind of subjective observer the “scientific community” disparages. Psychoanalysis offers a point of view about human suffering – a point of view about being human – that is different from the medical/scientific point of view, one that includes a uniquely human dimension that includes aspects that are existential, moral, phenomenological, and experiential, none of which can be found to exist outside a subjective human world. It would be a great tragedy if, in the name of progress, this human dimension that psychoanalysis is uniquely positioned to address is set aside because it does not lend itself to quantitative empirical research.