Wednesday, 5 November 2014

In Favour of Objectivism about Psychotherapy Outcomes

A lot of people in my field dislike the use of quantitative measures to determine the value of what they are doing. Some of the emotional intensity of this view can be seen in the conversation I had on Twitter after posting a link to an article by Richard Gipp. The idea seems to be that objective measures "miss" something that can only be framed in language. People's psyches are fragile and complicated, and using a numerical scale is somehow riding roughshod over this, or doing to violence to the subjectivity of the other. This post is a response to (though not straightforwardly an argument against) Gipps' piece, which contained many fascinating points I don't really speak to here. My aim is to persuade you that "objectivist" approaches to measuring psychotherapy outcome are a good thing.

I am not making a rational argument (though I hope it's not irrational); that has been done consistently over the past 60 to 70 years and it is fairly widely acknowledged that numerical information has its own self-contained logic. This is an attempt at polemic. I want to convince you at a gut level that the use of numbers works for people who use services, that it can actually be quite noble in all the ways that certain forms of clinical writing claim to be. Furthermore, I want to suggest that, for all its value, the most poetic and optimistic clinical writing can act to conceal reality in important ways, potentially giving a veneer of respectability to processes which have little meaningful impact. Conversely, just because there is something rather prosaic about the notion of an "evidence-based-therapy", it is in fact perfectly compatible with all the beauty and subtlety we see in more "subjectivist" approaches.

In regard to the first point, the promise of insight, self knowledge or a deep connection with someone else does not necessarily carry along with it the promise of "feeling better" in important ways. I have learned a lot about myself through experiences of psychodynamic therapy or supervision, but to some degree one can separate the process of self-understanding (itself, in my view, an extremely valuable thing) and the process of feeling substantially less rotten about one's life. Although I find it invaluable to have the head-space to wonder about my relationship to my desires and my personal history; to think about the way they rebound in the minutiae of my social interactions in the present, I am not always sure how essential these are for my capacity to continue getting out of bed in the morning or avoid feeling like I want to kill myself.

Getting somehow "better" (and better is necessarily a vague word, in psychotherapy outcome research. It has ended up meaning whatever is indicated in the questionnaire you choose: "less anxious"; "less depressed" by a certain number of points on a scale) is not always a beautiful process. Something could be good for you psychologically without necessarily reaching your subtlest places. Some of the times I have made the most important changes in my well-being or happiness have been of the "crass" variety; events I could re-describe as "behavioural activation" or "cognitive restructuring". These are not Orwellian portents of a psychotherapy devoid of the human factor, they are clumsy attempts to describe ways we can change ourselves (in the right context) rapidly and  effectively .

More importantly, there is simply no incompatibility between a blunt (but objective) measure of psychotherapy outcome and a fine-grained "appreciation" of the unique and subjective aspects of the experience. Something could be useful in the crass numerical sense (indexed by a clinically interesting drop in an Anxiety measure) while also being moving, poignant, invigorating, thought-provoking, inspiring and so on.

To assume otherwise is to place a peculiar store in one narrative version of events as though "the truth" about someone's subjectivity resides in one place and one place only. Truth is trickier than that. What is "the truth" about a person's experience of a depressive breakdown; their narrative of events? The narrative of the people they love? A measure of their moods on a series of psychological questionnaires? Or does the truth lie somewhere beyond all these, in an inarticulate mesh which can only be variously approximated by different representations?

One critical response to the varieties of a treatment like CBT is to regard them as a form of authoritarian "training" or "brainwashing". This is to take the language of CBT too seriously, to imagine that your experience of that language is identical with the experience of the therapeutic relationship in which its techniques are deployed. "Cognitive restructuring" sounds quite mechanistic, but depending on how it is conducted it can mean something closer to "helping someone consider alternative readings of their situation" or "expanding a person's psychic possibilities". One could experience cognitive restructuring and find the experience elevating and beautiful. One could experience it as an intrusion by an idiot who has no appreciation for how difficult your life is. Or your reaction could lie somewhere between those extremes.

Precisely the same is true for any modality of therapy. Psychoanalysis (for some reason the most poetically described form of therapy) can be constructed as a disintegration and reconstruction of the ego through a profound subjective attunement between analyst and patient. It can be beautiful (it can certainly be written about beautifully by clinicians). It can also be experienced as sadistic, or as pointless (For some reason this perspective is more frequently seen in the narratives of patients like Susanna Kaysen in "Girl Interrupted", or Jenni Diski than in the writing of psychoanalysts themselves).

These disconnects are why I like numbers and think you should too. Efforts to represent the truth are all around us. Although patient narratives ought to be taken very seriously, in clinical professional circles the narratives of practitioners (every clinical psychologist has a copy of Irving Yalom somewhere at home) are generally given more credence. Given this fact, it is nothing short of wonderful if a healthcare system can be organised around a system of aggregating numerical indices of individual experience. We can, if we want, say that quantitative measures are an impossible attempt to objectify the subjective, but their value doesn't rely on this vaunted ambition. Numbers are a simple and systematic language. You indicate how you feel at time 1, and when time 2 comes along, any observable difference can easily be registered. It is much harder for clinicians to deny the fact that more people report feeling worse at time 2 than it is for them to re-construct the whole encounter so as to undermine any testimony that doesn't fit with their own.

None of this is to say that quantitative measures should "trump" patient narratives, but the way that different decisions are made will mean that different sorts of information are prioritised. When a healthcare organisation decides to fund a treatment, it has to know whether said treatment represents a meaningful improvement over something cheaper. Numbers are easier in making this determination. However, when deciding if mistreatment is occurring in a care setting, a single person's narrative ought to all that is needed for substantive concerns to be raised. In the quotidian process of navigating psychotherapy, a clinician cannot hope to proceed without attending, to almost everything done or said by the person with whom they are working.

When it comes to statistical data, it is hoped that we can learn to love the numbers which many people find so alienating. Behind each number lies a person, so used correctly they are an excellent way of finding out important information about real lives and real experiences. Ideally we would be able to think in two registers at once; deploying the skills of the most technically competent statistician and the empathy and interpretative nous of a novelist or poet.

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