One of the current obsessions in the world of talking treatments is the notion of ‘outcomes’ – preferably measurable ones. In the UK this is being led by the Improving Access to Psychological Therapies (IAPT) programme and is closely linked to the ideology of evidence-based practice. I use the term ‘ideology’ deliberately because there is actually very little science in evidence-based practice (although a great deal of pseudo-science): in fact, as one writer pointed out, there is very little evidence for evidence-based practice1.
In the IAPT programme, the focus is the effectiveness, or to use the proper term, efficacy, of the work that therapists do. And the evidence for such efficacy is to a large degree dependent on the outcomes of the work with individual clients. Such outcomes are obtained by asking clients to fill out one or more questionnaires at the beginning or end of each session. There may be one questionnaire that looks at depression, another that looks at anxiety, and so on. Essentially, the client is asked a number of questions relating to various aspects of their psychological wellbeing, and asked to rate their responses, often on a scale of one to ten. Depending on the questions, a lower or higher score than the one the clients scored in the previous session is taken to indicate either an improvement or a deterioration in their psychological wellbeing.
At the end of the work (which is normally only after a few sessions) the results of the client’s responses are analysed and, depending on the scores, a judgement is made as to whether the client is ‘moving to recovery’ or not. This may sound ‘scientific’ but it isn’t. There are numerous flaws in the whole methodology, not least the idea of the therapist asking their client, in the context of a therapeutic relationship, to rate their psychological wellbeing – and to attempt to quantify this. Apart from anything else, there is the whole question of transference: to what extent is the client trying to tell the therapist what he or she thinks the therapist wants to hear. Or, they may be deliberately trying to ‘sabotage’ the whole therapeutic alliance by giving very negative responses.
But putting all these criticisms aside for a moment and assuming that the client actually does feel better at the end of therapy – what does this actually mean? Does this mean the client is cured? Some people would argue that, yes, they are. If, for example, someone comes into therapy feeling very depressed and after a few sessions feels a lot happier, a lot less depressed, then surely they are ‘cured’ or ‘better’? Of course, they are if the definition of ‘cure’ is to make someone feel happier or better. But actually, using this definition, it’s not that difficult to ‘cure’ someone of, for example, depression or anxiety – at least in the short term (and sometimes it can be very short term indeed).
The key question here is whether it’s the aim of talking treatments to ‘cure’ people at all – at least in the sense I’ve just described. People who feel depressed, to go back to our example, usually have a very good reason to feel that way; and might it not be good idea to explore what that reason might be? This is not easy, and it can take a great deal of time and effort – often because the client would rather not know why they are feeling this way. On the other hand, the price of not knowing can be even higher…
- Devisch, I. & Murray, S.J. (2009) ‘We hold these truths to be self-evident’: deconstructing ‘evidence-based’ medical practice. Journal of Evaluation in Clinical Practice, 15 (6), p.pp.950-954. [↩]