Some Things Cannot Be Measured in Numbers

I recently read that psychoanalytic psychotherapy is a dying profession because its practitioners will not produce evidence-based techniques based on experimental research. There is a push for concrete “proof” that psychotherapies work, and many psychotherapists are dismissivie of therapies that will not subscribe to this demand. We seem to be more easily convinced that something is true if there is some kind of quantitative data “proving” it rather than our own or other people’s experience.

I think this arises for two reasons. First of all, with medical insurance increasingly controlling access to health care, the problems of rising costs and efficiency become driving factors in what is available and what is considered proper protocol in medicine. This becomes a social trend, and influences how we think about self-care for which we are paying. Psychotherapy falls into a grey area, being health care in one sense and not in another. Psychotherapy is designed to move us toward our optimal quality of life. At one end of the continuum, a person can be non-functional because of psychological problems. This is akin to having a broken leg: it does not function. Insurance will pay to repair the leg.

But once a leg is functional, there are levels of functioning beyond that. With proper training, a leg can kick a field goal, run a marathon, or lift heavy weights. Insurance does not cover services to bring the leg to that level. In the same way, insurance will cover mental health care up to the level of “normal” function, but this does not address unhappiness, quality of life, or optimal experience. To move into these olympic levels of well-being we are on our own.

So unreflectively using an evidence based model can help us with the “functioning” part of the equation because that can be measured in numbers. Beyond that, there is quality of life, and that is entirely subjective. I can describe another person by talking about their height or weight or salary or grades in school. These are all numbers. But as any recruiter can tell you, this is not going to help you understand that person. It tells you something, but not the most significant factors.

The second trend underlying a push for evidence-based proofs of medical and mental health care is our wish for easy and concrete means of making judgements. It is difficult to assess a complex situation, and we are relieved if there are experts who will tell us what to do or studies that show definitively what is the right answer. For psychotherapy now, we have increasingly sophisticated means of researching its effects, but fundamentally you cannot measure a sunset and that is where our limitations lie. Much like the credit card commercials that say “bicycle, $100, gas for trip to park, $10, time with our children, priceless,” there are some things you cannot buy, measure, calibrate, grade or quantify. This stymies us when we are faced with important decisions, and we are quick to hold onto what look like guideposts. There is, unfortunately, no substitute for slow reflective thought. And fallibility. Zut.

About norasblog

I am a psychotherapist with a private practice in downtown Chicago.
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2 Responses to Some Things Cannot Be Measured in Numbers

  1. DrSteve says:

    It is a worry, I agree.
    However, you can see, I’m sure, how unconvinced someone from outside would be by: “There is, unfortunately, no substitute for slow reflective thought. And fallibility. Zut.”
    EBP can, and has, been used to save money. Thats’ a perversion of it’s original intent.
    1. Taken as it was originally intended – as an ecouragement to practitioners to keep up to date with research and to guide their practices accordingly – and EBP could re-vitalize psychotherapists.
    2. Taken as gate-keeping – as constraints on what is permissible – and psychotherapy becomes reduced to a collection of minor thruths about homo sapiens.
    3. Ignore it and we are likely to remain stuck in our pasts:
    “They say the biggest influence on the therapy you practice – and the therapy you aspire to, your imago of therapy – is the therapy you experience as a patient. And this holds for me, if you add the admission that I remember few details of the treatment.” (Peter D. Kramer)

  2. norasblog says:

    Dr Steve, thank you for your comment. It is true that Evidence Based Practice (EBP) has become a bludgeon as it is currently used, and is extremely compelling at first glance. However, meta-analyses of studies of psychotherapy reliably show that it is not the method or technique which determines outcomes, but the quality of the alliance between the therapist and patient, as assessed by the patient. The effects of differences in method are insignificant. EBP measures methods and techniques, not alliances. There will always be “consumers” of therapy who are concrete in their thinking, goals, and measurements, and these clients will not be drawn to interpretive, long-term modes of analysis and growth. EBP can be useful to them in determining which model of treatment they would like to pursue. Long-term treatment is about a developmental process, not a task or problem. It is about quality of life, not specifically symptom relief. It is a different undertaking.

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