The Problem with 'Evidence-Based' Therapy - A Response to Mick Cooper

I’ve been reading and rereading Mick Cooper's recent blog post in response to my criticism of one of his recent research papers. Mick Cooper is a giant in the field of psychotherapy and I appreciate our ongoing conversation. I also appreciate Mick’s use of my words and also the seriousness with which he takes my position. I get the feeling that, despite our clear differences, Mick and I could nonetheless enjoy a fascinating conversation about this over a beer.

It seems from Mick’s article and many of the responses to it that I have been typecast as yet another closed-minded, parochial, intellectually lazy therapist – the notion that, because I place no real value in research studies, clinical trials, or indeed any research involving questionnaires, statistics, diagnoses, etc., that I must be stuck in a fixed, ignorant mindset, dwelling in a comfortable, formulaic bubble in my practice, from within which I kid myself that I help clients, thereby justifying my indifference to research. Mick and others seem to believe that I fear engaging with research that would, it seems to be uncritically accepted, improve my practice if only I had the courage to bear the fear and discomfort involved. Not a bit of it. I am scared of many things (losing the people I love, getting a terminal illness, falling off a large building, lions, tigers, etc.). However, reading research papers and even trying to take them seriously (I actually used to, before I began to understand how real therapy works) isn’t one of them.

The reality is that so many psychology research papers, including in the field of psychotherapy, are bone-dry, clinical, jargon-filled, statistic-obsessed documents that seem purposefully designed to obfuscate, impress, and blind the reader with a sort of meaningless science-salad. Mick Cooper acknowledges this when he writes, ‘if you look at some of the leading journals in the field, even with my PhD in psychology and years of researching and writing, I haven’t much of a clue what’s going on’. However, Mick goes on to suggest that the reason so many therapists are put off by this is because they lack scientific training, and so avoid the research because they fail to understand it.

Again, far from it. I do not have a scientific background, but this doesn’t handicap me in understanding the language used in so many of these papers, as unnecessarily technical, abstract and verbose as it is. Rather than not understanding this research, it simply doesn’t engage me. I am wholly unmoved by it. It bores me to the core of my being. For me, the onus is firmly on the researchers writing these papers to explain why they deem such language necessary and how they think it relates in any meaningful way to the practice of real psychotherapy, defined here as therapy that helps people create meaningful and lasting change in their lives. An honest answer on the part of the researcher, I believe, would involve the acknowledgment of the role of vanity, the desire to impress, and the understandable motivation to maintain a career in academia, which I’d imagine involves a constant pressure to publish the kind of research favoured by funders, insurance companies, and the academic and scientific elite.

More importantly, perhaps my indifference to research is adding to what Mick Cooper calls the ‘massive hole where contemporary research evidence could be’. Mick goes on to write, ‘In the last few decades, for instance, person-centred therapy has been virtually pushed out of primary care in the UK because the evidence is for CBTs, not person-centred approaches’. Should I align myself with Mick in his call for person-centered therapists to engage more seriously with the kind of clinical trials that has elevated CBT to its status as the treatment of choice for so many difficulties in life? I don’t think so, as the glaring assumption Mick makes here is that the evidence in favour of CBT and other evidence-based treatments is valid. In other words, Mick seems to uncritically accept the idea that these therapies actually facilitate meaningful, lasting change in the lives of people having them.

This is most important as promoting a therapy as ‘evidence-based’ carries weight. Indeed, for most people seeking therapy (particularly if doing so for the first time, before these therapies have chance to fail them), evidence-based therapy means therapy that has been proven to work. What the unsuspecting public do not know is that the researchers and therapists promoting these ‘evidence-based’ therapies have, as psychotherapist Jonathan Shedler points out, performed a crafty sleight of hand in basing their studies on certain assumptions about how therapy works, smuggled in before the studies even start.

The first assumption is that, with the right treatment, meaningful change can and does occur quickly (the vast majority of these studies focus on therapy of between 8-12 sessions). Again, therapists like me who, over months and years, try to help people make sense of often enormously complex and entrenched ways of being in the world, know that therapy has barely even started 8-12 sessions in. The idea that any therapy or therapist can facilitate meaningful and lasting change in clients' lives in such a short space of time is a myth. Even CBT therapists know this.

A second assumption is that meaningful and lasting change occurs when we focus our efforts on symptom reduction rather than working with the whole person. The idea that the sole focus of therapy should be on symptoms belies the view that they exist, and so can be studied, independently of the rest of the person. It also assumes that symptoms like depression and anxiety are causes rather than complex outcomes of clients’ difficulties. In contrast, practicing real psychotherapy so often means working with and through underlying, often deeply entrenched beliefs and fiercely defended relational patterns. This often takes years, but the therapy usually moves on quickly from the initial complaint or symptom. In other words, the symptom becomes what Adam Phillips calls a conversation starter, rather than the sole focus of treatment.

A third assumption of researchers studying evidence-based therapies is that therapy can be done by following a manual- a session-by-session, structured document prepared before therapy has even started, and which can be generalized to work with an array of people seeking therapy. This, of course, renders the therapeutic relationship irrelevant and inconsequential. As long as the manual is followed, the therapist is interchangeable. Again, any psychotherapist practicing what I consider to be real psychotherapy knows that ultimately the therapy is the relationship.

Of course, clients having evidence-based therapies know nothing of the erroneous assumptions underpinning them. They know simply that the therapy has been proven to be effective. The reality is that the overwhelming majority of evidence-based therapies fail most people, most of the time. You’d be forgiven for not knowing this however because, even if there has been any genuine improvement during the study, by the time clients start struggling again with the same problems they had prior to the start of the therapy, the studies have long finished. I know about these failures only because so many of the people who have been through the production-line of evidence-based therapy eventually seek my help.

With these points in mind, it is clear that Mick and I view the practice of psychotherapy very differently. On the importance of maintaining an evidence-based practice, Mick writes:

When I go and see a physiotherapist, for instance, I want them to use the methods that have shown the best outcomes to date for my problems—if they did a treatment on me that they believed was effective, even if all the evidence ran against it, I’d be annoyed.

This is a most interesting statement. The most striking thing is the comparison between a psychotherapist and physiotherapist. Here Mick seems to suggest that the two disciplines operate under the same principles, i.e. that if both the psychotherapist and physiotherapist stay abreast of the latest research findings in their respective fields, and practice this, then they will ensure that what they do works. What this ignores is that physiotherapy, as far as I understand the discipline, involves learning to do something that has clearly defined right and wrong ways of doing it – the focus on and manipulation of the body - the kind of thing, for example, that one could learn from a textbook or manual. One would assume then, for the physiotherapist, there is in fact a clear alignment between the latest research and how they should practice. However, the practice of psychotherapy – again, that which actually helps clients create meaningful and lasting change in their lives - has no such clearly defined guidelines in terms of how it works. I neither ‘do a treatment’ nor ‘use methods’ on my clients. I do something far more effective. I listen, very, very closely, to try to ascertain what clients want from me and how I can help them. I have learned to trust my intuition over and above academic research in doing this because the ‘evidence’ - the reality that I’ve helped so many people in meaningful ways – strongly suggests that it works.

Mick's assumption here is that, when it comes to psychotherapy research, newer is better. This absolutely isn't the case, and I return here to the notion that in finding psychotherapy research studies fantastically boring and completely meaningless, I am treading water in my stagnant pool of ignorance. I engage in research all the time, just not the kind favoured and promoted by the evidence-based brigade. The research I engage in, I have found through experience, is far more relevant to the practice of psychotherapy. This includes philosophy (ancient through to contemporary), novels and essays dealing in various ways with the fundamental, inescapable aspects of the human condition, and literature in the field of psychotherapy where the authors give open, honest, jargon-free accounts of what being a therapist is really about (writers like Adam Phillips, Irvin Yalom, Susie Orbach, Karen Maroda, Henry Markman, Lee Grossman, Jonathan Shedler, Roy Barsness, Ernesto Spinelli, Valery Hazanov, Jeffrey Kottler, Dhwani Shah and, of course, Carl Rogers).

However, my most valuable and important research occurs in each therapy session I have. In my sessions with clients I continually throw out hypotheses in the form of questions and statements that occur in me organically, in response to both verbal and non-verbal communication. Clients’ responses let me know whether what I have said is helpful, and we proceed from there. In other words, I am constantly trying, through the closeness with which I listen to clients, to calibrate myself to them in a way that involves listening naively, rather than with any kind of surety. This requires humility, courage, the bearing of anxiety, and indeed the wish to disprove, rather than confirm, any assumptions I may form along the way. Indeed, whenever I start to believe that I know what is happening in therapy with a client I am immediately sceptical of it. Rather than simply repeating a comfortable groove with clients founded upon my ignorance of research, my relationships with clients are the most informative, profound, and humbling learning experiences I believe I’ve ever had.