Naughty-but-NICE: Research and cream cake.
Let me admit from the outset that I can be a suspicious person at times, and no more so when something is agreed by everybody as being thoroughly good! A bit like the ‘man in the crowd’ (see last issue’s Alterego column) I find myself taking exception. Call me rebellious or simply curious, but certainly suspicious. An example of this that’s been bothering me for some time is research. The two most common sentiments I hear about research into psychotherapy is that it’s good and that it’s boring – unlike cream cake. In fact research and cream cake seem the very opposite of each other - one moral but dull, the other immoral but enjoyable. The cream cake however is definitely not good for us, whilst research apparently is. But is it, and if so how?
Only 15% of factors responsible for change in therapy are about the therapeutic modality, and most therapies are roughly equivalent in effectiveness. Why then is so much interest shown in research aimed at establishing the efficacy of any particular modality? I’ve certainly never read any research project which concluded that the approach studied wasn’t effective. There is of course a political and economic value of such research in terms of approval by the eponymous Mr. NICE. His blessing might lead to the enhanced status of TA, with all the implications for the financial benefits to TA therapists and trainers. But perhaps Mr. NICE is, like the cream cake, more naughty-and-NICE. After all he’s wedded to that glamorous medical model Mrs. NICE and her modernist views on the causes and effects of objective truth. Together they live off the outcome measured offspring born from randomized control trials. Nice they are not!
Surely it’s impossible to design randomized control trial research studies that convince Mr and Mrs NICE that TA cures depression, for example, when there are several different schools of TA using significantly different theories and methods. Even amongst TA therapists who belong to the same school of TA there will inevitably be significant variations in the therapeutic relationship, and thus the therapy itself. In this sense TA is very different from Mr. NICE’s anointed ones - anti-depressant ‘therapy’, and the more regularized methods of CBT, EMDR, or mindfulness. With these modalities clients do get the same treatment, a manual-ised conformity amongst practitioners (seen as a good thing!) and thus amenable to the trials (but also tribulations) of randomized control.
Do we really want to get into bed with Mr. (or Mrs.) NICE, and if so at what cost? Is this where we want to invest our research energy? Will we even be successful, or will it simply lead us up to a dark corner of a double-blind alley down a dead-end road? More importantly, does it divert us from more valuable purposes of research?
For me there are two fundamental values of research, neither of which involve ‘proving’ the truth of the efficacy of particular modalities. The first is the advancement of our understanding of psychological problems and how psychotherapy ‘works’. There is a burgeoning development of qualitative research methods for pursuing this agenda that are gaining validity within the research community – methods that embrace relational principles of engagement (eg participant observation), the importance of experience (of both client and researcher) and the inevitability of uncertainty (eg regarding ‘truth’). This is the research I find more palatable, even if it’s not the NICE’s cream cake of choice, not their cup of tea.
This leads me back to the ‘research is good but dull’ point from earlier. My second fundamental value of research is how it contributes too and enriches the process of informed discussion, intrigue and controversy within our therapeutic community regarding the development of theory and practice. A paradigmatic example of this is the research of Daniel Stern which prompted a rich, wide-ranging and contentious discussion around key issues of child development and the implications for adult psychotherapy. His critique of Margaret Mahler’s ideas was significant not because it established a ‘truth’ – in contrast to Mahler’s ‘errors’ – but rather because of the very rich discussion it fostered. Stern’s ideas subsequently became the focus of further challenge and criticism in an ongoing turn of the epistemological wheel. This is why the foundation stone of any good research project is the review of the literature, the main purpose of which is to locate the project within ongoing debates about the subject matter, to identify a problem, lacuna or interesting question remaining unaddressed etc. In this way research is founded on what is of interest, controversial even, and thus much more likely to make research enjoyable - not NICE but simply nice!
And now back to enjoying my cream cake and reading both Kieran Nolan’s (PTSTA) fascinating Ph.D research dissertation on OCD, and Cathy McQuaid’s (TSTA) illuminating research based book on psychotherapy training.