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.
