 Those
who back integrating evidence-based research into psychotherapy
need to have their heads checked, says psychologist and
practising psychoanalyst Dr Jon Mills, PhD.
"Psychotherapy is very intuitive,
and it's about process over anything else," says the
Ajax, Ontario-based therapist. "Following a step-by-step
manual method doesn't fit into a natural or organically-developing
process."
Ultimately, a discussion about
clinical evidence in psychotherapy turns into an examination
of the very validity of psychotherapy as a profession,
and it burns Dr Mills to have to defend the value of
what he does and how he does it.
Dr Mills, who also chairs the Canadian
Psychological Association's Section on Psychoanalysis,
defends his profession in his latest book, Psychoanalysis
at the Limit: Epistemology, Mind, and the Question of
Science. And despite more than a century of substantial
growth in the field, it seems there's still much defending
to do.
PAINT-BY-NUMBERS
CARE
For Dr Mills, each of his clients are unique, and so
are their problems and issues � they are much more than
just the sum of their brain processes. Performing research
and then trying to apply the findings to different clients
can lead to "manualization" � cookie-cutter treatments
that ignore individuality.
This puts the therapist-client
relationship at risk. According to Dr Mills, it's the
chemistry of intimate back-and-forth exchanges over
a series of sessions that will tell you whether a client
benefits from treatment. If therapists start viewing
clients through the lens of research demands, he fears
they could start seeing patients as guinea pigs.
"It turns therapy into a mechanized,
antiseptic method that does injustice to what therapy
is all about," says Dr Mills. "It doesn't take into
account context, the contingencies that pop up in human
relationships, the specificity of the treatment intervention,
and the complexity of the therapeutic dyad."
There's already a body of research
that shows that patients feel a strong therapist-client
relationship, and this in and of itself is one of the
biggest benefits of psychotherapy. For Dr Mills, this
is precisely the reason why it's so hard to research.
Sometimes � even though the patient's symptoms haven't
disappeared, he or she reports feeling better after
a series of sessions, because he or she feels understood.
The rush for clinical evidence
ignores the individual style of a practitioner and this
could taint the usefulness of their data says Dr Mills.
"I'm a practitioner: although I teach, and I do case
studies, I make my living based on my clinical work.
An academic does research, not a person in the trenches,"
he says.
ACCOUNTANT
INVASION
What troubles him most is his feeling that money, not
the best interests of patients, is driving the demand
for empirical evidence. In the USA, managed care companies
expect practitioners to use techniques backed by data.
Bean counters are requiring therapists to document their
progress with patients � or as Dr Mills sees it, justify
their existence.
In Canada, psychotherapy coverage
usually runs out after half a dozen sessions; this forces
Dr Mills to do quickie therapy, that is, pragmatic short-term
problem solving that doesn't address people's deeper
needs.
"How can I be told by insurance
companies what the standard of care is?" he says. "Most
of the people I see have all kinds of deep-seated conflicts
that are emotionally driven and unconsciously mediated.
I can tell them what to do quickly and efficiently,
but the likelihood of them doing it is nil."
� by Sharon Aschaiek
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