A woman I used to know defined an intellectual as someone whose first question about anything is, “What’s the truth?” She contrasted this with the first question she thought most people ask: “What’s going to make me feel better?”
That’s probably not a good definition of an ‘intellectual,’ but it points toward a significant conflict we all face in deciding what to believe: the more reassuring ideas, the ones that make us feel good about ourselves and those we love or depend on, the ideas that make us optimistic about our prospects, may not be true.
Social science research on the conflict between truth and good mood is extensive. Depressed people tend to be more accurate in their estimations of how much control they have over their environments. Happy people tend to process challenging information in a highly biased manner to preserve their good cheer—mild sadness promotes accuracy. Most of us believe we’re better, smarter, more high-ranking than we are.
Still accuracy matters—over the long run, we’re more likely to do well if our beliefs generally allow us to coordinate our actions with each other’s and with reality. Truthfulness is a universal virtue for a reason.
In mental health care, the conflict between truth and good feeling takes many forms. Some are obvious, like the temptation to affirm a client’s self-justifications, rationalizations, and other wishful thinking. The most important conflict between truth and good feeling, though, is the central role that outcome studies play in “evidence based” practice.
Indeed, the very idea that outcome studies can “scientifically validate” a form of therapy fatally conflates good feeling and truth, so that citing “scientific validation” through clinical trials is more misleading than enlightening.
An outcome study, no matter how well designed, answers only one sort of question: does the therapy “work”? It never tells us whether the ideas behind the therapy or the beliefs induced by the therapy are true—or therefore, whether the practices and behaviors based on those ideas and beliefs are sound.
An idea does not have to be true to make us feel better. Practices do not have to be based on true ideas to structure lives agreeably to those who live them. Thus, knowing that a therapy “works” tells us nothing about whether the ideas and practices it conveys deserve respect.
Why does this matter? Therapy is not an autonomous country. Both therapists and patients exist within larger society, and they need to know and do things that have little direct bearing on the suffering that brings them into care. But a therapy that “works” can lead to beliefs and practices that set patients and therapists at odds with their social contexts and their more comprehensive intellectual needs.
Historically—and even now, outside of health care—science aims to describe and explain nature. Outcome studies don’t. They simply say, “If we do x, it has y affect.”
In English, we distinguish between “knowing that” and “knowing how.” In Greek, this distinction was captured in the difference between “episteme” and “techne.” Episteme, or “knowing that,” is the business of science and other attempts to describe and explain nature. Techne, or “knowing how,” has to do with craftsmanship and action.
Outcome studies should be seen as serving techne. In essence, outcome studies are a step in product development—a form of engineering research, not science. At best, they are part of quality assurance. But like all engineering, and no science, they have no claims to our assent unless we happen to want to buy the product.
When we pretend that outcome studies “scientifically validate” therapy, we confuse a product that can be used to specific ends with knowledge of how the world works. That’s a pretty serious confusion.
Truth commands assent. Products don’t. The fact that a therapy makes its practitioners and clients happy imposes no obligation on anyone else to cooperate with those happy sellers or consumers. It doesn’t even tell us that being happy in that way deserves anyone’s respect.
When we are crafting and choosing therapies, we need to take into account a great many things other than how it affects the suffering that brings us into care. That’s why the correct response to any positive outcome study is, “What significance does that have?”—or, more colloquially, “So what?”
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.