Therapy works? So . . . ?

Bob Fancher, PhD
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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?”

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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.

26 COMMENTS

  1. Dr. Fancher thank you for this compelling article. I have read it twice and will read it again a couple more times. Your comment about the value of those who are feeling depressed or sad was insightful. As a biblical counselor (much different from a Christian counselor) I often point out to my clients that every emotion has a unique purpose and should have a time and place to be expressed. It is a biblical principle to be authentic in every way. Setting aside the obvious issues of potential abuses, there is value in all that life offers; including, but not limited to, conflict. There are many products available (as you suggested) to the consumer to marginalize, minimize, and escape conflict; to be obtain happiness. In the process, these products often lead to missed opportunities of personal growth and community interdependence. These “happy” products may serve the individual (presently), but they tend to do little for the community or the individual’s future generations. Perhaps the Creator has given us the ability to feel sad – to mourn – in order that our lives can be reordered; realigned for optimum productivity and effectiveness. I’m amazed that among the goodness of the Creator’s work we find that the default position of the universe is decay (by His design). Unless energy is enacted or invested everything will eventually fall apart. Maybe the feelings of sadness or being depressed is initially a means of awakening the individual to an opportunity to recreate the world. Do the “happy” products undermine this opportunity?

      • Thanks again, Dr. Fancher.

        I read your referenced article “Someone to Talk To”, and was particularly drawn to your statement, “A great many of us, in private conversation, will talk about how we sometimes feel that we fill a “priestly” role.” That is precisely how I see my role as a biblical counselor, but perhaps not as some might expect.

        In historical Judaism community leadership was primarily expressed in one of three roles: priestly, judicial, and prophetic. Each would be adorned or clothed in specific ways to reflect their particular role, and although they were appointed by God, they were chosen from among the common people.

        My point has to do with the priest. He was not particularly special in terms of pedigree or intellect. He was common, yet after being chosen he was elevated – set apart – for a higher purpose. This was signified by a breast piece he wore over his heart; a item bearing the identifications of all the tribes. Less for the the benefit of others this garment served to remind the priest that he was not the judge or the prophet. He was a mediator, and when he spoke to God he did so on behalf of the people. He represented the people.

        When my clients sit and share their life’s issues with me I am reminded that I am their priest; not their judge or their prophet. Not a priest in the typical religious sense; but I do hear their confessions. I am not offering to them forgiveness, but I do represent their brokenness to the Creator. I prepare a banquet table and serve them biblical principles. I do not “beat them up” for being sinners or for falling short of a code, ethic, or commandment. My role is to mediate their journey to wholeness, healing, and restoration. Just as the ancient breast piece covered the heart of the Jewish priest, I too must be reminded to serve others with non-judgmental compassion, mercy, and great care.

        Dr. Fancer, today I care less about how you and I differ, and I care more about how we share the care for the well-being of others. In our small virtual exchange I have come to respect you and the direction we both are pursuing. May your work be fruitful, and may many be nourished by that fruit.

        • Priests in biblical Israel were actually set apart by birth and pedigree. Only kohanim, considered descendants of Aaron, could serve as priests in the Temple in Jerusalem, and are the only ones who could perform specific ritual functions and had their own codes of ritual purity. Levites, considered descendants of Levi, could do other specific ritual functions in the Temple. As for their intellect or training, that is another matter, but the priestly classes in ancient Israel was definitely based on birth and parentage.

          • Your point is made accurately. My point is that within the parameters of the tribe of Levi – the lineage of Aaron – are common everyday men; any of whom were theoretically a candidate for the priesthood and in turn would share a role in the service of the Temple. The selection within this tribe was not based on economic status, educational pedigree, or some other “favored” status. In fact, Levitical men were prohibited from owning property or entering into business enterprises for profit. They were all volunteers.

            The whole idea of “holy, sacred, or consecration” was based on the idea of the “common set aside for the purpose of God”. The Greek-influenced idea of “holy” would suggest something based on an innate quality of the subject’s form or design. Hebrew holiness, in contrast, is what is ascribed to a person by the Creator. Thus, to be holy was less about a family name or an inheritance and more about the way in which one served others.

            So what is the point of all of this? Dr. Fancher writes in “Someone To Talk To” about the often overlooked value of pastoral care. The kind of care given outside the rank and file of those who are clinical, certified, and mental health professionals. This is not to suggest that these caregivers are not compassionate; but, it is to point out that there is another effective source that individuals can talk to. Thank you.

  2. I agree that outcome studies to not validate the veracity of of the process/mechanisms of a therapy’s affect on someone’s mood/well-being. As you say, outcome studies do show that participation in a therapy can lead to particular outcomes. I want to be clear about what I mean by outcomes-I define an outcome as an intended benefit a participant experiences.

    Without a strong understanding of suffering/well-being, why people feel worse or better, and the mechanisms of changing them, outcome studies are a place to start to assess at least what people people can expect to get when they often seek from therapy, feeling/living better or getting some relief from psychiatric symptoms.

    There is so much therapy happening, all kinds of therapy, and even ones that are validated to show effect for particular outcomes (reduced depression, reduced panic, etc.), mechanisms of change are still elusive (and the proposed mechanism for that therapy is not proven by outcomes occurring). Because we are unlikely to scientifically get at the mechanisms of suffering wellbeing without some kind of strong theory (not have really held up on its own), I think outcome studies are a perfectly reasonable place to start to assess all of the therapy that is happening out there now. I am not yet asking anyone to have evidence of WHY something works, but I think it is essential to have evidence THAT something works and works well and often enough beyond any risks that may be involved. Many popular psychotherapies (analysis, dynamic, etc.) do not even have this information, while at least the “scientifically validated” studies do.

    Doing outcomes research at least lets people make informed decisions about what they can expect from participating in a particular kind of therapy, and can identify ineffective or potentially harmful therapies and help limit people from being exposed to them. Hopefully, I have some faith in that in working more inductively, trying to build and test theory starting from what works (as opposed to theorizing mental health and designing treatments to fit that theory), we can start to get some more insight in the mechanisms of suffering and the mechanisms of its alleviation.

    To be honest, I am seeing that psychotherapies for depression, no matter what they are, tend to work by increasing hopefulness for improvement, ie placebo. I’m ok with this, and learning the mechanism for change for depression is placebo can lead to more refined treatments and do more informed process research to better understand and apply those mechanisms.

    I think patients/clients need to be as clear as possible about what outcomes they are looking for when seeking treatment, clinicians need to be able to support them in identifying those outcomes, and a clinician has to decide if s/he is capable of engaging in psychotherapeutic work associated with the identified outcomes, and if not, refer their client to someone who can. I have come across many people who have had treatment prolonged, experienced extreme dissatisfaction, and stopped seeking support because clinicians made the decision about if it would be better for someone to feel better to learn more truths when the client was expecting and hoping for the other experience.

    • Jeff–

      Thanks for the thoughtful, substantial comment.

      I’m not trying to debate the evidence-based versus not issue in this post. I’m making a different point: Even with the best outcome studies, therapists are selling a product, not teaching their clients how the world works.

      We have to evaluate products–and their salesforces–differently than we evaluate the discoveries of scientists. Therapists are generally less than accurate in their self-understanding, and less than honest in their pitches to clients, because they pretend to have and convey knowledge when, even if you grant that outcome studies are accurate and probative, what they’re selling just isn’t that.

      • Dr. Fancher,

        I see that we don’t disagree much. I believe we both agree that therapists do not well inform clients about what the process they are embarking on is about, and what they can expect from it, and whether or not that is what a client wants. We also agree that knowing that something works for a particular effect does not show how/why it works.

        I just don’t see psychotherapeutic intervention as product to be that troublesome if in fact participating in the intervention is likely to be helpful to a point that a patient wants particular help and knows the likelihoods of success and risks involved. Informing a client truthfully is the responsibility of the therapist, and I agree, this does not happen often or well.

        I think my most visceral reaction to your post was my interpretation that you think positive outcome studies (studies that show intended, meaningful benefits) don’t ask about their significance or implying that they aren’t significant. Reducing panic attacks, eliminating suicidal ideation, having the capacity to experience deep pleasure after not, atc. are all outcomes identified in studies, and I think they are significant. I guess I was thinking that you do not believe symptom reduction is meaningful, or that in evidence supported treatments those outcomes are not discussed in context of someone’s lived experience.

        I agree knowing why psychotherapies are helpful would be great and should be goal. But implicit in this is that they are helpful. Even if a psychotherapy leads to more truths but does not actually lead to any outcomes, one could argue that truths were “outcomes” of psychotherapy, but then I would argue what is the significance of those truths if someone entered therapy to address depressive symptoms and just spent a lot of time and money in the process?

        • Yes.

          All I mean by this phrase is “accurate information about reality.” Education aims to help us understand how the world works. Mental health professionals claim to know a great deal about how the world works–they claim to know things they would not know without their specialized educations. Whenever we tell someone that a particular idea is true, we are making a claim about how the world works.

          • I guess I don’t assume that therapists know how the world works or that their role is to help their clients determine how the world works or have any more specialized knowledge of how the world works than anyone else. A therapist telling someone they understand how the world works and that participating in therapy will also help that person understand it I agree would be wrong in doing so, both ethically (therapists should not charge a fee and keep clients in therapy for long periods of time to slowly reveal how the world works) and just descriptively (they don’t necessarily know how the world works any better than anyone else, if the world works in a particular, static way in the first place).

            Perhaps I am confused in that we differ much on the role of psychotherapies. I think psychological interventions can be helpful for all sorts of things, be it solidarity, support in addressing problems one is facing, and encouragement, though I don’t think these specific uses are the limits of how psychotherapies can be helpful nor all these uses limited to therapists or client-therapist relationships. Some psychotherapies have strong evidence that they have high likelihood to be meaningfully helpful for alleviating particular distresses. I don’t see this as problematic if someone wants to address symptoms.

            Any therapist that charges a fee is selling something, whether a specific kind of relationship, access to a couch, treatment of particular symptoms, bullshit, thoughtful reflection, or whatever. I do believe what people are selling and the ways/intents of their selling need to be evaluated, and clients need to be wary of what they are getting and how it aligns with their own goals. We licence therapists to help align therapist goals with patient interests and require informed consent and ethics exams to help therapists not take advantage of clients, but I agree, it happens often, regardless of the kinds of therapy a therapist utilize. I perhaps naively think that folks who utilize ESTs with people for whom their is evidence that their use would alleviate symptoms, and that is what a client wants, are upfront about how therapy can be helpful and then closely monitor progress or lack of it, and present reasoned and evidence informed options with clients about how to proceed if client goals are not being met and work with that client to make a choice that works best at that time.

  3. The episteme-techne dichotomy in therapy reminds me of the confidence-skill dichotomy in math education. My experience teaching high school math has been that many students (especially boys) consistently report high confidence (happiness) in their math abilities while displaying low to average proficiencies; conversely, many other students (especially girls) report low confidence while displaying good proficiencies.
    At the same time, some instructors teach (and grade) to improve confidence, while others teach to improve skill. The former can do immense harm if carried to dishonest extreme. Most good teachers aim for a thoughtful blend of the two. I assert that students of excellent teachers acquire proficiency in the subject and a confidence that reflects their cumulative experience of a true success.

    • Thanks, Buzz.

      I first taught in college a bit over thirty-five years ago, and I’ve been shocked at the changing standards of teaching. I think our “be happy” culture does promote grade inflation, and making students feel good about themself at the expense of demanding rigor. I know the teachers who did the most to help mature my mind also did the most to make me feel bad about myself, in the early going of working with them, because they revealed my ignorance and fuzzy thinking and deflated my naive self-confidence. But you’re certainly right that the best teachers know how to use a “spoonful of sugar.”

    • Odd responding to my own earlier placeholder thought but hey!

      I did like the piece and thought, yeah I think he’s got that right.

      I’m wondering if you’re thinking talk therapy should be more focused on episteme or techne or both or doesn’t it matter. I’m struggling where to go next assuming your accuracy with the piece.

      • Thanks for coming back to this, David.

        We need both episteme and techne, but we need to know the difference. Therapists exert an influence, and claim an authority, that we really don’t deserve, when we use the fact that clients come to feel better to claim knowledge about how life works and how people ought how to think, feel, and act.

        My concerns with this issue are many–I written about them in my book, “health and Suffering in America.” For one thing, I believe that we generally foist off on clients our own values, hidden under definitions of “health.” Generally, when a mental health type calls something “healthy,” he has next to no evidence that health has anything to do with it. He or she is saying, “This is how I think it would be good for you to live.” I think mental health types often exert a bad ethical influence in this way. I’ll write more about this in future blog posts.

        But if I smuggle in my values, while helping you feel better, and claim simply to be doing what’s “scientifically valid,” you probably adopt those values while thinking you’re simply conforming to something scientists’ have discovered about the world.

        I am also appalled at how many things even the most self-righteously “evidence based” therapists teach their clients that are radically at odds with much better science found outside the clinical psych fields. Cognitive behavior therapy, for instance, is simply flat wrong in much of what it says about cogniition and emotion. By claiming to be “scientifically validated,” and adducing clinical trials as if they were strong science, CBT’ers convince clients to believe things about minds and emotions that simply do not stand even the most rudimentary comparison to the genuine scientific–“episteme”–record. CBT is at least as bad as psychoanalysis in foisting off preposterous beliefs on its clients. But adducing clinical trials as if they were good science obscures this fact.

        Finally, for now, I am deeply disturbed that under the influence of “evidence based” practice, what clients are allowed to talk about, and how they’re supposed to think about the things they talk about, is drastically circumscribed. Most things that bother most clients have not been, and cannot be, submitted to clinical trials. And the fact that taking a certain attitude toward the things you talk about makes you feel better quicker is not strong evidence that you really ought to be taking that stance. Feeling better is not evidence of truth–often, far from it. I’ll write more on that over time, too.

        ‘Hope that helps. And I do appreciate your thinking more about my post.

  5. Brilliant! Therapy as commodity, beware the salesperson.

    As I understand it most outcome studies on therapy show it to be effective no matter what the school is. What therapists offer is understanding, solidarity and encouragement to deal with your problems – a simple sounding message that is hard to put into practice. We can all do this for each other is we so wish. Good teachers, community workers, counsellors, self help groups and good friends all do this.

    Understanding the world, now that is more a political problem. In the UK there is a Social Materialist school whose leading light is David Smail and the Midlands Psychology Group who say, ”
    We are a group of clinical, counselling and academic psychologists who believe that psychology—particularly but not only clinical psychology—has served ideologically to detach people from the world we live in, to make us individually responsible for our own misery and to discourage us from trying to change the world rather than just ‘understanding’ our selves. What are too often seen as private predicaments are in fact best understood as arising out of the public structures of society.” http://www.midpsy.org/

    Or am I reading you wrong? I hope not, but you never know….

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