Looking for Evidence That Therapy Works

[HereSince1628]

4. But they probably are subject to contemplation and improvement.

I find it reassuring that the conversation is occurring within the industry.

From a non-clinician's perspective and speaking only for myself…

The mind vs body thing seems to me to really be a point of view subsequent to poor understanding. Such distinctions don’t end merely with mind and body. If one walks down that path, pretty quickly you encounter conceptualizations of spirit/soul. It seems pretty clear that all available empirical manifestations of mind conform with expectations that it is an outcome of biotic activity.

As an adequately trained biologist, I’m not comfortable going down a path where I have to consider mind, soul, and body to be independent entities. I'm so uncomfortable with it, that I've refused treatments that require acceptance of 'something spiritual greater than myself'. Moreover, I don’t think discussion along that path is fundamental to identifying contributors to the existing concerns about psychiatric treatment mentioned in the OP. So, I'm going to step aside from that while acknowledging it is a fascination of many people.



It’s generally true that understanding progresses from low resolution to high resolution. It seems to me that clinical psychology is progressing in the same pattern. It’s not entirely a shuffling of fashion from one diagnostic or treatment method to another, although prevailing acceptance may introduce fashionable influences.

Some failures/mistakes/short comings of mental health treatment are going to result from and be exacerbated by the lack of understanding of the structure and function of the brain and its integration with the rest of the body.

But not all.

I’m of the opinion that clinical psychology is sufficiently advanced to take notice of and consider how possible it is to address common concerns. I rather suspect it does, and that all the things I mention below are quite well known.


So...my thoughts about empirical evidence.

The evidence available for psychiatric diagnosis is primarily discerned during clinical presentation. Most often therapists find evidence in what a client says, and the emotion expressed when they say it. Additionally issues of grooming, injury, hygiene also provide important, sometimes definitive, information.

Yet, patients can’t always express themselves very well. For example the common self-assessment of ‘how are you feeling on a scale of 1-10?’ is a capacity that is acquired and refined by patients during, not before therapy.

Unlike white blood cell counts, blood pressure, A1c, creatine levels etc., the information acquired in a therapist’s office doesn’t often come as a value on a numerical scale that’s amenable to comparisons of normal physiological ranges as are the results of the lab tests done on blood in a primary care clinic. I’m not saying it’s impossible for a therapist to get some numbers. Structured assessments that patients fill out on line and that are computer evaluated are available but not always used. I've never read about an assessment that wasn't criticized by someone as having short-comings.


The evidence that does manifest during a session must be expressed by the patient, perceived correctly, and given appropriate significance. “Symptoms” must be assessed with respect to their being deserving of clinical attention.

The nature of searching is that the seeking focuses on a search image. Although clinicians must manifest satisfactory abilities to meet certification/licensing requirements, clinicians certainly vary in their capacity to seek and find diagnostic evidence.

Diagnostic guidelines after all are just guidelines, and education and experience, as well as such things as conformational bias are in play. In the end, all evidence is not, and can’t be, equal. Some of it will be identified as diacritical.

Practical limitations push for efficiency and short cuts in decision making are human nature. Knowledge, experience (and even mistaken understanding) may suggest identities can be assumed on the basis of defining “spot” characters.

My experience suggests to me, that clinicians develop a capacity similar to that of batters in baseball who internalize all the activities of observation, perception and assessment of clues about pitches into a ‘feeling’ about what pitch is being thrown at them. In the first few minutes of an intake interview, clinicians have such a ‘feeling’ for the way a client’s presentation ‘looks’ and they take a swing at a diagnosis.

Attempts may be made to find supporting evidence, but these really are vulnerable to confirmational bias.

The question arguably becomes: is the resulting diagnosis based more about empirical presentation or the things that have confounded observation, perception, and analysis? Is it possible to separate the therapist from the diagnosis?

Even if everything goes correctly, it's still likely that clients have more than one pitch to throw. A single intake session may not reveal all the features of a client's presentation. That's likely true for patients with co-morbidities, or for patients who have fluid emotions and unstable sense of self.

An evidence based diagnosis must be made on only the available information. Early determinations can be expected to be based on incomplete evidence. That's not so much a fault as it is a characteristic of the way information is revealed over the course of therapist-client interactions.


The question being begged here is 'Does this matter at all'?

It may not, a diagnosis can be presumptive/hypothetical and there are opportunities to “get it right” later in therapy.

Moreover, having all the evidence so that the diagnosis is correctly differentiated, may make not a practical difference.

The treatment could be much the same... skills training to deal with distress from one source is much like skills training to deal with distress from another source...cathartic relief following 'getting it out' is cathartic relief, etc.