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I have a really good memory for concepts, ideas, experiences, and emotions. This did not seem very useful for the first half of my life, and led to good deal of obsessional thinking about the meaning of it all, the alternative universes I might have created if I’d just said something cool instead of whatever I actually said during one of my many awkward and confusing social interactions. The useful type of memory, the memorization kind, has pretty much always bored and baffled me. Numbers, names, equations, and citations, the kinds of things they employed to evaluate me throughout grade school, always led to the common refrain – I simply wasn’t trying hard enough. And frustratingly, I knew they were right, because I knew that I could memorize things, it was just mind-numbingly repetitive, requiring focused effort that produced endless anxiety, mostly out of a desire to escape.
So whenever I get into an argument about evidence-based practices, I always want to cite this specific paper that I can’t cite. I can remember who introduced the paper to me, and the setting, even the gist of the results, but never the paper itself: a recently-published meta-analysis of different types of therapy that showed, with numbers, what I’d always known, in my gut, as a young therapist: that dynamic therapies have a better outcome than strictly cognitive behavioral therapies. The way that they differed was what struck me most. When looking at dozens of well-conducted assessments of therapies tested against one another for their level of effectiveness, it appeared that cognitive-based and dynamically-based therapies had virtually the same success lowering symptoms of anxiety and/or depression after a period of time-limited therapy. The difference became apparent during the follow-up period. People undergoing CBT therapies saw the benefits of therapy erode slowly, while the group undergoing dynamic forms of therapy stabilized and continued to improve, even after their period of therapy ended. Incredibly, according to the article previously mentioned, the overall effectiveness of CBT itself has eroded in the decades since becoming the dominant force in mental health intervention.
For an absolutely brilliant overview of this battle between dynamic therapies (those focused on understanding the impact of early relationships, life experiences, and relational patterns) versus cognitive behavioral therapies (focused primarily on the notion that negative patterns of thought produce negative attitudes and feelings of depression) read the article by Oliver Burkeman in The Guardian (the link appears at the conclusion of this editorial). Burkeman makes the same arguments I have always felt to be true quite intuitively, that CBT did well in assessments of its outcomes because CBT defined the outcomes it sought, and further (and rather audaciously, in my opinion) defined their chosen parameters of mental health as fundamentally-meaningful rather than relatively-arbitrary. It seemed like teaching to the test based on a fundamentally-false premise, that you could end your suffering simply by thinking about it differently. The dynamic therapists, as represented by the psychoanalysts mentioned in Burkeman’s piece, instead argued for complexity, and the development of a meaningful understanding of one’s individual suffering by identifying its root causes.
The great teachers of dynamic therapies (Irv Yalom and Nancy McWilliams being my personal lodestars) advocate that, in order to be a great therapist, you should learn about art, literature, history, culture, current political and social movements, and religions, always remaining aware that, fundamentally, you can only scratch the surface in any of these areas of knowledge. Evidence-based practices suggest that you read a manual, and if you have questions, read the manual more carefully or perhaps start with something basic, more straightforward. Since all therapists address problematic thought habits, let me say here that I do believe CBT-type therapies are helpful, offering structure and, sometimes, immediate relief, and help to illuminate the submerged iceberg of unique life experience within each one of us. I use cognitive processes all the time in my work. The one area that Burkeman does not address, one commonly chuckled at by adherents of dynamic types of therapy, is the idea that the benefit from cognitive therapies is due to the presence of a caring therapist far more than the cognitive nature of the intervention.
Everyone wants to measure everything. What does your nonprofit organization do and how do you know? When you attempt to quantify experience, you simplify. This challenge was spelled out quite eloquently in a recent (and excellent) New Yorker article written by Larissa MacFarquhar about the Ford Foundation, discussing the potential negative impact of “strategic philanthropy,” aimed at using business thinking to assess a nonprofit’s value.
“If donors and nonprofits felt that they had to measure their results, might that not lead them to focus on limited sorts of things [outcomes] that could be measured precisely? … And what would happen to things that could not properly be measured at all, such as oppression, or justice?” (What Money Can Buy, New Yorker p. 41, 1/4/16).
Dave Leon LCSW is the founder/director of Painted Brain and a frequent contributor to Painted Brain News