If They Don’t Make You Happy, Sue Them

3 ..7

Let us take a closer look at these requirements. First is the need for a manualised treatment based on a protocol-like approach. This means that the therapist is reduced to an executive who has to follow the book – as a matter of fact, he or she is turned into the university professor’s research assistant who is not allowed to take any initiative during the treatment. Anyone with clinical experience knows that therapy doesn’t work this way, that each individual treatment is different because each client is different. In case there are people in the audience who think that this is only the case for psychoanalysis, I have a convincing anecdote. A couple of years ago, there was a big conference in my country at the occasion of 25th anniversary of the organisation for psychiatry and psychotherapy. I was one of the five keynote speakers; everyone of us had at least 20 years of clinical practice and each speaker represented a different psychotherapeutic school: behavioural, cognitive, systemic, experiential and psychoanalytic. In spite of our different backgrounds, we had at least one thing in common. During the panel discussion, it became obvious that not one of us followed his or her own book, let alone a manualised one. The explanation was very simple: we can’t predict beforehand what will be important during a particular treatment, and a good therapy is always to a certain extent tailor made to a particular client.

The second requirement concerns the need for a limited and preferably fixed number of therapeutic sessions. The insurance companies love this idea. Well, long term follow-up research has demonstrated what every experienced clinician knows: the effect of a psychotherapy is among other things determined by its length, and although most short term psychotherapies might initially be successful, there is an enormous relapse within one year. Again, the conclusion is quite clear: psychotherapy doesn’t work that way.

The third requirement is even more baffling, because the exclusion of every patient who suffers from co-morbidity means that about two thirds of the potential clients are excluded from these studies. I am always wondering where these researchers find these kinds of clients, I never see them! The moment you start listening to a patient with a supposedly “simple phobia” or an isolated “panic disorder”, things very quickly get more complicated, and the idea of “single” or “isolated” disappears quite fast.

Let us now return to the obligation for psychotherapy to prove its effectiveness. For the time being, the most accepted way to test it is by using the Evidence Based methodology. As I explained, this methodology can only be applied to a very limited number of psychotherapies and even then, for only a very limited number of patients. It is at this point that we meet a perverse twist with a disastrous effect. Instead of concluding that this methodology is too limited to do the job, the message is that every therapy that cannot be tested by RCT is simply not scientific or effective. This is what I call a perverse reversal and the perversity doesn’t stop there, on the contrary. The next step is that the insurance companies refuse to refund those therapies that are not tested. Next and consequently, the teaching institutes tend to focus nowadays almost exclusively on those few therapies that do match the criteria of the Evidence Based approach!