Thank you, Katherine McArthur, both for challenging my own cherished beliefs, and also for allowing me to clarify what I really think about the relationship between counselling and scientific methodologies
Thank you, Katherine McArthur (‘RCTs: A personal experience’, Therapy Today, September 2011), both for challenging my own cherished beliefs, and also for allowing me to clarify what I really think about the relationship between counselling and scientific methodologies.
There is only one thing that I think she has made over-complicated: ‘bad faith’, as I understand it, means doing something that I do not, in my heart of hearts, believe in. I do not mean belief as dogma, but belief based on a constant testing of experience. In this respect true science and true belief are not really very different – which would help to explain why both Newton and Einstein saw no contradiction between scientific and spiritual endeavour.
Why, therefore, do I not believe in RCTs? The basis of such testing assumes that we can establish an objective measure of something (anything). This may be appropriate if we want to test how much water results from combining so much oxygen and so much hydrogen. The results are likely to be pretty consistent. Even here, experimenters prepared to question their results have realised that there will be variants, and that these appear to relate to the nature of the experimenters.
When it comes to medical RCTs, the waters become still muddier. People do not exist inside test tubes (and neither do cancers). The variables include both the observable and the unobservable: the observable includes other bacteria or viruses living inside the individual (how many of these are ever taken into serious account?); the unobservable includes patients who may be taking herbal or homoeopathic remedies, eating better or worse than other patients (whatever that means), or even going for counselling. They will not necessarily tell the researchers; even if they do, the researchers may not include these factors in their data.
At least there is one factor which can be separated out when testing out a new drug: the subjects of a trial will not know whether they are getting the drug or a placebo. How is this scenario to be replicated in a counselling RCT? Does one group get Rogerian counselling, whilst the other just gets an hour’s conversation each week? Given what we now understand about the importance of the therapeutic relationship, might an hour’s conversation with an understanding, albeit untrained, listener be at least as valuable as an hour with a trained but fundamentally useless counsellor?
At each stage in this progression from test tube to human relationship, the variables mount up so much as to render the process at the very least highly questionable. If we then consider the fact that, as pointed out above, even a test tube will respond to the individual experimenter, I really cannot see what I can hope to achieve.
And I still take on board Katherine McArthur’s viewpoint. She clearly believes in what she is doing, and will therefore, I am equally sure, obtain extremely valuable results. What I question further, however, is whether, even given the possibility of overcoming every reservation I have suggested here, and proved, beyond reasonable doubt for the benefit of NICE, that person-centred counselling (for instance) is of far greater value than any amount of CBT, drugs or electro-convulsive therapy, this would make the slightest difference to what is currently happening.
The point about ‘improvement’ is that what I value as improvement for myself or for a client may have little or nothing to do with what the exchequer regards as improvement. I regard counselling as fundamentally subversive. Fulfilment may involve coming to question every accepted convention or truth. This may not suit governments or government agencies, generally committed to maintaining the status quo.
I am also quite certain that there is a fundamental dishonesty in the way in which NICE comes to its conclusions. This is not necessarily conscious; but it is this lack of conscious awareness which makes it so peculiarly powerful.
A prime example: there is absolutely no objective evidence to prove the effectiveness of most modern psychiatric treatments, or even to justify psychiatric diagnoses. And yet the psychiatric establishment has an absolute financial and political stranglehold over this field. It is utterly entrenched in its own value systems and self-perpetuating language, and has lost the means even to question its beliefs or motives. This sort of ideological manipulation of facts, more than anything else, is what will keep humanistic therapies out of the NHS.
These are the reasons why I cannot subscribe to RCTs; and I wish the greatest good fortune to those who do. I am quite certain however that the NHS really doesn’t want us. It will take a miraculous change in attitudes for this to change. As it happens, I do also believe in miracles.
© British Association for Counselling and Psychotherapy 2011.