On Evidence Based Practice

The following are some of my ongoing reflections on the demand for evidence based practice. These are updated from time to time.

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I have a good friend who likes to denigrate psychoanalysis because it is not ‘evidence based’ and does not conform to ‘best practices.’ And it’s not just my friend; many people seem to view psychoanalysis this way… especially social workers. If Rutgers School of Social Work is representative of the profession more generally, then social work’s commitment to evidence based best practices is certainly no secret. But what is evidence based best practice? And to what extent should we concern ourselves with it?

9. We don’t need theory. We need facts and evidence. 

Of course, there are no facts or evidence without theory. Particularly in Lacan’s version of psychoanalysis, theory informs analysis’ aims and practice, and vice versa. The champions of evidence based practice should remember that there are no examples or evidence without a theory already in place. Evidence and examples are only recognized as evidence and examples when a theoretical paradigm is in place to recognize them as such. Consequently, the demand for facts and evidence while at the same time denigrating theory is myopic and symptomatic. Going on as if one could simply attend to evidence and examples without a theoretical paradigm is silly and naive. And focusing on facts and evidence without making explicit how those facts and evidence are generated and constituted by the theoretical paradigm that underpins them is sloppy scholarship. What we need isn’t evidence and examples but rather better theoretical rigor, awareness, and engagement (See Bruce Fink, Reading Seminar XI: Lacan’s Four Fundamental Concepts of Psychoanalysis).

8. Therapy and analysis needs to be pragmatic.  

I’m sorry, but I’m not persuaded that therapy or psychoanalysis is to serve pragmatic aims, and this is because pragmatism and it’s “pragmatic aims” often means compliance with social, economic, and political norms and realities. As I understand it, many of our patients are our patients precisely because they are the dark underbelly produced by the brutalities of our social system. They are the alienated, extorted, and exploited our economic system produces. They are the deviants produced by our political regimes and their norms.  (See Bruce Fink, Reading Seminar XI: Lacan’s Four Fundamental Concepts of Psychoanalysis).

7. Therapy and analysis is about getting patients healthy, and evidence based practice guides the way in doing that as fast as possible with the fewest amount of resources.

So what does “getting healthy” mean in our society except getting to a place where one submits to the demands of capitalism, health insurance companies, socialized health care, public order, and “mature adult relationships?” Why not instead think therapy and analysis as that which illumines the ways these structures are operative in creating mental illness, and then as a space in which persons can be mobilized against those very structures. My hunch is that dominant powers would not consider this, “getting healthy.”  (See Bruce Fink, Reading Seminar XI: Lacan’s Four Fundamental Concepts of Psychoanalysis).

6. We need evidence based practice because time is money. 

Evidence Based Practice is not ideologically innocent. The techniques of thearpy and psychoanalysis should resist, confront, and refuse to submit to capitalist ideologies of “time is money” and “professional conduct,” both of which are in the service of bourgeouis norms (See Bruce Fink, Reading Seminar XI: Lacan’s Four Fundamental Concepts of Psychoanalysis).

5. Evidence Based Practice is about what’s good for the client.

The “Good” is not neutral or obvious. While most therapists are expected to interact with their patients in ways that are clearly for their patient’s good, what consitutes good here is always understood in terms of what is socially acceptable at a particular historical moment. Instead of working for our patient’s good, Lacan suggests we work for our patient’s desire, their Eros. Liberation therapists suggest we work for their liberation. Let’s not think about about is good for the client, since the good is generally assumed to be what’s good in the eyes of the dominant social order. Instead lets think of working for our patient’s liberation from the demands of the social order (See Bruce Fink, Reading Seminar XI: Lacan’s Four Fundamental Concepts of Psychoanalysis).

4. We know that the version of science Freud was working with is flawed. Ours, however, is much more robust. 

No doubt there are good reasons for situating many of Freud’s ideas within their historical context. To my mind his economic and mechanical models are good places to start. But I think it’s problematic to claim that Freud’s ideas are invalid because the version of science Freud was working with is now bunk. We go on to say that if only Freud knew what we now know about neuroscience, and so forth… as if we aren’t just as embedded in our own culture of arbitraryness? Moreover, I think we ought to pay equal attention to the language of today’s neuroscience. Even theorists such as Bolwby, for example, talk about things being “wired in” – as if we’re robots.

3. Psychopharmacology not only provides facts and evidence, it also demonstrates that more inferential models of the mind are misguided.

The evidence based crowd uses an outrageous double standard in evaluating psychotherapy and psychopharmacology. There is literally zero evidence for the sort of polypharmacy commonly practiced today, nor many systematic studies of using psych. meds over the longterm. Most drug trials are 6-12 weeks and tell us little about the impact of these meds months or years later.  Yet a doc prescribing 4-5 meds to a patient over 3-4 years is uncritically reimbursed even though there is not an iota of evidence to support such practices. And when the FDA clinical trials are carefully reviewed, even the evidence for the efficacy of short-term monotherapy with antidepressants and other meds becomes highly suspect.  (And ditto for many, many very costly non-psychiatric medical procedures such as spinal fusion, tubes for ear infections and so on.)

2. Evidence based practice utilizes statistical data, which is dependable.

a. We know that values and political pressures influence the choice of problems and the statistical methods used. National data is always permeated with value and technical issues

c. Statistical priorities are driven by social and political goals.

d. Political judgments are implicit in the choice of what to measure, how to measure it, and how to present and interpret that data.

e. Data sets aren’t data sets; they represent political and social perspectives and procedures imbued with ends in mind.

f. Statistical theory doesn’t tell us what kinds of data to collect or what variables to report; these are the province of other scientists who are the puppets of policy makers and funders.

g. Wording of questions and variables implies a political and social component. For example, the national unemployment rate is based on a certain notion of work that is ideologically infused.

h. Data collection usually happens as a result of political mandates.

(see Stephen Fienberg’s Ethics, Objectivity, and Politcs: statistics in a public policy context).

1. Evidence based practice draws on rigorous lab reports. 

The fact is that no science can live or evolve on its own. Every science depends on individuals. And every individual brings to science and data their world, their desire, their pathology. Another way of saying this is that individual worlds (in the Hediegaarian and Hegelian senses), individual and social desires, and individual and social pathologies inevitably play a role in constituting “science.”  It is naive to think that lab testing and lab reports lack the pathology of desire. It is naive to think that designs can control the pathology of desire. Lab testing, lab reports, and research designs do not control the pathology of desire; they are examples of it.

 

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