This paper utilises critical theory to reflect upon current debates that focus on psychological therapies, effectiveness and outcomes and considers the implications of this for our practice. Within this debate an implicit consequentialist stance is taken in regards to the differing approaches to therapy; which eschews ethical questions regarding process makes all therapies appear equivalent (Dodo Bird Effect). One result of this is that psychological therapy commissioning becomes focused upon economic ‘efficiency’ and therapeutic outcome measures.
The theme of the conference, critical psychotherapy, raises the interesting question of what does it mean to be ‘critical’? This often implies an uncovering of something hitherto unseen, even latent, and that when made manifest draws out new insights. So here I think that there is a danger that the focus upon outcomes and the particular way that the Dodo Bird Verdict has been accepted begins to ignore the ethical dimension of the therapeutic relationship and as long as ‘therapy’ is characterised by certain elements and is bona fide, then what happens within the relationship seems to become less thought about.
Outcome measures involving choice of outcome/user generation are considered to provide meaningful choice, respond to aims/priorities of ‘service users’ and even empowerment. Despite these representing an improvement upon patient reported outcome measures they remain problematic. Critical theory helps us to problematize this; by considering whether ‘choice’ made within a restricted code is really a ‘choice’. The place of therapy, I argue, is not to provide an alternative ‘code’ to supplant that which is considered hegemonic, but rather to provide the space, partly to question such ‘codes’.
The general trend in psychotherapy research has been to try and identify those effective elements of a therapy that represent the ‘active ingredient’, that ‘thing’ that causes a particular therapeutic affect. This has led to an increasing focus upon outcomes in order to measure the impact of what is often described as a ‘treatment’. There are many different outcome measures, some developed by ‘experts’, some developed through reference to ‘service users’ and others that are ‘patient-generated’. Different outcome measures offer different measurements and some types may be better suited than others. Counselling and psychotherapy as a thoughtful and curious practice often questions such approaches. As social beings we exist within a set of rules that allow us to communicate and engage with others in a ‘safe’ way; however that we need conventions, codes and language does not mean we should not think about these things. For instance, we should think carefully and critically about the implications of outcome measures for practice and how they both provide choice, but also restrict this. Critical theory further contributes to this debate as it highlights how sometimes the way choice is open and restricted does not always affect different people equally.
If all goes well I will be presenting the developed paper “Outcome Measures, Paternalism and Psychotherapy” at the UPCA conference.