What role should empirical evidence have in determining contemporary
psychological practice?
CREST/RCTE Conference: Roehampton University May 2015.
Richard Rorty, the neo-pragmatist philosopher, was fond of asking ‘what’s the cash value of that
idea? What kind of a life does thinking like that, talking like that, believing that, get you?’ Well,
having worked in the NHS for a number of years, I’ve got a fair idea of the kind of life we get
when we think of psychotherapy as a treatment resulting in outcomes to be measured,
monitored and managed. So perhaps I can persuade you - for a few minutes at least - to think
of it instead as a practice resulting in gifts to be cultivated, treasured and shared.
Marcel Mauss, the sociologist, reminds us that gift-giving and gratitude have always acted to
shore up society. Drawing on Mauss’s work, Lewis Hyde looks at a range of anthropological
studies to illustrate the function of gift-giving in so-called primitive communities and how these
systems were underpinned by a belief in the importance of giving things away rather than
keeping them. The crucial quality of the gift, he suggests, is that it must be passed along from
one person to the next, thereby increasing the feeling bond, the relationship between people,
tribes and communities. Holding on to the gift, on the other hand, takes it out of circulation.
Rather than spreading from one person to the next, the gift is now appropriated, seized,
grabbed. It becomes another privately owned thing, a commodity if you like. It can be traded,
and thereby loses its capacity to make a connection between people. Gifts bring us together;
possessions separate. This is mine, not yours.
Whilst a gift most commonly means a material object, it’s a word that is also used to describe a
talent or inner potential. Hyde is deeply interested in the creative potential inherent in the
practices of art, science, spirituality, teaching and healing: ‘I have hoped to speak’ he says ‘of
the inner gift that we accept as the object of our labor, and the outer gift that has become a
vehicle of culture. I am not concerned with gifts given in spite or fear, nor those gifts we accept
out of servility or obligation; my concern is the gift we long for, the gift that, when it comes,
speaks commandingly to the soul and irresistibly moves us’.
As a psychotherapist, I find something compelling about this notion of the ‘transformative’ gift –
the gift that changes us profoundly as a result of psychological healing or spiritual teaching. One
of the most important things about transformation – as we know all too well in our clinical work is that it cannot take place immediately: there is work to be done, often difficult, extensive and
painful inner work that we have to do in order to effect change. And the question that Hyde asks
is this: ‘what motivates us to undertake this labour, this work?’ Why would we put ourselves to
all this trouble? His answer is that we do it because of a feeling of love and gratitude towards
the teacher or therapist who initially stirs our sense of inner potential. Gratitude for our
awakening is the catalyst that inspires us to labour, to develop and eventually realise the gift
within. Only when we have done this work on ourselves can we pass the gift on by putting it
into practice, using and sharing it in our everyday lives. This is the final act of gratitude that
indexes our real acceptance of the original gift.
But here’s the rub. ‘Gratitude’, says Hyde ‘requires an unpaid debt, and we will be motivated to
proceed only so long as the debt is felt. If we stop feeling indebted, we quit, and rightly so. To
sell a transformative gift therefore falsifies the relationship; it implies that the return gift has been
made when in fact it can’t be made until the transformation is finished. A prepaid fee suspends
the weight of the gift and de-potentiates it as an agent of change’.
So a fee, paid in advance, cuts off the forces of gratitude. Now, instead of feeling grateful, we
feel entitled. We have paid for something, so we must have it. This is so commonplace
nowadays in our marketized public sector services, we hardly notice it when patients arrive
claiming their right to six sessions of CBT for their anxiety. It is also commonplace within higher
education where students now seem to feel increasingly entitled to qualifications for which they
have been forced to take out enormous loans. But of course, the market culture producing a
sense of entitlement relies on people knowing what they are paying for – and this means that
therapies delivered within a market culture will tend to be geared to something that can be
specified in advance – generally, the eradication of pain and discomfort. A gift culture, resulting
in a sense of gratitude, relies on patients working at something – a new perspective, a change
of heart, an awakening to a new quality or potential within the self - that cannot be known or
specified in advance. Transformation cannot be agreed ahead of time.
This doesn’t mean that we shouldn’t get paid for what we do as psychotherapists - but it does
involve recognising that a portion of our paid work will necessarily involve what Hyde might call
‘gift labour’. Gift labour is not market labour. Gift labour cannot be exploited or promoted in the
way market labour is, driven by costs and rewards, outcomes and results, incentives and
deterrents. The gift is bestowed, not bought. It’s not subject to Payment by Results.
If we are lucky, when we undertake our own psychotherapy, we may feel we’ve received a gift
for which we are grateful. (The therapist may feel grateful too). The work of both goes back into
society, back into circulation, by the therapy or supervision offered to others, the articles and
papers written, the journals edited, often - interestingly - for no or very little money. In this way,
the gift remains in circulation, it grows; it flows; it connects us to others. It stays alive.
But when psychotherapy is relentlessly strong-armed into the marketplace it becomes the
servant of that very marketplace and can no longer thrive in a spirit of giftedness. It is owned,
guildified, rubber-stamped, approved, parcelled-out and organised by powerful state interests,
whose chief whip I would like to suggest is the evidence-based movement.
We need to
remember that despite its endorsement of so-called scientific ‘objectivity’, this evidence-based
movement is anything but neutral. It has emerged as a consequence of contemporary neoliberal
preoccupations with rationality, transparency, professional accountability and, most of all, costeffectiveness. As such, it is inextricably linked to government policy, the medical model - and
now of course to Payment By Results. In IAPT, for example, therapy is traded for weekly
outcome measures indexing the depressed patient’s return to the neoliberal fold of work,
productivity and consumption. Services are now funded on this basis.
That there is a great deal of despair, cynicism and burnout in the psychotherapeutic field today
is, I think, largely a function of the way in which the evidence-based movement, under cover of a
presumed scientific neutrality, coerces us into offering a commodified, target-driven version of
psychotherapy in which what Hyde calls ‘the spirit of the gift’ struggles to survive. But the
supreme irony of such evidence-based practice is that without the ‘spirit of the gift’, there is no
therapy to be had at all.
We might like to remember that the NHS was originally offered as a hugely significant gift to
the British people, something they received with gratitude because it freed them from worry
about illness and old age. What was the nature of that gift? I think it was a promise that the
NHS would remain a protected space, a market-free zone. No-one would profit from the
healthcare system except the patients who relied on it. Neoliberal policies, the recent Health
and Social Care Bill and the increasing privatisation of NHS services have changed all that.
Perhaps much of the rage and despair felt by the public about the breakup of the health
service is due to a realisation that what was once felt to be a gift is now something from which
businesses are making a profit in the name of efficiency. Of course, the more the NHS is
treated as a trading floor, the more staff and patients can be treated like disposable products.
We’ve heard a lot about the consequences of this recently in the Francis Report.
Ultimately, evidence-based practice is concerned with questions of value. But we might like to
ask: what is the value of the psychotherapist to society? What is the social value of alleviating
psychological distress? It seems to me these are the shadow research questions that haunt
psychotherapy outcome studies, indexing a radical doubt in our culture about the value of the
inner life; an uncertainty about the worth of the human beings we treat.
What kind of a life do you get when you believe these questions matter? Well, John Berger
wrote a beautiful meditation on the working life of a dedicated country doctor, Dr John Sassall,
chronicling his profound involvement in the lives, ailments and concerns of patients in a small,
rural community. The book ends with an attempt to find a measure of Sasall’s impact on these
people with whom he shared his life for over 25 years. After trying to calculate the number
and type of his medical successes and failures, Berger eventually gives up, admitting that we
simply do not know how to measure this one man’s contribution to society.
‘By measure’ he says, ‘ I do not mean calculate according to a fixed scale but rather take the
measure of a man doing no more and no less than easing the lives of a few thousand of our
contemporaries.’
‘ All that I do know’ he concludes ‘is that;…..a doctor who has surpassed the stage of selling
cures, either directly to the patient or through the agency of a state service, is surely
unassessable’.
I think I’ll leave it there.