Saul Rosenthal, PhD

Boston Area Health Psychologist

In the article What your therapist doesn’t know, author and psychologist Tony Rousmaniere argues that therapists should incorporate psychotherapy metrics into our practice. In general, I very much agree with him, although it’s a complex topic with no easy answers. Rousmaniere, while advocating for metric-based treatment, does a good job laying out both pros and cons. On the one hand, more and more fields are utilizing metrics as feedback to alter and improve performance. On the other hand, psychotherapy is an extraordinarily complex and individualized piece of work that might not lend itself to influence by statistical analysis.

While there are plenty of reasons to praise and criticize the article (just read through the article’s comments to get a sense), there are a couple of points that really stick out to me.

Speaking as a dataphile, the idea of utilizing objective information to improve my clinical work is fantastic. However, I’m not quite diving into the world of metric-based treatment right away. There are a couple of problems I have with it, particularly in the context of psychotherapy.

Advocates for metric-based treatment argue that clients provide more honest, valid and objective information when they complete questionnaires. When speaking directly with clinicians, there is a positive bias, perhaps so the clinician feels they are doing a good job or to avoid the anxiety of talking about symptoms.

Problem number 1 — the presumption is that individuals are more honest when responding to questionnaires than when talking with people.

Now, there is some evidence for that, but there also is a plenty of evidence that responses change based on how questions are asked, what the respondent thinks will happen with the information, etc.

Problem number 2 — metric-based treatment pushes treatment towards a one-size-fits all model. On the one hand, evidence-based treatment (of which metric-based is one aspect) have been a boon. Systematic investigation into treatment has been central to most of the progress we’ve made in all of health care.

On the other hand, the vast amount of differences from person to person makes it very difficult to design a fully metric-based approach. Without getting into the design or philosophy of research, it is impossible for high quality research to fully reflect the experience of the individuals who walk through our doors. What are we supposed to do if a client does not respond to “gold-standard treatment” or if they are experiencing a condition that is not well studied? Turn them away?

Obviously not. The American Psychological Association addresses this issue by stating that Evidence-Based Practice in Psychology needs to integrate the best available research evidence with the clinician’s expertise in the context of the client’s characteristics, cultural background and preferences. In other words, there is no one-size fits all.

Data-based treatments are one leg of treatment. My concern is that in our ever-increasing movement towards data-driven treatment, we will forget the other legs. Not to push the metaphor too far, but it’s obvious what happens to a one-legged stool.

I practice what perhaps can be titled data-informed treatment. Just as a good chef uses a recipe as a necessary but not always sufficient starting point, a good clinician does more than follow metric-based treatment protocols. We use our expertise to determine how to integrate evidence-based approaches into treatment that honors the individual sitting in front of us. That is best treatment. And whether I am giving a client a questionnaire, examining brain wave patterns as part of neurofeedback or working to develop a therapeutic relationship with my client, best treatment is what I continually strive to provide.

March 21st, 2017

Posted In: Psychotherapy