of such values are faced with the dilemma of either refusing to quantify the value in question, in which case it disappears from the sum altogether, or else of trying to attach some quantity to it, in which case they misrepresent what they are about and also usually lose the argument, since the quantified value is not enough to tip the scale” (p 103). Some outcomes of psychoanalysis may indeed be costed, but these may be some of the least important. The cost saved may not “tip the balance” in favour of psychoanalysis. "#0!)Z*0%6#$1!):!)B(7)90! The second common criticism concerns the ownership of outcome: “Whose outcome is the outcome of psychoanalysis, anyway?”. It may be in principle impossible to decide between the competing claims of different individuals. For example, a treatment that enhances the quality of life of one person may be deleterious to a spouse or an employer. This is particularly evident in the case of the psychoanalytic treatment of children where the treated child’s desired outcome may be in conflict with that of the parent’s, or indeed that of the sibling. Ideally, notwithstanding the insurmountable practical problems, all individuals significantly concerned with an analysand should be assessed as part of the outcome study. The research enterprise itself is clinician led. It is the clinician-researcher that decides whose outcome will form the basis of evidence based practice. Thus all outcome investigations, perhaps particularly that of psychoanalysis, will be arbitrary, and limited by the selection of the individual(s) on whom outcome is measured. An extension of the arbitrariness problem of outcome ownership concerns the status of client choice as an indication of outcome. It could be argued that the client is in a privileged position relative to the investigator in determining whether the treatment is helpful. Interestingly, when user groups are asked they tend to strongly favour approaches to most mental health problems which are psychologically rather than pharmacologically based, or at least they plead for a greater emphasis on psychological help. When individuals perceive their difficulties arising out of psychosocial causes, they understandably seek redress in the same domain i.e. the interpersonal. It is also worth noting that psychoanalytic therapy often has greater prima facie acceptability than exposure-based cognitive behaviour therapy (for example with patients with OCD, Apter, Bernhout, & Tyano, 1984). Yet the desire of the user, “client satisfaction” is not generally acceptable as an adequate criterion for outcome. By this criterion, many treatments known to be ineffective and even harmful, (e.g. recreational drugs such as nicotine counteract anxiety) could be selected. Psychotherapy researchers are particularly conscious of the danger of imposing ethnically rooted cultural biases on what is designated as “needing treatment” and to be a “good outcome” (Bernal, Bonilla, & Bellido, 1995). For instance, the achievement of selfhood through the separation- individuation process is one of the cornerstones of psychotherapeutic interventions. Yet is Lasch (1978) correct that the emphasis on individual achievement in Western culture is excessive and that an appropriate submission to the goals of the family and community (Kagan, 1984) may be a far better indicator of healthy adaptation? Such differences are particularly acute in the area of child development and parenting. Rogler (1989) outlined some of the practical steps which culturally sensitive outcome research requires. In particular, it is important to ensure that interventions are consonant with the subjective culture of the ethnic group to which it is applied and that instruments used are able to integrate cultural meanings with the pertinent scientific categories. In reality, this is an ideal to strive for, but it is rarely achieved. @.4*/15!/$#/&(#2! Finally, it is commonly asserted that a uniquely evidence based treatment approach can lead to activities which are at odds with common morality. A good example of this is the success of aversive conditioning and other punishment based techniques in behavioural control of individuals with
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