The New York Times has been running regular articles about the health care debate in the US Congress, and as the debate drags on, the Times gets further and further into the minutia of the proposed legislation. Their “Prescriptions” blog provides running commentary, and today’s includes what seems to me a well-balanced (fair and balanced?) portrayal of a small corner of the larger debate, namely whether the Senate’s health care legislation will cover non-evidence based practices… like prayer.
Turns out that Christian Scientists, some of whom rely on prayer alone in healing illness, have some friends in the Senate. Lest you think this is purely a conservative cause, the late Ted Kennedy was an advocate for government coverage of their services. I’m not exactly sure what the cost structure of prayer is (the Times blog has a figure of $20 a day for Christian Scientist practitioners — uh, separation of Church and State?), but this fascinating debate goes far beyond Christian Science — American Indian medicine includes spiritual practices, and would also likely be covered by the proposed legislation — and may even have relevance for psychology.
How does evidence based medicine apply to psychology? Well, some psychologists test their therapies, and in general they find that… most of them work pretty well in alleviating many problems for many people. Moreover, it turns out that the professional identity of the treater makes little difference — for instance, pastors, on average, get results that are, on average, as good as Clinical Psychologists (for those of you who want evidence of this, do a Google Scholar search for “Dodo bird effect” or “Luborsky et al 1999”). Why might this be? My take on it is that it’s likely related to a psychological “placebo effect.”
Often we hear about the placebo effect in the context of testing new medication. Placebos are pills with no inherent medical properties that doctors conducting experiments give to patients in their “control group” in order to rule out the salutatory psychological effects of getting any treatment (i.e., the expectation that patients will get better contributes to them getting better). If experimental pill X has a greater effect that placebo pill Y, we can say that pill X is evidence based. We know that placebos usually have real effects — in those studies that have a “no treatment” group (i.e., no placebo, no experimental poll), the placebo group almost always does much better than the no treatment group. Thus placebos are actually evidence based, in as much as scientific evidence shows that they work better than nothing. I personally always ask my doctor for the placebo. It usually costs less and has fewer known side effects… er, okay, that’s a joke. Placebos wouldn’t work if you knew they were placebos. You see, you have to believe.
Which brings us to psychology. (And to the very real power of religious faith, but I’m going to focus on psychology.) It is my reading of the literature on evidence based practice in psychology that most of the effect of psychological interventions is due to a placebo effect. Not there aren’t any practices that improve upon the placebo, there are. But those practices (commonly referred to as “evidence based practices” or “empirically supported treatment”) usually have only shown that they do a little bit better than the practices they are compared to. Most of the effect is due to the patient (or “client,” if you prefer) deciding they are going to get treatment and showing up to talk to a welcoming person. So, should we reimburse those practices that we think are akin to placebos simply because they work?
There are lots of things that contribute to well-being, and not all should be considered treatment of the reimbursable kind. Let’s make sure to cover those psychological practices for which we have good evidence are better than simply showing up for treatment and believing you’re going to get better. For those problems for which we don’t have good evidence based practices, let’s (1) encourage health care research and (2) acknowledge the healing power of non-professional support. But let’s not pay for something that can be acquired from somewhere else.