The blue binder sits on the corner of the wooden table. It contains three hundred pages of data on generalized anxiety. The spine shows a series of numbers that indicate the study year. This document represents the gold standard for therapeutic evidence.
The researchers conducted this study over . They recruited twelve hundred people from three major cities. They wanted to find out if a specific therapy worked. The results were positive and the charts showed a clear decline in symptoms.
The Selection Filter
Page four of the report lists the exclusion criteria in small type. It states that participants with depression were removed from the study. People with a history of substance use were also removed from the sample. The researchers wanted a group of patients with one single difficulty.
They also excluded anyone who was undergoing a major life transition. People who had recently lost a job did not qualify. Individuals going through a divorce were sent away. The study required people who were anxious but otherwise stable.
This search for a single difficulty creates a specific kind of knowledge. It allows the researcher to say that a treatment works for a specific label. The results are clear and the data is easy to read.
Most people do not have one single difficulty. They carry a collection of problems that interact with each other. An anxious person often has trouble sleeping. A person who cannot sleep often feels a low mood during the day.
The View from the Auditorium
I pretended to be asleep during a lecture on clinical trial design. I sat in the back row of the auditorium with my chin on my chest. I heard the speaker talk about the necessity of clean data.
“Messy” participants ruin the statistical power of the trial.
– Speaker in the Auditorium
He was a man with a very expensive watch. He used a laser pointer to highlight the successes of the study. He did not talk about the people who were turned away at the door. He focused on the narrow success of the narrow sample.
They are the individuals who wait in the reception area of a clinic. They have jobs and families and physical illnesses. These factors make them unsuitable for a high-level research study.
Case Study
Laura S.K. is a neon sign technician who lives in a drafty apartment. She works with noble gases and glass tubes. Her hands must be steady when she applies the heat. She suffers from a combination of panic attacks and chronic fatigue.
If Laura applied for the study in the blue binder, she would be rejected. The researchers would see her fatigue as a confounding variable. They would tell her that she does not fit the profile for the research. She is too complicated for the science to measure.
Laura builds signs for storefronts in the city. She understands that a single crack in the glass ruins the entire vacuum. She must be precise with her torch.
The gap between the studied population and the treated population is large. It is one of the most significant facts in modern healthcare. This gap remains invisible to the general public. People believe that “evidence-based” means “tested on people like me.”
The evidence is actually strongest for the people who are the least typical. A person with only one diagnosis is a rarity in a clinical setting. Most clinicians spend their time translating research for complex people. They take the “clean” tools and apply them to “messy” lives.
Isolating a single cause and effect by removing external influence.
Where the wind and the rain are always present simultaneously.
The fundamental dissonance: Science requires isolation, but life requires integration.
The researcher seeks a vacuum. He wants to see one cause and one effect. He removes the wind and the rain from his experiment. This experiment does not happen in the world where people live.
The clinic is not a vacuum. It is a place where the wind and the rain are always present. A therapist sees the anxiety and the back pain at the same time. These things cannot be separated for the sake of a chart.
I once made the mistake of following a manual too strictly. I had a client who was grieving and also experiencing panic. The manual told me to ignore the grief and focus on the breathing. I lost the trust of that client in .
The client saw that I was looking at a book instead of a person. He felt that his grief was being treated as a distraction. It was not a distraction to him. It was the center of his life.
We often apply findings with a high level of confidence. This confidence is sometimes a leap of faith. We assume that a treatment for “pure” anxiety will work for “complicated” anxiety. This assumption is not always supported by the data itself.
The researchers do not mention this leap in the summary. They write about the efficacy of the intervention. They write about the p-values and the standard deviations. They do not write about the limitations of the human experience.
The clinical guidelines are built on these studies. These guidelines determine what insurance companies will pay for. They determine what the health service will offer to the public.
A person might search for help late at night. They look for a name for their suffering. They find a label and they find a recommended treatment. They do not see the list of exclusions on page four.
The team at
understands this tension. They use the evidence-based pathways because they are the best tools available. They also know that the person in the chair is not a statistical average. The clinic treats more than fifty different conditions with specific methods.
These methods are anchored to the NICE guidelines. These guidelines are the best map we have for the mind. But a map is not the territory. A clinician must know when to follow the map and when to look at the ground.
Where the Map Meets the Ground
The ground is often uneven. It is covered in the debris of a real life. There are financial worries and relationship problems. There are old memories that do not fit into a diagnostic category.
A neon sign requires a vacuum to glow. The gas inside must be pure. If the gas is contaminated, the light is the wrong color.
We glow in the middle of the mess. We thrive when we are seen as a whole. This wholeness is exactly what the research trials must remove. They remove the person to find the result.
This is not a scandal. It is a methodological requirement. You cannot attribute an effect if everything is happening at once. The researcher must isolate the variable to see if it changes.
But we must explain this to the patient. We must be honest about the limitations of the evidence. We must admit that the science was built on someone else. It was built on a person who had fewer problems than the patient.
I remember the silence in the auditorium after the lecture. No one asked about the excluded people. No one asked how to treat the people who were too “messy” for the trial. We all looked at the charts and we all nodded our heads.
The charts were very beautiful. They were printed in high resolution on a large screen. The lines moved in the direction that everyone wanted them to move. They moved toward recovery.
Recovery in a Trial:
A significant change in a numerical score on a standardized questionnaire.
Recovery in a Life:
The ability to stand in a shop, go to work, or hold a steady hand with a torch.
Recovery in a trial is a change in a score. Recovery in a life is a change in a day. It is the ability to go to work or to talk to a friend. It is the steady hand of a neon technician.
Laura S.K. does not care about p-values. She cares about the fact that she can now stand in her shop without a panic attack. She cares that she can sleep despite her back pain. Her recovery is a complex event.
The vacuum in the binder cannot hold the gas of a real life.
We must continue to conduct research. We must continue to build evidence. But we must also remember the people who do not look like the data. We must remember the people who were turned away.
The blue binder is still on the table. It is a useful object. It contains important information. But it is only a starting point for the conversation.
The real conversation happens when the clinician closes the binder. It happens when the therapist looks at the person. It happens when we acknowledge that the evidence is only half of the story. The other half is the human who is sitting in the room.
The clinicians who work in condition-specific pathways have a difficult task. They must hold the science in one hand and the person in the other. They must follow the evidence without losing the individual. This is the true work of the clinic.
Beyond the Label
We call it evidence-based practice. It should perhaps be called evidence-informed practice. The evidence informs the work, but it does not dictate the outcome. The outcome depends on the relationship between two complex systems.
The patient is a complex system. The therapist is a complex system. The research trial is a simple system. We must not mistake the simple for the true.
I eventually opened my eyes in that auditorium. I saw the researcher packing his laptop into a leather bag. He looked satisfied with his presentation. He had proven that his method worked in a vacuum.
I walked out into the city air. The air was full of noise and exhaust and people. It was a messy environment. It was the only environment where the therapy actually mattered.
The neon signs were beginning to flicker on above the shops. They were bright and colorful against the gray sky. They were beautiful because they were functioning in the middle of the world. They were not in a lab. They were on the street.
