That leaves us with an important question unanswered.
If the effectiveness or the efficacy of many psychotherapies or psychoanalysis cannot be measured with RCTs, how can it be measured? Can it be measured at all?
To attempt at answering the question we first need to think about what we mean by the term effectiveness. It might look self-evident but I am afraid it is not.
(Please note that what follows applies only to psychoanalysis, or psychoanalytic psychotherapy.)
Let’s take the following hypothetical example.
A young woman presents herself to a psychoanalyst. She has a specific problem which she complaints about, severe insomnia; could the analyst please help her?
As you can imagine, countless avenues are opening, and the analyst will attempt to explore them and identify the ones that bear more fruit.
He will do that by inviting the young woman to talk freely about whatever she feels is relevant or important. He will do so because he knows that by allowing a subject to speak, the young woman in our example, he will allow for certain connections to come to light. His intention, in other words, is not so much to “cure” an insomnia but to find out how this insomnia “fits” in his patient's life.
As work continues, the analyst might be able to help his patient recognize that her insomnia was, say, an expression of an hitherto unknown undercurrent of dissatisfaction with her life, that it reflected a tension between unexpressed desires and, say, a need for social conformity.
Gradually, the focus of both patient and analyst is shifting from the initial presenting symptom (insomnia) to the sources of dissatisfaction in the patient’s life. At some point our young woman might realize that the insomnia that made her suffer so much is not so unbearable anymore; it might have even disappeared. This and other changes will happen quietly, in the background, while work continues.
In general, when a person goes to see an analyst they do so because they suffer from something, e.g. a symptom, and they don’t want to suffer anymore. The analyst offers to explore how this symptom came to be, hoping to shed light on the factors that contribute to this symptom. There are reasons to expect that in the process the symptom will disappear –and it usually does– but the analyst’s main focus was never the symptom as such. That’s the most fundamental difference between psychoanalysis and other kinds of treatment.
To employ a medical analogy, when you have headache you might take a pain killer; but if you want to fight an infection you need antibiotics. Psychoanalysis is like the antibiotic; it fights the infection, not its symptoms.
Now, in general attempts at quantifying the effectiveness of a psychological treatment focus on the alleviation of symptoms –insomnia, phobia, depression etc– or on the self-assessment of the patients who received the treatment. In other words, you either check to see if the symptoms have disappeared or you ask the patient how they feel.
I think it has been made clear by now that both gauges are inappropriate in the case of psychoanalysis. It is expected that symptoms will change or disappear and by help of a psychoanalysis; similarly a person’s perception of well-being will definitely be affected by psychoanalysis, mostly in a positive way. But any attempt to quantify the effectiveness of psychoanalysis in those terms is doing no justice to it. It’s like feeling tempted to dismiss antibiotics because they are not pain-killers.
In short: if we need to find evidence, we need to search for different kinds of evidence. Questionnaires, Likert scales and checking for symptoms will not do.