In every human endeavor, the question naturally arises as to whether our way of doing things can be improved. Those with power, money, or face at stake in the way things are done resist asking this question, and if asked, they resist any answer that bucks the status quo. Eventually, younger blood comes along that either genuinely wonders how to do things better (this is rare) or needs a new answer to the question that improves their own power, money, or status. The upshot is that outcome measures are developed in an effort to assess whether the current process works, and then the outcome measures become enshrined and practitioners direct their efforts at scoring well on outcome measures rather than at improving things. In other words, the outcome measures dictate what is meant by quality and inadvertently squelch progress.
In upper-class culture, the host gets the same kind of credit for the meal that a restaurant gets. The outcome measures are taste, efficient service, cheerful ambience, and satisfaction of hunger. In middle-class culture, there is an expectation that the food, but not the wine, is self-prepared, but not self-grown. In some subcultures, growing one’s own food provides a status bump, while in others, growing one’s own food creates a loss of face. This depends on whether the garden was a hobby or a necessity. My point for now, though, is that once a yardstick is established in a local subculture, hosts organize their efforts around the yardstick and not around the vocation of feeding people, and it is only the latter that can lead to genuine improvement through innovation. When yardsticks of health dominate, the taste generally suffers and vice versa. In some areas of endeavor, innovation itself becomes the yardstick, and all other virtues die out; this is what has happened to poetry, dance, theater, and literature in some subcultures, where the importance of innovation has trumped the interest in communicating uplifting ideas to the audience, or even in entertaining the audience.
It is important for educators to ask themselves if what they are doing works. With a liberal arts education, a good outcome measure might be the number of books the students read in their tenth year after graduating. In high school geometry, a good outcome measure might be whether students are intrigued by the question of why their bedroom doors don’t fit snugly in their frames like their bureau drawers do. But these outcomes are hard to measure, so instead we develop tests that are easy to administer, and then we expect schools to teach to the tests. In my view, this has produced a generation of students who don’t think about what skills they need to become expert clinicians but instead think that if they do well on the tests, they must be expert clinicians.
Teaching to the test is also in danger of dominating psychotherapy. I believe that almost every psychotherapy benefits from naming explicit goals, and I don’t mean “less anxiety” or “less depressed.” I mean goals that state what patients will do that they don’t currently do, or what they will refrain from doing that they currently do. But to me, the purpose of stating goals is to energize the patient’s interest in the therapy and to tie the difficult work of therapy to an outcome in order to strengthen the alliance around, say, revealing one’s innermost thoughts or listening to challenging feedback—it’s worth doing if it’s linked to a goal. Instead, the goals of therapy have become a yardstick of their own, and therapists nowadays are often expected to show progress toward the goals after every session. No one would reprimand a heart surgeon because the patient in recovery is even less energetic than she was the day before. No one would complain that a violin student’s rendition of a Mozart concerto is no better than it was last week. Working toward the goal in psychotherapy promotes intermittent therapies over weekly or bi-weekly relationship-based therapies; it also justifies medication, which often leads to short-term benefits and long-term harms.
But the main problem, in my view, is not teaching to the test per se, or working toward the goal per se. The main problem is that this manner of education and psychotherapy is like following a recipe in the kitchen. Everyone becomes a sous chef and no one is a chef. The problem with even the best recipe is that it cannot take into account the variables of what ingredients are available and in what quality, the preferences of the diners, and the varying skills of the cook. (Notice that these are the same variables that define evidence-based medicine: available treatments, patient preferences, and the skill of the doctor.) Manualized psychotherapy and teaching to the test, like following a recipe, ensure that a practitioner who wants to be extraordinary will have to find another line of work. They ensure that the work itself will be a job and not a vocation, that teaching and psychotherapy as careers will not appeal to people who care about enlightening others, overthrowing moribund ideologies, or developing good citizens, because these vocational motives are hard to measure.
Chekhov, a doctor himself, saw the problem clearly in 1897. “She had begun to teach school from necessity, without being called to it; and she had never thought of a call, of the need for enlightenment; and it always seemed to her what was most important in her work was not the children, not enlightenment, but the examinations. …It is a hard, humdrum existence and only stolid cart horses … can bear it a long time; lively, alert impressionable people who talk about their calling and about serving the ideal are soon weary of it and give up the work.” We are losing many of our best people to fields that are still seeking answers and do not claim to have found them, to fields that require the engagement of the self, to fields that still offer the intellectual and spiritual excitement of a career and not just the security of a job.
