The Lack of a Lack in ‘Evidence-Based’ Practice

Psychoanalysis teaches that subjectivity is an organised response to an absence, be it a lack, void, or frustration. In a sense, to progress through an analysis is to gradually assume this lack (and its unconscious influence), and to practice as an analyst oneself it is therefore necessary to have undergone an analysis.

Consider how things stand in the rest of the psy disciplines. If one wishes to be an evidence-based practitioner, then one entrusts one’s clinical practice to standardised rituals, themselves constructed on the basis of inept metaphysics coupled with correlational statistics. Statistics are a fine explanatory element in sport, but much less so for science, though some practitioners struggle to tell the difference. As a consequence, there is no real point of lack in an evidence-based practice. There is an answer for everything, whether it is one more ‘strategy’ or diagnosis, one different or larger prescription, one additional ‘homework’ task. There is a forgetting of the conformist nature of the intervention, and of the broader context in which it is pursued, and there is no need whatsoever for the practitioner to know anything in particular about him or herself. The ‘evidence-based’ practitioner has no lack, no unconscious, no unexamined motives. It is as if a psychological intervention was much like replacing a car battery, a merely technical application of knowledge.

On the basis of the structural categories of psychoanalysis, it may be possible to discern at least three meanings of the lack of a lack in the ‘evidence-based’ psy disciplines.

The first is a neurotic approach. Just as practitioners suffer from professional shame about their practice, so do they experience anxiety. One response to this anxiety is to seek recourse to a series of ready-made answers from a supposed authority in order to temporarily defer the lack, rather like the rituals of an obsessional neurotic. The practitioner can maintain the fantasy that his or her discipline is rigorous, though angst will be the inevitable result when this fantasy fails (and it likely will). In this sense, the clinician’s interventions are, in a strict sense, principally for the benefit of the clinician; the patient is a necessary but somewhat incidental prop to a clinical fantasy.

A second strategy is for the lack to be foreclosed, that is, for the practitioner to earnestly believe that he or she knows all that there is to know, that his or her system is complete and flawless. This is the clinician as master. To adopt such a position is, literally, madness. Medicine and psychology throw up such cases from time to time.

The third position – and I think it a very common one – is for the practitioner to disavow his or her lack. That is, he or she readily concedes that of course, s/he doesn’t know everything; of course, human encounters can never be reducible to standardised strategy-mongering; of course, knowledge is asymptotic rather than totalising; but nevertheless, s/he proceeds as if the precise opposite were the case. This position – disavowal – is perverse, in a structural sense, with quant methods and evidence-based ritual as the fetish, namely, the prosthesis necessary in order to cover up a lack. Paradoxically, of course, such prostheses underscore the very lack they are intended to hide, and thus it is little surprise that those outside of the psy-disciplines – whether in other academic disciplines, or the patients themselves – do not necessarily endorse the psy-clinicians wild claims to scientificity. It is not merely a case of the emperor having no clothes, but rather, of having bizarre and tawdry ones which fail to function even as a fig leaf.

 

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