Views on RCTs

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Maddie1
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Views on RCTs Oct 13, 2015 16:43:52 GMT

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Post by Maddie1 on Oct 13, 2015 16:43:52 GMT

Randomised Controlled Trials (RCTs) are the research methodology of choice for the state (Vossler and Moller, 2015). As such, the results of RCTs inform which psychotherapies should be funded by the state. I will return to the issue of state funding shortly but in the first instance I think it is useful to look at some of the basic principle of RCTs which are outlined by Vossler and Moller (2015) as follows:

Randomisation

‘If you are comparing groups in an RCT, it is important that they are as similar as possible (e.g. on average, equally depressed) so that any difference you find is due to the intervention (treatment/no treatment) and not to group differences.’

Homogenisation of samples

‘RCTs are usually highly selective in recruiting their participants. Potential participants are screened to minimise co-occuring (comorbid) conditions (e.g. depression and anxiety) that could increase variability of the response to the treatment […]’

Manualisation of treatment

‘The involved practitioners are supposed to deliver the counselling or psychotherapy intervention following a particular ‘manual’ of practice (i.e. a therapy manual with specific prescriptions or general practice guidelines). […] this is done, to avoid, as much as possible, variation between therapists so that all participants in a particular group receive exactly the same intervention/treatment.’

(p7)

It is argued that the basic principles which constitute this approach make it possible to prove the efficacy of the psychotherapeutic treatment (ibid). In other words, this approach is designed in order to prove any positive results that arise (e.g. a client’s depression lessening) are ‘due to the intervention’ rather than external factors. From this perspective, other forms of research into psychotherapy are considered not to be sufficiently rigorous to provide this proof (Cooper, 2012). Providing this ‘proof’ can be regarded as crucial for our profession; we must be able to demonstrate to the public that we are providing a service that yields results (Coyne and Niels Kok,2014). However, I agree with Vossler and Moller (2015) that: ‘ […] every research methodology has its weaknesses and limitations, and RCTs are no different in this respect.’ (8)

McLeod (2015) points out that some of the limitations of RCTs are due to ethical issues that arise from this type of research into psychotherapy. He highlights the ways in which the ‘scientific rigour’ associated with RCTs in psychotherapy ‘[…] may conflict with the best interests of the client.’ (pp68-9). As such he describes some of the ethical issues thrown up by the use of RCTs. The question of client preference is one such issue pointed to by McLeod (2015). He states that:

‘There is good evidence that many clients have preferences for the sort of therapy that they believe will work for them, and that receiving a preferred treatment leads to better outcomes. In an RCT, there is a risk that a client will be allocated a non-preferred treatment. […] it is hard to gain access to good quality therapy in many localities, so there may be pressure on the person to go for whatever they can get. It is also the case that participants may not find a way, on the basis of the information available, to know whether the therapies that are being trialled map on to their preferences.’ (pp 68-9)

McLeod (2015) also considers there to be issues with the way in which practitioners in RCTs are required to follow manuals of treatment. According to him ‘[…] professional discretion is severely limited’ (ibid) in RCTs and this may well not serve the best interests of the client. This will also distort the findings of the research. Taking the example of an RCT undertaken to test CBT versus psychodynamic psychotherapy; if a psychodynamic psychotherapist would, in their regular clinical setting, treat a client in one way but in an RCT must adhere to a particular treatment approach as set out by the manual, the results of the psychodynamic psychotherapy may not be as positive as they might have been without this restriction (Bohart and House, 2012).

McLeod (2015) also highlights the issue of researcher allegiance in RCTs. This is particularly relevant in terms of state funding because RCTs have been used by certain psychotherapeutic approaches to demonstrate the superiority of their approach over and above other approaches in order to receive state funding. Cognitive Behavioural Therapy (CBT) as a treatment method for depression funded by the NHS is a prime example of this. Many of the research studies used by proponents of CBT in order to achieve NHS funding were RCT studies conducted by CBT practitioners or advocates of CBT (Cooper, 2012).

Bohart and House (2012) set out some additional criticisms of RCTs. They assert that RCTs hide the fact that ‘[…] there may well be people in both groups who are worse off after ‘treatment’’ (192). Clearly, if it is indeed the case that some people are left in a worse conditions psychologically post research and this is hidden, then the results of the study are distorted and big ethical questions are raised about how individuals engaging with RCTs into psychotherapy be protected.

Bohart and House (2012) also point out that individual responses are ignored in RCTs: ‘ RCT methodology ignores the different responses of different individuals to the same treatment, so that […] it simply cannot help with the everyday question: “What is the treatment of choice for this individual patient?”’ (193).

Given the limitations of RCTs it is unfortunate that they are viewed by the state as the best form of research available to test the efficacy of psychotherapy. Bohart and House assert ‘Because the RCT is the ‘gold standard’ in medicine, it is also assumed a priori to the gold standard in psychotherapy research too […] - arguably a glaring example of the colonizing hegemony of a positivistic, control-orientated modernity which assumes its one-size-fits-all methodologies to be universally applicable to all dimensions of reality.’ (192). In the real world of psychotherapy, one size does not fit all and must not be seen to do so. The hierarchy of research methodologies that exists - with RCTs at the top of the hierarchy - is deeply concerning. I believe RCTs have a place in psychotherapy research and can inform the field but the results gleaned from them are much more helpful, relevant and valid when utilised alongside the results gleaned from other research methodologies (McLeod, 2015). However, because RCTs are currently the research method of choice when it comes to the provision of state funding, I think that it is crucial for psychotherapists from all theoretical backgrounds to conduct research using this methodology. If psychotherapists from different schools of thought do not engage with the system as it is (and conduct the required research) then it will be much more difficult for them to exert influence moving forwards.

References:

Bohart , A and House, R (2012) in ‘Against and For CBT: Towards a constructive dialogue’ [Edited by House, R and Loewenthal, D] PCCS Books, Ross-on-Wye

Cooper, M (2012) ‘Essential Research Findings in Counselling and Psychotherapy; The Facts are Friendly’ Sage, London

Coyne and Niels Kok (2014) 'Salvaging Psychotherapy Reseach: A Manifesto’ [Accessed on 08/10/15 at: www.researchgate.net/publication/266020903_Salvaging_psychotherapy_research_A_manifesto]

McLeod, J (2015) ‘Doing Research in Counselling and Psychotherapy’ Sage: Los Angeles, London, Washington DC, New Dehli and Singapore

Vossler, A and Moller, N in (2015) ‘The Counselling and Psychotherapy Research Handbook’ Sage, London

clarem
New Member

Posts: 11

Views on RCTs Oct 14, 2015 10:38:19 GMT

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Post by clarem on Oct 14, 2015 10:38:19 GMT

Thank you Maddie, for this detailed review and I agree fully with all that you have stated.

Funding from the NHS and perhaps other sponsorship depends of the type of research to be conducted

‘Health care professionals are increasingly required to base clinical decisions on the best available evidence. Evidence based medicine (EBM) is a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values.’ (Akobeng A. 2005)

Akobeng A. (2005) produced an overview from the BMJ discussing RCT’s in detail including effectiveness and measurable outcomes. He also states

‘This notion has given rise to the concept of ‘‘hierarchy of evidence’’. The hierarchy provides a framework for ranking evidence that evaluates health care interventions and indicates which studies should be given most weight in an evaluation where the same question has been examined using different types of study’

Akobeng (2005) identifies the Hierarchy of evidence for questions about the effectiveness of an intervention or treatment

Systematic review of RCTs with or without meta-analysis
RCT
Cohort studies
Case-control studies
Case reports
Opinion

There 3 main points of view held by psychotherapists are:
1. Those that believe the use of RCT is not only an appropriate research methodology for the field but the best one.
2. Those who believe that RCT sometimes are appropriate but should not be privileged above other approaches
3. Those who believe RCTs to be completely inappropriate
(Moodley R. 2013)
What does the future hold with this diverse opinion?

BACP submitted to the Health Select Committee’s inquiry into NICE -an overview which critically debates the issue with clinical research in psychotherapy

‘Mental health research is seriously under-funded. RCTs are expensive, as are systematic reviews to synthesise RCT data. There is limited systematic review and RCT evidence for the efficacy of psychological therapies, with the exception of CBT for a range of conditions. Many psychological therapies remain unevaluated by RCT. Therefore NICE guidelines are based on a robust but very narrow evidence base.’ (BACP. 2015)

RCT allows clinicians to assess the quality of the research and whether the therapy simply works or not. It is recognised and endorsed by NICE.
I agree with Maddie, psychotherapy is in a difficult situation, for the modality to become credible and recognised as treatment of choice with NICE RCT need to be conducted.

Roy Moodley, Uwe P. Gielen, Rosa Wu (2013) Handbook of Counseling and Psychotherapy in an International Context. Routledge. London

A K Akobeng (2005) Principles of evidence based medicine. Arch Dis Child 2005;90:837–840)

(http://www.bacp.co.uk/research/about_research/health_select_committee.php accessed 14/10/15 5)

ashman
New Member

Posts: 7

Views on RCTs Oct 24, 2015 10:17:52 GMT

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Post by ashman on Oct 24, 2015 10:17:52 GMT

An RCT's purpose is of course to provide rigorous assessment of whether their exists a cause-effect relationship between the treatment and the outcome and to assess the cost effectiveness of a treatment (1).

To be able to make an informed decision on which therapy to choose,based on scientific evidence, is I believe a good thing. However, the fact that their is huge body of evidence (using the preferred method of research by the government),for a treatment isn't necessarily evidence of the efficacy of the treatment in relation to the efficacy of other treatments.

The non relational therapies such as CBT, which have a more manualised reductive approach to psychotherapy, lend themselves to being assessed quantitatively, whereas the more relational, exploratory, non directive approaches to therapy such as humanistic, experiential, psychodynamic etc, are more easily assessed qualitatively.

With RCT's being quantative and the preferred method of research for financial support by NICE and SIGN the governments advisory bodies for the psychological professions,it's inevitable that unless the other more exploratory modalities of psychotherapy undertake more RCT's they will face the risk of extinction. With more funding being exclusively issued to treatments such as CBT or MBCT, those who are not offering these treatments may find themselves struggling for work and ultimately have to find other ways of earning a living.

In his article in vol. 19 issue 7 of Therapy Today Mick Cooper writes :

"The recently launched Improving Access to Psychological Therapies programme, responsible for the allocation of £173 million to the development of mental health services in the UK, will focus exclusively on those therapies for which there is clear evidence of effectiveness through randomised clinical trials" (2).

Underlying it all is a dichotomy of thought, that of the realist, empirical epistemology which sees reality as out there and verifiable through data and the postmodern constructivist epistemology, which sees reality as a social constructed and verifiable by the subjective exploration of reality.

References:
(1) www.bmj.com/content/316/7126/201

(2) www.therapytoday.net/article/show/212/the-facts-are-friendly/#sthash.JsDI7yD3.dpuf

eddiechauncy.blogspot.co.uk/2012/01/what-are-ontology-and-epistemology_12.html

Resmeth3

Views on RCTs

Post by Maddie1 on Oct 13, 2015 16:43:52 GMT

Post by clarem on Oct 14, 2015 10:38:19 GMT

Post by ashman on Oct 24, 2015 10:17:52 GMT

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