Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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What really matters in psychotherapy is output, not input, standards
- Douglas M McFadzean (30 August 2004)
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The best design for psychotherapy studies
- Arthur Rifkin (1 September 2004)
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Re: What really matters in psychotherapy is output, not input, standards
- D B Double (2 September 2004)
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Re: The best design for psychotherapy studies
- D B Double (2 September 2004)
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Douglas M McFadzean, Counsellor in Primary Care Stirling GP Locality
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Duncan Double's points about control groups and the failure to maintain double blinds in research are undoubtedly important. Wampold (2001) has discussed these issues at length in his landmark work which clearly proves that psychotherapy is inadequately described by a medical analogy. However, it is disappointing that Double's final comment: "... alternative providers should meet standards of training approved by such bodies as the UK Council for Psychotherapy (UKCP) and the British Confederation of Psychotherapists (BCP)" flies in the face of the research evidence. Hogan's (1999) extensive research on psychotherapy regulation yields recommendations to "regulate output, not input", as "current requirements [to enter the profession] have not been shown to be related to effective performance." To my knowledge, the main professional bodies in the UK have failed to substantiate the claims that their training and accreditation criteria ensure more effective or more ethical practitioners. What matters most to the patient is outcome, and that should be the primary focus of improving "standards", rather than bolstering spurious training hegemonies. 1. Wampold B. The Great Psychotherapy Debate. Mahwah, New Jersey: Lawrence Erlbaum, 2001. 2. Hogan D B. Protection, not control. In Mindfield: Therapy On The Couch. London: Camden, 1999. Competing interests: None declared |
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Arthur Rifkin, attending psychiatrist Zucker Hillside Hospital, Glen Oaks NY 11004, USA
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Why should it be so difficult to assess psychotherapy? A pill placebo seems an adequate control group. True, the subjects know in which group they belong, but independent raters unaware of the treatment can do assessments. If subjects have a bias favoring psychotherapy or pills, that may affect the results, but that is a useful outcome measure. For most serious mental disorders, we have proven drug treatments. The important question then, is not does psychotherapy show superiority to pill placebo, but how it compares, as well, to proven drug treatment. If the pill placebo performs better than psychotherapy, and worse than active drug we could interpret that to mean the active pill did work, and pill placebo is better than a psychotherapy placebo. Why should it be difficult to measure the clinical effect of psychotherapy. If psychotherapy claims to alleviate symptoms as well as, or better, than drug treatment, why can't we use the same measures of symptoms? Yours truly, Competing interests: I receive funding from Pfizer for a study of Geodon in autistic disorder. |
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D B Double, Consultant Psychiatrist Norfolk and Waveney Mental Health Partnership
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I take Douglas McFadzean's point.1 In fact I am inclined to agree with it. My comment about the standards of psychotherapy training was made as the last sentence of a letter than was essentially about improving choice for psychotherapy in the NHS. On the other hand, I find it difficult to think that training is not important. For myself, I would choose a therapist on the British Confederation of Psychotherapists' register, even one who is a member of the British Psychoanalytic Society (BPS). Others will have different preferences. As far as I know there is only one practitioner in Norfolk, where I work, who is a BPS member, and he works outside the NHS. Clearly if people are to have access to personal therapy, they will need to consult other therapists and counsellors. Richard House, commenting in a rapid response on the same article as my letter, highlights the concerns about institutional professionalisation of psychotherapy.2 I too wish to encourage innovation and diversity. We need liberation from the state of mind we're in, driven by risk and accountability.3 My point is that should the NHS invest more in psychotherapy provision, this is likely to lead to welcomed improved opportunities for training. I do not wish to create a training hegemony, and agree that the quality of performance is what matters. At the risk of creating at the end of a letter another throwaway remark which may be interpreted as controversial, what I would like to see is more emphasis on long-term therapy, rather than the short-termism in which the NHS tends to get trapped.
Competing interests: None declared |
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D B Double, Consultant Psychiatrist Norfolk and Waveney Mental Health Partnership
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Arthur Rifkin may think me too sceptical about the measurement of treatment outcome.1 I am more cautious than him about the apparent proven effectiveness of drug treatment for serious mental disorders.2 I'm glad he recognises that expectancy can affect outcome, but the finding of generally small effect sizes in meta-analyses makes me wonder how much we may be misinterpreting amplified placebo effects as signs of efficacy. I have no objection to trials comparing psychotherapy with placebo pills. The lack of a pill-placebo arm in many such studies has rendered their interpretation more difficult.3 I just do not want to encourage the mistake that psychotherapy trials can be conducted double-blind or the pretence that drug trials are really as double-blind as we would hope.
Competing interests: None declared |
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