psychotherapy and research

STIJN VANHEULE 101disorders, will be excluded from research samples. Since research indicatesthat co-morbidity is present in 50% to 90% of all psychotherapy patients(Ruscio & Holohan 2006; Westen, Novotny & Thompson-Brenner 2004),one could conclude that only 5% to 25% of the patients consulting forpsychotherapy, are included in research on protocols. Even this estimation isoptimistic since it does not take into account the percentage of persons whorefuse to participate in research. Patients consenting to participate in RCTsand especially in efficacy studies are usually known to be highly motivated,which is not the case for the total reference population of psychotherapypatients (Richardson 2001; Tansella et al. 2006). As a consequence we canonly conclude that the samples used in RCTs tend not to be representativeof the actual population of persons that seek help from psychotherapists. Tothe extent that this is the case, it is methodologically objectionable to generalizeconclusions from RCTs to the population of psychotherapy patients.Yet this is what is currently done. Effectiveness studies starting from patientsamples that are representative for the reference population of patients areactually, in this respect, much more trustworthy (e.g. Bateman & Fonagy2008).A third assumption Westen, Novotny and Thompson-Brenner (2004) critiqueis that in RCTs psychological symptoms are typically understood andtreated in isolation from personality dispositions, character traits or structuralviews on people’s mental organization. This idea is problematic sincebasic psychological science indicates that both are related – and in complexways (Luyten & Blatt 2007; Westen, Novotny & Thompson-Brenner 2004),and in clinical practice psychotherapists do take the broader context ofsomeone’s mental functioning into account. For example, imagine treating apatient who has only a major depressive disorder, as well as a patient with amajor depressive disorder and a clearly schizoid or psychotic way of relatingto the world. In practice, the presence of these schizoid or psychotic characteristicswill have a necessary impact on the approach to the depressiontreatment. However, in the theoretical model of the DSM these characteristicsare just considered as additive and not as interacting. Thankfully,studies indicating that personality does influence the outcome of RCTs andin fact interacts with the process of treatment are being published (e.g.Bagby et al. 2008; Blatt & Zuroff 2005; Luyten & Blatt 2007).A last assumption critically commented upon by Westen, Novotny andThompson-Brenner (2004) concerns the ‘interest’ factor; the idea that protocolpsychotherapies – meaning standardized manualized therapies that fitthe RCT logic – are both interesting and promising ways of approachingpsychotherapy (– see also Goldfried 2000; Goldfried & Eubanks-Carter2004). RCT psychotherapy is protocol psychotherapy that strictly adheres toa manual in which all steps of an intervention are prescribed in detail. Amanual of this type aims at removing all idiosyncratic influences of thetherapist providing the treatment; the only point of reference is nomothetic