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106 BRITISH JOURNAL OF PSYCHOTHERAPY (2009) 25(1)hopefully without a disorder. RCTs make clear to what extent modules havean effect, but what it is exactly that produces this effect remains unclear.Nomothetic group designs with their focus on the group tend to obscure theanatomy of change (Borckardt et al. 2008), whereas what we need is morepragmatic knowledge of the so-called active ingredients of successful therapies(Weinberger & Rasco 2007).With respect to the outcomes under study, I think that not only largertime-frames should be taken into account when studying patients infollow-up designs, but also the nature of outcomes assessed should be substantiallyenlarged. The evidential criteria currently used in debates on thescientific status of psychotherapies are narrow and far from universallyagreed (Richardson 2001; Sturdee 2001). Yet fundamental debate on thetopic is rare, despite being certainly justified given the substantial impact ofmeasurement error in commonly used instruments (Hoyt 2000). Within theRCT logic, patients are passive recipients of interventions. Their personalexperience of change; their subjective appreciation of the transformation atherapeutic intervention produces – which might well go beyond a reductionof symptoms – is typically neglected. This is peculiar given the fact thatsubjective experiences are the materials clinicians typically work with.Much more attention should be given to patients’ accounts of how therapyaffected them.Theories in turn should be used more explicitly in research. The elaboratedand often quite specific theories available in our field could be usedin much more straightforward ways than is usually done. For instance, muchmore detailed questions could be asked on what part exactly the transferencedid or did not play in making a given therapeutic relationship effective,than is usually the case.ConclusionThe idea that only randomized controlled trials, and only results producedthrough the evidence-based medicine paradigm can provide us with decentempirical support for psychotherapies is greatly overrated. Building onimportant critical appraisals of other authors, I argue that randomized controlledtrials tend to provide us with data that are neither inherently clinicallyvalid, nor necessarily relevant. The implications of these studies arepotentially damaging as the treatment protocols produced for RCTs tend tobe forced upon clinical practice as the only scientific ways of doing psychotherapy.They undermine the richness and diversity of clinical work. Conversely,I do think that systematic research which takes complexity intoaccount is relevant for psychotherapy. Research can be a powerful tool forfurther developing our discipline. Research designs that are closely relatedto clinical concerns and clinical practice do exist, and motivated therapistscan quite easily integrate them into their work.
STIJN VANHEULE 107Note1. This statistical term refers to extraneous variables that have an unintentionaleffect on the variables under study.ReferencesAblon, J.S., Levy, R.A. & Katzenstein, T. (2006) Beyond brand names of psychotherapy:Identifying empirically supported change processes. Psychotherapy:Theory, Research, Practice, Training 43: 216–31.Allison, D.B., Franklin, R.D. & Gorman, B.S. (1997) Design and Analysis of Single-Case Research. Mahwah, NJ: Erlbaum.American Psychiatric Association (2000) Diagnostic and Statistical Manual ofMental Disorders, 4th Edn, Text Revision. Washington, DC: American PsychiatricAssociation.Bagby, R.M., Quilty, L.C., De Fruyt, F., Rolland, J.-P., Kennedy, S.H. & Rouillon, F.(2008) Dimensional personality traits and treatment outcome in patients withmajor depressive disorder. Journal of Affective Disorders 107: S87–S88.Bateman, A. & Fonagy, P. (2008) Eight-year follow-up of patients treated for borderlinepersonality disorder: Mentalization-based treatment versus treatment asusual. American Journal of Psychiatry 162(12): 2387–9.Beutel, M.E., Rasting, M., Stuhr, U., Rüger, B. & Leuzinger-Bohleber, M. (2004)Assessing the impact of psychoanalyses and long-term psychoanalytic therapies onhealth care utilization and costs. Psychotherapy Research 14: 146–60.Blatt, S.J. & Zuroff, D.C. (2005) Empirical evaluation of the assumptions in identifyingevidence-based treatments in mental health. Clinical Psychology Review 25:459–86.Borckardt, J.J., Nash, M.R., Murphy, M.D., Moore, M., Shaw, D. & O’Neil, P. (2008)Clinical practice as natural laboratory for psychotherapy research. American Psychologist63: 77–95.Briggs, S., Maltsberger, J.T., Goldblatt, M.J., Linder, R. & Fiedler, G. (2006) Assessingand engaging suicidal teenagers in psychoanalytic psychotherapy: A case consultation.Archives of Suicide Research 10: 323–37.Cosgrove, L., Krimsky, S., Vijayaraghavan, M. & Schneider, L. (2006) Financial tiesbetween DSM-IV panel members and the pharmaceutical industry. Psychotherapyand Psychosomatics 75: 154–60.Eccles, M. & Mason, J. (2001) How to develop cost-conscious guidelines. HealthTechnology Assessment 5: 16.Fonagy, P. (2006) Evidence-based psychodynamic psychotherapies. In: PDM TaskForce (eds), Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance ofPsychoanalytic Organizations.Fonagy, P., Gergely, G., Jurist, E. & Target, M. (2002) Affect Regulation, Mentalization,and the Development of the Self. New York, NY: Other Press.Fonagy, P., Roth, A. & Higgitt, A. (2005) The outcome of psychodynamicpsychotherapy for psychological disorders. Clinical Neuroscience Research 4:367–77.Freshwater, D. & Rolfe, G. (2004) Deconstructing Evidence-based Practice.Abingdon: Routledge.Frovenholt, J., Bragesjo, M., Clinton, D. & Sandell, R. (2007) How do experiences ofpsychiatric care affect the perceived credibility of different forms of psychotherapy?Psychology and Psychotherapy – Theory, Research and Practice 80: 205–15.Goldfried, M.R. (2000) Consensus in psychotherapy research and practice: Wherehave all the findings gone? Psychotherapy Research 10: 1–16.
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