psychotherapy and research

STIJN VANHEULE 97condition frequently used in psychotherapy research is called ‘treatment asusual’. Seldom is it defined what this ‘treatment as usual’ looks like (Weiss,Catron & Harris 2000; Westen, Novotny & Thompson-Brenner 2004),although it has been agreed upon that this condition should be representativeof treatments actually applied in the intended reference population(Tansella et al. 2006). If it is not CBT or psychoanalytic, interpersonal orclient-centred therapy, then what is it? Moreover, if some psychotherapistcan be found who is willing to deliver this barely imaginable therapy that isboth nothing and everything, and which nobody believes in, is it not selfevidentthat the allegiance effect discussed earlier will explain what it is allabout? After all, the allegiance effect learns that precisely a therapist’scommitment to a certain type of therapy is a most powerful explanatoryvariable for the outcome of psychotherapy. Experimental therapies areinterventions that collaborators to a study are strongly committed to, while‘treatments as usual’ are included with the aim of serving as a contrast.Westen, Novotny and Thompson-Brenner (2004) consider the latter as‘intent-to-fail’ against which the superiority of the experimental condition isto be proven (see also Wampold et al. 1997).The proper and effective use of RCTs in psychotherapy research is lessself-evident than we might suppose. Essential characteristics like applyingtrue blinding in a trial, realizing randomization in which patients are blindto the nature of treatments, and using a proper, rather than intent-to-failcontrol condition, are all inherently problematic. As a result we might questionwhat applications of RCTs in psychotherapy can genuinely contribute.Can these ever be as stringent as in medical research without neglectingessential characteristics of psychotherapy? The risk we run by attuningpsychotherapy to the RCT model is that its basic tenets become eroded. Byincluding psychotherapy in RCTs, a price is paid. Whereas in medicalresearch, pharmaceuticals are typically discovered and refined in laboratoryconditions as well as tested in RCTs before they are introduced in clinicalsituations, psychotherapeutic interventions arise from clinical practice itself,and not from the laboratory (Goldfried & Eubanks-Carter 2004; Westen &Bradley 2005). Psychotherapy that is attuned to or developed within an RCTformat (I will call it ‘RCT psychotherapy’) is thought to have the academicadvantage of creating clean experimental conditions with good internalvalidity, which enables researchers to draw conclusions about the causalityof changes in patients. Yet the disadvantage is that, by standardizing psychotherapyinto packages, conditions are created that are antithetical to clinicalpractice.The constituent elements of those packages are initially drawn fromclinical practice. But these are then significantly adapted to fit experimentalconditions and then re-presented as informative for clinical practice. Thislast step is based on beliefs which are not proven and have hardly beenstudied.Whereas in RCTs internal validity is usually optimal, external validity– meaning the pragmatic usefulness in clinical practice – is often