RCTs in psychotherapy Flashcards
1
Q
Introduce the role of RCTs in psychotherapy outcomes research
A
- Randomised control trials (RCTs) are currently deemed the gold-standard research for producing evidence
- Sitting just below the systemic review and meta-analysis/synthesis in the hierachy of evidence
- Outcome data from RCTs is utilised by NICE to determine which psychotherapies are recommended
- RCTs are not without criticism
- This essay will discuss some of the advantages and disadvantages when applied to psychotherapy outcome research, and how research can be more inclusive for the best interests of the patients
2
Q
Why is it important to clarify EBT and EBP?
A
- Important to clarify evidence-based treatment and evidence-based practice as they are innappriopriately used interchangably, introducing confusion into their discussion
- EBTs are interventions that have produced therapeutic change in controlled trials
- EBP is clinical practice that is influenced by evidence, clinical expertise, and patient considerations (Kazdin, 2018)
3
Q
What study designs are utilised in evidence-based treatment?
A
- It is a misconception that EBT is only produced by RCTs
- Whilst the gold standard, other control studies include non-randomised study designs such as cohort studies and case-control studies
- Both of which can be used in quantitiative and qualitative analysis
4
Q
Discuss the role of meta-synthesis in the hierarch of evidence
A
- Each study design has its benefits and weaknesses and should be evaluated accordingly
- Murad et al (2016) propose a modified hierarchy of evidance to account for this
- Example, poorly rated RCTs are less robust that highly rated cohort studies
- The top of the hierarchy consists of systematic reviews anda meta-analyses
- Qualitative data can be similarly meta-synthesised, producing a higher hierarchal position than RCTs
5
Q
Outline RCT study design
A
- Random allocation of individuals within the sample to one of at least two groups
- Large sample to ensure randomisation equally distributes a variety of known and unknown confounders
- One group is given the treatment/intervention of choice
- Other is typically a wait-list control (WLC) or treatment as usual (TAU)
- This design allows findings of causation, as any differentiating results should be due to intervention
6
Q
Discuss the challenges RCTs face in psychotherapy research
A
- Whilst RCTs have greatly enhanced knowledge in areas such as drug effect, its implementation in psychotherapy research is contested
- It is difficult if not impossible to blind therapists
- Certain factors exist only in psychotherapy, such as allegiance bias
- Aetiology and explanatory models continue to be debated for many mental illnesses
- Complex psychosocial interactions means that specfic factors which bring about change are harder to isolate or control (Burgess, 2018)
7
Q
What is the major problem with RCTs from a clinical standpoint
A
- Central concern for use of RCTs is the potential lack of generalisable findings
- Two studies will be used to demonstrate this
- Watson et al (2003): allegiance-balanced RCT comparing CBT and process-experiential therapy (PET) in the treatment of derpession
- Fonagy et al (2015): RCT comparing long-term psychoanalytic psychotherapy (LTPP) plus (TAU) vs TAU alone for treatment-resistant depression
8
Q
Outline the criticisms of RCTs
A
- Generalisability of RCT
- Therapist factors
- Patient factors
- Technique factors
- Methodology
- Randomisation
- Outcome measures
- Statistical power
9
Q
Discuss how therapist factors impact the generalisability of RCT
A
- Therapist factors include interpersonal skills, training, experience, and allegiance bias
- Watson et al (2013) used counselling masters/doctorate students from a single univeristy and a couple of psychologists
- All adhered to either CBT or PET
- Received equal training as per treatment manuals, from respective experts
- Average experience just over 5 years
- Can be argues that use of a single university limits generalisability to other training backgrounds
- Fonagy et al (2015) used therapists qualified with the British Psychoanalytic Council
- Average experience of 17 years
- LTPP is not explicitely recommended in NICE guidelines for depression
- Potential for negative allegiance bias towards TAU only group
10
Q
Discuss how patient factors impact the generalisability of RCTs
A
- Patient factors include demographic, social factors, individual depression presentation, and prior treatment
- Currently these do not appear to consistently predict treatment outcomes, except fro chronicity and severity of depression (NICE, 2018)
- Practice-based individualised evidence is best to identify the releveant factors in each patient
- This evidence will best inform personal care plans
11
Q
Discuss concerns over representative samples in RCTs
A
- Common concern is that study samples are not representative of clinical patients
- Suicidality and intellectual disability are often excluded from depression studies, but this is not invariably true (Kazdin, 2008)
- Important to remember research is also dictated by practicality, public interest, ethics approval, and cost-effectiveness
- Empirical testing has shown that severity, complexity, and comborbidity do not impede the therapeutic change in EBT (Kazdin, 2008)
- It will always be possible to state “my patients are worse, different, more complex”, and no amount of studies will absolutely resolve this (Kazdin, 2008)
12
Q
What is the problem with criticisng the generalisability of RCTs?
A
- Criticisms over generalisability based on therapist and patient factors is a double-edged sword (Kazdin, 2008)
- This very same argument can be placed on clinical practice
- The uniqueness of patients creates non-generalisable results from both research and prior clinical experience
- Clinical judgement has not fared well over decades of evaluation (Kazdin, 2008)
13
Q
How do technique factors impact generalisability of RCTs?
A
- RCTs often utilise a more-structured approach to assessment and intervention compared to clinical practice
- Fonagy et al (2015) prohibite the use of short-term psychotherapy, normally featured in the guidelines
14
Q
Critique how outcomes are measures in psychotherapy RCTs
A
- Results are reported in terms of statistical significance and clinical significance
- Former ascertains if outcome was due to chance, and requires a quantitative element
- Quantification of human nature uses arbitary cut-offs
- Solution: appreciate pitfalls of RCTs and adopt more qualitative research to exist alongside
- Meta-synthesis sits at a higher positon in the hierarchy of evidence
- Clinical significance does not necessarily equate to improvements in everday life
- Due to arbitary cut-offs in research (Kazdin, 2008)
- Solution: utilise EBP whihc incoporates clinican expertise, and session-by-session analysis to best improve individual circumstance
15
Q
Outline NICE’s stance on clinical guidelines
A
NICE acknowledges and explicitely states:
- Lack of evidence does not equate to evidence of no effect
- Recommendations do not replace for clinical judgement
