Psychotherapy in the Era of Evidence-Based Practice · Psychotherapy in the Era of Evidence-Based...

Psychotherapy in the Era of Evidence-Based Practice

Challenging its subordination to medical Science and calling upon the need to building bridges

between research methodologies

Felicitas Rost, PhDPresident, Society for Psychotherapy Research (SPR) UK

Research Lead, Portman Clinic, T&P NHS FT

BACP – Working with research in practice, universities and

colleges conference 13 June 2019

The Origins of Psychotherapy

• It became a ‘moral treatment’ in the 18th Century – developed based on non-evasive therapeutic methods.

• Berta Pappenheim dubbed Breuer's’ method the “talking cure” and Freud began to develop this method further, coming to be known as the ‘father of psychotherapy’.

• By 1980 there were more than 250; by 1996 more than 450 and by 2000 over a thousand different named psychotherapies (Herink, 1980; Mclennan, 1996)

Dr Felicitas Rost - keynote presentation BACP 13.06.19

Evidence-based vs. Pseudoscience

Picture from

freshspectrum.com


Draft Revision of the 2009 Guideline for Depression in Adult


Stakeholder Campaign against NICE draft guideline for depression in adults


Flawed Methodology in NICE guideline

If the methodology is not changed:

➢The guideline will force a U-turn on the progress made in providing equity of access to a wide range of psychological therapies.

➢It will restrict patient choice and shared decision making stressed by the NHS reform (2009).

➢ It will discriminate against psychological therapies in spite of service users preference over pharmacological alternatives (Dekker et al, 2008; Van et al, 2009).


Evidence-based practice (EBP or EBT)

• “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” Sackett (1996). He also emphasised the importance to integrate the clinician’s expertise.

• It is supposed to distinguished from empirically supported treatments (EST), however, it’s often used interchangeably to denote the pursuit of rigorous methods and manualised interventions (Lambert & Ogles, 2004).

• It became popularised as a general reference to CBT (Tolin et al., 2015).


History: EBP = EBM

• The approach has been shaped by medical science.

• The gold standard for testing efficacy is the randomized double-blind, placebo-controlled group design.

• Strict Hierarchy of evidence.


Controversy – Three positions

Lady Justice Damien Hirst’s: Verity

Credit: Wikipedia20 meters tall sculpture in Ilfracombe, Devon

(photographs taken personally)


Three Positions on EBP

• 1. Those who engage with the EPB movement, carry out studies and meta-analyses, thereby adjusting and developing the methodology.

• 2. Those who refuse and repudiate this kind of outcome research and call EBP a myth.

• 3. Those who defend the “classical” EBP movement vehemently, thereby ignoring the results and developments that have been achieved.


Is Psychotherapy Effective?

• Eysenck (1952,1961,1966) vs Bergin (1971) & Luborsky et al (1975)

• First meta-analysis carried out by behaviourists Smith & Glass (1977) ➢Those receiving psychotherapy were superior to the outcomes of those not receiving it (ES =

0.8). They also found that behaviour therapy was not superior to other psychotherapies.

• After hundreds of meta-analyses: the verdict remains the same (Wampold & Imel, 2015).

• It’s not only effective for most disorders, but also as effective as medication (e.g. Hollon et al, 2006; Cuipers et al, 2013).

• The effects are longer-lasting than medication (Hollen et al., 2016) and results in lower relapse rate (Nordal, 2010).


Are different Types of Psychotherapy more effective?

Difference between different psychotherapies are negligible – providing evidence that the dodo bird verdict (Rosenzweig, 1936) was correct.

Credit: Wikipedia


Efficacy of specific psychotherapies for specific disorders?

1. Valid studies provide evidence that some therapies are more effective for certain conditions than others.

Reisner (2005): “all therapies are generally equal some therapies for some conditions may be more equal than others.”

Credit: www.odeoncafedc.com

2. When contrasted with the many studies available that

have not shown a superiority effect, its difficult to make

much of these small differences (Wampold, 2018).

Credit: https://jcoynesterDr Felicitas Rost - keynote presentation BACP 13.06.19

https://jcoynester.wordpress.com/tag/dodo-verdict/

EBP needs improvement (position 1)

• Insufficient power (Norcross, 1995).

• Researcher allegiance effect is not considered (Dragioti et al., 2015) .

• Variation of therapists are ignored (Barkham et al., 2017).

• Problems could be addressed by improving research designs though adequately powered trials, with clinically representative samples and interventions and clinically meaningful comparison groups, reporting statistical and clinical ES (Parry, 2000).


EBP is a myth (position 2)

• Many doctors prescribe treatments that don’t meet the rigorous criteria of EBP, and fail to deliver those that have been shown to work (Holmes, 2000).

• This kind of outcome research is “a myth” and the dodo bird verdict “vacuous nonsense” (Marzillier, 2004).

• Psychotherapy is fundamentally a personal transaction and therapeutic actions “cannot be reduced to a series of technical procedures, nor can they be scientifically proved, just as you cannot prove scientifically the value of friendship or a good marriage. “(ibid, p. 394).


What makes psychotherapy effective? Common Factors

• “Ever since the end of the 20th century, research has confirmed what the founders of psychotherapy had asserted: that the patient–therapist relationship is an interpersonal process central to the cure” (Mendelberg, 2018).

• Central to good therapeutic outcome is the patient-therapist relationship (APA, 2012; Orlinsky, Rønnestad, & Willutzki, 2004).

• Empathy, collecting feedback, forming alliance in individual treatment, facilitating cohesion in group treatment, goal consensus, collaboration, positive regard, corrective emotional experience are more effective than the particular treatment model (Wampold & Imel, 2015; Castonguay & Hill, 2012).


EPB is the only real science (position 3)

• Common factors construct is experimentally untestable and that it “relies on repudiation of scientific evidence” (Asnaani & Foa, 2014).

• Call for the need of new technologies, such as virtual humans and avatars, are needed to “better allow researchers to control for “common factors” (Rollman et al., 2018; Zhu et al., 2014).


NICE – holding on to EBP

• It endeavours to answer the research question of a treatments efficacy by only including data derived from RCTs.

• All studies are scrutinized and appraised using the GRADE system.

• It follows the aspiration to identify THE treatment for the condition, thereby rank-ordering psychotherapies in terms of their clinical effectiveness and lately also in terms of their economic effectiveness.


New statistical technique: Network Meta-analysis (NMA)

• Network meta-analysis (…) is a meta-analysis in which multiple treatments are being compared using both direct comparisons of interventions within RCT and indirect comparisons across trials based on a common comparator

(Mills et al. 2013)

Graph from: BMJ, Mills,

Thorlund & Ioannidis (2013) Dr Felicitas Rost - keynote presentation BACP 13.06.19

Is a middle-way possible ?

“Science is and should not be antithetical to human experience (…) As psychiatrist we travel back and forth across the chasm that separates large-scale, statistically verified science on homogenous populations from intensely personal human experience. We have to know the evidence, but we cannot abandon our roots in the humanistic core of our work.” (Clemens, 2010)

So in that spirit, I am wondering whether we can build a bridge over that chasm?

Credit: Hope2Action Blog - WordPress.comDr Felicitas Rost - keynote presentation BACP 13.06.19

https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwiqiOmAqfrgAhUHA2MBHUGdAtAQjB16BAgBEAQ&url=https://hope2action.wordpress.com/2012/08/24/no-margin-for-error-crossing-the-chasm-between-financial-forecasts-and-accounting-results/&psig=AOvVaw3v32zxxza3lkOkyuVl-7OH&ust=1552401495445618

Need for a Sea-Change. A paradigm is needed that:

➢ Considers the historical and sociological forces that shape the reality it operates in.

➢ Takes the complexity of mental phenomena and psychological treatments serious.

➢ Accepts that problems with external validity are inescapable and therefore regards RCTs only as one part of the research cycle.

➢ Gets rid of the arbitrary and unhelpful hierarchy of evidence and calls for a science that combines data and findings from a range of research methodologies.


Need for a Sea-Change

• Creating sound public policy requires that we draw on a diverse range of evidence (Health Foundation, 2017; Thomas, 2017).

• A good model is one that seeks to integrate scientific knowledge, clinical judgment, and expertise (Goodheart’s, 2006).

• Case study and qualitative evidence should inform the existing Guidelines as part of a ‘multi-level synthesis’ (ibid).

• Lazar, 2010: psychotherapy not only clinically effective but also cost effective was published by.


The NICE Guidelines Manual


None of our suggested

changes have been

implemented in the update

of the manual in 2018!!

Call for Scientific Rigour and Integrity

• Guideline Developers need to keep scientific equipoise and integrity.

• Before a novel measure, criteria or technique can be used, it needs to undergo the usual rigorous validity and reliability tests carries out within the scientific community.

• Methods chosen need to be transparent, clearly outlined and justified. In the case of utilising a novel method, it needs to be stated as well as the limitations of it clearly explained.

• Proper stakeholder Involvement is important.


Conclusion

• A one-size-fits-all model in mental health is untenable.

• A range of psychotherapies have been shown to be effective, the ambition to identify the most effective treatment and provide a rank-order restricts patient choice and shared decision making.

• Acknowledging the fact that overall 50% of all patients benefit from psychological treatments and medication, a society ought to offer a choice.


Conclusion continued

• Our research endeavours ought to be directed towards a systematic examination of who benefits and who does not from which treatment and therapist and at what particular point in their life to help guide treatment recommendations better.

• In so doing, we need to find a way how we can honour the complexity and multidimensionality involved.

• Mixed-method designs and synthesis of findings from different methodologies is needed.


“Perhaps we would do well to heed the seemingly disparate

warnings of Hume, Bacon, Freud, and Meehl. From Hume (and

later Kant) we learned that we cannot escape the subjectivity of

the observer—that we will never see the world exactly as it is.

From Bacon we learned that we must try anyway, and that

scientific method is our best guide. From Freud (and later

Kahneman and Tversky, Dawes, and others) we learned that our

minds can play all kinds of tricks on us, and that systematic self-

reflection, self-scrutiny, and knowledge about the biases to

which we are prone are as essential for clinicians and scientists

as for our patients. And from Meehl we learned that the scientific

mind and the clinical mind can coexist, if ambivalently, in a

single field—indeed, in a single person—and that the dialectic

between the two may be essential for a scientific psychology.”

Westen & Weinberger (2004), p. 610


Thank you very much for your attention!

Dr Felicitas Rost:

[email protected]


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