Evidence in the Psychological Therapies A Critical Guidance

for Practitioners - 1st Edition

Visit the link below to download the full version of this book:

https://medidownload.com/product/evidence-in-the-psychological-therapies-a-criti
cal-guidance-for-practitioners-1st-edition/

Click Download Now

ii

Maudsley NHS Trust and Honorary Senior Lecturer at the Institute of

Psychiatry. Bernard Roberts is Consultant Psychiatrist in
Psychotherapy to the Parkside Clinic.
 Evidence in the
Psychological Therapies
A Critical Guide for Practitioners

Edited by Chris Mace, Stirling Moorey and

Bernard Roberts
 First published 2001 by Brunner-Routledge
27 Church Road, Hove, East Sussex BN3 2FA
Simultaneously published in the USA and Canada
by Taylor & Francis Inc
325 Chestnut Street, 8th Floor, Philadelphia PA 19106
This edition published in the Taylor & Francis e-Library, 2005.
“To purchase your own copy of this or any of Taylor & Francis or Routledge’s
collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.”
Brunner-Routledge is an imprint of the Taylor & Francis Group
© 2001 Selection and editorial matter, Chris Mace, Stirling Moorey and
Bernard Roberts; individual chapters, the contributors.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Evidence in the psychological therapies: a critical guide for practitioners/
edited by Chris Mace, Stirling Moorey, and Bernard Roberts.
p. cm.
Includes bibliographical references.
ISBN 0-415-21247-2 (hbk.: alk. paper)—ISBN 0-415-21248-0 (pbk.:
alk. paper)
1. Psychotherapy. 2. Psychotherapy—Outcome assessment. 3. Evidence-
based medicine. 4. Evidence. I. Mace, Chris, 1956– II. Moorey, Stirling.
III. Roberts, Bernard, 1949–
RC480.5 .E875 2000
616.89′14–dc21 00–44647

ISBN 0-203-97782-3 Master e-book ISBN

ISBN 0-415-21247-2 (hbk)
0-415-21248-0 (pbk)
 Contents

List of figures and tables vii

List of contributors viii

1 Evidence in psychotherapy: a delicate balance 1

CHRIS MACE and STIRLING MOOREY
2 A lawyer’s view of evidence 12
JOHN JACKSON
3 Research, evidence and psychotherapy 27
MICHAEL RUSTIN
4 Randomised controlled trials: the gold standard? 46
SIMON WESSELY
5 Evidence, influence or evaluation? Fact and value in 60
clinical science
PAUL STURDEE
6 Evident causes: the nature of reason in psychotherapy 78
DIGBY TANTAM
7 Single case methodology and psychotherapy 89
evaluation: from research to practice
GRAHAM TURPIN
8 Working hypotheses in psychoanalytic psychotherapy 111
KEVIN HEALY
9 Hypothesis testing in cognitive-behaviour therapy 124
SIMON JAKES
10 Comparing models in cognitive therapy and cognitive 141
analytic therapy
DAVID ALLISON and CHESS DENMAN
11 Evidence-based practice and the psychodynamic 154
psychotherapies
PHIL RICHARDSON
vi

12 Practice-based evidence in psychotherapy 170

FRANK MARGISON
13 Making a success of your psychotherapy service: the 194
contribution of clinical audit
MARK AVELINE and JAMES WATSON

Index 206
 Figures and tables

Figures

1.1 The aims of evidence-based practice 3

4.1 Trends in suicide rate 53
7.1 Stable baselines 100
7.2 Withdrawal designs 102
7.3 Example of SCED applied to a psychodynamically oriented 107
case
13.1 The audit cycle 196
13.2 The full audit cycle 196

Tables

1.1 Levels of evidence of therapeutic effectiveness 4

7.1 Practical issues to be addressed 104
 Contributors

David Allison, RMN, is a cognitive therapist at Addenbrooke’s

Hospital, Cambridge.
Mark Aveline, MD, FRCPsych, DPM, has been a consultant
psychotherapist in Nottingham for 25 years. With interests in training,
group and focal therapy he has held many administrative roles
including the UK Presidency of the Society for Psychotherapy
Research. His publications include Group Therapy in Britain (1988),
From Medicine to Psychotherapy (1992) and Research Foundations
for Psychotherapy Practice (1995).
Chess Denman, MB, BS, MRCPsych, is Consultant Psychiatrist in
Psychotherapy at Addenbrooke’s Hospital Cambridge and an
associate clinical lecturer at Cambridge and East Anglia Universities.
Trained in cognitive analytic therapy and Jungian analysis, she has
written papers on sexuality and the evidence base in psychotherapy.
Kevin Healy, MB, BCh, BAO, DCH, DObs, DPM, MRCPsych, is
Consultant Psychotherapist and Director at the Cassell Hospital,
Richmond. Treasurer to the Association for Psychoanalytic
Psychotherapy in the NHS, his publications cover clinical audit,
psychotherapy purchasing and outcome research.
John Jackson, BA, LLM, barrister-at-law, is Professor of Public Law
at Queen’s University, Belfast. Formerly deputy director of the
Institute of the Study of the Legal Profession at Sheffield University,
he is co-author (with San Board) of Judge without Jury: Diplock
Trials in the Adversary System (1995).
Simon Jakes, MA (Oxon), M.Phil., AFBPS, is a clinical
psychologist with the Thames Gateway NHS Trust. A registered
cognitive behaviour therapist he has written on the clinical
application of CBT to hearing loss, tinnitus and psychotic illnesses.
Chris Mace, BSc, MD, MRCPsych, is Senior Lecturer in
Psychotherapy at the University of Warwick and Consultant
Psychotherapist to South Warwickshire Combined Care NHS Trust.
 ix

Previous books include The Art and Science of Assessment in

Psychotherapy (1996) and Heart and Soul: The Therapeutic Face of
Philosophy (1999).
Frank Margison, MSc, FRCPsych, MD, is Consultant Psychiatrist in
Psychotherapy at the Gaskell Psychotherapy Centre, Manchester
Royal Infirmary. He is past editor of the British Journal of Medical
Psychology and UK Vice-President of the Society for Psychotherapy
Research. He has published extensively on the impact of illness on
parenting, psychotherapy training, and research into psychotherapy
outcome.
Stirling Moorey, BSc, MB, BS, FRCPsych, is Consultant
Psychiatrist in Cognitive Behaviour Therapy to the South London and
The Maudsley NHS Trust and Honorary Senior Lecturer at the Institute
of Psychiatry. With Stephen Greer he wrote Psychological Therapy
for Patients with Cancer (1989) and was co-editor of Psychological
Treatment in Disease and Illness (1993).
Phil Richardson, PhD, is Head of Psychology to the Tavistock
Clinic, London and Visiting Professor to the University of Essex. He
is a past Chair of the Research Committee of the British
Psychoanalytical Society and is currently editor of the British
Journal of Medical Psychology. He has a special interest in the
evaluation of psychological treatments across many areas of medical
psychology.
Bernard Roberts, FRCPsych, is Consultant Psychiatrist in
Psychotherapy to the Parkside Clinic. A member of the British
Psychoanalytical Society, he has worked as a clinical manager within
the NHS, having a particular interest in institutional health. He was
convenor of the conference on which the present book is based.
Michael Rustin, MA, is Professor of Sociology and Dean of the
Faculty of Social Sciences at the University of East London and
Visiting Professor at the Tavistock Clinic. A co-editor of Soundings,
his publications include The Good Society and the Inner World (1991)
and (with Margaret Rustin) Narratives of Love and Loss: Studies in
Modern Children’s Fiction (1987).
Paul Sturdee, BA (Hons), MA, is a lecturer in the Philosophy and
Ethics of Mental Health at the University of Warwick. An
experienced postgraduate teacher, he is reviews editor of Philosophy,
Psychiatry and Psychology, and has contributed papers on
irrationality and psychoanalysis.
Digby Tantam, MA, MPH, PhD, FRCPsych, is Clinical Professor of
Psychotherapy in the Centre for Psychotherapeutic Studies and
Associate Director of the School of Health and Related Research at
the University of Sheffield. A former chair of the United Kingdom
x

Council for Psychotherapy and the Universities Psychotherapy

Association, he has published widely in clinical psychiatry,
psychotherapy and applied philosophy. He is editor of Clinical
Topics in Psychotherapy (1988).
Graham Turpin, BSc, M.Phil., PhD, FBPS, is Professor of Clinical
Psychology at the University of Sheffield. His extensive publications
on the application of psychophysiology to psychopathology and
clinical psychology include the Handbook of Clinical
Psychophysiology (1989), and a co-authored guide to single case
methodology for practitioners is forthcoming.
James Watson, MD, FRCP, FRCPsych, is Professor of Psychiatry to
Guy’s, King’s College and St Thomas’ School of Medicine. His
publications cover cognitive behavioural therapy, cognitive analytic
therapy, group therapy and service provision.
Simon Wessely, MA, MSc, MD, FRCP, FRCPsych, is Professor of
Psychological Medicine at Guy’s, King’s and St Thomas’ School of
Medicine and the Institute of Psychiatry. An authority on chronic
fatigue syndrome, his papers also cover pain, schizophrenia, treatment
trials and epidemiology.
 Figure acknowledgements

We would like to thank the following for permissions granted

Figure 4.1. From Jennings, C.Barraclough, B. and Moss, J.R. (1978)
‘Have the Samaritans lowered the suicide rate?’, Psychological
Medicine 8:413–422. Reprinted by kind permission of Cambridge
University Press.
Figure 7.3. From Stephen Kellett and Nigel Beail: ‘The treatment of
chronic post-traumatic nightmares using psychodynamic-interpersonal
psychotherapy: A single case study’ British Journal of Medical
Psychology (1997), 70, 35–49. Copyright © The British Psychological
Society.
Figure 13.1 and 13.2. From Crombie, I.K., Davies, H.T.O. et al.
(1993) The Audit Handbook. Chichester: Wiley. Copyright © 1993 John
Wiley & Sons Limited. ‘Reproduced by permission of John Wiley &
Sons Limited’.
Every effort has been made to trace copyright holders and obtain
permissions. Any omissions brought to our attention will be remedied in
future editions.
 Chapter I
Evidence in psychotherapy
A delicate balance

Chris Mace and Stirling Moorey

‘Evidence in the Balance’ was the title of a conference organised by the

Psychotherapy Faculty of the Royal College of Psychiatrists, the
University Psychotherapy Association and the Association of University
Teachers of Psychiatry. The discussions that took place of why and how
psychotherapeutic services might be more ‘evidence based’ deserve a
wider audience. Since the meeting, ways in which ‘evidence’ is likely to
impinge on everyday practice have been clarified within the National
Health Service’s programme of ‘clinical governance’. This strategy, and
the wholesale reform of the service’s institutions that it entails, has been
a cornerstone of the drive to include quality assurance within the
responsibilities of NHS providers (cf. Mace, 1999). Evidence-based
practice is no longer a movement that any clinician can ignore.
The psychotherapies, given their respect for the uniqueness of the
individual, the complexity of the questions with which they deal, and
attitudes towards scientific method that range from willing borrowing to
deep distrust, pose particular problems for this movement. The contents
of this book should ensure that a psychotherapist, whatever his or her
interests, is not only better informed about the clinical implications of
evidence-based practice, but better able to recognise its strengths and
weaknesses, and able to meet its requirements at the level of service
organisation.

Science and psychotherapy

The relationship of systematic research to clinical practice has varied
according to individual interests and the history of different
psychotherapeutic schools. Cognitive-behavioural psychotherapies, with
their past association with learning theories derived from animal
experiment and laboratory studies of human cognition, have been seen
as intrinsically more ‘scientific’ than psychoanalytic practices
developed through engagement with patients in planned therapeutic
environments. Hans Eysenck (1990) used to claim that a psychologist
2 CHRIS MACE AND STIRLING MOOREY

with no clinical experience, but properly versed in experimental method,

required about six weeks to translate this scientific understanding into
clinical practice. Despite the claims of both Freud and Jung to offer a
scientific understanding of the unconscious mind, psychoanalysis has
been regularly singled out by philosophers of science as a prime
example of a ‘pseudoscience’ (e.g., Popper, 1962). These stereotypes
may require some adjustment. While cognitive-behavioural approaches
in clinical practice are increasingly based upon clinically rather than
experimentally derived models, psychodynamic practice has been
enriched by much closer reference to findings in developmental
psychology (cf. Chapter 3 in this book).
In recent years, the efficacy rather than the validity of psychotherapy
has been subjected to increasingly sophisticated scrutiny. Research into
psychotherapy outcomes had been taken to support the view that
psychotherapy was effective, but that there was little overall difference
between different forms of psychotherapy. Following a suggestion of
Lester Luborsky (Luborsky et al., 1975) this is often called the ‘Dodo
bird verdict’ after Lewis Carroll’s Alice’s Adventures in Wonderland. In
Carroll’s story, the Dodo proposes that a ‘Caucus-race’ is held and,
after half an hour or so of running, announces that the race is over and
‘Everybody has won, and all must have prizes.’ One might question the
rigour of the Dodo’s methodology—the race course is a ‘sort of circle’,
the participants all start at different points along the course, and they
can begin running when they like and leave off when they like: a set of
rules that seemed to have been used in some of the early psychotherapy
trials! There is an increasing sophistication in outcome research, with
attempts to specify the goals of treatment more clearly, to define the
treatment delivered and to ask questions such as ‘what therapy works
for which condition’ (cf. Roth and Fonagy, 1996). Techniques such as
meta-analysis for aggregating research findings, which had supported
the Dodo bird verdict, have been refined with more discriminating
results. Some researchers are now reasserting that among the
psychotherapies (in the words of another modern fable) ‘some are more
equal than others’.

Principles of evidence-based practice

While some psychotherapy practitioners have always been motivated to
translate clinical questions into ones that can be answered through
systematic research, the directional shift that turns research into an
activity that should normally guide practice is new and decisive. It has
been justified by the existence of findings in many clinical fields that
appear sufficiently robust to provide a rational basis for selection
between treatments in the care of individual patients. The underlying
 A DELICATE BALANCE 3

Figure 1.1 The aims of evidence-based practice.

philosophy of evidence-based care can be summed up diagrammatically

as a transition between two states of affairs (see Figure 1.1).
In the first situation (column ‘A’) ignorance about the relative
efficacy of treatments prevails; the majority of available interventions
are taken to be harmless, with small but significant minorities being
either distinctly beneficial or clearly harmful. The task of evidence-
based practice is to increase the use of the former and to eliminate the
latter, this being the desired state of affairs represented by column ‘B’.
(Chapter 4 offers an exemplary discussion of the importance of both of
these.) To do this, there not only need to be recognised standards of
what kind of research findings will count as clinical evidence, but a
mechanism for translating these into clear, widely disseminated
recommendations that fulfil the needs of any clinicians and patients
4 CHRIS MACE AND STIRLING MOOREY

Table 1.1 Levels of evidence of therapeutic effectiveness

Source: After Ball et al. (1998)

asking specific questions about ‘best practice’. This is the role of clinical
guidelines, statements that reflect the balance of research evidence and
clinical consensus as to the action that is ordinarily appropriate to a
given problem. This guidance will indicate the treatments that should be
adopted and any that may be considered but which are no longer
recommended, in accordance with the shift from ‘A’ to ‘B’ in
Figure 1.1.
Decisions as to what counts as the most valid kind of evidence are
unlikely to be universal across all kinds of clinical knowledge, nor to be
immutable. However, it is fair to report that hierarchical judgements do
prevail, and the grading given in Table 1.1, discriminating between the
quality of evidence for an intervention’s therapeutic effectiveness, is
fairly typical.
The highest grade of evidence is identified with the Randomised
Control Trial (RCT). Here, the impact of a treatment is studied
following attempts to eliminate bias by randomly allocating alternative
treatments to study patients according to a protocol over which an
experimenter has no personal control. Assessments are conducted by
people ignorant of (‘blind’ to) the nature of the treatment given, and
ideally patients too remain ignorant of the kind of treatment they have
received—an almost impossible requirement in psychological
treatments. This ideal standard of objectivity can be diluted in a number
of ways—whether evaluation was in fact comparative, the quality of
matching between comparison groups, the extent to which those
entering the study are followed up. These are all reflected in the
gradings described in Table 1.1. It does not and cannot take into
consideration additional questions—vital to the validity of individual
research reports as a means of addressing clinical decisions— such as
how far treatments evaluated under experimental conditions resemble
 A DELICATE BALANCE 5

those provided in routine care, or how far outcome measures used by

researchers are clinically meaningful.
At most levels, evidence can be in the form either of a report of
validated research (e.g., a RCT), or a systematic review of several
reports which fulfil clear criteria for their inclusion in the review. This
has generated a need for information concerning individual research
studies to be indexed and archived in formats which guarantee their
accessibility to clinicians seeking evidence of the comparative merits of
interventions they may provide. It has also meant that systematic reviews,
collating all work meeting a given quality standard that allows a
question to be answered, have assumed great significance. The trend for
their compilation and dissemination to be sponsored is likely to grow. At
the same time, recognition that the quality of systematic reviews is
restricted by the availability (and completeness) of published reports of
the work they examine is likely to fuel demands that the results of all
funded research, whether these fulfilled a study’s original objectives or
not, are made publicly available for incorporation in systematic reviews
(cf. Sturdee in Chapter 5).
Beyond the dissemination of evidence in pre-digested forms in these
ways, evidence-based practice has been seen to depend upon the
translation of evidence in practice guidelines. These distil the practical
implications of research into clear advice concerning what kinds of
action constitute ‘best practice’ in a given situation with the present
state of knowledge. In this way, clinical guidelines, in defining
objective standards of practice, provide a clear reference point by which
actual practice might be audited and, in principle, improved. Whereas
guidelines have been produced in the past by professional bodies, the
introduction of such new structures as National Service Frameworks,
and the National Institute for Clinical Excellence (NICE) within the
National Health Service, provides a mechanism by which guidelines can
not only be approved and disseminated but adopted as standard clinical
practice throughout the public health system.

Evidence and psychotherapy

‘Evidence’ has several facets which are treated in turn through the
remainder of this book. The first concerns the nature of evidence
itself. In an effort to dig behind the assumption that we all know what
counts as evidence, the distinguished lawyer John Jackson was invited
to explain the nature of evidence in law (Chapter 2). It is apparent that
the legal concept of evidence—grounded in the need to resolve a case—
differs significantly from the scientific one on which the evidence-based
practice movement bases its proposals. In law, testimony is valued only
6 CHRIS MACE AND STIRLING MOOREY

for its contribution to resolution of a dispute—irrespective of how far it

may also provide a truthful description.
The contrast with the view that equates evidence with that which is
scientifically validated will be apparent from Chapter 4. In it, Simon
Wessely justifies the importance that has been placed upon the
randomised controlled trials among the kinds of research evidence that
are available. As several other contributors highlight the special
difficulties of conducting controlled trials for psychotherapeutic
treatments (cf. Chapters 11 and 12) their necessity needs to be fully and
widely accepted. The case Wessely presents is powerful, depending not
only on the relative quality of RCTs as a form of evidence for the
efficacy of a treatment, but also on their unique capacity to demonstrate
in the face of received wisdom when treatments are positively harmful.
Wessely’s polemical tone is reciprocated by Paul Sturdee’s in
Chapter 5—a discussion of the dangers of allowing an evidence-centred
approach to dominate clinical practice when the ‘evidence’ in question
is only partial. Sturdee looks at the impact this attitude can have on the
balance between physical and psychotherapeutic treatments for people
with mental health problems—not only on how they are perceived, but
on their potential availability. Indeed, Sturdee’s objections to the
selective use of evidence in the name of objectivity suggest that the
courtroom model may not be such an inaccurate image of clinical
debate. To correct things, Sturdee makes several suggestions. One, the
idea that an approach is not properly evidence-based until all relevant
evidence is actively sought and then taken into account, is slowly being
accepted. However, some fundamental conflicts between the values of
science and the individual that he also indicates seem more intractable.
A different evaluation of the evidential thinking in psychotherapy is
offered by Michael Rustin (Chapter 3). While Wessely and Sturdee
concentrate on the outcome or efficacy of psychotherapy, Rustin
illustrates how research can be used to substantiate the theories which
therapists use to guide their practice. Given that much therapeutic
practice is founded on theories of human development and the impact of
early experience on adult functioning, external evidence that supports
these accounts of development will consolidate knowledge shared
within the psychotherapeutic community. Evidence of this kind also
exposes limitations of the drug metaphor. Psychotherapy sets out to
explain as well as to treat, and gains a different kind of authority when
its explanations are seen to have validity independent of their usefulness
in treatment. However, this should not be confused with evidence that
its treatments are effective, any more than evidence of a treatment’s
efficacy is a valid argument for the truth of its theoretical basis. (A
definitive discussion of the difference between these arguments will be
found in Grünbaum, 1984).