Randomized Controlled Clinical Trial in Psychotherapy Research: An Epistemological Controversy

Abstract

is a Brazilian psychologist with an MA in clinical psychology. She is currently completing a PhD in developmental psychology at Universidade Federal do Rio Grande do Sul (Porto Alegre, Brazil) and developing part of her doctoral studies at University of Strathclyde in Glasgow, United Kingdom. She is a person-centered therapist and the coordinator of the person-centered training program of Delphos Institute in Brazil. She is the author of a book in Portuguese with Newton Tambara about the theory and practice of client-centered therapy and has published articles and book chapters in English. SummaryThis article discusses the epistemological underpinnings of the use of the randomized controlled clinical trial (RCT) in psychotherapy research. It is argued that underlying the therapy-choice dispute overtly targeted by the RCT is an epistemologically controversial (and covert) theory-choice dispute. Furthermore, the RCT is not a theory-neutral evaluative method but rather a research method shaped by assumptions that originate in behaviorist theories of therapy. Because there is no neutral language or basic vocabulary shared by the competing theories that would enable the comparison of their observation reports and because behaviorist and nonbehaviorist therapies are grounded in incommensurable theories, an RCT cannot be used to compare them. Therefore, RCT cannot be held up as the definitive method for investigating psychotherapy. The current perspective of sociology of science is provided to explain the AUTHOR'S NOTE: The author wants to express her gratitude to Bert Rice, Jane Balmforth, and Jane Edwards for their helpful revisions.

Méta-analyse et efficacité des psychothérapies : faits et fictions

“…En effet, ce type de dispositif méthodologique repose sur des présupposés épistémologiques selon lesquels il est possible d'évaluer objectivement des interventions psychothérapeutiques, conçues comme des techniques, pour des troubles psychiques spécifiques (Freire, 2006). Il semble pourtant évident que des thérapeutes formés à la même approche, même s'ils acceptent de proposer une intervention manualisée, diffèrent les uns des autres dans leur manière d'exercer la psychothérapie (différences inter-individuelles), sans compter que leur pratique varie sans doute d'un client à l'autre et d'une séance à l'autre (différences intra-individuelles) (Kramer, de Roten, et Despland, 2005 ;Najavits et Weiss, 1994 ;Rifkin, 2007).…”

“…Dépendant d'une « vision médicale » de la psychothérapie, cette initiative a suscité et suscite encore de vives controverses et de nombreuses résistances (Freire, 2006 ;Wampold, 2001 (Zimmermann, et al, 2008).…”

“…Dans un contexte où les systèmes de santé sont de plus en plus marqués par des impératifs économiques, il est par ailleurs probable que les écoles de psychothérapie qui refuseraient toute forme d'évaluation (prioritairement basée sur l'essai clinique randomisé) soient de plus en plus mises à l'écart. Il est pourtant souhaitable que la recherche en psychothérapie fasse preuve d'un pluralisme méthodologique, et n'ait pas comme unique ambition de répondre à la question de l'efficacité (Freire, 2006 Elliott, 2001Elliott, , 2002Fishman, 1999 ;Stiles, 2003 ;Watson, Goldman, et Greenberg, 2007). Parallèlement à ce renouveau, les chercheurs se préoccupent actuellement plus de comprendre ce qui fait que chaque forme de psychothérapie est efficace (ingrédients processuels) en se centrant par exemple sur l'alliance thérapeutique, les caractéristiques du patient, ou encore les qualités personnelles du psychothérapeute indépendamment de son école thérapeutique (Cooper, 2008).…”

Where is the Dialogue? A Social Constructionist View of Empirically Supported Treatments

“…By following a positivist epistemology in the evaluation of psychological treatments, randomized controlled trials (RCTs) became the preferred research design (Budd & Hughes, 2009;Freire, 2006). This is a design which is widely used in the pharmaceutical industry for the evaluation of new drugs (Goldfried & Wolfe, 1998;Honos-Webb, 2005) and its employment in the EST movement means that psychological treatment is considered to be just like a drug of which the presentation and operation could and should be independent of the context in which the research takes place, one of the preconditions for the use of RCTs.…”

“…The EST movement presumes that psychotherapy is like medical treatment (HonosWebb, 2005); like a pill or an operation a psychotherapy technique is viewed as linearly influencing a condition internal to the client -depression is seen in a similar way as measles or malaria. Instead of creatively dealing with the complexities of human functioning this reductionist and objectivist thinking, whilst empowering research, is widely considered to be clinically impoverishing, tending to turn psychotherapists into technicians following a manual (Freire, 2006;Mullen & Streiner, 2004;Slife, Wiggins, & Graham, 2005;Woody et al, 2005). Imagine a Milton Erickson or a Carl Whittaker working from a manual.…”