There has been a recent exchange of articles in Therapy Today (May- Sept 2011) on the merits or otherwise of Randomised Control Trials (RCTs) in the field of counselling and psychotherapy. This could be seen as part of a wider debate concerning the whole question of efficacy of various types of talking therapy and the need, in some peoples’ eyes, for evidence based practice. And in turn, these debates are taking place in the concept of the roll-out of the IAPT (Improving Access to Psychological Therapies) programme in England and the role that NICE (National Institute for Health and Clinical Excellence) has in effectively legitimating (and de-legitimating) various approaches to talking therapy.
There seems to be an increasing polarisation – and bitterness – between those therapists and academics who appear opposed to the introduction of RCTs (and possibly any other kind of quantitative methodologies) as a way of assessing the efficacy of talking therapies (and here we are talking about non-CBT approaches), and those who think the therapy world needs to embrace this kind of approach – if only out of expediency.
The latter approach was encapsulated in an article by Mick Cooper in the May issue of Therapy Today. Although Cooper does not come across as an ardent ‘convert’ to RCTs, the crux of his argument is that in the current policy and commissioning climate the therapy world has little option but to at least try RCTs. Otherwise, those who don’t will become marginalised. Cooper’s article evoked a number of responses, both favourable and oppositional, mainly in the forms of letters to the Therapy Today, but also in a more substantial rebuttal in the July issue by Andy Rogers, Jennifer Maidman and Richard House. The crux of their argument is that there are other valid approaches to evaluating efficacy in talking therapies, and there is no real need to ‘sell out’ to the policy makers and commissioners.
In many ways, though, this seems like the latest manifestation of a longstanding debate within the social sciences (and when it comes to questions of methodology this is where I would situate talking therapies) between the positivists/post-positivists and a variety of positions that includes post-modernism, hermeneutics, and phenomenology. I would also argue for a third position, critical realism, which is gradually gaining ground. Somewhat ironically, perhaps, Cooper seems very sympathetic to the second position but argues that these kind of ideas have just not caught on with the policy makers. This immediately raises an interesting question: why not? Or, to put it another way, why are policy makers – and presumably commissioners, only interested in therapies that have been subjected to RCTs – or at least, are most favourable towards such therapies?
I think the answer to this is quite simple: because they are being advised by the experts, particularly at NICE, that RCTs are the best way to evaluate the efficacy of talking therapies (and it just happens that CBT has the best evidence base using this methodology…..). For every NICE guideline, a panel of experts (the Guideline Development Group) is formed. It is their job to review the evidence for interventions for a particular condition. And in most cases the GDG relies on a ‘hierarchy of evidence’ model, with meta-analyses of RCTs at the ‘top’ and expert opinion at the ‘bottom’. Case study reviews come second from the ‘bottom’.
Assuming that policy makers and commissioners are, broadly speaking, being guided by the ‘experts’ (even though expert opinion appears to have little value when it comes to evidence!), then why are the experts themselves using a particular framework or hierarchy of evidence in the first place? So perhaps the original question in the title of this post should be changed to: why does some evidence count for more than others?
Cooper, M. (2011) Meeting the demand for evidence-based practice [Internet]. Available from: <http://www.therapytoday.net/article/show/2447/print/> [Accessed 26 September 2011].
House, R., Rogers, A. & Maidman, J. (2011) The bad faith of evidence-based practice: beyond counsels of despair [Internet]. Available from: <http://www.therapytoday.net/article/show/2554/print/> [Accessed 26 September 2011].