The Dodo verdict * Luborsky… * Everybody has won and all must have prizes * Are we in an Alice In Wonderland world? Visual summary * Who wants what kind of answer? * Academic tradition from Eysenck 1952 – efficacy, traditional positivist approach * Health Service – demand out of control (?) so need market discipline / rationing * Therefore cost-benefit, clinical utility, effectiveness ratings needed * Consumers / customers / patients, so satisfaction surveys? (eg. Seligman 1995) * Alternative methodologies? Social constructionist account? NIMH depression study * TDCRP (Elkin 1994, Elkin et al 1989, and subsequent output) randomised control trial * 3 sites, 250 clients randomly assigned * 4 conditions: CBT, IPT, IMIpramine, PLA. * Manualised with quality control * IMI did best, 2 therapies close behind. * Reinforces equivalence paradox Research in therapy outcome * General points: * All research is a compromise between competing priorities – eg. rigour versus meaning * No study is definitive * Replicability essential – substantive findings are well replicated * Research has stated and un-stated bias The outcome equivalence paradox * Models of therapy differ in content * ….and in mechanisms of change * ….and in the Behaviour of therapists * (shown to differ in practice) * So diverse theories are diverse in practice and could be expected to produce diverse outcomes * But, paradoxically, outcomes are broadly equivalent Resolving the equivalence paradox 1: The dodo verdict is wrong * Matrix paradigm: 10 x client / therapist / technique / setting = 10,000 cells * But NIMH – 12 cells at huge cost * Manualising & dismantling as research strategies * Specific improvements not noticed in the noise of many variables Resolving the equivalence paradox 2: The dodo verdict is still wrong * Sensitivity of review (meta analysis) * But Mackay, Barkham, Rees & Stiles (2003) found most reviews (n=255) poor on some or all of reporting * How studies searched for & located * Exclusion / inclusion criteria * Providing reliable unbiased assessments of studies reviewed Resolving the equivalence paradox 3: The dodo verdict is right * Outcomes equivalent because common factors are the change agents * Broadly 2 groups * Warm involvement * Communication of new perspective * Frank (1973) all social influence * Frank & Frank (1991) re-moralisation * Rogerian core factors * Therapeutic alliance Therapeutic alliance ) * Bordin (1979) * Bonds – emotional bond between client & therapist * Goals – agreement on goals of treatment * Tasks – quality of client & therapist involvement in tasks of therapy * Just conceptual umbrella for several client & therapist variables? * Circularity problem: Success à improved alliance  more success. Which is the causal factor? Implications of equivalence paradox * End of canonical status of schools? eclecticism, integration, anything goes? * Continue with Paul’s project? – DH evidence based clinical practice guideline * Little firm evidence for common factors (Stiles et al 1986) * Little evidence for specific ingredients either argue Ahn and Wampold (2001) * Common versus specific factors a current, live debate.