Gary Thomas joins the growing body of sceptics who are, like us, fundamentally challenging the fashionable positivistic totem that is the randomised controlled trial, both in terms of its alleged scientific validity and its far from impartial ideological usage (“No one can control for a sense of when 4-3-3 might turn the game”, Opinion, 7 February). RCTs are research procedures that adopt a particular worldview, underpinned by a set of metaphysical assumptions that are never questioned: indeed, the politics of these paradigmatic controversies are rarely if ever discussed. Most specifically (and consistent with Thomas’ arguments), in the subtle realm of psychotherapy and counselling, RCTs cannot help in any way with the everyday clinical question: “What is the most effective help that I can offer this unique individual sitting before me?”
The National Institute for Health and Clinical Excellence unyieldingly privileges RCT-based research, so its guidelines for therapy on the NHS inadequately represent our work, relying as they do on narrow research methodologies inappropriate for investigating most therapy modalities. The toxic effect of this narrow ideological obsession is threatening the existence of a wide range of clinically effective therapeutic approaches that have thrived in the NHS for decades. Activities such as psychotherapy (to which the RCT blunderbuss does a particular kind of totalising violence) require different, “local” decision-making and evaluation - and a great deal of such sensitive research has been conducted successfully for decades.
How much longer are we going to remain cowed and brutalised by the combination of accountancy and mathematics that the trials at their worst represent? When they are applied inappropriately, RCTs can be very bad for people’s net overall (mental) health.
Richard House, University of Winchester; Andrew Samuels, University of Essex; and Denis Postle The Alliance for Counselling and Psychotherapy