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Are RCTs designs essential to advance EST?

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Garry Leonard

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EST (Part 1) • Essentials to know from pg. 632-643 • 10 arguments (assumptions) are made against EST:  CBT and Interpersonal psychotherapy are both EST (empirically supported treatments). Assumption is that EST has been subjected to scientific data and trials…this is done by the means of RCT (randomized controlled trial). First psychotherapy study…no difference between waiting list and psychoanalysis. American Psychology Association wanted to start designing psychotherapy studies so we can study or design studies that have experimental validity.  Difference between efficacy and effectiveness is that efficacy is the outcome of an experimental design that has high control (experimental and control groups are the same) or are RCTS and effectiveness are not RCTs. Major argument is that ESTs concentrate on RCTS more than external validity. Effectiveness maximizes external validity and efficacy maximizes internal validity.  What should we base our scientific data on? Efficacy or Effectiveness or both?  This design mimics the design used in medicinal studies for psychological disorders...control vs experimental. Psychotherapy is more complex and there is more variability (hard to control interaction, length of time).  What is difference between EST and RCT? RCT is a type/method of EST.  Psychological Processes are Malleable. ESTs focus on those psychological processes that can be changed (symptoms can be changed). CBT tries to target the symptoms of the outcome. But can you do that is 6-16 weeks? There are some symptoms that cannot be malleable because some cannot change or it has taken a while to get them. Some symptoms are a part of personality. CBT says that personality is separate from symptoms or personality can change. CBT is not about the event, but about how you thought about the event, therefore it is changing your thought process and not looking at why. Therefore there may be developmental factors that cannot be changed in 6-16 weeks, but some symptoms are. Weston is a psychoanalyst and an empiricist.  Manualization: you create a manual and do not deviate from it. This creates the control of psychotherapy so both treatment groups are the same (a part of efficacy: internal validity). In a tight design, you have to look at therapist compliance. It’s not how psychotherapy works because in the real world you would deviate from that (effectiveness). Behind closed doors, therapists do not follow the manual. Therefore therapy with manuals is artificial.  Patients have only one primary problem: You want to make sure everyone has the same disorder. If there is comorbidity, they are not used in the experiment, but in the real world most people with depression have comorbidity of anxiety. Therefore, it isn’t realistic. If you use only depression it increases your internal validity. Intervention is that you have to use more than one manual if they have more than one disorder. To find out if they have a disorder: you use the DSM and structured interviews to diagnose the disorder. DSM is always changing, therefore how can you use this manual as a benchmark of how we diagnose a disorder. Therefore the DSM will not give a reliable diagnoses  The paradox of pure samples: The paradox is that most patients that want treatment have more than one disorder, but samples used are patients that have one disorder. If you don’t use an RCT, your work most likely won’t be published.  When following a manual, your treatment has to be sequenced. There is no evidence that the sequence is actually scientifically valid. There is no evidence that you have to follow the sequence; therefore it isn’t effective if everyone doesn’t follow the same
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