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Knowing what or understanding how: The role of RCTs in changing clinical practice

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Knowing what or understanding how: The role of RCTs in changing clinical practice

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    1. Knowing what or understanding how: The role of RCTs in changing clinical practice Ivan Eisler Reader in Family Therapy Institute of Psychiatry, Kings College London

    2. All who drink this remedy recover in a short time except those whom it does not help who all die. Therefore it is obvious that it only fails in incurable cases. Attributed to Galen 2nd century A.D.

    6. Debriefing “the experiences of 700 CISM teams in more than 40,000 debriefings cannot be ignored, especially so when the overwhelming majority of reports are extremely positive” Mitchell & Everly, 2003

    7. Debriefing Review of 15 RCTs of single session debriefing showed no short term difference between debriefing and control 2 RCTs with long term follow-up showed worse outcome following debriefing (particularly in those with worse initial trauma)

    8. The development of 'empirically validated treatments'

    9. Limitations of randomized treatment trials Subjects selectivity classification dropouts Nature of treatments restricted nature treatments time limitations common factors Evaluation of outcome efficacy v effectiveness short term v long term outcome clinical v measurable outcome outcome from whose perspective

    10. The evolution of clinical practice

    13. Conclusions It is important to distinguish the role of evidence in making “categorical” decision and ongoing “process” decisions The RCT paradigm provides a useful but limited test of the efficacy of treatments RCTs (cumulatively) can have an important effect on professional consensus which influences the allocation of resources, training as well as clinical practice RCTs, by limiting clinical autonomy, will often lead to unexpected results which challenge beliefs about mechanisms of change and conceptualization of treatment Changes in clinical practice require a change in the understanding of how treatments work which requires a mixture of inductive and deductive reasoning

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