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by Peter Fonagy
?4&![-2.*,*/1.*$#!$,!&,,&/.*)&#&22!2.-'*&2!*#!%23/4$1#1532*2! In this section we shall consider the current climate in health care services which is largely responsible for the drive for effectiveness research and briefly overview some of the methodological issues that confront these studies. In the last part of this section we shall overview studies of psychoanalytically orientated psychotherapies. @)*'&#/&!X12&'!0&'*/*#&!1#'!*.2![-2.*,*/1.*$#2! 5026)*6!30#$*&!(#0!$*6$6(0*70!)*!0Y$&0*70! Psychoanalysis is a clinical intervention. Its aims and ambitions, at least from the point of view of most patients, are clearly associated with those of other healing arts such as surgery, physiotherapy and osteopathy. Admittedly, this is just one aspect of the psychoanalytic enterprise, but one that is crucial to its standing within most of the cultures where it is practised. Over the last ten years, all aspects of medicine have come under scrutiny, where increasingly both commissioners and funders of medical intervention, as well as those managing and directing clinical services, have embraced the values of “evidence based medicine” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Clinical judgement is no longer accepted as sufficient grounds for offering medical treatment. Recommendations at national policy as well as at local health care provider level are expected to be based upon evidence of effectiveness. What factors account for this change? 4(,%+()MB%&#%@("+(& Evidence based medicine is founded on an ideal – that decisions about the care of individual patients should involve the “conscientious, explicit and judicious use of current best evidence”. Much is claimed in favour of this approach, particularly in North America and Western Europe. The arguments in favour of it include (a) the more effective use of resources, (b) improvements in clinician’s knowledge, and (c) better communication with patients (Bastian, 1994). From an ethical point of view, the strongest argument in support of evidence based medicine is that (d) it allows the best evaluated methods of health care to be identified and enables patients and doctors to make better informed decisions (Guyatt, Sackett, Cook, & the Evidence Based Medicine Working Group, 1994; Hope, 1995). All these are good reasons but all were as relevant to medicine in the past as at the moment. So why the current emphasis? 1-%&:"B),)?@B&M@?aL#">+*& The real driving force behind evidence based medicine is unlikely to be a genuine concern for the quality of care. The movement appears to be largely driven by financial consideration and the hope of health care organisation to be able to reduce escalating costs by focussing on the most cost effective option given a range of treatments. Governments and health funds find the notion of allocating health resources on the bases of evidence quite attractive. In North America, D.K. Eddy in an important editorial suggested that healthcare funds should be required to cover interventions only if there was
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