“challenging behaviour”. The fact that there is evidence supporting the efficiency of these techniques cannot and does not make them right. More generally, ethical concerns arise out of the implementation of randomised control trials. While such trials have the potential to prevent the propagation of worthless treatments, for example insulin coma therapy, they raise major ethical issues in the context of subject selection, consent, randomisation and the continuing care of subjects once trials are complete. Randomised control trials require the clinician to act simultaneously as physician and research scientist. Patients are simultaneously invalids and research subjects. It is questionable if the physicians’ moral responsibilities towards patients can be consistent with the recommendation that the patient should participate in a randomised control trial, principally because of this conflict of interest (Hellman & Hellman, 1991). It has been suggested that such trials may be recommended by the physician if clinicians are in a state of “therapeutic equipoise”, that is they are genuinely in doubt about the value of different interventions (Lilford & Jackson, 1995). Such equipoise may be achieved in the case of treatments with moderate affects which might otherwise be obscured by bias and random effects. However, equipoise may not be achievable when interventions have great benefits and risks and then alternative clinical procedures to be investigated by other methods. Is therapeutic equipoise applicable to the recommendation of psychoanalytic treatment? Interestingly, neither psychoanalysts nor the opponents of psychoanalytic treatment believe that this is the case. Psychoanalytic clinicians are so firmly convinced of the appropriateness of 4 or 5 times a week treatment that they tend to consider it unethical to recommend less intensive alternatives. Sceptics, on the other hand, feel that the sacrifice demanded of the patient and his/her family is such that randomisation to a psychoanalytic arm is normally ethically unacceptable. In principle, the existence of these opposing views might somehow be combined to construct an attitude of therapeutic equipoise, but in reality it is simply tantamount to what may be an insurmountable obstacle facing a randomised controlled trial of psychoanalysis. ?4&!2.1.-2!$,!/$#/&(#2!1X$-.!&)*'&#/&!X12&'!0&'*/*#&! Many other concerns could be raised about the appropriateness of subjecting psychoanalysis to outcome evaluation. We raise some concerns here in part to demonstrate our awareness of the issues and in part to underscore that the clamour for evidence should be met with caution and sophistication. It needs to be recognised that objections to research will not win the day. It is unlikely that the prevailing view which places controlled studies at the top of the hierarchy of evidence will change no matter what the pressures of arguments. The complexities of issues surrounding resource allocation, the drive to seek certainty and simplicity at the level of policy making are such that alternative formulations will not be heard. Psychoanalysis is not alone among medical treatments with a weak evidence base. Evidence to the standards required is available for relatively few medical interventions (Kerridge, Lowe, & Henry, 1998). The drive for an evidence base for the selection of treatment interventions will inevitably mean a biased allocation of resources to those treatments for which rigorous evidence of effectiveness is relatively easily collected or where funds are independently available to carry out more lengthy and complex effectiveness research. Brief therapy benefits from the former, pharmacotherapy from the latter. Psychoanalysis is further disadvantaged by the opposition to many of its fundamental propositions among fellow mental health professionals and influential leaders (Crews, 1995; Grünbaum, 1984; 1986; Webster, 1995). These kinds of considerations drive us to override our concern and accept the imperfect solution of outcome research with the overriding objective of preserving the discipline. The best strategy available to us is to collect all the data available rather than enter an epistemological debate amongst ourselves. The debate is inaudible to those outside the discipline. Further, it would sap our energies when this is required for a collaborative effort to make the best case possible for
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