psychoanalysis as a clinical method. Even those of us who are engaged in collecting evidence for the effectiveness of this discipline have major methodological as well as epistemological concerns. These should not be set aside, forgotten about, but nor should they become an alternative focus. It should be remembered that the debate over the effectiveness of psychoanalysis is one of pragmatics not of principles. There is a clear danger that the therapy that is “without substantial evidence” will be thought by all to be “without substantial value” (Evidence Based Care Resource Group, 1994). Once this idea is allowed to flourish, a cultural change becomes inevitable, a change which at least temporarily has the power to stop the development of our discipline – through the rejection of psychoanalysis as the therapeutic choice, through discouraging young people from entering the profession and through bringing psychoanalytic contributions to mental health disciplines and other subjects into disrepute. =&.4$'$5$Y*/15!%($X5&02!*#4&(&#.!.$!&)15-1.*$#!(&2&1(/4! Research into psychoanalysis is inevitably a compromise between usual clinical procedures and the demands of scientific influence. Clear thinking about the applicability of research findings rests on an understanding of the nature of these compromises. In this section we shall briefly list some of the issues which must be taken into consideration in interpreting and evaluating evidence for the effectiveness of psychoanalysis. While these issues are well known and obvious to some, they may be less familiar to others. More important, we list them here in part to show that researchers are well aware of these problems and while not necessarily able to resolve the issues, at least it should be clear that they are working towards this end. '::$7274!Y0%6B6!0::07($Y0*066! The term efficacy refers to the results a treatment achieves in the setting of a research trial, while clinical effectiveness is the outcome of therapy in routine practice. The discrepancy arises because trials are required to show “internal validity” (Cooke & Campbell, 1979); that is, they permit causal inferences to be made on the basis of the observed relationship between the variables. In this context, the absence of a relationship must imply the absence of a cause. Achieving internal validity normally requires modifications to clinical procedures, which are rarely seen in everyday practice. The most common of these are: (a) the selection of diagnostically homogenous patient groups, (b) the randomisation of these patients into treatments, (c) the employment of extensive monitoring of the patient’s progress, (d) the careful specification of therapeutic procedures to be used and (e) the monitoring of their implementation. These requirements clearly pose a threat to “external validity”, to the extent to which the inferred causal relationship between variables may be generalised. Thus demonstrations of efficacy are not necessarily demonstrations of effectiveness. The fact that a treatment is highly efficacious under strictly controlled conditions cannot be thought to mean that it will have the same value in the context of ordinary clinical practice. This problem is by no means unique to the investigation of psychodynamic treatment. To take a simple example, a pharmacological agent with distinctly unpleasant but harmless side effects may be shown to have considerable efficacy in a double blind controlled trial. No one would be surprised that it proves to be ineffective in clinical practice since patients frequently and conveniently “forget” to take this pill. In the trial, serum levels were carefully monitored and subjects whose blood levels indicated that they did not take their drug were excluded from the analysis. The same applies in trials of psychological treatment. Frequently psychotherapy is not delivered in practice as well as it is in the context of a carefully monitored trial. By contrast trials may underestimate the effects of a therapy by randomly assigning patients to treatments they do not wish to have, whereas in clinical practice their preference would be carefully noted by their treating physician.
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