– one which is considered inactive, at least from the point of view of the active treatments offered – is beset by the difficulty of finding an activity which could be guaranteed to have no therapeutic element, which controls for the effect of attention and which is also viewed by patients as being as credible as a psychiatric intervention. Many recent studies restrict themselves to the comparison of active treatments; as evidence has accumulated for the general efficacy of therapy, institutional review boards (ethical committees) have become unwilling to sanction trials which could be seen to deprive patients of help (e.g. see Elkin, 1994). 5%+L,-&"!&,-%#@:A& Setting up an RCT is a major undertaking, and consequently a great expense. Although there are exceptions, most trials limit the amount of intervention offered (frequently to around 16 weeks). While this may be appropriate for some therapies (principally behavioural or cognitive-behavioural approaches), psychodynamic therapists (e.g. Fonagy & Higgitt, 1989) could – and do – argue that the techniques they employ were never designed for delivery over such a short time-frame. Psychoanalysis is in most countries an open-ended treatment and it is hard to imagine forcing it into a frame where the number of sessions is determined independently of the individual treatment process. \%+%#@B)(@M)B),A& Few RCTs achieve the implementation of psychological therapies under conditions which might be obtained in routine practice. As noted above, because they are characterised by a concern to maintain internal validity, their applicability could be seen as limited. For example: patients will have been selected to conform to diagnostically precise categories patients will have been exposed to multiple assessments therapies will be applied with some precision, often under supervision researchers will often be particularly enthusiastic and particularly expert in the techniques they employ. '@,)%+,&:#%!%#%+?%&@+*&#@+*"$&@BB"?@,)"+&,"&,#%@,$%+,& Patients are not passive recipients of treatment, and their preferences for differing forms of treatment may be critical to their participation in clinical trials (Brewin & Bradley, 1989). The bias introduced by consequent attrition from treatment is invisible within studies, but may be particularly relevant to clinical practice. N10*!(%$2<6! This methodology is intermediate between the single-case design and the randomised control trial. Although entry to treatment may be governed by strict criteria, there is no control group. Such designs often reflect a more naturalistic treatment protocol than is the case with RCTs. At the simplest level such studies offer important information concerning: the likely benefit the average patient might derive from the treatment what features of presentation are likely to be associated with relatively good outcome how effective a particular service is in terms of outcome which aspects of a patient’s problems are likely to be addressed by a treatment given a certain natural variability in treatment delivery, what aspects of treatment are associated with felicitous consequences and which are accompanied by equivocal outcomes.
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