Mind
The verdict of the Dodo: why the Dodo must or must not die – Second picture

The verdict of the Dodo: why the Dodo must or must not die – Second picture

Is there a relative superiority of efficacy and / or efficiency of a treatment? An attempt has been made to answer this question by directly comparing psychotherapy with clinical trials, randomized controlled trials and meta-analyzes.

This contribution is the second in a series of articles on the subject. The first contribution helped us to understand Rosenzweig’s point of view on the efficacy of psychotherapeutic procedures

Someone will object: there exists or could exist, in any case, a relative superiority of efficacy and / or efficiency of a treatment. And this would mean that ONE has won.

This hypothesis was formulated and tested through direct comparison between psychotherapies. The comparison techniques used were clinical trials, randomized controlled trials and meta-analyzes. The fundamental study, consisting of a meta-analysis of meta-analysis, was carried out by Luborsky et al. in 2002. In their meta-analysis, which analyzed 17 meta-analyzes comparing different psychotherapies, an effect size of 0.20 emerged, too small and statistically insignificant. This coefficient further decreased (0.12) when they took into account the “loyalty effect” (Therapist and Researcher Allegiance).

Therapist and Researcher Allegiance, in psychotherapy research, means that the outcome of treatment comparison studies will systematically increase the effect of that favored by researchers.

In 2001 Ahn and Wampold (2001) conducted a meta-analysis on the different components that can be included in psychotherapeutic treatment, and conclude that there are no significant differences in outcomes dependent on the presence or absence of specific factors, and therefore that a specific specific component was necessary to the therapeutic effect.

Furthermore, a meta-analysis (Henry, Schacht, Strupp, Butler, & Binder, 1993) on the effects of manualized therapies, which would represent the gold standard of psychotherapy, showed that adherence to the manual did not increase the effectiveness of the therapy. on the contrary, it was related to the deterioration of the therapeutic alliance in numerous studies examined.

We can cite further studies on the question of the superiority of one treatment over others and we will have fluctuating, ambiguous, contestable results, etc.

A question must be asked here: are they sensible and what are the randomized controlled trials (CRT) for?

Howard et al. pose some basic method questions that can explain, at least in part, why the “Dodo effect” can occur, and which are related to the problems created by procedural difficulties in setting up studies, by the limitations of experimental designs (such as example the representativeness of the measures used to evaluate the treatment processes), as well as the same persuasive power of the results (Howard, Krause, Sauders, & Kopta, 1997).

Blatt notes that dimensions such as the interactions between the personalities of participants in clinical interaction, beliefs about what works or does not work in therapy, the type of relevant psychopathological manifestations, and the possibility that there are different effects are often not taken into consideration. in different people (“different strokes for different folks”), which Blatt defines different effects “in vitro” and “in vivo” (Blatt, 1992).

In 2009 Budd and Hughes emphasize how the validity of randomized controlled trials in the field of psychotherapy is afflicted by distortions of the results, since they incorporate assumptions related to their adherence to the reductionist rational. For example, the inappropriate use of clinical samples which, although homogeneous from the point of view of nosographic diagnosis according to the standard diagnostic criteria (DSM, to understand us) are not from that of “ecological” validity, both for the high comorbidity between psychopathological conditions, both for the blurred boundaries between the different conditions. The same authors note that the criterion of considering the type of therapy as an independent variable is not founded. There is a further difficulty related to the object of study, that is, the possibility of clearly distinguishing and comparing the different types of intervention, also due to the tendency of therapists to mix techniques belonging to different models. Finally, a fallacious assumption is determined by the drift towards a reductionist perspective of the processes that govern the onset, maintenance and treatment of mental disorders, considered analogous to those that govern organic diseases. In this analogy, psychotherapy is a “cure” and sessions are the “dose”. But, as many have argued, mental disorders do not behave like medical constructs, and it is therefore necessary to be very cautious in applying the same logic in building studies and in interpreting them (Borsboom & Cramer, 2013). Finally, a fallacious assumption is determined by the drift towards a reductionist perspective of the processes that govern the onset, maintenance and treatment of mental disorders, considered analogous to those that govern organic diseases. In this analogy, psychotherapy is a “cure” and sessions are the “dose”. But, as many have argued, mental disorders do not behave like medical constructs, and it is therefore necessary to be very cautious in applying the same logic in building studies and in interpreting them (Borsboom & Cramer, 2013). Finally, a fallacious assumption is determined by the drift towards a reductionist perspective of the processes that govern the onset, maintenance and treatment of mental disorders, considered analogous to those that govern organic diseases. In this analogy, psychotherapy is a “cure” and sessions are the “dose”. But, as many have argued, mental disorders do not behave like medical constructs, and it is therefore necessary to be very cautious in applying the same logic in building studies and in interpreting them (Borsboom & Cramer, 2013). psychotherapy is a “cure” and sessions are the “dose”. But, as many have argued, mental disorders do not behave like medical constructs, and it is therefore necessary to be very cautious in applying the same logic in building studies and in interpreting them (Borsboom & Cramer, 2013). psychotherapy is a “cure” and sessions are the “dose”. But, as many have argued, mental disorders do not behave like medical constructs, and it is therefore necessary to be very cautious in applying the same logic in building studies and in interpreting them (Borsboom & Cramer, 2013).

I realize here that I am saying things so obvious and obvious that, perhaps, it was not worth the effort to try and write about them. Yet it is necessary.

In any case and for the sake of discussion, we consider the “ruffled race” a valid procedure for designating a winner; even so is it really true that UNO wins?

I will give you an example in which NOBODY wins: the competitions in the judiciary or for the notarial qualification. In these competitions there is a minimum voting threshold to be suitable, therefore it is possible that despite having a certain number of places available, but it is possible (theoretically and often also concretely) that competitors can finish first, without winning no prize, because they do not reach the minimum required score. What is a satisfactory minimum standard for winning in the competition between psychotherapies? In fact, it is possible to be better than others, but not successful. I believe this is Dimaggio’s thesis. In this case I would say “that a psychotherapy wins, but does not convince”.

But it may also be possible that MANY (OR ALL) win, even if ONE is only the first, and also in this case also the verdict of the Dodo would be completely true. Being first and being successful are not necessarily superimposable terms.

Let’s talk about drugs, for example antihypertensives. There are at least 5 categories of drugs (Diuretics, Sartans, ACE inhibitors, beta blockers, vasodilators). Two of these categories act on function (sartans and ace inhibitors), while within the group of diuretics there are several mechanisms of action that obtain the same clinical effect. The same can be said for vasodilators (which include calcium channel blockers, alpha lytic, catapresan).

ALL the categories of drugs mentioned are effective, therefore ALL win and ALL receive the prize, without there being a ranking in which ONE is the first.

In conclusion, efficacy, i.e. winning, has to do with belonging to a whole (the set of winners), finishing first has to do with a ranking and the first in the ranking may or may not belong to the whole of the winners.

It can also be objected that some logic errors are made when accepting the Dodo verdict, for example inferring from the difficulty in identifying the most effective treatment the equivalence between the treatments. But this is not our case, in fact what we are going to verify is that, showing all the treatments of equal efficacy, something must unite them. The story starts from the finding of similarity in the results and ends with the attempt to explain the overlap of the result.

WHO has ever said, however, that the treatments are the same? The effects and some specific effects (on the explicit symptoms and taken as indicators of a nosographic diagnosis, perhaps DSM approved?) Are (can be) the same, but it is not at all said that ALL the effects are the same!

Luborsky himself maintains together with Asay (1999) that the explanations for the overlapping of outcomes can be at least three. First, that different therapies can achieve similar results through different processes. Second, that the results may have been different, but that the research in question had not identified or recognized them. Only the third explanation is that “common factors” can be active, but not emphasized by central change theory in a single school.

There may be a second mistake, this time linked to the lack of consideration of the actual superiority of some treatments as it appears from the scientific literature, in fact some treatments have proven to be better than others.

The question here is: better for what, better than what? The previous discussion and the innumerable others that have followed one another over the decades contain many hypotheses and theorizations in this regard.

Just by way of example, we cite the article by Kazdin and Bass (1989), who questioned the value of most of the comparative studies passed on the basis of a “lack of statistical power” and that of Lambert et al., Who it indicates, in fact, “serious problems in the accurate measurement of behavioral change” (Lambert, Christensen, DeJulio, 1983).

If the “ruffled” race is a bizarre choice, who proposes it and looks for a winner at all costs and shoots on the Dodo verdict?

According to some authors who have guided me in this review, two classes of people: the association of American psychologists, who fears that non-professional operators will offer competitive aid interventions with coded and certified psychological ones, and insurance agencies that want short treatments and economically convenient (Belopavlovic et al, 2018) (among the agencies, of course, there are health services, first of all the British one, thatcherianically reformed, I add).

And yet, despite this, we (all of us, I believe) continue to run incessantly, waiting to receive recognition, even if late and partial, because we cannot do without it.

Running is not a good way to dry yourself, as weighing the horse is not the best way to gain weight. But some like to run and others like to weigh horses. To others it seems convenient that there is a run or a weigh. So it is and so be it!

I thank my son Filippo, a brilliant logician, for suggesting the articulation of the discussion on the background.

I thank Mancini for his lucidity, which also allows his interlocutors to clarify their ideas.

I thank Ruggiero and with him Sassaroli and Caselli, who offers the opportunity to think about what we do.

The merits of my comment are of all the authors cited; banalities, inaccuracies and errors all mine.

1- The verdict of the Dodo: why the Dodo must or should not die – Background and First picture – Published on State of Mind on June 29, 2020
2- The verdict of the Dodo: why the Dodo must or should not die – Second picture – Published on State of Mind on 30 June 2020
3- The Dodo verdict: why the Dodo must or should not die – Third picture, Epilogue and penultimate verdict – Published on State of Mind on 01 July 2020