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Dear Editors
There is one serious and unfortunately commonplace error in Stijn Vanheule's studious paper in the February issue (BJP 25(1): 91-109). While contending that the Randomised Control Trial (RCT) and the medical research model are grossly unsuited for psychotherapy (and I would add for drugs, ECT, and treatments in general in the mental health field), he takes for granted that they are totally acceptable in clinical medicine. Actually, they are not, being often convincing or suggestive, but occasionally irrelevant or worse. It should be better known that the patient in RCTs is no longer a person but one of 50 or 100 nameless containers of some pathology or other for which a treatment is tried out. Is that good enough? Sometimes, but not always.
For 10 years in Britain, the National Institute for Clinical Excellence (NICE) has issued what have become imperatives rather than so-called guidelines for medical treatment, which are indeed based on RCTs but also on what it somehow calculates the NHS can afford in the number of Quality Adjusted Life Years to be gained by whatever new drug. At this point, the NHS doctor only needs, and increasingly uses, a computer in his pocket to decide what treatment a patient should have.
Clinical judgement and experience thus go out of the window even though the day-to-day conditions confronted in medicine, such as high blood pressure, arthritis, asthma, pregnancy, ageing, to mention a few, do not lend themselves to any unitary approach by guidelines.
There are any number of RCTs showing that anti-depressants and ECT are useless, yet clinical experience over fifty years vividly provides the reverse. Meanwhile, NICE has ordained that psychotherapy in the NHS be synonymous with cognitive-behavioural therapy, although in real life it achieves little of consequence and then only briefly.
In sum, I am urging that psychotherapy be recognised as in the same universe as clinical medicine. Vanheule's paper seems to contradict that.
Yours sinc