Psychotherapy and the trustworthiness of randomised controlled trials

One of the criticisms levelled at psychoanalytic psychotherapy is the absence of evidence for its effectiveness and, especially, the absence of randomised controlled trials (RCTs). By comparing outcomes for randomly selected groups of individuals who receive different treatments or none, these trials set out to prove the effectiveness or not of treatments. RCT is often described as the gold standard of research. In the past, psychoanalytic psychotherapists have been reluctant generally to undertake research and especially research that uses RCTs. This attitude towards research seems to be changing with an increasing number of research studies that demonstrate the effectiveness of psychoanalytic psychotherapy. See, for example, my blog post ‘Psychodynamic psychotherapy brings lasting benefits through self-knowledge’ –

More research into the efficacy of psychoanalytic psychotherapy is certainly desirable and as practitioners we should be self-critical enough to welcome external validation of our methods. However, it’s worth also being aware that much medical research, including RCTs, is less scientifically sound than is often thought.

A recent article in the Atlantic describes the work of John Ioannidis and his team at the University of Ioannina. See

The team is investigating the credibility of published biomedical research, including looking at studies that were originally thought to be conclusive, but have later proved to be incorrect. In one of their papers they looked at 49 of the most highly regarded and frequently cited medical papers published in the last 13 years. Of these papers, 45 contained claims for effective interventions, but only 34 of these had been retested, leaving 11 without independent verification. Of those studies that were retested, 14 or 41% ‘had been convincingly shown to be wrong or significantly exaggerated’. So two fifths of these key papers, when retested, were shown to be misleading, papers that were widely cited and referred to by physicians for guidance.

Also worrying was the persistent influence of these misleading studies. The article mentions ‘three prominent health studies from the 1980s and 1990s that were each later soundly refuted…(where) researchers continued to cite the original results as correct more often than as flawed—in one case for at least 12 years after the results were discredited’.

The Atlantic article describes several factors that Ioannidis claims can distort research outcomes and influence the likelihood of publication. These include the pressures of competition for funding and academic success, and plain wish fulfilment on the part of the researchers.

Research into all forms of therapy is to be welcomed. However, the efficacy of some approaches is more easily investigated with RCTs and these forms of therapy are often held up as having a more secure evidence base. These are claims that should be challenged. The work of Ioannidis and his team shows that RCTs do not necessarily provide a trustworthy and scientific proof of efficacy.

Schizophrenia and ‘The Insanity Virus’

A recent article in Discover links the development of schizophrenia with a human endogenous retrovirus, HERV-W. The article follows the work of E. Fuller Torrey and others in exploring a viral basis for schizophrenia.

Endogenous retroviruses are the remains of viral infections that occurred in past generations and that became encoded within the genome. In the case of HERV-W, this encoding may have taken place millions of years ago in an early primate ancestor. The HERV-W is one of several ancient viruses that have left their imprint upon the human genome.

It is currently believed that in most cases these viral remnants in our DNA are not expressed and have no effect upon humans. There is some evidence, though, that HERV-W may play a role in the development of both multiple sclerosis and schizophrenia. The suggested pathway involves early infections that trigger the virus, leading to an immune reaction that damages our nervous system and that can eventually cause either of these conditions. Later infections may also play a role.

This is a line of research that could offer future ways of helping to prevent or to treat schizophrenia. As such it is an important endeavour. However, it is a common error to argue for a single cause for a complex, multi-factorial process. The Discover article falls into that trap, as shown by its title: ‘The Insanity Virus’. Even if the theories of Torrey and others prove to be correct, what they give us is a description of one factor in the development of schizophrenia. Other factors, including the individual’s environment, are also likely to play a role. The suggested pathway involves the human immune system, which has been shown to be heavily influenced by psychological factors such as stress. For that reason our early emotional life may play a crucial role in the development of schizophrenia, even within the causal model proposed by Torrey.

Torrey and other writers looking for a purely biological explanation for mental disorders discount the importance of the infant’s early experience of their world. This ignores the intimate ways in which our mind and body interact and effect each other’s development. It is an approach to human beings that is as one sided as the purely psychological. It is also a view that ignores the healing potential of therapeutic relationships.