Friday, January 16, 2015

You Can’t Always Get What You Want: Research and Policymaking

In October 2013, Bill Miller (the primary developer of motivational interviewing [MI]) addressed a group of MI trainers in Krakow, Poland. He took note of the fact that despite its nearly mythical status, randomized clinical trials of MI have only shown treatment effects 58% of the time; 42% of studies have found little or no effect. Make no mistake about it: MI has produced significant effects across diverse areas of psychotherapy, including within prison-based treatment settings. Just the same, the wisdom and courage of Miller’s statement belies the understated tone in which he made it. As our field patiently awaits the results of gold-standard studies proving that what we do works, some researchers, like Bill Miller, have gone beyond the has-it-been-effective-in-a-randomized-clinical-trial question and are taking note of an emerging but often unrecognized trend: treatments competently implemented in many areas are not necessarily effective in all of them.


A few years ago, this was the case with an implementation of multi-systemic therapy in Ontario (for a more complete description of these findings, click here). More recently, another examination of MST in Canada appears to have produced beneficial preliminary effects, but is not without acknowledged methodological problems such as a small sample size and process issues (e.g., 65% of participants who provided scores on the Therapist Adherence Measure –Revised rated their therapists as being sufficiently consistent with MST principles. This is below the recommended target of 80%). Between the experiences of multi-systemic therapy and motivational interviewing, professionals should always keep in mind the bigger picture of their efforts and bear in mind that in program implementation (as in life) we don’t always get what we want.


In 2012, a review of studies examining a parenting-skills program appeared, and did not get the level of attention that it deserved. Philip Wilson and his colleagues conducted a systematic review and meta-analysis of 33 studies of the Triple P parenting program. Although this may seem unrelated to the treatment of people who have sexually abused, their findings are valuable to all policymakers. At first glance, the Triple P parenting program boasts numerous successful randomized-clinical trials and meta-analyses; numerous jurisdictions have promulgated and paid for its implementation. While these accomplishments have been praiseworthy, Wilson and his colleagues found numerous problems with the research and question basing public policy on flawed research. Among the authors’ conclusions:


In volunteer populations over the short term, mothers generally report that Triple P group interventions are better than no intervention, but there is concern about these results given the high risk of bias, poor reporting and potential conflicts of interest. We found no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term. Given the substantial cost implications, commissioners should apply to parenting programs the standards used in assessing pharmaceutical interventions (p. 1).


The examined bias across studies as well as bias within studies, blinding of assessors, percentage of clients who dropped out, etc. In one instance, the authors noted that:


Although it claimed to have achieved a reduction in the incidence of episodes of child maltreatment [5], it actually demonstrated an unexplained rise in reports in control areas rather than a drop in Triple P intervention sites. The description of the random allocation was poor, and the analysis was simplistic, being a two-sample t-test of county-wide measures. In particular, although some form of stratification or matching was used (it was not clear exactly how this had been done), there was no evidence that this had been accounted for in the analysis. For example, if counties were randomized within pairs, then the within-pair differences in the changes from baseline would have been of interest, but these were not reported. Therefore, although there are positive conclusions from this study, some doubt remains as to their validity (P. 8).


In this author’s estimation, Triple P appears to have produced very good results and has doubtless improved many lives. Just the same, Wilson et al.’s points are well taken: where large-scale public policy is concerned, we should be very careful how we place stock in single studies or even groups of studies, and ask more questions than simply “does it work.” Likewise, there is a body of research finding that bona fide treatments often produce equivalent results (Wampold, 2001), returning us to the question “what works with what client under what circumstances.” Ultimately, professionals and policymakers should be data driven.


  David S. Prescott, LICSW

Wampold, B.E. (2001). The great psychotherapy debate. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.