Editorial: Evaluating Interventions in Child Mental Health: The Importance of Care Provider and Contextual Influences

Abstract

B R U C E WA M P O L D I N H I S B O O K The great psychotherapy debate, highlights the tension between a narrow, ‘medical’ model of evaluating psychological treatments and a broader evaluative framework which takes contextual factors into account, including the influence of the therapists themselves on treatment outcome (Wampold, 2001). Such ideas have fuelled an interesting debate in the field of psychological treatment research and a special section of the journal Psychotherapy Research was recently devoted to the topic of the extent to which therapist effects had a bearing on treatment outcome (Hill, 2006). Wampold’s main contention is that therapists account for a greater proportion of the variance in treatment outcome than any particular model of psychological intervention and hence greater attention should be paid to the attributes of effective therapists. One of the studies to be examined most in relation to this issue is the NIMH Treatment of Depression Collaborative Research Program (TDCRP) Multicentre Randomized Controlled Trial (RCT). This RCT compared the outcome of Cognitive Behaviour Therapy (CBT) vs. Interpersonal Psychotherapy (IPT) vs. Antidepressant medication vs. Placebo in adults with Major Depression. Minimal differences between different models of intervention were identified, and subsequent re-analyses of the data looking for therapist effects in the CBT and IPT arms came to conflicting conclusions. One analysis found significant therapist effects (Kim, Wampold, & Bolt, 2006) while another, using different statistical methods, found no effects (Elkin, Falconnier, Martinovich, & Mahony, 2006)! What is the relevance of all this to child mental health? Intuitively as practitioners many of us will hold the view that the qualities and skills of the person delivering a particular treatment and the setting in which the treatment is undertaken may be as important as the actual model of intervention itself. However, this issue has received little attention in the field of child mental health research. This is likely to change in future following the publication of the CONSORT guidance extension for RCTs of nonpharmacologic treatments (Boutron, Moher, Altman, Schulz, & Ravaud, 2008). CONSORT, or the Consolidated Standards of Reporting Trials, is the gold standard guidance by which RCTs are reported. Researchers generally undertake to conduct and report on trials according to CONSORT. The new guidance, published this year, emphasizes that in fields such as surgery or psychotherapy, where the intervention is generally complex and multi-dimensional and influenced by the skills and expertise of the ‘care provider’ as well as the setting in which the treatment is undertaken, care must