Control Groups

Forming adequate control groups is a dilemma in all psychotherapy research (see also A.P.A. 1982 for full review o f this, and more recently Roth and Fonagy 1996). Following the difficulties o f assigning ethnicity in the retrospective study, it was decided that it would not be possible to use a matched pairs research design, matching patients according to their ethnicity, in order to compare outcome. Similarly, matching on race or culture would also be difficult. However, as ethnic, racial and cultural background can be important factors in patient’s presenting symtomatology (see 1.2., 1.11, 1.13, 1.14 1.15 and 1.16), ignoring this, and merely matching on age, sex and presenting problem could distort the results.

Moreover, to offer alternative therapies (i.e. to compare Nafsiyat therapy with an alternative therapy) would also have the same problem, the presence o f ethnic, racial and cultural differences o f both the therapist and the patient could introduce an

unknown and unidentified bias. Therefore the typical control group o f "matched patients" was abandoned.

One could pose the question as to whether patients could have been matched with others from other Centres, or indeed whether more patients could have been evaluated. This research started from the premise that as many variables as possible needed to be controlled, as a commonly expressed concern amongst researchers is that, in therapy research, there are too many (uncontrolled) variables.

Apart from the linguistic and cultural difficulties in matching, outlined above, which obviated the matching o f patients (remembering the difficulties experienced by the Menninger Clinic (1972) in matching their patients). There is also the added problem o f whether intercultural therapy carried out in other Centres varies in form or content from the type o f therapy carried out at the Centre. By limiting the variables one can provide a baseline from which other “intercultural” Centres can be evaluated. Questions can then be asked what is the same and what is different between each o f the Centres.

In this research the following variables were kept constant

o Process o f referral (written referrals, standard replies) o Process o f assessment (by one person)

o Process o f therapy (in terms o f place, length, forms to be filled out etc) o Process o f supervision (carried out by one supervisor)

o Process o f research (same personnel)

o Constancy in understanding o f intercultural therapy.

Other reasons also influenced this decision. As Nafsiyat is a voluntary agency operating from independent offices and is not funded for clinical work other than psychodynamic therapy; it was impossible to operate an alternative therapy design (e.g. psychodynamic versus behaviour therapy) for financial reasons. To send some patients to an alternative place for therapy (e.g. for behavioural therapy) was not considered an option ethically, therapeutically^ or scientifically (it would introduce too many variables), and the problems o f matching (outlined above) would also hold

Including other Centres in this research would have necessitated extra resources (in terms o f reviewing therapy processes and training personnel in completion the research forms). In order to have constancy in research process, the research staff would have needed to have travelled to the other Centres to carry out the research. This was not feasible (in terms o f time or finances).

An alternative way o f matching is "waiting list control" groups. A review o f the literature suggests that even where patients have been offered therapy, a proportion fail to turn up because they have explored various types o f therapy and have taken up the first offer o f help (Brandt 1964, see also I, 17.7.2). Moreover an earlier attempt to recall Nafsiyat patients several months after therapy had finished, failed due to the high number o f patients who had moved from their previous address. This suggested that

^ There are therapeutic issu e s : if a p sych oth erap ist d e c id e s that p sych oth erap y is th e b e st option, how do th ey d e c id e which alternative therapy to refer on to?

Nafsiyat patients have transitory living arrangements, and ealled into question the probable suecess rate o f sueh a strategy (ef. Rosser et al 1987).

Therefore patients were their own control. This had the advantage o f circumventing most o f the problems outlined above and the ethical dilemmas posed by them. The A.P.A (1982) notes difficulties with this type o f control group. These are related to the natural history o f the disorder, in terms o f the effects o f treatment, spontaneous remission or the normal diminution o f symptoms over time. As information on diagnosis and aetiology, duration and remission o f mental health problems in an ethnic minority group is often criticised, it was difficult to provide comparative information. Therefore one measure o f the effectiveness o f therapy is to look at how long patients had been aware o f their symptoms which indicates the ehronicity (or otherwise) o f the problem and hence provide some evidence to refute the likelihood o f spontaneous remission.

Although the main thrust o f the research was an outcome study, each group’s emphasis was different. The schedules reflected this, with data being collected on soeiodemographic (D.O.H. and researchers), symptomatic (D.O.H. and researchers), and therapeutic questions (therapists and researchers). As the organisation was small, it was impossible to commit large resources (time, money and extra therapy time) to the research. It was necessary to dovetail the research into the ordinary running o f the Centre. A review o f the referral procedure confirmed that a schedule format would be the most effective procedure, and hence the questions were designed so that research

information could be collected at the same time as therapy data. For example, during the assessment, soeiodemographic details (such as age, sex) would normally be collected as well as referral source and reasons for referral, and hence collecting the additional information on ethnicity and gender o f the therapist requested and allocated as well as the more specific information on patient ethnicity seemed appropriate to collect at the same time (see Appendix 1 for sample schedules and see Figure 4.1 below).

Figure 4.1 Detail of Schedule Presentation (see Appendix 1) Title o f schedule Information to be

Collected Form Completed bv/ Relevant Session Case History RFl^ soeiodemographic diagnostic and therapy information C D / Assessment Psychiatric Symptom Checklist (PSC) RF2 symptoms (psychological /behavioural) CD Assessment

Social History Form

RF4