Randomised controlled trials form a central building block within the prevailing evidence-based mental health paradigm. Both methodology and paradigm have been widely problematised since their emergence in the mid-late twentieth century. We draw on the concept of 'strategic ignorance' to understand why the paradigm still prevails. We present focus group data gathered from 37 participants (service users, public, carers, general practitioners, commissioners) concerning the way they made sense of a randomised controlled trial of psychotherapy for treatment-resistant depression. Thematic analysis of the findings revealed an overall critique of randomised controlled trial methods which we refer to as 'non-strategic ignorance'. Specifically, participants problematised the construct of depression, unseating the premise of the randomised controlled trial; they were sceptical about the purpose and highlighted its failure to show how therapy works or who might benefit; the randomised controlled trial was seen as inadequate for informing decisions about how to select a therapy. Participants assumed the treatment would be cost-effective given the client group and nature of the therapy, irrespective of any randomised controlled trial findings. Each area of lay ('non-strategic') critique has an analogous form within the methodological expert domain. We argue that 'expert' critiques have generally failed to have paradigmatic impact because they represent strategic ignorance. Yet parallel non-strategic critiques have common sense appeal, highlighting the potential power of lay voices. The discussion considers whether the evidence-based mental health paradigm is faced with epistemological problems of such complexity that the conditions exist for a new paradigm in which service user views are central and randomised controlled trials peripheral.
AimsA rigorous and systematic patient feedback system is important for identifying gaps, improving the quality of care and encouraging patient involvement in service delivery. In the Adult Complex Needs Service of the Tavistock Clinic, a tertiary psychotherapy centre, only 5% of patients have provided feedback when requested. This Quality Improvement (QI) project aimed at improving the return rates of the Experience of Service Questionnaire (ESQ) and the CORE Outcome Measure by 10% within a year.MethodThe QI methodology was used to help identify factors contributing to the low response rate, including views amongst stuff about how such feedback, and the method of its delivery, might affect a psychoanalytically-informed treatment. Previously these forms were posted or handed out in person. In the first Plan-Do-Study-Act (PDSA) cycle, the method of distribution was changed by sending out the questionnaires to patients electronically, using an online survey platform. In the second PDSA cycle, the CORE-34 questionnaire was replaced with a shorter version, the CORE-10. This was in order to test our hypothesis that a shorter questionnaire would result in an increase in the response rates.ResultIn the first cycle of change, 197 patients were emailed for both the CORE-34 and ESQ and a total return rate of 31% was achieved. This signified an increase of 26% in the response rate. Overall more ESQ forms were completed (35% uptake) compared to CORE-34 forms (28% uptake). In the second cycle 199 patients were emailed with the CORE-10 and ESQ forms. The response rate was 21% and 18% respectively. Although the response rates decreased slightly in the second PDSA cycle the results indicated that this method of distribution was capturing a greater range of patients who had not previously provided the service with this sort of feedback.ConclusionSending out the outcome measures electronically and adopting shorter versions of the CORE questionnaire increased the feedback response rate significantly, and provided the service with useful data as to patients' experience of their treatment journey here.
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