Crisis Dialogue for Acute Psychotic State and Ethical Difficulties: What Do You Do When Trials Are Interrupted Because Clinicians Find the Intervention Too Effective?

Abstract

Clinical studies carry with them a paradox: The more obviously efficient an intervention is, the more ethical problems its trials pose. This article discusses the ethical problem of breached equipoise principle because of the perceived effectiveness of a nonblindable verbal technique, crisis dialogue (CD). CD is designed to help establish a therapeutic relationship with persons in a suspected psychotic state. In a pilot randomized controlled study in Yverdon, Switzerland (usual treatment vs. usual treatment + CD), after inclusion of 30 patients, clinicians expressed a consensual opinion that CD was effective in most cases. Following their opinion, the joint clinical and research team decided that the study had to be discontinued and that CD should be tried with all patients for ethical reasons. This poses an ethical problem with potential far-reaching consequences: In this interrupted study, differences between groups in terms of clinical outcome (Brief Psychiatric Rating Scale, Clinical Global Impression), therapeutic alliance (Working Alliance Inventory, Difficult Doctor–Patient Relationship Questionnaire), and patient satisfaction were consistent in favoring CD, but these differences did not reach statistical significance in most measurements. The early interruption of the study because of perceived effectiveness of the intervention can be seen as unethical as well because chances were high that a larger sample would have shown more conclusive results, allowing for faster introduction of CD in various clinical settings with corresponding improvement of patient care.

Centrality and Decentration

“…A score of "D1" reflects awareness that events, activities, thoughts, feelings, and emotions in the lives of others may be unrelated to oneself, whereas a score of "D2" reflects an awareness that others hold a valid and different perception of events. The highest score "D3" reflects an even broader awareness that others have relationships with one another that are unrelated to (Graz et al, 2015); but no long-term therapeutic implications any relationship to oneself and that the courses of the lives of others are multidetermined by factors unrelated to oneself. It also involves the ability to recognize that the events that occur in regular life are often the result of complex emotional, cognitive, social, and environmental factors that vary according to the individual people involved.…”

“…Indeed, Grivois was deeply interested in addressing centrality in the psychotherapeutic dialogue. He developed a method of crisis intervention (Graz et al, 2015) that approached centrality with the patient allowing for a “copernician turning point” (Raballo et al, 2006), in which a deeper sense of others and the world help to work again the patient feeling as if he or she is the center of everything to “keep them safe from the [delusional] sense” (Grivois, 2001, p 177). Although not often cited in the scientific literature, this method has been supported in several clinical studies (Graz et al, 2015).…”

“…He developed a method of crisis intervention (Graz et al, 2015) that approached centrality with the patient allowing for a “copernician turning point” (Raballo et al, 2006), in which a deeper sense of others and the world help to work again the patient feeling as if he or she is the center of everything to “keep them safe from the [delusional] sense” (Grivois, 2001, p 177). Although not often cited in the scientific literature, this method has been supported in several clinical studies (Graz et al, 2015). However, if this method is effective in periods of crisis, Grivois, like Conrad, offered few indications about how to address centrality in the long term and on the interventions needed in postacute phases of psychosis.…”