Dismantling designs

Dismantling designs are an alternative to psychological placebos, waiting lists, or comparative designs. In a dismantling design, the full clinical treatment package is compared with the full package minus one element in order to establish which elements are necessary and sufficient for change. Variations on this theme include 'additive' or constructive designs that examine whether adding a new element enhances the efficacy of a treatment package.

As an example, dismantling designs have been usefully applied in the evaluation of the behavioural treatment of obsessive-compulsive disorder. The full treatment package involving exposure and response prevention techniques has been compared with each of the individual components of the package. (1.Z> Patients were randomly assigned to either the full exposure and response prevention package, exposure alone, or response prevention alone. Those receiving the full package improved significantly more than did the patients in either of the control treatments. At follow-up assessments, 80 per cent of patients receiving the full package remained improved at follow-up, whereas only 27 per cent of those in the single components groups remained 'improved'.

The advantage of dismantling strategies in psychotherapy research is clear. Causal statements about differences in improvement between treatment conditions can be made, since all factors (including non-specific elements) except one are held constant, and the problems involved in other types of control groups are avoided. These designs, in general, should probably be used more often than they are. Some psychotherapies, however, may not easily lend themselves to such dismantling strategies. Moreover, it may be premature to attempt to dismantle a treatment package when questions about the efficacy of the whole package need to be resolved first.

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