A Franchise Protocol, an Instagram Claim, and Twenty-Two Booked Clients
The manager of a private clinic in Hawalli has bought a franchise for a six-session 'Trauma Release Protocol' (TRP) and wants you to run groups for adults with PTSD. The franchise brochure claims 92% remission, based on the developer's own pre-post data from 40 clients: no control group, no blinded assessment, and 35% dropout. The manager wants pre- and post-group PCL-5 scores only, and plans to post before-and-after testimonials on Instagram as '90% success at our clinic'. He offers you a bonus tied to group completion rates. Twenty-two clients are already booked to start in three weeks. Two have active suicidal ideation with plans, one has an untreated psychotic disorder, and the clinic has no outcome database or supervision structure. Your MOH licence lists you as a clinical psychologist; the clinic owner is not a clinician.
1. Appraise the evidence for TRP and state what could and could not be concluded from the evaluation the manager proposes. Then outline a defensible minimal evaluation.
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Appraisal. The developer's dataset is a single-arm pre-post series with 35% attrition, no blinding, no control, and an obvious allegiance conflict - the developer sells the protocol. It cannot separate specific effect from regression to the mean (clients typically present at a peak of distress), expectancy, therapist attention, group support, natural recovery, or selective reporting of completers. '92% remission' is not a finding; it is a marketing statement. A pre-post PCL-5 at your clinic with the same design would generate exactly the same confounds and would not license a claim of efficacy.
What could be concluded from the proposed design: that scores changed among those who completed and were followed up. That is it. It cannot support '90% success', and it cannot support a comparison with established treatments.
Minimal defensible evaluation:
- Pre-register the plan and the primary outcome before the first group.
- Use a structured interview for diagnosis (CAPS-5) plus PCL-5 as the repeated self-report; blinded assessor at post-treatment and at three-month follow-up.
- Consecutive sampling with explicit inclusion and exclusion criteria; report attrition and analyse by intention to treat, not completers only.
- A comparison condition - an evidence-based trauma treatment you can actually deliver (prolonged exposure, cognitive processing therapy, or EMDR, which has a trial base), or at minimum a benchmarked waiting list - and fidelity checks on delivery.
- Adverse-event monitoring, supervision, and a data custodian.
- Report effect sizes with confidence intervals; a change of about 10 points on the PCL-5 is the usual threshold for a clinically meaningful individual change, but group means need proper analysis.
If the clinic will not fund this, say clearly that the honest output is a service evaluation described as such, not an efficacy claim.
2. Identify the ethical and professional problems in the request and how each should be resolved.
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1. Misleading advertising. '90% success' based on uncontrolled testimonials is a false or misleading health claim, and health advertising is regulated. Resolve by refusing to authorise or endorse the wording, proposing factual text ('a six-session group programme; outcomes are being evaluated'), and requiring written client consent for any testimonial - with the caveat that even consented testimonials are not evidence.
2. Informed consent. Clients must be told that TRP is not established, what evidence exists, what the alternatives are (with their evidence base), and that they may withdraw. Consent obtained by omission is invalid.
3. Conflict of interest. A bonus tied to completion creates a direct incentive to keep unsuitable clients in the group and to suppress dropout. Decline the bonus or have it untied from clinical outcomes; disclose the arrangement.
4. Inclusion and exclusion. The two clients with active suicidal ideation and plans are not group candidates until stabilised and individually risk-managed; the client with untreated psychosis needs psychiatric assessment before any trauma processing. Screening and a clear referral pathway are non-negotiable, and the manager cannot override them.
5. Competence and supervision. You may only deliver what you are trained and supervised in. If TRP is outside your competence, or if no supervision exists, that is a reason not to proceed.
6. Records and data protection. No outcome database means no audit, no adverse-event capture, and no protection for clients' data. Set one up before the first session.
7. Scope of practice. The owner is not a clinician; clinical decisions, including exclusions, sit with the licensed clinician. Put that in writing.
3. What do you say to the manager, and what do you do if he overrules you?
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The conversation. Lead with the commercial case as well as the ethical one: an unevidenced claim made publicly is a regulatory and reputational risk, and a clinic that cannot show its outcomes will lose referrals once a complaint or an audit arrives. Offer a face-saving alternative: run the group as a properly evaluated pilot, advertise it accurately, screen clients, exclude and refer the high-risk cases, and publish real numbers when you have them. Offer to draft the consent form and the client information sheet yourself. Put the proposal in one page with dates, costs, and who does what.
If he overrules you:
- Do not sign, approve, or appear in advertising you believe is misleading. State your objection in writing to the manager and to the medical director.
- Document the clinical decisions you made and the reasons, including exclusions, so the record shows who decided what.
- Escalate: the clinic's licensing authority and the professional body that regulates your practice; the MOH if advertising rules are being breached.
- Consider withdrawing from the programme. Staying to 'manage the damage' is defensible only if you retain clinical control over screening, consent, and claims; if you do not, your presence lends credibility to the claims.
The 22 booked clients. They are the immediate priority. Triage them before the start date: risk-screen everyone, refer the two with active suicidal ideation to individual crisis care, refer the client with psychosis for psychiatric assessment, and offer those who are suitable an evidence-based trauma treatment you can actually deliver with supervision. Tell them honestly what is and is not known about TRP. A three-week delay to do this properly is a clinical decision, not an inconvenience.