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Empirically Supported Treatments (ESTs): Context, Consensus, and Controversy
by John C. Norcross, Ph.D.
Learning Objectives
- Learn about the efforts of the APA Society of Clinical Psychology Task Force to identify empirically supported treatments for adults and to publicize these treatments to fellow psychologists and training programs.
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Learn why there is no more central issue to clinicians than the evolution of evidence-based practice in psychotherapy.
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Learn how and why researchers remain divided on what parts of psychotherapy should be “validated” and what qualifies as evidence.
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Learn why an empirically supported treatment may or may not actually be considered the “treatment of choice,” depending upon the clinician’s the oretical orientation and research perspective.
Empirically Supported
Treatments (ESTs): Context, Consensus, and Controversy
John C. Norcross, Ph.D.
THE CONTEXT
Recent years have witnessed the controversial
promulgation of practice guidelines and evidence-based treatments in
mental health.The introduction of such guidelines has provoked practice
modifications, training refinements, and organizational conflicts. For
better and for worse, insurance carriers and government policymakers
are increasingly turning to such compilations to determine which psychotherapies
to approve and fund. Indeed, along with the negative influence of managed
care, there is probably no more issue central to clinicians than the
evolution of evidence-based practice in psychotherapy (Barlow, 2000).
Foremost among these initiatives in psychology
was the APA Society of Clinical Psychology’s Task Force efforts to identify
empirically supported treatments (ESTs) for adults and to publicize
these treatments to fellow psychologists and training programs. Since
1993 a succession of APA Division 12 Task Forces (now a standing committee)
constructed and elaborated a list of empirically supported, manualized
psychological interventions for specific disorders based on randomized
controlled studies that pass for methodological rigor (Chambless & Hollon,
1998; Chambless et al., 1996, 1998: Task Force on Promotion and Dissemination
of Psychological Procedures, 1995). ESTs were judged to be either well-established
efficacious or probably efficacious on the basis of the existing research.
As two examples, for the treatment of
obsessive-compulsive disorder, the Division 12 Task Force concluded
that exposure plus response prevention was a well-established efficacious
treatment and that cognitive therapy and relapse prevention were both
probably efficacious. For the treatment of major depression, behavior
therapy, cognitive-behavioral therapy, and interpersonal therapy were
found to be well-established efficacious treatments, while brief psychodynamic
therapy, self-control therapy, and social problem solving to be probably
efficacious (The entire list is posted at www.apa.org/divisions/div12/rev_est/index.html).
Subsequently, ESTs have been identified
for both older adults and children (Gatz et al., 1998; Lonigan, Elbert,
& Johnson, 1998 Spirito, 1999). The influential A Guide to Treatments
That Work (Nathan & Gorman, 2002) also followed from the Division 12
work.
In response, the APA Division of Counseling
Psychology issued their own principles of empirically supported interventions
(Wampold, Lichtenberg, & Waehler, 2002) and the APA Division of Humanistic
Psychology (Task Force, 1997) published guidelines for the provision
of humanistic psychosocial services. In an effort to expand and, to
some extent, counterbalance the emphasis on treatments, the APA Division
of Psychotherapy commissioned a task force to identify empirically supported
(ther-apy) relationships – or ESRs. The recent Psychotherapy Relationships
That Work (Norcross, 2002) summarizes the Division 29 work.
Interestingly, APA itself has not promulgated
practice guidelines or treatment guidelines for specific disorders.
Instead, they have published Criteria for Evaluating Treatment Guidelines
(2002) as well as Criteria for Practice Guideline Development and Eval-uation
(2002) (and before that, a Template for Developing Guidelines, Task
Force, 1995). A key feature of guidelines for APA is that they are aspirational
in nature, unlike standards which are mandatory. In fact, APA policy
requires that any guidelines note explicitly that they are not intended
to be mandatory, exhaustive or definitive. “APA’s official approach
to guidelines strongly emphasizes professional judgment in individual
patient encounters and is therefore at variance with that of more ardent
adherents to evidence-based practice (Reed, McLaughlin, & Newman, 2002,
p. 1042).”
APA policy distinguishes between practice
guidelines and treatment guidelines: the former consist of recommendations
to professionals concerning their conduct, whereas the latter provide
specific recommendations about treatments to be offered to patients.
The evidence-based movement addresses both types, but primarily treatment
guidelines.
All of these efforts are part of a worldwide
movement toward evidence-based practice in mental health. In Great Britain,
for one example, a Guidelines Development Committee of the British Psychological
Society authored a Department of Health (2001) document entitled Treatment
Choice in Psychological Therapies and Counselling: Evidence-Based Practice
Guidelines. In Germany, the federal government commissioned an expert
report on the effectiveness of psychotherapy to guide the revisions
of laws regulating psychotherapy (Strauss & Kaechele, 1998). In psychiatry,
the American Psychiatric Association has published at least a dozen
treatment guidelines, on disorders ranging from schizophrenia to anorexia
to nicotine dependence.
THE CONSENSUS
The call for accountability in health
care is here to stay. All mental health professionals will need to respond
to the clarion call for evidence-based treatments by demonstrating the
safety, efficacy, and efficiency of their practices. In fact, demands
for evidence-based treatments from various constituencies will escalate
in the future.
The extant efforts to promulgate evidence-based
psychotherapies have been noble in intent and timely in distribution.
They wisely demonstrate that, in a climate of accountability, psychotherapy
stands up to empirical scrutiny with the best of health care interventions.
In other words, ESTs have addressed the realpolitik of the socioeconomic
situation (Messer, 2001; Nathan, 1998).
The evidence-based movement within psychology
has attempted to proactively counterbalance documents that accord primacy
to biomedical treatments for mental disorders and largely ignore the
outcome data for psychological therapies. That is, the demonstrable
effectiveness of psychotherapy – compared to no treatment, compared
to medication, and compared to other forms of health care – is being
more widely and forcibly communicated to essential stakeholders.
The vast majority of ESTs identified
to date – 60% to 90% depending on the list – are cognitive-behavioral
treatments. ESTs share the following characteristics: they involve skill
building, have a specific focus, involve relatively brief treatment,
and rarely use traditional assessment measures (O’Donohue et al., 2000).
Upwards of two-thirds of controlled outcome studies in psychotherapy
for both children and adults have been conducted on behavioral and cognitivebehavioral
therapies.
The evidence-based movement is one means
of bridging the practice-research gap. By educating practitioners about
the research base, EST lists may foster evidence-based practice. Specifically,
ESTs serve the public and the profession by helping training programs
readily identify effective and promising therapies upon which their
training efforts can be partially based, as well as aiding practitioners
by providing data to support their choice and efficacy of psychological
interventions (Chambless & Ollendick, 2001).
The multiple surveys of graduate programs,
internship directors, and doctoral students consistently report relatively
modest knowledge of and training in ESTs (e.g., Calhoun et al., 1998;
Crits-Christoph et al., 1995; Hays et al., 2002; Pilkonis et al., 2002).
The future will bring increased emphasis on ESTs during graduate training
and continued education. This will occur, in part, because some didactic
instruction and clinical supervision in empirically supported therapies
is now required for APA accreditation in both internship and doctoral
programs (APA, 1996).
The next generation of ESTs will highlight
the multidimensional contributions to psychotherapy outcome: the treatment,
the relationship, and the patient. In fact, an ongoing collaboration
between the APA Society of Clinical Psychology and the North American
Society of Psychotherapy Research is attempting to integrate empirically
supported treatments, relationships, and client contributions for specific
clusters of disorders. Larry Beutler and Louis Castonguay co-chair the
Task Force, and their book is scheduled for publication in 2004.
THE CONTROVERSY
The ethical and professional commitment
to evidence-based psychotherapy is widely, if not universally, accepted
among mental health practitioners. It is similar to publicly prizing
Mother and apple pie. In principle, we are all committed to identifying,
practicing, and promulgating those psychosocial treatments that work.
In application, the controversies reside in the definitions and details
of identifying those evidence- based or empirically supported therapies.
The research community remains divided
on what parts of psychotherapy should be validated and what qualifies
as evidence. At least half a dozen special sections of professional
journals have addressed and debated the issue of ESTs. For example,
Stricker (2000), in a previous article in The Register Report, believes
that what is most likely to be validated across theoretical orientations
are broad principles of change, such as the value of the therapy relationship
or exposure, rather than specific techniques. Many others find the almost
exclusive reliance on randomized clinical trials in ESTs to be excessively
restrictive; they argue that the cumulative results of rigorous process
research, processoutcome research, and naturalistic effectiveness studies
should also qualify as evidence in determining what works.
A psychotherapy listed as an EST may
or may not be considered the treatment of choice depending on the clinician’s
theoretical orientation and research perspective. ESTs have demonstrated
in controlled research that they outperform (on symptom or functioning
measures) a waiting list control, no treatment, or treatment as usual
comparison. Some clinicians argue that ESTs thus represent de facto
treatments of choice that should be widely conducted and taught because
we know that they work. Other clinicians argue that researched treatments
are simply that – researched – and not necessarily treatments of choice.
They also note that the methodological paradigms, outcome measures,
and medical model conceptualization of ESTs are theoretically bi-ased
in favor of a cognitive-behavioral orientation.
In particular, EST lists do little for
those psychotherapists whose patients and theoretical conceptualizations
do not fall into discrete disorders (Messer, 2001). Consider the client
who seeks more joy in his/her life, but who does not meet diagnostic
criteria for any disorder, whose psychotherapy stretches beyond 20 sessions,
and whose treatment objectives are not easily specified in measurable,
symptombased outcomes. Current evidence-based compilations have little
to contribute to his/her therapist and his/ her treatment. Not all psychotherapies
or practitioners embrace an actionoriented, symptom-focused model.
The practice community is similarly divided
on producing and disseminating EST lists. APA Division 12 and scientistpractitioners
in the cognitive-behavioral tradition are, as a group, favorably disposed;
APA Division 42 and full-time practitioners in the psychodynamic and
humanistic traditions are, as a group, vigorously opposed. The controversy
has spread into the professional literature and onto the floor of the
APA Council of Representatives.
As three members of APA’s Practice Directorate
(Reed, McLaughline, & Newman, 2002, p. 1040) put it:
Guidelines documents have been increasingly
scrutinized in the APA policy process because of increased practitioner
sensitivity to mandates and limitations as a result of their experience
with managed care and increased anxiety about the potential legal
risk to practitioners created by guidelines. This reaction has often
surprised those involved in the development of the guidelines that
have been reviewed as potential APA policy, as these individuals have
generally been well-intentioned in their efforts to support, educate,
or protect practitioners rather than controlling them or putting them
at risk.
Coming full circle, the ascendancy of
evidence-based treatments is an inevitable, consequential, albeit controversial,
movement in mental health. Early attempts to identify ESTs are commendable
efforts to aggregate and codify available research in order to inform
practice and to guide training.
Yet, these are only the first steps,
not the final destination; good efforts, not yet ideal (Nathan, 1998).
Future evidence-based compilations in psychotherapy will need to unify
the practitioner and researcher communities and to balance competing
clinical and scientific values. These goals can be approached, in my
view, by adopting broader rules as to what qualifies as evidence, by
expanding the focus of what is empirically supported to relationship
methods and patient contributions, by matching treatments to client
variables beyond discrete DSM diagnosis, and by tending to the strained
marriage between psychological science and psychotherapy practice (Norcross,
1999).
AUTHOR
John C. Norcross, Ph.D. is Professor
and former Chair of Psychology at the University of Scranton, Scranton,
PA, a clinical psychologist in part-time practice, and an internationally
recognized authority on behavior change and psychotherapy. Dr. Norcross
is a member of the National Register Board of Directors.
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