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Fiddling While Psychology Burns?
by Peter E. Nathan, Ph.D.
I’ve been a psychologist a long time,
but I’ve never witnessed as much distress among both practicing psychologists
and academic clinicians as I have over the issue of experimentally supported
treatments (ESTs) and practice guidelines (PGs).
On one side of the issue are the psychologists
who believe experimentally supported treatments and practice guidelines
are premature, simplistic, and divisive, conceivably a Machiavellian
plot by the other side to assert complete dominion over what’s left
of the psychotherapy enterprise after managed care finishes with it.
On the other are the psychologists who lament the failure of the field
to appreciate the revolution in effectiveness and accountability ESTs
and PGs represent - and seriously debate among themselves whether those
who continue to offer treatments which have not been shown to be effective
ought to be brought up on
charges of ethical violation.
Psychologists fiddle while the profession
burns. While we’ve been arguing, the psychiatrists have produced a series
of comprehensive practice guidelines (American Psychiatric Association,
1993, on Major Depressive Disorder; 1994, on Bipolar Disorder; 1995,
on the Substance Use Disorders: Alcohol, Cocaine, Opioids; 1996, on
Nicotine Dependence; 1997, On Schizophrenia). Ironically, these PGs
are based in substantial measure - albeit inconsistently and self-interestedly
(Persons et al., 1996) - on the very data on experimentally supported
treatments about which we psychologists have been quarreling. Flawed
or not, however, the psychiatrists’ practice guidelines are destined
to impact very substantially on mental health practice: they are likely
to become recognized as standards of care by some third-party reimbursers
and managed care companies.
All this being so, it seems time - actually,
well past time - to ask whether organized psychology is going to permit
psychiatry and the American Psychiatric Association, by fiat, to establish
the standards of practice by which psychologists are bound. I’d much
prefer a different outcome.
ESTs and PGs: Pro and Con
The issues surrounding ESTs and PGs came
to a head for psychologists when a Division 12 Task Force published
“Training in and Dissemination of Empirically-Validated Psychological
Treatments: Report and Recommendations”, which contained a condensed,
preliminary listing of experimentally supported psychosocial treatments.
Three categories of treatments, well-established
treatments, probably efficacious treatments, and experimental treatments
(treatments not yet established as at least probably efficacious), were
proposed. Twenty-two “well-established treatments” for 21 different
syndromes and seven “probably efficacious” treatments for seven disorders
were listed. With the exception of family education programs for schizophrenia,
and interpersonal therapy for bulimia and for depression, all the “well-established”
treatments were behavioral, most of them cognitivebehavioral. Similarly,
all but the brief psychodynamic therapies listed as “probably efficacious”
were behavioral.
Why do behavioral approaches to treatment
figure so prominently in these two lists? One reason is that they have
been found effective for a number of disorders. Other reasons, however,
have less to do with efficacy than with the preferred criteria for judging
state-of-the-art outcome research. Cognitive behavioral treatments are
more likely to induce the discrete behavioral changes that current outcome
measures are designed to reflect. Moreover, they lend themselves especially
well to manualized treatment programs, and tend to induce desired changes
within a short enough time period to fit into the typical, time-limited
outcome study. As EST methodology develops further, a continuing issue
will be whether treatments drawn from traditions not as compatible with
current outcome research methods will receive experimental confirmation.
Reactions to the Division 12 ESTs were
distinctly mixed. Former Division 12 president Sol Garfield, a distinguished
psychotherapy researcher, was one of those most troubled by the guidelines:
... (Garfield) judges ‘the language
of the (Task Force) report (to be) overly strong and the recommendations
premature.’ Most pointed of his criticisms is that ‘the emphasis on
validated therapies for specific diagnostic entities seemingly implies
a greater knowledge of the variables that produce or facilitate positive
change’ than he thinks is warranted by the state of our data and knowledge
... His concerns extend to the Task Force’s requirement that studies
pointing to ‘well-established treatments’ utilize treatment manuals;
manualized therapy, he believes, idealizes and, thus, distorts the
psychotherapy setting. He is also convinced that psychotherapy patients
in research studies are sufficiently different from their counterparts
in the real world as to affect both therapy process and outcome ...
Finally, Garfield laments the failure of the Task Force to acknowledge
the important role common factors like therapist variance play in
determining therapy outcome, in favor of the Task Force’s emphasis
on form of therapy. Garfield is convinced that psychotherapy research
over several decades has revealed the primacy of these process variables
over therapy form in determining therapy outcome. (Nathan, 1996, p.
252)
In an invited commentary on Garfield’s
assessment of the Division 12 ESTs, I disagreed with his view that they
were premature, concluding instead that “the time has come to develop
methodological criteria by which to identify strong studies validly
reflecting effective treatments” (Nathan, 1996, p. 252), a point made
as well in a comprehensive volume summarizing treatments that work I
recently co-edited (Nathan & Gorman, 1997). In my response to Garfield,
I acknowledged limitations in current methodologies for assessing outcomes,
despite marked advances in them over recent years. I also stressed the
importance of developing additional effective psychosocial treatments.
Nonetheless, I concluded that “we have made sufficient progress in both
(methodology and effective treatments) to justify taking a chance and
beginning the process” (Nathan, 1996, p. 252).
Others have also found merit in experimentally
supported treatments and practice guidelines. Clinton, McCormick, and
Besteman (1994), Jacobson & Christensen (1996), Ogles, Lambert, and
Sawyer (1995), Schooler (1994), Schulberg and Rush (1994), and Wilson
(1995) have all described the diverse benefits of experimentally supported
treatments and therapy practice guidelines. Using bulimia nervosa, on
which much of his clinical research has focused, as an example, Wilson
(1995) makes a particularly eloquent case for the widest possible dissemination
of empirically-validated treatments:
Moving aggressively in the direction
of developing and implementing empirically-validated treatment methods
would seem imperative in securing the place of psychological therapy
in future health care policy and planning ... The development and implementation
of empirically-validated treatments is seen by many mental health professionals
as not only desirable but ethically imperative. It has been commonplace
for some time now to emphasize patients’ right to treatment and their
right to refuse treatment. But patients should (also) have a right to
safe and effective treatment. (Wilson, 1995, p. 163)
ESTs have, however, failed thus far to
earn strong support from a group I would have assumed would be strongly
attracted to them, the faculty of clinical psychology training programs
in universities and professional schools. A survey of these programs
(Crits Christoph et al., 1995) revealed surprising variation in the
number of empirically-validated psychotherapeutic treatments taught
- from 0% to 96%. Furthermore, Wilson (1995) laments, “ ... underscoring
the lack of attention to empirically-validated treatments, the report
revealed that more than one fifth of the programs did not teach anything
about 75% or more of the treatment methods listed by the Task Force”
(p. 165)*.
Even strong supporters of ESTs have acknowledged
additional telling limitations in them, including the crucial distinction
between findings from laboratory-based studies of treatment efficacy
and real-world data on effectiveness (Hollon, 1996; Seligman, 1995),
as well as the more general reliability and validity problems associated
with both kinds of outcome research (Sechrest, McKnight,
& McKnight, 1996).
Can We Find Common Cause?
It’s not hard to understand either the
concerns of those psychologists who oppose ESTs and PGs in their present
form or the enthusiasm of those who support them. Like others, I support
them because they have the potential to maximize the effectiveness of
what we do and make our interventions more fully accountable. Just as
importantly, creation of our own practice guidelines, based on our own
ESTs, will enable us to establish our own standards of practice, rather
than ceding that responsibility to the American Psychiatric Association.
But I also understand why ESTs and PGs
in their present form are so objectionable to so many colleagues. Simply
said, a major reason is that they appear to disenfranchise substantial
numbers of colleagues, including long-term therapists, psychoanalytic
psychotherapists, psychoanalysts, and group and family therapists. Moreover,
the fact that current treatment outcome methods seem to harmonize so
closely with the practice of cognitive behavior therapy creates the
appearance that the EST process, in its present form, is stacked against
the non-behavioral treatments in which so many psychologists have invested
so much for so long.
With Goldfried and Wolfe (1996) and Newman
and Tejeda (1996), I look forward to the time when we can put our differences
aside, find common cause, and join together to confront a greater threat
than psychologist-generated experimentally supported treatments: the
specter of psychiatry’s practice guidelines becoming psychology’s, just
as psychiatry’s diagnostic system has become psychology’s. Taking these
steps, though, is far easier said than done. It will require a level
of trust, patience, and mutual understanding between practitioners and
clinical researchers that has been sadly lacking to date.
My hope, though, is that both sides can
agree that further efforts to develop the methodology and criteria for
identifying ESTs make sense - and that they can come together to design
jointly the developmental studies that must still be undertaken. (Recent
suggestions on ways to bring practitioners into more active collaboration
with clinical researchers for this purpose (e.g., Barlow, 1996; Howard
et al., 1996) are particularly encouraging.) The ultimate product -
ESTs which many more professional psychologists can endorse - will permit
us to move on to creation of our own empirically-derived psychological
treatment guidelines: our own standards of practice.
References
American Psychiatric Association. (1993).
Practice Guidelines for the Treatment of Major Depressive Disorder in
Adults. American
Psychiatric Association, 150 (No. 4, Supplement), 1-26.
American Psychiatric Association. (1994).
Practice Guideline for the Treatment of Patients with Bipolar Disorder.
American Journal of Psychiatry, 151(No. 12, Supplement), 1-36.
American Psychiatric Association. (1995).
Practice Guideline for the American Psychiatric Association. (1996).
Practice Guideline for the Treatment of Patients with Nicotine Dependence.
American Journal of Psychiatry, 153 (No. 10, Supplement).
American Psychiatric Association. (1997).
Practice Guideline for the Treatment of Patients with Schizophrenia.
American Journal of
Psychiatry, 154 (No. 4, Supplement), 1-63.
Barlow, D.H. (1996). Health care policy,
psychotherapy research, and the future of psychotherapy. American Psychologist,
51, 1050- 1058.
Clinton, J.J., McCormick, K., & Besteman,
J. (1994). Enhancing clinical practice: The role of practice guidelines.
American Psychologist, 49, 30-33.
Crits-Christoph, P., Frank, E., Chambless,
D.L., Brody, C., & Karp, J.F. (1995). Training in empirically validated
treatments: What are linical psychology students learning? Professional
Psychology: Research and Practice, 26, 514-522.
Division 12 Task Force. (1995). Training
in and dissemination of empirically-validated psychological treatments:
Report and recommendations. The Clinical Psychologist, 48, 3-23.
Garfield, S.L. (1996). Some problems
associated with “validated” forms of psychotherapy. Clinical Psychology:
Science and Practice, 3, 218-229.
Goldfried, M.R. & Wolfe, B.E. (1996).
Psychotherapy practice and research. American Psychologist, 51, 1007-1016.
Hollon, S.D. (1996). The efficacy and
effectiveness of psychotherapy relative to medications. American Psychologist,
51, 1025-1030.
Howard, K.I., Moras, K., Brill, P.L.,
Martinovich, Z., & Lutz, W. (1996). Evaluation of psychotherapy: Efficacy,
effectiveness, and patient progress. American Psychologist, 51, 1059-1064.
Jacobson, N. & Christensen, A. (1996).
Studying the effectiveness of psychotherapy: How well can clinical trials
do the job? American Psychologist, 51, 1031-1039.
Nathan, P.E. (1996). Validated forms
of psychotherapy may lead to better validated psychotherapy. Clinical
Psychology: Science and Practice, 3, 251-255.Nathan, P.E. & Gorman,
J.M. (1997). Treatments that work. New York & Oxford: Oxford University
Press.
Newman, F.L. & Tejeda, M.J. (1996). The
need for research that is designed to support decisions in the delivery
of mental health
services. American Psychologist, 51, 1040-1049.
Ogles, B.M., Lambert, M.J., & Sawyer,
J.D. (1995). Clinical significance of the National Institute of Mental
Health treatment of
depression collaborative research program data. Journal of Consulting
and Clinical Psychology, 63, 321-326.
Persons, J.B., Thase, M.E., & Crits-Christoph,
P. (1996). The role of psychotherapy in the treatment of depression.
Archives of
General Psychiatry, 53, 283-290.
Schooler, N.R. (1994). Translating treatment
research findings into clinical action. American Journal of Psychiatry,
151, 1719-1721.
Schulberg, H.C. & Rush, A.J. (1994).
Clinical practice guidelines for managing major depression in primary
care practice. American Psychologist, 49, 34-41.
Sechrest, L., McKnight, P., & McKnight,
K. (1996). Calibration of measures for psychotherapy outcome studies.
American
Psychologist, 51, 1065-1071.
Seligman, M.E.P. (1995). The effectiveness
of psychotherapy: The Consumer Reports study. American Psychologist,
50, 965-974.
Wilson, G.T. (1995). Empirically validated
treatments as a basis for clinical practice: Problems and prospects.
In S.C. Hayes, V.M.
Follette, R.M. Dawes, & K.E. Grady (Eds.), Scientific standards of psychological
practice: Issues and recommendations (pp. 163-
196). Reno, NV: Context Press.
* The Guidelines and Principles for Accreditation
of Programs in Professional Psychology were approved in February 1995
by the
Committee on Accreditation. Domain B: Program Philosophy, Objectives,
and Curriculum Plan (3) (c) states that the program ... should include
training in empirically supported procedures and exposure of the student
to the current body of knowledge in effective intervention and the evaluation
of the efficacy of interventions. It is unknown the degree to which
programs have increased their attention to these topics.
AUTHOR
President/Chair, National Register of
Health Service Providers in Psychology
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