cpa-sm.gif (1004 bytes) DISCUSSION DOCUMENT

Empirically Supported Treatments in Psychology: Recommendations for Canadian Professional Psychology
Task Force on Empirically Supported Treatments (Section on Clinical Psychology of the Canadian Psychological Association)


Responses to the Task Forces Reports

Thirty years ago Paul (1967) recommended that the field of psychotherapy research focus its efforts on determining which treatments work for which patients under what conditions. The Division 12 initiative to define a list of empirically supported treatments is an effort to address Paul’s challenge. A review of the literature which has emerged in response to the Task Force initiative reveals general agreement with the need to identify effective treatments for specific conditions. However, concerns have been raised with several aspects of the initiative. These can be categorized as concerns with the terminology used and the process undertaken by the Task Force, concerns based on the methodology used in most psychotherapy research, and concerns stemming out of the potential impact of compiling such a list. (For a detailed response by the first chair of the Task Force to many of the issues discussed below, see Chambless, 1996a, b).

Concerns with Terminology and Process

A number of commentators have taken issue with the term "validated" treatment, often pointing out that validated implies a greater degree of precision and authority than is supported by current research (e.g., Garfield, 1996, 1998). As stated in the 1996 Task Force report, the committee members acknowledged the legitimacy of this criticism and indicated that the term "empirically supported" is preferable. However, there is more to this than simple semantics, for even among supporters of the initiative, there is ambivalence about the use of the term validated. Empirical validation, like science in general, is an ongoing process; validation, therefore, is never complete. Even if one accepts this stance, there may be problems in the actual determination of whether a treatment meets the requirements for designation as validated or supported. For example, Garfield (1996) noted that the Task Force was inconsistent in the application of its own criteria. Specifically, several of the studies cited as supporting the validity of certain treatments employed very small samples upon which definitive conclusions could not be made. Others included statements by the investigators that reflected a need for caution in accepting the results as definitive.

A related concern was expressed by Wampold (1997) regarding differences within the scientific community with respect to the nature of the current status of psychotherapy research. He noted that the strategy of the Task Force was to start with an empty set of empirically supported treatments to which were added those treatments that met the established criteria. He pointed out that this strategy may be inconsistent with the state of psychotherapy research, which often indicates that most bona fide treatments are equally efficacious, with differences between treatments often tending to be small and limited to one or two outcome measures. His proposition was that one should begin with the assumption that all bona fide treatments belong on the list and that treatments can then be removed once they have been found to be inferior to others on a preponderance of measures. Although appealing, such a strategy overlooks the possibility that the reason many treatment studies find few differences among treatments is that they lack the statistical power to detect any such differences (Kazdin & Bass, 1989).

The Task Force has also been criticized for engaging in limited consultation prior to publication of its report (Garfield, 1996). If a listing of treatments is to be useful in routine practice, then some attention should be paid to the nature of services actually delivered in typical service settings. This would ensure that all forms of clinical intervention had an equal opportunity to be represented on the list before any list of treatments was disseminated. To illustrate this point, several interventions with supporting empirical evidence that are used in health psychology and/or rehabilitation settings were not listed until the third version of the list was published. Although no listing will ever be complete, there could be potential negative consequences of an efficacious intervention not appearing on the list.

Concerns with Methodology used in Psychotherapy Research

Some psychologists have noted that the conclusions of the Division 12 Task Force are limited by the methodological considerations involved in most psychotherapy research. For example, Wampold (1997) and Garfield (1998) argued that efficacy research has primarily focused on detecting differences between various treatment approaches and has attempted to homogenize treatments and clinicians in a way that may have diluted the most important ingredients of successful intervention. In other words, the emphasis on evaluating treatment strategies has led to a neglect of the contribution of the qualities of the clinician, the nature of the therapeutic relationship, and the intricacies of clinical judgement necessary to determine how best to respond to clients’ concerns.

In current treatment research, the necessity for treatments to be delivered in a standardized manner has necessitated the use of treatment manuals. The use of a manual is a key component of the current requirement for inclusion of a treatment as being empirically valid. A number of criticisms have been leveled at the use of treatment manuals, including that they focus the researcher’s attention on clinician adherence rather than clinician competence (Wampold, 1997) and that they can only present general principles of a treatment approach, making them potentially unsuitable as tools to guide the delivery of treatment (Havik & VandenBos, 1996; Levant, 1995; Smith, 1995; Strupp & Anderson, 1997). In response, supporters of the use of treatment manuals argue that they facilitate dissemination of a treatment (Dobson & Shaw, 1988) and that they provide optimal strategies for interventions in routine practice (Wilson, 1996, 1997). Furthermore, the depiction of treatment manuals as requiring strict adherence to a set of techniques that must be followed in a lock-step fashion is clearly at odds with explicit statements in many manuals that flexibility in the application of the procedures is essential to the success of the treatment (e.g., Beck, Rush, Shaw, & Emery, 1979). As suggested by Addis (1997), the skill in the use of a manual lies somewhere between the poles of total, inflexible adherence and sole reliance on clinical judgment. However, even proponents of the use of treatment manuals acknowledge that an important gap in the literature is the limited data on the effectiveness of treatment delivered by clinicians using manuals under usual clinical conditions. If treatment manuals are to be used to guide intervention in clinical settings, it is essential that data be gathered on this topic.

Relatedly, a key recommendation of the Task Force was that training programs prepare students in at least two of the empirically supported treatments. Although some suggestions are emerging (Calhoun, Moras, Pilkonis, & Rehm, 1998), there is not as yet a widely accepted definition of competence that could be used to ensure that students receive adequate training. Moreover, with some exceptions (e.g., Shaw & Dobson, 1988), we have not been able to develop easily applied measures of core competence for most treatments. If the expectation is that clinical programs should engage in such training using treatment manuals as a resource, then teaching and supervision manuals may be also needed.

Finally, there are also concerns about the use of efficacy studies to guide the practice of clinical services. Many critics have suggested that efficacy studies cannot be used to "validate" psychotherapy as it is conducted in the field (e.g., Goldfried & Wolfe, 1998; Seligman, 1995; Shapiro, 1996). The nature of most clinical treatment research requires, among other elements, the screening of clients/patients for suitability, random assignment to treatment condition, and intensive training and monitoring of clinicians providing the intervention. As in all research, efforts to enhance the internal validity of a study result in lowered external validity. Accordingly, the extent to which the results of most treatment research generalize to routine practice is unclear.

The potential problems associated with developing service delivery systems based on psychotherapy research have been discussed for many years (e.g., Kazdin, Kratochwill, & VandenBos, 1986; Parloff, 1979). If nothing else, the Division 12 initiative has caused this issue to resurface and to be taken much more seriously by researchers and practitioners alike. There is now much more appreciation of the critical need for effectiveness research that explicitly examines the impact of treatment in routine clinical settings. However, the issue of the generalizability of therapy research cuts both ways. If one contends that most psychotherapy research is not directly generalizable to routine practice, then, logically, one must also refrain from citing the findings of large scale meta-analyses of this literature (e.g., Smith, Glass, & Miller, 1980) to support the position that psychotherapy is effective in treating a wide range of disorders and psychological problems.

Concerns with the Impact of the Report

The reaction of many practitioners to the task force initiative has been highly charged, to say the least. For example, one prominent opponent has described the initiative as irresponsible and has characterized the list of empirically supported treatments as a clear example of blacklisting (Silverman, 1996). Such reactions appear to be due to several inter-related concerns that stem from the tension between science and practice, and from economic factors related to current service delivery. The first is that, as discussed above, evidence from efficacy trials is given precedence over the clinical experience of licensed professionals. A second concern is that potential clients and third-party payers may misinterpret the task force list as indicating that only these treatments are effective. Despite disclaimers by the Task Force, there is significant worry that any treatment not on the list will be viewed as ineffective, rather than as being untested (Sleek, 1997).

A third concern is that the list consists of predominantly short-term, cognitive-behavioral interventions. As a result, clinicians offering long-term treatments (i.e., more than 20 sessions) may not be able to defend their practice to companies providing reimbursement for psychological services. The type of research demanded for designation as empirically supported (e.g., use of treatment manuals, two or more treatment studies) may not be easily accomplished for forms of long-term therapy, as the research would be both organizationally demanding and very expensive. In the context of granting agencies that give preference to funding research on short-term treatments, it may be exceedingly difficult to develop the database necessary to evaluate long-term treatments (cf. Task Force on Promotion and Dissemination of Psychological Procedures, 1995). This is seen by some as serving to undermine the legitimacy of psychodynamic and psychoanalytic interventions and privileging cognitive-behavioral approaches.

A fourth issue is that there are currently major gaps in the availability of empirically supported treatments for a number of psychological disorders. As a primary example, the list of empirically supported treatments is almost entirely devoid of treatments for personality disorders. One may conclude that this reflects the absence of effective treatments for such disorders; however, it may be equally accurate to explain the limited representation of treatments for personality disorders on the basis of the criteria developed by the Task Force and the aforementioned difficulties in conducting research on longer term interventions.

All of these concerns exacerbate the fears of American practitioners who are coming to terms with the monumental changes in the delivery of psychological services brought about by the growth of managed health care systems. Over the past two decades, the dominant form of service delivery in the United States has become one in which mental health services are managed by third-party payers (e.g., insurance companies, government agencies, employers). As a cornerstone of managed health care is cost-containment, managed care organizations are attracted to cost-efficient interventions with demonstrable outcomes (Mash & Hunsley, 1993). Unfortunately, all too often the focus of these organizations has been on reducing costs by limiting access to services. In such an environment, many practitioners are concerned that any evidence that could be used to reduce payment for services will be used in a forceful and imprecise manner: specifically, they are worried that the disclaimers offered by the Task Force will be ignored in the rush of managed care organizations to disallow reimbursement for any intervention not designated as empirically supported. There continue to be concerns about the inappropriate use of empirical evidence by managed care entities (Sleek, 1997); however, based on information provided to us by two prominent American psychologists who are actively involved in the process of practice guideline development, no managed care entity has used the APA Task Force listing to certify or deny payments for psychotherapy services (Steven Hayes, personal communication, December 12, 1997; Kirk Strosahl, personal communication, January 5, 1998).

Next: Alternative Options for Promoting Evidence-Based Practice


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