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By Paul Stevens., Ph.D., and Ofer Zur, Ph.D.
CHAPTER I: ORIGINS OF THE MOVEMENT FOR EMPIRICALLY-SUPPORTED TREATMENTS
Within the field of psychotherapy, a battle has raged for years between those who favor a scientifically-based medical model approach and those who lean toward a philosophical view that continues to see psychotherapy as more of an art form than a science (Norcross, 2001). Those in favor of the medical model argue that clinical psychologists are scientists, and psychotherapy is, and should be, based on scientific theory. They cite the need for clear standards of practice which can provide proven techniques that produce measurable results. Others in the field remain steadfast against using the medical model as a basis for practice, arguing that it does a disservice to those who seek treatment by limiting options and reducing clients to diagnoses and labels. While even the most ardent supporters on both sides of the debate readily acknowledge a certain amount of common ground between the two positions (Asay & Lambert, 1999), the debate continues and shows no signs of letting up.
In recent years it is clear that the pendulum has swung firmly in favor of those who champion the medical model. Over the past two decades managed care has had an ever-increasing role in determining the landscape of psychotherapy and how it is conducted. Fewer and fewer sessions are being approved for reimbursement, more controls and restrictions have been implemented, and there has been a significant increase in the use of medications, often in lieu of psychotherapy. As a result of these changes, many in the field saw a need to respond with clearly defined methods of treatment that were cost-effective and could be shown to produce results. With these concerns as the motivating factors, it appears the patient’s best interest took a back seat to meeting the requirements of managed care. It is within this atmosphere that the movement for Empirically Supported Treatments began.
In order to meet the challenges of the increasing emphasis on accountability and cost control, and in an attempt to resuscitate what was seen as a dying belief in the efficacy of psychotherapy, a Task Force was set up by Division 12 of the American Psychological Association (Society of Clinical Psychology) to develop a definition and list of empirically supported procedures (Beutler, 1998; Kendall, 1998; Deegear & Lawson, 2003).
The Task Force
Division 12 President Dr. David Barlow appointed Dr. Dianne Chambless to chair a Task Force on the Promotion and Dissemination of Psychological Procedures. This Task Force was charged with developing criteria for empirically evaluating psychological treatment, and with making recommendations as to the best methods for educating psychologists, the public, and mental health service payers about these treatments.
The Task Force aimed to cover a broad range of interests, and included members from numerous theoretical orientations, (cognitive-behavioral, psychodynamic, and interpersonal) and from various settings (academic psychology departments, medical schools, and private practice) (Task Force on Promotion and Dissemination of Psychological Procedures, 1995).
Original Treatments Evaluated
The original list of treatments was developed by following the same criteria that the Food and Drug Administration used to determine drug efficacy. In keeping with this model of inquiry, the Task Force required that Empirically Supported Treatments had to be described in a manual, and the implementation of which, could be replicated by others, and proven to be effective with a specific mental disorder. Regarding the use of manuals for Empirically Supported Treatments, the Task Force on Psychological Interventions Division of Clinical Psychology had this to say:
What qualifies as a manual? In building this resource, we attempted to locate materials that provide sufficient detail to allow a trained clinician to replicate the treatment. Of course, no treatment manual is adequate in the absence of solid theoretical grounding and supervised training in the particular approach. Recognizing this, we have also included, when available, information about training in these approaches. We specifically excluded conference workshops as a training resource, because these workshops typically do not offer the opportunity for supervised experience (Sanderson & Woody, 1995).
In addition, rather than evaluating treatments without reference to particular disorders, or evaluating treatments as they applied across various disorders, the Task Force opted for a strategy of evaluating treatments according to their application to specific mental health disorders (e.g., exposure/guided mastery for specific phobia, brief psychodynamic therapy for depression). Eventually, the Task Force identified 18 Empirically Supported Treatments and 7 efficacious treatments from various orientations including behavioral, cognitive, and interpersonal.
The Task Force Report
The initial report of the Task Force was presented at the APA convention in the summer of 1993, and was subsequently adopted by APA’s Division 12 in the fall of that year. The Task Force report was adopted by the APA’s Council of Representatives in February, 1995, and later that year was published in Division 12’s newsletter, The Clinical Psychologist (Task Force on Promotion and Dissemination of Psychological Procedures, 1995).
Originally the Task Force used the term “Empirically Validated Treatments.” These treatments have also been referred to as “Empirically Supported” and “Empirically Based.” The 1996 report acknowledged that the term “Empirically Validated” may not be the most appropriate descriptor, and that the term “Empirically Supported” was preferable. Since that time this has been the designation preferred by the APA (personal communication, Division 12). In The Task Force Report, Training in and Dissemination of Empirically-Validated Psychological Treatments: Report and Recommendations, two primary categories of treatments were proposed: 1) well-established treatments and 2) probably efficacious treatments. A third category, experimental treatments (not yet established as at least probably efficacious) was also discussed (Chambless, et. al .,1998; Nathan & Gorman, 1998).
CHAPTER II: CRITERIA FOR TREATMENTS TO BE CONSIDERED EMPIRICALLY-SUPPORTED
The criteria used by the Task Force for determination of Empirically Validated Treatments included:
FURTHER CRITERIA FOR BOTH 1 and 2:
The criteria used to determine Probably Efficacious Treatments included:
CHAPTER III: EMPIRICALLY SUPPORTED TREATMENTS IDENTIFIED BY THE TASK FORCE
The list of ESTs from the original Task Force, and a brief description of some of the psychotherapies that have met the Division 12 basic scientific standards for effectiveness include the following, categorized by disorder being treated:
BULIMIA
Cognitive Behavioral Therapy
Treatment References/Manuals:
Fairburn, C.G. (1985). Cognitive-behavioral treatment for bulimia. In D.M. Garner and P.E. Garfinkel (Eds.) Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: Plenum Press.
Fairburn, C.G., Marcus, M.D., & Wilson, G.T. (1993). Cognitive-behavioral therapy for binge eating and bulimia nervosa. In C.G. Fairburn & G.T. Wilson (Eds.) Binge Eating: Nature, Assessment, and Treatment. New York: Guilford Press.
Description of Treatment: Treatment is based on a model that emphasizes the critical role of both cognitive and behavioral factors in the maintenance of the disorder. Of primary importance is the value that attaches to an idealized body weight and shape. This leads women to restrict their food intake in rigid and unrealistic ways, a process that leaves them physiologically and psychologically susceptible to periodic loss of control over eating, namely binge eating. Purging and other extreme forms of weight control are attempts to compensate for the effects of binge eating. Purging helps maintain binge eating by reducing the patient’s anxiety about potential weight gain and disrupting learned satiety that regulates food intake. In turn, binge eating and purging cause distress and lower self-esteem, thereby reciprocally fostering the conditions that will inevitably lead to more dietary restraint and binge eating. It follows from this cognitive model of the maintenance of bulimia nervosa that treatment must address more than the presenting behaviors of binge eating and purging. In addition, dietary restraint must be replaced with more normal eating patterns, and dysfunctional thoughts and feelings about the personal significance of body weight and shape must be altered. The cognitive model also suggests that treatment may need to address negative self-evaluation, perfectionism and dichotomous thinking, and perhaps also the ability to tolerate negative affect.
The commonly used form of cognitive-behavioral therapy (CBT) for binge eating and bulimia nervosa derives directly from Fairburn’s first formulation of this approach in Oxford in a treatment manual in the early 1980’s. A more recent, expanded version of this manual was published in 1993 (Fairburn, Marcus, & Wilson, 1993). Although there are differences in the ways in which cognitive-behavioral treatment has been implemented across different clinical and research settings, at the core, all are derived from the Oxford approach. It is the current Oxford manual that sets the standard for outpatient treatment of bulimia nervosa and is increasingly being adopted in major clinical research centers (Wilson, Fairburn, & Agras, in press). Wilson, G.T. (1997). Cognitive behavioral treatment of bulimia nervosa. The Clinical Psychologist, 50(2), 10-12.
Interpersonal Therapy
Treatment References/Manuals:
Fairburn, C.G. (1993). Interpersonal psychotherapy for bulimia nervosa. In G.L. Klerman & M.M. Weissman (Eds.) New Applications of Interpersonal Therapy. Washington, DC: American Psychiatric Press.
Description of Treatment
Interpersonal psychotherapy (IPT) is a short-term focal psychotherapy in which the goal is to help patients identify and modify current interpersonal problems. It was developed in the 1940’s as a treatment for clinical depression. More recently, it has been applied to other problems including recurrent depression, substance abuse, marital problems and eating disorders. In this paper its application to bulimia nervosa is considered.
IPT for bulimia nervosa resembles IPT for depression in its style and structure. Thus it is a non-interpretive, non-directive form of individual psychotherapy involving 15 to 20 50-minute sessions over four to five months. The treatment has three stages. In the first, the goal is to engage the patient in treatment, identify current interpersonal problems and establish a treatment contract. This usually takes three or four sessions. Three sources of information are used to identify the problems: first, an evaluation of the interpersonal context in which the eating problem developed and, more importantly, has been maintained; second, an assessment of the quality of the patient’s current interpersonal functioning; and third, as examination of the interpersonal context of individual bulimic episodes. This stage ends with the therapist and patient deciding which of the identified problems will be the focus of the remainder of treatment.
As originally developed, the second and third stages of the treatment are identical to IPT for depression except that the patient is put under more pressure to change. The eating disorder is not directly addressed: if it is mentioned by the patient, the therapist promptly shifts the focus on to its interpersonal context.
IPT for bulimia nervosa appears to be as effective as the leading treatment for the disorder (see below), a specific adaptation of cognitive behavior therapy (CBT) (Fairburn, 1981; Fairburn, Marcus, & Wilson, 1993). Since neither treatment is a panacea, there is a need to explore ways to enhancing their efficacy. A logical approach would be to combine the two so that both the eating disorder and accompanying interpersonal problems were directly addressed. Unfortunately this is not possible since the styles of the two therapies are so different as to make them incompatible. For this reason the author’s group now combines IPT with the use of a self-help program based directly on the cognitive behavioral approach (Fairburn, 1995). The patient follows the self-help program with the encouragement of the therapist whilst at the same time receiving IPT. This combination seems to work well.
Whether IPT for bulimia nervosa can be used in a group format is uncertain. A group version has been used by Wilfley and colleagues to treat obese patients who binge eat (Wilfley et. al., 1993).
Summary of Studies Supporting Treatment Efficacy
Two studies, both conducted by the author’s group at Oxford, provide the empirical support for using IPT to treat patients with bulimia nervosa. In the first (Fairburn, Kirk, O’Connor, & Cooper, 1986), cognitive behavior therapy was compared with a form of short-term focal interpersonal therapy. Patients in both treatment conditions improved substantially with the changes being maintained over a twelve-month treatment-free follow-up period.
In the second study, we replaced the original interpersonal treatment with IPT since it was similar in style and focus while having the advantage of being better established and there being a detailed treatment manual. The results indicated that CBT and IPT were equally effective (Fairburn, et. al., 1991; Fairburn, et. al., 1993). CBT was more rapid in its action with almost all the changes occurring during treatment itself, whereas with IPT the changes were more gradual but they continued during follow-up.
Taken together, the findings of these two studies suggest that short-term focal interpersonal therapy provides a new method for treating bulimia nervosa. It has yet to be established whether certain types of patient respond preferentially to this treatment as against CBT. Fairburn, C. G., (1994). Interpersonal psychotherapy for bulimia nervosa. The Clinical Psychologist, 47(4), 21-22.
CHRONIC PAIN
Cognitive Behavioral Treatment
Treatment References/Manuals:
Cognitive Behavioral Treatment for Arthritis Pain (Contact: Francis Keefe, PhD, Pain Management Program, Duke Medical Center, Box 3159, Durham, NC 27710). Turk, D.C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitive-behavioral perspective. New York: Guilford Press.
Description of Treatment
Cognitive behavioral treatment (CBT) for pain management is based upon a cognitive-behavioral model of pain (Turk, Meichenbaum, & Genest, 1983). The hallmark of this model is the notion that pain is a complex experience that is not only influenced by its underlying pathophysiology, but also by an individuals’ cognitions, affect, and behavior (Keefe & Gil, 1986).
CBT for pain management has three basic components. The first is a treatment rationale that helps patients understand that cognitions and behavior can affect the pain experience and emphasizes the role that patients can play in controlling their own pain. The second component of CBT is coping skills training. Training is provided in wide variety of cognitive and behavioral pain coping strategies. Progressive relaxation and cue-controlled brief relaxation exercises are used to decrease muscle tension, reduce emotional distress, and divert attention from pain. Activity pacing and pleasant activity scheduling are used to help patients increase the level and range of their activities. Training in distraction techniques such as pleasant imagery, counting methods, and use of a focal point helps patients learn to divert attention away from severe pain episodes. Cognitive restructuring is used to help patients identify and challenge overly negative pain-related thoughts and to replace these thoughts with more adaptive, coping thoughts. The third component of CBT involves the application and maintenance of learned coping skills. During this phase of treatment, patients are encouraged to apply their coping skills to a progressively wider range of daily situations. Patients are taught problem-solving methods that enable them to analyze and develop plans for dealing with pain flares and other challenging situations. Self-monitoring and behavioral contracting methods also are used to prompt and reinforce frequent coping skills practice.
CBT for pain management is typically carried out in small group sessions of 4 to 8 patients that are held weekly for 8 to 10 weeks. The groups are typically led by a psychologist or psychologist-nurse educator team. Keefe, F. J. (1996). Cognitive behavioral therapy for managing pain. The Clinical Psychologist, 49(3), 4-5.
CHRONICALLY MENTALLY ILL
Token Economy Programs
Treatment References/Manuals:
Ayllon, T., & Azrin, N. (1968). The token economy: A motivational system for therapy and rehabilitation. New York: Appleton-Century-Crofts.
Description of Treatment
A Token Economy is a treatment intervention based on operant conditioning and the principles of shaping behavior through positive reinforcement. The Token Economy was first proposed by Ayllon and Haughton (1962) in their work with schizophrenic patients who were refusing to eat properly. Patients were charged a penny to enter the dining room. The patients earned pennies by demonstrating socially appropriate target behaviors. In 1968 Ayllon and Azrin developed a more refined method. In this approach, a patient’s particular likes and dislikes are first identified, and are then used to reinforce socially approved activities. Patients are given tokens for such things as eating a meal or making their beds that can later be exchanged for privileges each patient may want. Tokens become conditioned reinforcers for target behaviors.
Token Economies are uses most frequently with psychotic patients and the developmentally disabled. Token economies have also been shown to be effective with juvenile delinquents, chronically disturbed adults, and children with conduct disorders.
DEPRESSION
Cognitive Therapy
Treatment References/Manuals:
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford.
Description of Treatment
Cognitive therapy for depression has its roots in the cognitive theory of depression (Beck, 1967). It is an active, structured, problem-focused, and time-limited approach to treatment which is based on the premise that depression is maintained by negatively biased information processing and dysfunctional beliefs. Treatment is designed to help patients learn to think more adaptively and thereby experience improvements in affect, motivation, and behavior. The efficacy of cognitive therapy for depression has been demonstrated in over 30 clinical trials (Dobson, 1989).
The general approach in cognitive therapy for depression involves guiding patients through a number of structured learning experiences. Patients are taught to monitor and write down their negative thoughts and mental images to recognize the association between their thoughts, feelings, physiology, and behavior. They learn to evaluate the validity and utility of these cognitions, test them out empirically, and change dysfunctional cognitions to reflect a more adaptive viewpoint. As therapy progresses, patients learn to identify, evaluate, and modify underlying assumptions and dysfunctional beliefs that may have predisposed them to depressive reactions. The therapist also teaches (or reactivates) adaptive coping skills such as breaking down large problems into smaller, more manageable steps, and decision-making by cost-benefit analysis. Activity scheduling, self-monitoring of mastery and pleasure, and graded task assignments are commonly used early in therapy to help patients overcome inertia and expose themselves to potentially rewarding experiences.
Cognitive therapy sessions follow a structure that includes a brief check on mood and symptoms, agenda setting, bridging from the previous session, reviewing homework (self-help assignments that patient does between sessions), discussing issues on agenda, setting new homework, and summarizing and getting feedback from the patient about the session. Cognitive therapists use a variety of strategies and techniques to help depressed patients address their thinking including psychoeducation, guided discovery, Socratic questioning, role-playing, imagery, and behavioral experiments.
Patients typically require about eight sessions to gain a reasonable level of mastery with the model and the skills involved. A significant reduction in symptoms often occurs during this initial stage of therapy. The remaining sessions are used to evaluate and modify dysfunctional beliefs that impair functioning and make the patient vulnerable to future depressive episodes, build relapse prevention skills, and discuss termination issues. Many patients show a remission of symptoms in 8-12 sessions. A full course of treatment is considered to be 14-16 sessions although severe cases can take longer. Maintenance of treatment gains is enhanced by occasional booster sessions during the first year after termination. Butler, A. C. & Beck, A. T. (1995). Cognitive therapy for depression. The Clinical Psychologist, 48(3), 3-5.
Interpersonal Therapy
Treatment References/Manuals:
Klerman, G.L., Weissman, M.M., Rounsaville, B.J., & Chevron, E.S. (1984).
Description of Treatment
Interpersonal Psychotherapy of Depression (IPT) was developed in the New Haven-Boston Collaborative Depression Research Project by Gerald Klerman, MD, Myrna Weissman, PhD, and their colleagues for the treatment of ambulatory depressed, nonpsychotic, nonbipolar patients. Over the past 20 years, IPT has been carefully studied in many research protocols, has been demonstrated to successfully treat patients with depression, and has been modified to treat other psychiatric disorders (substance abuse, dysthymia, bulimia) and patient populations (adolescents, late-life, primary medical care). It has primarily been utilized as a short-term (approximately 16 week) therapy, but has also been modified for use as a maintenance therapy for patients with recurrent depression.
IPT is based on theories emanating from the interpersonal school of psychiatry (H. S. Sullivan et al.) and empirical data related to attachment bonds and social roles. It was designed to be used without medication or in combination with anti-depressants. Many of the techniques used in IPT are familiar to practitioners of dynamic and supportive forms of psychotherapy. However it includes specific strategies such as assessing the symptoms of depression, relating the onset of the depressive inventory and selecting a focus for the treatment from the following problem areas: delayed/incomplete grief, role transitions, role disputes or interpersonal deficit. These tasks are usually accomplished in the first three sessions. The middle phase (sessions 4-13) is devoted to work on the specific problem area with the goals of alleviating the symptoms of depression and improving interpersonal relationships. In the termination phase (sessions 14-16) the course of treatment is reviewed, progress reinforced, feelings about ending the therapy addressed and future problems anticipated. Cornes, C. L., & Frank, E. (1994). Interpersonal psychotherapy for depression. The Clinical Psychologist, 47(3), 9-10.
ENURESIS
Behavioral Treatment
Treatment References/Manuals:
Azrin, N.H. & Besalel, V.B. (1979). A Parent’s Guide To Bedwetting Control. New York: Pocket Books.
Full Spectrum Home Training for Nocturnal Enuresis. (Contact: Arthur C. Houts, Department of Psychology, University of Memphis, Memphis, TN 38152).
Description of Treatment
Our best evidence from controlled studies shows that for monosymptomatic bedwetting, the treatment of choice is some type of behavior therapy that includes using a urine alarm device (Houts, Berman, & Abramson, 1994). One of these alarm based behavior therapies is called Full Spectrum Treatment. This treatment package was designed to be taught to families in a 90 minute professional consultation and then implemented in the home by parents.
All aspects of the treatment are spelled out in a manual given to parents, and the parents and child complete an explicit behavioral contract that specifies what each is to do to implement the treatment at home. For example, all procedures including the necessity to wake the child are specified in the contract section for using a body worn urine alarm. The protocol also incorporates Retention Control Training where the child practices holding back from the urge to urinate for longer and longer intervals until the child can successfully withhold for 45 minutes. Once a child attains 14 consecutive dry nights during treatment, a modified form of over learning is implemented until the child attains 14 additional consecutive dry nights. Over learning consists of having the child continue to use the alarm device while deliberately drinking larger and larger quantities of fluid immediately before going to bed. Houts, A.C. (1996). Behavioral treatment of enuresis. The Clinical Psychologist, 49(1), 5-6.
GENERALIZED ANXIETY DISORDER
Anxiety Management
Treatment References/Manuals:
Anxiety Management for Generalized Anxiety. (Contact: Secretary, Department of Psychology, Warnerford Hospital, Headington, Oxford, OX3 7JX).
Cognitive Behavior Therapy
Treatment References/Manuals:
Controlling Anxiety. (Contact: Secretary, Department of Psychology, Warnerford Hospital, Headington, Oxford, OX3 7JX).
Brown, T., O’Leary, T., & Barlow, D.H. (1994). Generalized anxiety disorder. In D.H. Barlow (Ed.), Clinical Handbook of Psychological Disorders: New York.
Description of Treatment
Cognitive-Behavioral Therapy is a combination of cognitive and behavioral approaches designed to help people reduce the anxiety reflected as obsessions and to reduce their compulsive behavior. Cognitive-Behavior Therapy techniques often include Exposure, which involves facing the situations that are most feared while implementing Response Prevention, or not allowing the client to perform the associated compulsive rituals.
Other cognitive-behavioral techniques include:
Settle, W. (2003). Lecture notes for obsessive compulsive disorder: Diagnosis and treatment. University Counseling Center, University of Notre Dame, Notre Dame IN, 46556. https://www.nd.edu/~wsettle/OCD_Lecture_2003.html, Retrieved 8/1/04.
PANIC DISORDER
Cognitive Therapy
Treatment References/Manuals:
– Barlow, D.H., & Cerny, J.A. (1988). Psychological Treatment of Panic. New York: Guilford Press.
– Barlow, D., & Craske, M. (1994). Mastery of Your Anxiety and Panic – II. Albany, NY: Graywind Publications.
– Clark, D.M. (1989). Anxiety states: Panic and generalized anxiety. In K. Hawton, P.
– Salkovskis, J. Kirk, & D.M. Clark (Eds.) Cognitive Behavior Therapy for Psychiatric Problems. Oxford: Oxford University Press.
– Salkovskis, P.M., & Clark, D.M. (1991). Cognitive treatment of panic disorder. Journal of Cognitive Psychotherapy, 3, 215-226.
Description of Treatment
Cognitive therapy for panic disorder is a relatively brief (8 to 15 sessions) treatment derived from the cognitive theory of panic disorder. According to this theory, individuals who experience repeated panic attacks do so because they have a relatively enduring tendency to misinterpret benign bodily sensations as indications of an immediately impending physical or mental catastrophe. For example, palpitations may be interpreted as evidence of an impending heart attack. This cognitive abnormality is said to lead to a “positive” feedback loop in which misinterpretations of body sensations produce increasing anxiety. This in turn strengthens sensations, producing a vicious circle that culminates in a panic attack.
Treatment for panic attacks starts by reviewing with the patient a recent panic attack and deriving an idiosyncratic version of the panic vicious circle. Once patient and therapist have agreed that panic attacks involve an interaction between bodily sensations and negative thoughts about the sensations, a variety of cognitive and behavioral procedures are used to help patients challenge their misinterpretations of the sensations. The cognitive procedures include identifying observations that are inconsistent with the patient’s beliefs, educating the patient about the symptoms of anxiety, and modifying anxiety-related images. The behavioral procedures include inducing feared sensations (by hyperventilation), focusing attention on the body or reading pairs of words (representing feared sensations and catastrophes) to demonstrate possible causes of patients’ symptoms, and stopping safety behaviors (such as holding on to solid objects when feeling dizzy) to help patients disconfirm their negative predictions about the consequences of their symptoms. As with cognitive therapy for other disorders, treatment sessions are highly structured. An agenda is agreed on at the start of each session, and repeated belief ratings are used to monitor within-session cognitive change. In addition, frequent summaries are used to guarantee mutual understanding. At the end of each session a series of homework assignments are agreed on as well.
Controlled trials in the United States, England, Germany, The Netherlands, and Sweden (see Clark, 1997, for a review) show that cognitive therapy is an effective treatment for panic disorder. Intention-to-treat analyses indicate 74% to 94% of patients become panic free, and the gains are maintained at follow-up. The effectiveness of the treatment does not appear to be entirely due to nonspecific therapy factors as three trials have found cognitive therapy to be superior to alternative, equally credible, psychological interventions.
Clark, D. M. (1997). Panic disorder and social phobia. In D. M. Clark & C. G. Fairburn (Eds.), Science and practice of cognitive behavior therapy (pp. 121-153). New York: Oxford University Press.
POST TRAUMATIC STRESS DISORDER
Cognitive Behavioral Therapy
Treatment References/Manuals:
– Clinical Handbook/Therapist Manual on PTSD. (Contact: Donald Meichenbaum, University of Waterloo, Department of Psychology, Waterloo, Ontario, Canada N2L 3G1, Phone: 519-885-1211, ext. 2551).
– Cognitive Behavioral Group Therapy for Social Phobia by R. Heimberg Contact: Karen Law, Center for Stress and Anxiety Disorders, Pine West Plaza, Building 4, Washington Avenue Extension, Albany, NY 12205).
Cognitive Behavioral Therapy involves a combination of behavioral approaches based on learning theories, and cognitive therapy revolves around the theory that our thoughts control a large part of our behaviors.
Group therapy is psychotherapy conducted with three or more individuals who generally share a similar concern or problem.
Social Effectiveness Therapy: A Program for Overcoming Social Anxiety and Phobia (Contact: Samuel M. Turner, Ph.D. or Deborah C. Beidel, Ph.D., Turndel Inc., Suite 200, 615 Wesley Drive Charleston, SC 29464).
CHRONIC HEADACHE
Behavioral Treatment
Treatment References/Manuals:
Blanchard, E.B., & Andrasik, F. (1985). Management of Chronic Headache: A Psychological Approach. Elmsford, NY: Pergamon Press.
DISCORDANT COUPLES
Behavior Therapy
Treatment References/Manuals:
– Jacobson, N.S., & Margolin, G. (1979). Marital therapy: Strategies based on Social Learning and Behavior Exchange Principles. New York: Brunner/Mazel.
– Baucom, D.H., & Epstein, N. (1990). Cognitive-Behavioral Marital Therapy. New York: Brunner/Mazel.
OBSESSIVE COMPULSIVE DISORDER
Behavioral Treatment
Treatment References/Manuals:
– Steketee, G. (1993). Treatment of Obsessive Compulsive Disorder. New York: Guilford Press.
– Riggs, D.S. & Foa, E.B. Obsessive compulsive disorder. In D.H. Barlow (Ed.), Clinical Handbook of Psychological Disorders. New York: Guilford.
SPECIFIC PHOBIA
Systematic Desensitization
Systematic Desensitization is a treatment in which a client is gradually exposed to increasingly anxiety-provoking stimuli while reducing anxiety with relaxation strategies. The goal of Systematic Desensitization is for the client to ultimately confront a fear or phobia without the anxiety that was previously associated with the stimuli.
Treatment References/Manuals:
Wolpe, J. (1990). Practice of Behavior Therapy (4th Edition). New York: Pergamon Press.
Exposure Therapy
Treatment References/Manuals:
Marks, I. (1978). Living with Fear. New York: McGraw Hill.
Information regarding the ESTs and their manuals taken from Sanderson WC, Woody S. (1995, 1996). Manuals for Empirically Validated Treatments: A Project of the Task Force on Psychological Interventions. Division of Clinical Psychology, American Psychological Association.
CHAPTER IV:CONTROVERSY GENERATED BY EST
As one might expect, a fair amount of controversy surrounded the original Task Force Report. While many saw this as a long-needed step in the right direction, others saw the report as premature, simplistic, and conceivably a plot to give complete control of the field of psychotherapy to managed care once and for all (Nathan, 1997).
Concerns and Contentions Associated with EST
Division 32 Response to the Report
In response to the Division 12 Task Force report, Division 32 of the APA (Humanistic Psychology) responded with a report of its own in 1997, Recommended Principles and Practices for the Provision of Humanistic Psychosocial Services: Alternative to Mandated Practice and Treatment Guidelines (Humanistic Psychologist, 24, 64-107).
From the Preamble to this document some of the opposing views are clearly articulated:
In these days of public accountability–a movement which humanistic psychologists who offer services to the public support—various groups are producing documents specifying guidelines for appropriate practice. Division 12 of the American Psychological Association has produced its criteria for deciding upon “empirically validated treatments,” (recently rechristened “empirically supported treatments”).
Humanistic psychologists are concerned about documents such as these because they privilege approaches that a) adopt a medical model view of psychological dysfunction and its remediation, b) are focused on symptom removal, and c) are technological in nature. Further, they are based on a particular model of science—a positivistic natural science method which many humanists view as more appropriate for examining the effects of drug treatment than for examining the complex inter-relationships that characterize humanistic (and many other) forms of psychotherapy. Humanists do not reject natural science research. However they do reject attempts to privilege such methods in the study of human behavior, and to set these methods up as the ultimate criteria for deciding upon the effectiveness of psychotherapy. Therefore humanists reject the idea that therapy must be studied as treatment-of-disorder, and that it must be manualized, the two central criteria of the “empirically supported treatments” guidelines of Division 12.
Humanistic psychologists do support the need for empirical research, and for the provision of services that have some evidence backing up their effectiveness. However, both natural and human science methods are of value and neither should be privileged over the other. Therefore, humanistic psychologists would be in favor of “empirically supported services,” only with different criteria than those specified by Division 12. A Task Force of Division 32 is engaged in an ongoing effort to specify such criteria.
A link to the full body of the aforementioned article, “Recommended Principles and Practices for the Provision of Humanistic Psychosocial Services: Alternative to Mandated Practice and Treatment Guidelines Task Force for the Development of Practice Recommendations for the Provision of Humanistic Psychosocial Service” appears at: https://www.academyprojects.org/alternatives.htm.
Division 12 Response to the Contentions
To their credit, the Division 12 Task Force has, from the beginning, considered itself to be an ongoing, fluid, and dynamic process, subject to change, revision, and development. As a result of the initial and ongoing complaints, the Task Force added an epilogue to their initial report addressing some of these concerns. They suggested research be ongoing, and readily acknowledged that their report represented a limited study. They suggested that the report was intended to be preliminary. They also noted that a variety of styles and formats may be appropriate for the treatment manuals.
In 1995, the Task Force was renamed the Task Force on Psychological Interventions and has subsequently become known as the standing Committee on Science and Practice (CSP) (Herbert, 2003). In 1996, this group published an updated version of the report (Chambless et al., 1996), that began with a series of qualifying remarks regarding the use of the list of empirically supported treatments. It ended with an addendum disclaiming any intention for the list of Empirically Supported Treatments to be seen as treatment guidelines and urging that the list not be misused in deciding payments for psychological services. Another update was published in 1998.
The Task Force continues to review treatments on a regular basis. These reports and additional information can be ordered through Division 12 office of APA (Division 12 Central Office, P.O. Box 1082, Niwot, CO, USA, 80544-1082). https://pantheon.yale.edu/~tat22/empirically_supported_treatments.htm, Retrieved 6/6/04.
CHAPTER V:IF NOT EST, THEN WHAT? COMMON FACTORS AMONGST EFFECTIVE CLINICAL INTERVENTIONS
Research has shown us that psychotherapy works, and that its effects are lasting (Wampold, 2001). The average patient in psychotherapy does better than 79% of patients who are not using psychotherapy. Research also shows that despite the therapy model or theoretical orientation it is the similarities between models of therapy rather than the differences that account for the effectiveness of psychotherapy (Miller, Duncan & Hubble, 1997).
These similarities or “common factors” have come to represent an important area of understanding in the field of psychotherapy. They have been recognized as crucial elements in successful therapy outcomes for some time (Rogers, 1951; Hubble, Duncan, & Miller, 1999; Ahn & Wampold, 2001), and studies indicate the existence of these common factors across therapies of all types (cognitive, dynamic), mode (individual, group, couples, family), dosage (frequency, number of sessions), or specialty (type of problem, professional discipline) (Hubble, Duncan, & Miller, 1999).
These common factors include the person of the therapist, the working alliance between the client and the therapist, the gaining of hope and expectancy of improvement, and the client’s own resources (Lambert, 1992).
Relationship or therapist’s factors include the therapist’s ability to develop a therapeutic alliance, therapist’s ability to be caring and empathic, ability to organize and take charge in session, therapist’s display of competence and self-confidence.
Other factors include hope and expectancy factors, client’s expectation that change is possible, client’s openness to therapist’s expressions of hope, therapist’s ability to intervene, therapist’s functioning as a model or example, therapist’s overall skill set, and therapist’s selection of treatment approaches.
Client factors include a client’s strengths, abilities, talents, individual coping skills, resiliency, extended support system, client’s theories of change, client’s state of readiness to change, and presenting problems.
In order to study these factors, John Norcross, president of APA Division 29, established a Task Force on Empirically Supported Therapy Relationships. Investigation by this Task Force emphasized the person of the therapist, the therapy relationship and the non-diagnostic characteristics of the patient (Norcross, 2001).
EST TASK FORCE REPORT
This research was summarized by Lambert and Barley (2001), and suggested that the focus of the studies conducted by the Division 12 Task Force accounted for no more than 15% of the variance in therapy outcomes (Levant, 2004).
On examining the factors that influenced therapy outcome, the therapy relationship and factors common to different therapies were found to account for 30%, patient qualities and extra therapeutic change accounted for 40%, and expectancy and the placebo effect accounted for the remaining 15%.
The differences between various models cannot account for the effectiveness of treatment. Rather, evidence accumulating for several years indicates that when two bona fide treatments are compared there is surprisingly little differences between the outcomes. It is clear from this and other studies that common factors and the areas of similarities between models play an important, if not definitive, role in determining successful psychotherapy results.
CHAPTER VI:THERAPIST FACTORS
Research (Wampold et al., 1997) and experience tell us that the client is the most important factor in determining psychotherapy outcome. A client’s personal attributes and resources are key ingredients to the therapy process, including such things as a willingness to persevere, an ability to be open to experience and growth, trust and faith, an optimistic attitude, a support group of family or friends, and belonging to a religious community. In addition, those fortunate happenstances and interactions that may occur between therapy sessions – a new job, a successful resolution to a problem, a chance reading of a useful book – all contribute significantly to therapy outcomes. While there is little we as therapists can do to effect the personal client factors, the therapist factors are well within our domain.
Numerous studies and examples show the importance of therapist factors. In 1981, Bloodstein analyzed 116 published reports of stuttering therapy and found that substantial improvement occurs as a result of almost any kind of therapy in about 60%-80% of cases. He concluded that the therapy itself, separate from what occurs in therapy, has considerable capacity for effecting change (Bloodstein, 1981). Blatt concluded that clients who experienced their therapists as empathic and caring were shown to have the best response to antidepressant medication (Blatt, et al, 1996; Schramm, 1994-2001). And Scott Miller, of the Institute of Therapeutic Change notes, “Research has consistently found that the influence of treatment models on psychotherapy outcome pales in comparison to the personal qualities of the individual therapist – in some studies being three times more important than the model or theoretical orientation of the therapist” (Luborsky et al., 1986).
But perhaps no discussion of client/therapist factors, and perhaps no discussion of manualized treatments for that matter, would be complete without mentioning Carl Rogers and the Client-Centered approach to therapy.
Rogerian Client-Centered Approach
Although not included in any of the empirically validated treatments, few psychologists have subjected themselves and the therapy process to more direct clinical observation than Carl Rogers (Rogers, 1961; Rogers, 1980). Rogers was one of the first psychologists to earnestly and openly study the process of psychotherapy. Through the use of recording devices, he taped numerous therapy sessions and, along with his colleagues, investigated the process of therapy and the components of therapy that produced positive results. These studies formulated the basis for Client-Centered therapy.As a manual for conducting psychotherapy, it is doubtful that a better handbook will ever be produced than that found in “Characteristics of a Helping Relationship” in which Rogers delineates the “necessary and sufficient conditions” for psychotherapy (Rogers, 1961).
Rogers felt that a therapist, in order to be effective, must have three very special qualities: 1. Congruence — genuineness, honesty with the client. 2. Empathy — the ability to feel what the client feels. 3. Respect — acceptance, unconditional positive regard towards the client. (Rogers, 1980, pp 114-117)
According to Rogers, if the therapist evidences these three qualities, the client will improve, even if no other special “techniques” are used. If the therapist does not demonstrate these three qualities, the client’s improvement will be minimal, no matter how many “techniques” are used (Boeree, 1998).
The degree to which Rogers has influenced the field of psychotherapy is difficult to overstate. His approach permeates the field to such an extent that most therapists take for granted the importance of the therapeutic relationship, the use of reflection, active listening, and bringing the most congruent “real” self to the therapy session one can muster. The more we can bring these elements to the therapy session, regardless of our treatment approach or orientation, the more we will be in a position to help our clients.
CHAPTER VII:PROS & CONS: EST vs. OTHER METHODS FOR STRUCTURING CLINICAL INTERVENTION
Empirically Supported Treatments, practice guidelines, and the ideas of standardized practice have been making their way into the field of psychotherapy for some time, and the debate over their applicability and usefulness will undoubtedly continue for the foreseeable future.
PRO EST
Supporters of the EST movement see it as a necessary step toward the scientific development of the field (APA Division 12: A Guide to Beneficial Psychotherapy), arguing that empirically validated treatments are based in an honest scientific method and are not subject to the biased opinions of patients or professionals, or information obtained from uncontrolled research studies or other uncontrolled sources of information. They fear the field of psychology, if left unchecked, will become an unruly mob and a mish mash of therapies with no limitations, forcing the field to open itself not only to traditional therapies but anything, and anyone, that purports to be therapeutic.
In addition, a growing number of practitioners not only favor ESTs but advocate that they be used exclusively (Lilienfeld, Lohr, & Morier, 2001; McFall 1996; Weissman & Sanderson, 2001), explaining that the practice of good science requires empirical validation of theories and treatments, and therefore no form of psychotherapy that is not clearly supported by empirical findings of its effectiveness should be sanctioned.
Proponents cite among their reasons:
(a) the need to conform to managed health care (MHC) requirements for reimbursements, (b) the superior quality of actuarial prediction over clinical judgment, the importance of adherence to the medical model of treatment, (d) the importance of continuity across training program requirements (cf.Task Force, 1995), (e) the need to minimize therapist bias, and (f) the importance of maintaining a professional status of psychology (Kendall, 1998; Deegear & Lawson, 2003). Finally, supporters accuse opposing voices of being anti-scientific (Levant, 2004). Pro-EST clinicians seem to believe that those who do not support Empirically Supported research prefer unsupported research and invalidated treatments, which, of course, is simply nonsense.
“Promises and Problems in Modern Psychotherapy: The Need for Increased Training in Evidence Based Treatments”, reviews the advances in specifying empirically validated treatments, and advocates the further study and teaching of EST’s in psychotherapy training programs. Review the following link for further elucidation of the Pro-EST argument: https://people.hofstra.edu/faculty/william_c_sanderson/macyfoundationpaper.htm
AGAINST ESTThose who oppose ESTs, in fact, point to years of research that confirm the value of common factors. Studies show that the type of therapy and technique used by psychotherapists add very little to therapy if not accompanied by these common factors (Hubble, Duncan, & Miller, 1999; Stubbs & Bozarth, 1994). In contrast, other research shows that adhering to EST protocols, specific ingredients in therapy, and manuals have little to do with outcome (Deegear and Lawson, 2003), and may even be detrimental to effective therapy (Castonguay et. al., 1996).
Furthermore, there are those who see the devotion to the scientific method itself as problematic. Two hundred years ago bloodletting was a standardized and sanctioned healing methodology for treating a variety of maladies. While there are some rare conditions in which the removal of blood can be beneficial, for the most part bloodletting is now considered a superstitious practice used by unenlightened practitioners of the past that did more harm than good. Yet, bloodletting represented the best science of its day. It is the nature of science that, over time, the best methodologies and practices will be replaced by other, more advanced and effective technologies. Paradigms shift, techniques develop, breakthroughs occur, and an increased understanding of the natural world is advanced. It is likely that two hundred years from now any EST developed in this era will be viewed with the same mixture of humor and horror with which bloodletting is now regarded.
The argument against ESTs can be further examined in “The Specificity Myth: The Fallacious Premise of Mental Health Treatment.” The article examines the field of Empirically Validated Treatments, and contends that mental health treatment in the United States is founded upon the faulty premise that there are specific treatments for specific dysfunctions. The following is a link to that article: https://www.personcentered.com/specificity.htm
Clearly it is possible to find research and hyperbole to bolster each side of the argument for and against ESTs. This may not be the result of maliciousness, hot tempers run amok, or poorly performed experiments, but may simply be a case of two very different mentalities, two separate visions that, like Kipling suggests in his Ballad of East and West, “never the twain shall meet.”
CHAPTER VIII:CONCLUSION
Every so often something comes along that promises to be a panacea in mental health: Biofeedback, Neuro-Linguistic Programming, Prozac, and EMDR are just a few. Perhaps the movement toward ESTs is just the latest incarnation of this hope and, like the others, after the excitement dies down, perhaps ESTs will find their place among the various therapy approaches.
However, it is fearfully possible that the search for ESTs will serve only to limit and reduce the field, corralling it into something quite unrecognizable to those of us now practicing. The EST movement may well prove to be simply an unfortunate and unsuccessful attempt to find simple answers to complex questions.
It is a mistake to think that the problems of living can be so easily equated to physical illness. The challenges of living a life do not readily lend themselves to the domain of random clinical trials, and the promotion of the medical model may simply be a futile attempt to squeeze the square peg of the human soul into the round hole of Empirically Supported Treatments.
Mental health is an ongoing process, much more akin to one’s religious life or working out at the gym than it is to going to the doctor. Who would go to church or temple for six visits and expect to be complete in their spiritual lives? Who would hire a personal trainer, work out five sessions, and expect to be in optimum physical condition with no more work needed? Yet, this is the model in which we now find ourselves conducting psychotherapy, and the model the EST movement would encourage even more.
While there are those who belittled the idea, we may have to come to terms with the notion that psychotherapy is, in the end, more art than science. If so, to carry this line further, it is also true that not everyone who picks up a brush is necessarily a good painter, much as they might want to be. The EST movement brings images to mind of painting by number. Unfortunately, even if you follow the directions perfectly, at best you will have a painting that looks like it came from a kit purchased at the drug store.
The move toward ESTs attempts to bring clarity and order to the field of psychotherapy with proven techniques and manualized road maps. Though perhaps the identification of ESTs was a noble and well-meaning effort, psychotherapy cannot truly be so simplified and compartmentalized. It is difficult and demanding work, often requiring trailblazing, spontaneous thought and action, and at times, demands that we fly by the seat of our pants. Psychotherapy is messy business, and if we are going to be of service to anyone we are simply going to have to get our hands dirty.
As therapists we often encourage our patients to feel their feelings, and to stay with their uncomfortable and difficult emotions. The trend toward ESTs attempts to let the field of psychotherapy avoid the adult work and responsibility of tolerating ambiguity, bearing the pain of uncertainty, and living with the humbling knowledge that we do not have all of the answers.
Of course, ultimately it is not answers that we need. If answers were the answer, we would need only to call Dr. Laura or my aunt Camille who would be only too happy to provide them! Instead, we need to cultivate the willingness and ability to be with another person in a supportive, genuine, and caring way. After all the studies and debate, after all is said and done, this is what has proven to be worthwhile.
REFERENCES