Empirically Supported Treatment: Recommendations for a …

1 Empirically Supported Treatment: Recommendations for a New Model David F. Tolin, The Institute of Living and Yale University School of Medicine Dean McKay, Fordham University Evan M. Forman, Drexel University E. David Klonsky, University of British Columbia Brett D. Thombs, Jewish General Hospital and McGill University Over the 20 years since the criteria for Empirically sup- David Barlow, first published criteria for what were ini- ported treatments (ESTs) were published, standards for tially termed Empirically validated psychological treat- synthesizing evidence have evolved and more system- ments (Task Force on Promotion and Dissemination atic approaches to reviewing the findings from interven- of Psychological Procedures, 1993) and later termed tion trials have emerged. Currently, the APA is planning Empirically Supported psychological treatments . (Chambless & Hollon, 1998; Chambless & Ollendick, the development of treatment guidelines, a process that 2001).

2 The identification of Empirically Supported treat- will likely take many years. As an intermediate step, we ments (ESTs) has had substantial impact in psychology recommend a revised set of criteria for ESTs that will and related mental health disciplines. One immediately utilize existing systematic reviews of all of the available tangible effect of the movement to identify ESTs has literature, and Recommendations that address the been the validation of procedures for specific psycho- methodological quality, outcomes, populations, and logical problems, and the dissemination of that informa- treatment settings included in the literature. tion to practitioners, consumers, and other stakeholders Key words: clinical significance, Empirically sup- on the web ( ). ported treatment, GRADE tool, systematic reviews. [Clin Since (and perhaps in part due to) that early work, Psychol Sci Prac, 2015] the quantity of treatment outcome studies has increased dramatically.

3 A search of PsycINFO for the terms ran- domized controlled trial or randomised controlled CONSIDERATIONS IN THE EVALUATION OF Empirically trial (November 23, 2014) yielded only 20 citations Supported TREATMENTS: ARE Empirically Supported for the year 1995, compared to 123 in 2000, 427 in TREATMENTS STILL RELEVANT? 2005, and 950 in 2010. Among this increase in ran- Over two decades ago, the Society of Clinical Psychol- domized controlled trials (RCTs), we see a wide range ogy (Division 12 of the American Psychological Asso- of therapeutic approaches being evaluated for efficacy. ciation [APA]), under the direction of then President Since the development of the original list of ESTs, most of which were cognitive-behavioral treatments, efficacy trials for psychodynamic therapy (Milrod et al., Address correspondence to David F. Tolin, , Anxiety 2007), transference-focused psychotherapy (Yeomans, Disorders Center, The Institute of Living, 200 Retreat Avenue, Hartford, CT 06106.)

4 E-mail: Levy, & Caligor, 2013), family-based therapy (Lock et al., 2010), and interpersonal psychotherapy ( , Parker, Parker, Brotchie, & Stuart, 2006) have 2015 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association. All rights reserved. For permissions, please email: 1. appeared, to name a diverse few. The result has been a problem areas. This increased consumer education greater emphasis on empiricism among approaches that encourages clinicians who might otherwise not have previously lacked a history of accumulating research practiced in an Empirically Supported manner to support. This increase in diverse outcome research has acquire the necessary skills to begin offering scientifi- shifted the debate among practitioners of different the- cally based treatments. Perhaps the most ambitious oretical persuasions from mere assertions of theory to a illustration of the impact of the movement toward sci- consideration of empirical evidence.

5 Entifically tested treatments on clinical practice are the The quality of available research evidence has also National Institute of Clinical Excellence standards in increased substantially over the past 20 years. Detailed the United Kingdom (NICE; Baker & Kleijnen, 2000), and stringent guidelines have now been published established to ensure that clinicians practice specific and regarding the execution and reporting of methodologi- accepted Empirically based interventions for different cally sound treatment outcome studies (Moher, Schulz, psychological conditions (see http://guid- & Altman, 2001), and leading psychology journals such ). as the Journal of Consulting and Clinical Psychology Similarly, the Veterans Health Administration, which require that manuscripts adhere to such guidelines (re- serves nearly 6 million veterans in the United States, trieved November 23, 2014, from http://www.)

6 Has undertaken a complete overhaul of its mental ). These changes health practices and is implementing a systemwide dis- have led to a greater emphasis on study quality. Given semination of Empirically based treatments for posttrau- the emphasis on establishing procedures as Empirically matic stress disorder, depression, and serious mental Supported , guidebooks have been published that care- illness (Ruzek, Karlin, & Zeiss, 2012). fully document how to design sound therapy research Importantly, the early work on ESTs was an impor- investigations ( , Are an & Kraemer, 2013). Recently, tant catalyst for the APA's relatively recent emphasis on a review of trials of psychodynamic and cognitive-be- evidence-based practice (EBP). EBP is a broad template of havioral therapies, using a rating scale of various aspects activities that include assessment, case formulation, rela- of methodological quality and study reporting (Kocsis tionship factors, and treatment decisions that will assist et al.

7 , 2010), concluded that study quality and report- the clinician to work with a patient to achieve the best ing have been significantly improving over the past possible outcome. In 2006, a Presidential Task Force of four decades (Thoma et al., 2012). the American Psychological Association (APA Presi- The EST movement has led to changes in how stu- dential Task Force on Evidence-Based Practice, 2006). dents are trained in clinical practice. Although training adapted the Institute of Medicine's (2001) definition of programs still have a wide degree of latitude, EST lists evidence-based medicine, defining EBP as practice that help guide curricula and inform syllabi. Most promi- integrates three sources of information: patient charac- nently, the APA Commission on Accreditation's Guideli- teristics, clinical expertise, and the best available nes and Procedures (2013) encourages programs to train research evidence.

8 Students in assessment and treatment procedures based on It might well be asked, given the broad movement Empirically Supported methods, encourages placement in in psychology and other health disciplines toward EBP, training settings that employ Empirically Supported whether identification of ESTs is still a necessary task. approaches, and encourages internship training sites to We argue that it is, perhaps now more than ever. The include methods of demonstrating that interns possess three-legged stool of research evidence, patient char- intermediate to expert-level knowledge in ESTs. acteristics, and clinician expertise leaves room for Finally, the development of lists of ESTs has resulted debate about the relative importance of each; however, in greater protections for the public. By developing a we suggest that EBP is best approached as starting from list of established and Empirically Supported interven- the perspective of ESTs that is, for any given prob- tions, treatment-seeking individuals are now better lem, what treatment or treatments have proven effica- able to learn about and seek out information on cious?

9 This scientific information is then interpreted well-validated treatments for specific disorders and and potentially adapted based on clinician expertise and CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE 2. patient characteristics. Thus, where treatment selection problems in how research evidence is synthesized and is concerned, EBP might be thought of as an approach evaluated. The original Division 12 report on ESTs to ESTs, filtering that scientific information through delineated specific criteria (see Table 1) by which a the clinician's and patient's lenses (Djulbegovic & treatment would be regarded as probably efficacious . Guyatt, 2014; Tolin, 2014). or well established (Chambless & Hollon, 1998;. As a brief example, a clinician may want to select a Chambless & Ollendick, 2001; Task Force on Promo- treatment approach for an impoverished African Amer- tion and Dissemination of Psychological Procedures, ican man with a presenting complaint of depression, as 1993), and these criteria are still being used today.

10 In well as a significant drinking problem. Most likely, no brief, to meet the highest standard of well estab- published list of ESTs will match this situation per- lished, a treatment must be Supported by (a) at least fectly. However, using the filter system of EBP may two independently conducted, well-designed studies or lead to a helpful solution. Examination of the available (b) a large series of well-designed and carefully con- ESTs for depression alerts the clinician to the fact that trolled single-case design experiments. To meet the behavioral activation has strong empirical support in standard of probably efficacious, a treatment must be the treatment of depression (Lejuez, Hopko, & Hopko, Supported by at least one well-designed study or a small 2001; Lewinsohn, Biglan, & Zeiss, 1976; Martell, series of single-case design experiments. Addis, & Jacobson, 2001). The contributing research, Given the proliferation of clinical research over the however, did not address the present patient's charac- past two decades, the improved quality of clinical teristics such as socioeconomic status, race, and the research, and the adoption of more sophisticated meth- presence of a co-occurring substance use disorder.