by Michael D. Anestis, M.S.
As we have mentioned previously, one of the primary reasons Joye and I launched Psychotherapy Brown Bag was to draw attention to the gap between research and real world practices, and to increase the general public's understanding of the two. Ideally, this will lead to a dialogue between individuals from different perspectives and increase the overall level of care received by individuals suffering from mental illness. Today's article, in large part, will be interesting mostly to researchers and clinicians, but if you are neither of these, I hope you will consider reading further, as the focus of this article is relevant to anyone considering treatment. Unfortunately, what science tells us about treatments that work and what actually happens in real world practice are largely inconsistent with one another. The outcome of this issue will impact many individuals, particularly those in need of treatment.
One of our firmly held positions is that the use of empirically supported treatments (ESTs) is an ethical imperative. For those of you who do not frequently read PBB, ESTs are treatments that have been systematically studied and shown to be efficacious and/or effective as indicated by data collected during and after the study. In clinical settings, therapists use a wide variety of approaches to treatment. In all likelihood, the vast majority - if not all - of these therapists use their chosen therapy because they believe it works. The problem with this, however, is that not all treatments work and, of those that do, not all work equally well. This leaves the consumers - individuals struggling with mental illness - in a position that requires them to wade through a sea of options and hope that they have found the correct one. Proponents of ESTs aim to help consumers with that choice by providing documented evidence that indicates whether or not their treatments work, to what degree they work, and whether or not particular populations are best suited for one particular treatment versus another.
Unfortunately, for a variety of reasons, some of which I will mention later in this article, ESTs have not been universally implemented in real world practices. As a result, numerous researchers have made an effort to understand why this might be and in which settings ESTs are least likely to occur. Along these lines, Simmons, Milnes, and Anderson (2008) recently published an article in Eating Disorders that examined several such questions. Specifically, the authors wanted to see to what degree members of the Academy for Eating Disorders (AED) utilize ESTs in their practices when treating eating disordered clients, how much training they have received in ESTs, whether they would desire additional training, and what reasons they might have for not using ESTs. Division 12 of the American Psychological Association recognizes cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as ESTs for bulimia nervosa and binge eating disorder and the Maudsley model of family-based treatment as an EST for anorexia nervosa in adolescents and children. There is also compelling empirical evidence for the use of dialectical behavior therapy (DBT) in the treatment of bulimia nervosa and binge eating disorder. No other treatments have empirical support indicating that they are actually effective in treating eating disorders. The findings in this study, as you will see, reflect the strong gap between research and practice.
The authors mailed a survey to a total of 698 members of the AED, 677 of whom were currently actively seeing eating disordered clients and had supplied the AED with accurate contact information. 268 (40%) of those who were contacted returned completed surveys and were included in the analyses. From these surveys, the authors compiled the following data regarding the therapists:
| Sex | |
| Female | 86.20% |
| Male | 13.80% |
| Education | |
| Ph.D. Counseling Psychologists | 43.30% |
| Masters' Level Practitioners | 25% |
| Medical Doctors | 17.20% |
| Ph.D. Clinical Psychologists | 6.70% |
| Other | 7.10% |
| Theoretical Orientation | |
| CBT | 44.80% |
| Eclecticism | 21.60% |
| Psychodynamic | 7.50% |
| Interpersonal | 2.20% |
| Family Systems | 1.50% |
| Nutritional Counseling | 1.50% |
So, the majority of the participating AED members were female, the most frequent level of education was a Ph.D in counseling psychology, and CBT was the most frequently endorsed theoretical orientation (some of those who endorsed CBT also endorsed another orientation as well). 57.1% of those who responded indicated that they had received training in manual-based CBT or IPT, but of those with training, 50.7% reported that they did not use these treatments in their practices. This is a stunning finding, as it indicates that, even when trained in ESTs, many practitioners choose to use other treatments instead. The most frequently cited reasons for not using ESTs were the beliefs that ESTs are too rigid for real world practice and that manuals are not useful as well as a lack of training in ESTs and a theoretical orientation inconsistent with the use of manuals. Despite the hesitance to use ESTs in real world practice, 66% with prior training indicated that they would desire further training and 62% with no prior training indicated that they would like to be trained in ESTs.
In their follow-up analyses, the authors reported a few other interesting findings as well. Therapists who utilized ESTs had been in clinical practice for less time but were currently seeing a greater number of eating disordered clients. This might reflect the recent shift towards the use of ESTs, as a greater number of graduate programs are stressing training in ESTs and thus producing young scientifically-minded therapists more likely to integrate ESTs into real world practice.
Overall, these findings are troubling to me for a variety of reasons. First and foremost, they reflect the reality that very few individuals with eating disorders are actually receiving treatments that have been shown to work. Additionally, they reflect a fundamental lack of understanding of science, as many argue that ESTs are based on group findings that do not reflect individual clients even though group findings on average produce better results than do efforts to use intuition to guide individualized improvised approaches. Finally, they reflect a complete lack of accountability for therapists with respect to documenting that they are actually providing effective treatments. In the remainder of this article, I would like to outline a number of reasons why I believe the arguments against ESTs are problematic and the use of ESTs is an ethical imperative. I do realize, however, that these represent my opinion (and that of many esteemed colleagues) and welcome conversation that includes alternative perspectives. Everybody benefits from a more complete discussion of the issues.
ESTs are too restrictive for real world practice
Joye and I actually already addressed this issue in earlier articles (Joye's article - my article) on the evidence that ESTs produce results in real world practice that are as strong or stronger than those produced in controlled settings. The idea that manual-based treatments are too restrictive has never made sense to me and I think it simply reflects a lack of understanding of what manuals are and a lack of education with respect to ESTs. There is actually an immense amount of flexibility in ESTs. Manuals do not dictate what the therapist should say, how many sessions the therapist can spend on a particular skill, or what problems can be addressed in session. Additionally, for many diagnoses there are multiple ESTs, so if one does not seem to work, the therapist has alternative options available that might serve as a better fit for a particular client.
ESTs only address what the researcher thinks is important but mental illness is so much more than that
Clinicians are free to measure anything they want. If they think that a treatment such as CBT only addresses a subsection of symptoms and does not impact overall well-being, that is an important question to ask and the therapist can readily accumulate data that demonstrates these failings. The thing is, that data does not exist. Simply making claims with no evidence to support them is not compelling, particularly given that the health of clients hinges upon the use of effective treatments.
The studies that demonstrate the utility of ESTs are not representative of what we face in real world practice
There are two types of studies used to measure the utility of treatments. In efficacy studies, researchers look at the utility of treatments in controlled settings. For instance, to investigate the utility of CBT in treating bulimia nervosa, the researchers might exclude any clients that also meet criteria for another mental illness. Given that the majority of clients meet criteria for more than one diagnosis, this represents a threat to the external validity of the treatment - the degree to which the results generalize to the rest of the world. Several other restrictions are also often applied in these studies. The reason for doing this, however, is to first assure that the treatment has promise and that it is likely to translate to real world practice.
The second type of study - effectiveness studies - look at the utility of treatments in real world settings. Here, clients are not restricted and the results are more reflective of what occurs outside the lab. These studies are typically conducted after efficacy studies have indicated that a treatment holds significant promise. The thing is, thus far effectiveness trials have reported results that are just as compelling as those in the efficacy studies.
My clients are happy with treatment, so why should I change? Go back to your research and I'll go back to my clients.
This stance is not one I have heard often, but I have heard it, so it seems worthwhile to respond. The logic here is entirely flawed for a number of reasons. First, most researchers who run studies on treatment outcomes are also clinicians, so they don't need to go back to their clients. They're already there. In fact, they are the only ones in the argument who actually attend to both research and practice. It might make sense for the other individual to start reading research so that their argument can be informed rather than based purely on conjecture. Second, the most common number of sessions attended by a therapy client is one, meaning the vast majority of those who seek treatment drop out. I suspect the clinician is not asking those clients whether or not they were happy with treatment but rather basing their opinions on the memorable responses of clients who remained in treatment until a jointly agreed upon termination date. This represents a selection bias and, given the tendency for individuals who take this stance to point to the flaws in EST data, it seems a bit ridiculous to use this flawed data to support their own stance on the lack of importance of data. Additionally, a simple yes-no answer on overall happiness with treatment does not give us a measure of the degree to which symptoms have been reduced, treatment gains are maintained over time, and different areas of the client's lives are addressed relative to other treatments.
There are many questions to consider when weighing what type of treatment to use for a client with an eating disorder or any other mental illness. My hope is that, when clinicians choose to use treatments without empirical support, they take the initiative to compile data on that treatment. If the treatment works, the data will demonstrate that and researchers will advocate for its use. If a clinician is unable to produce any evidence for the effectiveness of a treatment other than vague reports of happiness from clients, it is irresponsible to ignore the mountains of evidence indicating that certain treatments are, in fact, highly effective.
My hope is that, if you maintain a different viewpoint on this issue than I do, this article has not offended you. In a perfect scenario, reading this will prompt you to comment, explaining your position and prompting others to respond to your comment, regardless of their positions on the matter. Communication is vital.
If you are looking to find a therapist who offers EST services, consult our EST clinics page. If you know of an EST provider not listed, email us and we will adjust the page accordingly.
If you would like to learn about training opportunities in empirically supported treatments, we recommend consulting the website for the Association of Behavioral and Cognitive Therapies, The Academy of Cognitive Therapy, and Behavioral Tech.
If you would like to read more about empirically supported treatments, we recommend the following products, all of which are available through our online store:
A Guide to Treatments that Work
Comprehensive Guide To Interpersonal Psychotherapy
Treatment Plans and Interventions for Depression and Anxiety Disorders
Cognitive Therapy Techniques: A Practitioner's Guide
Dialectical Behavior Therapy for Binge Eating and Bulimia
Cognitive-Behavioral Treatment of Borderline Personality Disorder
Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
