by Michael D. Anestis, M.S.
Over the past 11+ months, we have spent a substantial chunk of our time on PBB discussing empirically supported treatments (ESTs). From time to time, issues have come up regarding that discussion and we have done our best to respond to some points of contention in comment sections and follow-up articles. Today, I'd like to summarize a few points that tend to cause a bit of confusion, particularly given that some of them have come up in recent articles over the past couple of weeks.
What do you mean by empirically supported treatments?
ESTs are treatments that have been shown through scientific research to produce strong results for particular mental illnesses. The more times such findings are replicated in diverse populations by independent research groups, the more confident we become in that support. Click here to view the APA Division 12 website, which lists the research supporting each EST for each mental illness.
Generally speaking, randomized controlled trials (RCTs) are considered the "gold standard" approach to research. In such trials, participants are randomly assigned to receive one of the forms of treatment being researched in that particular study instead of simply letting the client pick the treatment or letting a therapist guess which treatment would be best. The reason for this is that scientists want to make sure that each treatment group is full of people who are similar to one another and that the differences between people are not influencing the outcome (e.g., people with more severe symptoms receiving one treatment and therefore making it look as though it performs worse than the alternative). RCTs are not perfect and many people raise important concerns regarding their use; however, no superior alternative is offered, leaving us with a strong but imperfect system.
To learn more about what we mean when we discuss "evidence" in research, I recommend clicking here. To learn more about what psychotherapy research trials look like, I recommend clicking here. That link will take you to an article in which I explain the differences between efficacy research and effectiveness research. In efficacy research, treatment is conducted in highly controlled settings in which a limited range of clients are able to participate. This helps scientists develop confidence that their treatment will work in "real life" settings before testing them on such samples. In effectiveness research, treatment is conducted in "real life" settings with a much broader group of participants. Such research helps us gain confidence that the results from early trials actually apply to the folks who typically walk into a psychotherapy clinic.
I don't believe cognitive behavioral therapy (CBT) works for everyone - this sounds like a "one size fits all" approach
This is a very important point to raise and it is completely understandable for you to feel a bit nervous about the EST movement if this is the impression you have of what ESTs are all about. In reality, a number of different issues are raised in this concern, each of which should be addressed separately.
As it turns out, CBT is not the only EST. A lot of research has been conducted on CBT and many of those studies have produced promising results. Importantly though, CBT is truly a class of treatments. CBT for one diagnosis is not identical to CBT for other diagnoses and even within a single diagnosis there are sometimes multiple forms of treatment that could be classified as CBT. All that being said, in some cases, CBT does appear to be the treatment that, on average, produces the best results for the greatest number of people (e.g., exposure and response prevention for obsessive-compulsive disorder). In other cases, CBT is only one of several equivalent and effective treatments for a disorder (e.g., depression) and in some other cases, CBT has not produced results that are really all that promising at all (e.g., anorexia nervosa).
So, as it turns out, nobody is saying that CBT will work for everyone or that it is always the treatment that should be chosen first. Instead, what advocates of ESTs are saying is that, when making a treatment decision, a therapist should first carefully assess the client to see which diagnosis or diagnoses he or she meets criteria for, then start off using the treatment that has the most evidence supporting its use for the symptoms that are causing the client the most distress and/or that put the client at the greatest risk to self and others. Sometimes that treatment will be CBT and other times it will not.
Even when CBT is the treatment of choice, however, this does not mean it will work for everyone. What research tells us is which treatments produce the greatest results on average for the largest number of people. Some people simply will not respond to that treatment just like some people do not respond to the medications for physical ailments that are typically the best choice and just like some individuals who smoke all of their life will never develop lung cancer. In any statistical relationship, there is variability, which means that what the results help us do is understand the most probable outcome, not to know for certain what will happen with every individual. So, EST proponents are simply saying:
"Let's start with the treatment that has the most support and regularly assess if it is working. If it isn't, let's try something else."
Nobody thinks that one size will fit all, but until we have a way to know ahead of time which clients will and will not respond to particular treatments, the only way to ensure the greatest results for the largest number of people is to start with treatments supported by research and then adjust from there if necessary.
If you would like to learn more about specific ESTs, click here to see the list of every article we have ever written on PBB that touches on this topic. Some articles, like this one, explain the EST concept overall and others talk about specific treatments and the research demonstrating the degree to which they tend to help people struggling from particular symptoms.
Somebody told me that it does not matter what type of therapy you choose, that what really matters is how you interact with your therapist
This point touches on two important issues: therapeutic equivalence and common factors in psychotherapy. We have touched on the therapeutic equivalence issue, also known as the dodo bird hypothesis, many times on this site. Rather than explain that issue here, I encourage you to click here and here to read more about it in past articles. Even though these are older articles, you can always leave comments in those comment sections and spark conversations that have been quiet for a while. We'll still see and respond to the comments and, if they spark a lot of interest, we'll publicize the conversation to draw more attention to it. In other words, if you have something to say, we'll do our best to make your voice heard on the matter.
The second issue, common factors, has also been the subject of a lot of attention on PBB. Specifically, we have spent a lot of time discussing the importance of the therapeutic alliance. If you click here and here, you'll see a number of articles we have written on this topic in which we look at the actual data that people have used to support the notion that the relationship one has with his or her therapist is more important than the specific techniques used in therapy. As you'll see, the data seem to support the notion that, for some treatments, alliance predicts future improvement whereas for others, symptom improvement comes first, after which clients tend to say that they have a strong alliance with their therapist. In other words, the importance of the alliance appears to depend upon which treatment is being used.
The bottom line, however, is that common factors like the therapeutic alliance and specific factors in particular treatments are not mutually exclusive. There is reason to believe that both are important. A therapist should work to ensure that he or she has a strong alliance with the client, but in order to produce the best results, that therapist should also utilize the specific techniques shown time and time again to produce the best overall results.
What do researchers know about psychotherapy? They're in a lab all day looking at numbers and I am not a number
I certainly can not argue that all of us researchers are great with people, but I suspect the same is true for all professions, including folks whose entire professional life is devoted exclusively to practicing psychotherapy. That being said, here's what I can say with confidence and hopefully these points will help you feel a bit better about the people conducting research on mental illness:
- All clinical psychologists with Ph.D's are trained in practicing psychotherapy. We all go through clinical practicums of various types while in graduate school and then have a clinical internship year before we receive our final degree. During that year, we work in clinical settings and spent the majority - if not all - of our time seeing clients. Data have demonstrated that individuals in research-based clinical Ph.D. programs accumulate, on average, the same number of hours accumulated in clinically-based Psy.D. programs (although there is certainly variability here) and perform at least as well on licensing exams. In other words, clinical training in these programs is quite strong.
- Many clinical psychologists who pursue a career as a researcher remain active as clinicians. This includes many of the most prominent researchers (e.g., Marsha Linehan, Thomas Joiner, Aaron Beck, Steve Hayes). In other words, the folks conducting this research are actually fully aware of the complexities involved in psychotherapy. In fact, the very reason they are doing this research is to remove some of the mystery involved in the process and to make it easier for us to ensure that we are providing the best care possible for the greatest number of people.
- There is no evidence that researchers think of clients as merely "numbers" or "the same as everyone else" any more than clinicians do. This is a statement that gets made quite often, but is not backed up by any evidence. Researchers are trained to understand numbers and to utilize sophisticated analytical procedures, but we are always acutely aware of the meaning of these numbers and that they represent individual people, each of whom brings his or her own unique life into the therapy room.
How can you research psychotherapy? You can't measure the soul and you can't summarize everything by listing a bunch of symptoms
Here again, some really important issues are raised, but some confusion clearly exists about what we are doing when we research psychotherapy and what we mean by "improvement." The idea that we can not measure everything that has to do with being human is an accurate one. Certainly there are aspects of life that are difficult if not impossible to measure. After all, we can't even universally agree on the meaning of a word like "soul." That being said, there are many things that we can measure, like the various symptoms of mental illnesses and the degree to which an individual is functioning effectively in their personal or professional life, and those things are very meaningful.
So the question really becomes, do we forget about the things we can measure simply because we can not measure everything or do we use the evidence we have and hope to develop ways to conceptualize the things that currently are outside our grasp? Scientists take the stance that it would be unwise to dismiss the importance of determining which treatments are best at decreasing debilitating and life threatening symptoms like suicidal ideation or behavior, panic attacks, depressive mood, anhedonia, mania, non-suicidal self-injury, binge eating, alcohol use, and many others. That being said, no therapist who utilizes ESTs kicks a client out of therapy if specific symptoms are addressed and the client still feels as though something requires attention. In other words, evidence-based psychotherapy does indeed focus on reducing (actually, hopefully eliminating) specific symptoms, but the therapist is also very concerned with less easily measured concepts. In a worst case scenario, once symptoms are relieved using a treatment based upon evidence, if the therapist feels unable to attend to a more vague sense of "discomfort" or "unease," the client can seek an alternative form of treatment from somebody who uses practices less likely to produce symptom improvement, but potentially more focused on these broader ideas.
Conclusion
Today's article by no means covers all of the issues that it could have. Plenty of other questions remain and Joye and I would love to hear thoughts you have that you believe went unaddressed here. If we have written on those topics earlier, we'll provide a link. If we haven't, perhaps you will inspire us to cover the topic at a later date. Regardless, my hope is that if you have concerns about research, we have addressed some of them, and that if you have a perception of researchers as uncaring or unaware of what psychotherapy really involves, you will re-examine that position. A lot of people within this field have very strong disagreements with one another on these issues, but I suspect that all of us are unified in our desire to help. What you find here today is an honest discussion of what we mean by evidence, and how it is applied in the world of mental health.
If you would like to learn more about empirically supported treatments or any of the other topics discussed on PBB, we highly recommend that you consult our online store for scientifically-based psychological resources.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
