by Michael D. Anestis, M.S.
Intense couple of weeks research-wise, so I've been a bit slow on posting here. Today though, I wanted to quickly review a cool study coming out of my homeland at FSU. Several years ago, PBB guest author Kelly Cukrowicz and colleagues (2005) reported on the improved patient outcomes at the FSU psychology clinic once the clinic - which sees patients from the community with no restriction on severity of mental illness - transitioned to the mandatory use of empirically supported treatments (EST's). In this study, Cukrowicz, Katie Timmons, Kate Sawyer, Kelly Caron, Haley Gummelt, and Thomas Joiner (2011) examined whether those improved outcomes had been maintained now that 10 years have passed since the transition to an evidence-based approach to the treatment of mental illness.
In the introduction, the authors addressed a number of common concerns about the nature of EST's, the degree to which results from studies generalize to everyday practice, and other similar issues. We've discussed those issues at length on PBB, so I won't repeat them here, but feel free to express those concerns in the comment section and we can absolutely have a conversation about those issues there (all perspectives are welcome).
The authors analyzed data from 92 individuals treated at the clinic prior to the shift to EST's, 81 treated during the first four years after that transition (the sample considered in the initial publication), and 376 patients treated between 2002 and 2008.
As was the case in the previous study (Cukrowicz et al., 2005), the Clinical Global Impression scale (CGI; Guy, 1976) was used as the primary outcome variable. The CGI rating measures the degree to which a therapist feels that his or her patient improved over the course of therapy. Importantly, raters were blind to the purpose of this study. In other words, all therapists at this clinic provide CGI ratings when they terminate a case and this was not done specifically for the purpose of this study and, additionally, the therapists were not aware that this study would take place at the time they were making the rating. Nonetheless, there are legitimate concerns that therapists might be motivated to say their patients improved regardless of whether or not that belief is accurate. To account for that, blind raters reviewed a randomly selected group of files and provided their own CGI ratings. The intraclass correlation coeffecient - a measure of the degree to which two independent raters tend to agree on something - was significant, meaning that independent reviewers tended to provide highly similar ratings of improvement.
The authors' central hypothesis was that the improvements noted in the original Cukrowicz et al (2005) study would be maintained or improved upon at the 10-year mark. This was, in fact, supported by the data. Individuals treated after the transition to EST's exhibited better treatment outcomes than did individuals treated prior to the transition. Additionally, individuals treated since 2002 exhibited better treatment outcomes than did the individuals treated in the immediate transition period. This indicates that the improvements were not only maintained, but in fact increased. Importantly, the authors also noted that individuals treated after the transition to ESTs attended fewer therapy sessions, were diagnosed with a greater number of mental illnesses in general, and were diagnosed with a greater number of personality disorders. This is a big deal because individuals who attend fewer therapy sessions, who are diagnosed with a greater number of mental illnesses, and who meet criteria for a personality disorder have been shown to typically have worse outcomes. In other words, these improved outcomes were found despite the fact that the client base appears to have been at greater risk for worse outcomes.
The authors also examined whether individuals treated with cognitive or behavioral therapies exhibited better outcomes than individuals treated with other approaches and, in fact, the data indicated that this was the case.
There are some important things to consider here. Perhaps most importantly, the CGI is not the best rating. Ideally, there would be enough patients within each diagnostic category that the authors could make more specific comparisons (e.g., did individuals with depression treated post-2002 exhibit greater improvement on the Beck Depression Inventory after accounting for their scores at intake?). This, however, would be difficult given the divserity of the sample seen in the clinic, so the use of the CGI allowed for a comparison of a broader group of individuals. What this means is that, in general, EST's resulted in better outcomes; however, the data did not demonstrate that specific patient populations (e.g., individuals with bulimia nervosa) improved more in response to ESTs.
Ultimately, this study is not meant to close the book on the debate about EST's, but it is an interesting look at the impact of using evidence-based approaches in a community clinic featuring a severe group of patients. It is another example of high quality research being conducted in a clinical setting and further support for the importance of scientific-mindedness in therapy.
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If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.
Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University.
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