Evidence-Based Treatments

Within the past 15 years, the field of psychotherapy has wrestled with how to identify the type and nature of evidence that will allow one to validly determine if and when a treatment is likely to be helpful or harmful. Numerous factors, including concerns expressed both by individual citizens and their political representatives, the diverse and contradictory nature of many claims about psychotherapy efficacy and effectiveness, and the alarming number of instances of damage produced by psychotherapy as reported in the news media, fueled these discussions. The debate over how to define an “effective treatment” in the fields of counseling and mental health has revealed some significant schisms among those who adhere to different methods of researching and practicing psychotherapy and counseling.

While counseling and clinical psychology have always been concerned with identifying the effectiveness of psychotherapy, the topic rose to a visible level when the Society of Clinical Psychology (Division 12 of the American Psychological Association, or APA) initiated a task force to identify treatments for which research evidence on treatment efficacy was available. This task force was initiated in 1993 and issued its first report of empirically validated treatments (EVTs) in 1995, with subsequent reports being presented in 1996 and 1998. Each report contained a list of brand-name treatments that were judged to meet certain criteria of effectiveness for a particular diagnostic group. However, as the list of effective treatments grew with each report, so did the concern both with what treatments were still missing from the list and with how “effectiveness” was judged for those treatments that were listed.

Eventually, more than 150 different models and manuals of treatment were identified by different working groups and professional associations, as being “empirically supported.” Armed with the list of endorsed procedures, clinicians faced a daunting task in their search to provide help to the struggling consumer or to achieve demonstrable levels of competence in order to service those who sought their help.

To address criticisms that the original task force report was too restrictive and exclusionary, the initial term of empirically validated treatments was changed in 1998 to empirically supported treatments (ESTs). This term was thought to be less strident and narrow. Likewise, the criterion of empirical support was expanded from two independent controlled trial comparisons to a requirement that a treatment's value also should be supported by a preponderance of available scientific evidence. Unfortunately, these modifications did not address the types of concerns that were emerging with the Division 12 effort.

Increasingly, individuals raised concerns that the list of brand-named therapies favored narrow theories over important factors within the relationship and the participants (therapist and client). They argued that these extratherapy factors contributed to change at least as much as did the treatment model itself. Many scholars pointed out that head-to-head comparisons usually found that there were negligible differences among various treatments in the actual amount of change accounted for and that treatments, at best, accounted for only about 10% of the change that was observed in patients over the course of treatment. The scholars and practitioners who raised these concerns asserted the importance of a new way of assessing the nature of effective treatments, one based on an analysis of [Page 590]research on participant and interpersonal contributors to the therapeutic relationship itself.

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