Jousting With Straw Men: Comment on Westen, Novotny, and Thompson-Brenner (2004).

Empirically supported treatments (ESTs) do not cure every patient, and the randomized trial is not a flawless methodology. Upon these often-noted and widely accepted points, D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004a; see record 2004-15935-005) built a critique of ESTs and EST research. However, important work developing effective, clinically relevant treatments for serious problems was omitted from the Westen et al. (2004a) review. Little documentation was offered for the purported "assumptions" of EST methodology that Westen et al. (2004a) criticized; and different review standards were applied to studies supporting versus those disagreeing with Westen et al.'s (2004a) views. Finally, the correlational research designs proposed as a remedy by Westen et al. (2004a) have far more serious weaknesses than randomized trials, thoughtfully applied to real-world clinical care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Healthy Dose of Criticism for Randomized Trials: Comment on Westen, Novotny, and Thompson-Brenner (2004).

D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004; see record 2004-15935-005) identified many important concerns in their critique of methods typically used in randomized controlled trials (RCTs) of psychotherapy outcome and by extension in methods of identifying empirically supported therapies (ESTs). Some of the concerns would be mitigated if empirical support of treatments were assessed multidimensionally (separating favorability of results from definitiveness of research methods used) and continuously rather than categorically. Other concerns can and should be addressed within the existing framework of RCTs and ESTs, including consideration of inclusion criteria other than a single Axis I condition, experimental evaluation of some of the procedural assumptions codified in psychotherapy manuals, and far more detailed reporting of RCT results. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the Merits of Clinical Judgment: Comment.

Comments on the article by D. Westen and J. Weinberger (see record 2004-19091-002), which criticized academic clinical psychologists for being cynical about clinical judgment and clinical practice. In our view, it seems unlikely that more than a few academic clinical psychologists believe that they have little to learn from clinical practice or experience. In this comment, we examine the arguments about clinical judgment made by Westen and Weinberger (2004). Westen and Weinberger (2004) conflate the effect of training with the effect of experience. Westen and Weinberger (2004) do not mention that the value of training in psychology has been well-supported by research. While Westen and Weinberger (2004) make positive comments about the types of feedback that clinicians receive, for a number of reasons, including the Barnum effect, psychologists can be misled by feedback. Westen and Weinberger (2004) also argue that "psychotherapists tend to have much more direct and immediate feedback than most other medical practitioners, who may prescribe a medication or perform a procedure and not see the patient again for a year" (p. 603). But when psychologists make a diagnosis or describe a personality trait, they frequently do not receive "direct and immediate feedback" on whether they are right or wrong. In contrast, physicians often receive highly valid feedback. Finally, in discussing the value of ratings made by clinicians, Westen and Weinberger (2004) observe that "empirically, we have found surprisingly little evidence of theory-driven observational bias in using clinician-report methods" (p. 601). The issue is important because Westen and Weinberger argue in favor of using clinician ratings to construct diagnostic criteria. If clinicians' ratings are biased, then the criteria will be biased. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The status of empirically supported therapies: Comment on Westen and Morrison's (2001) multidimensional meta-analysis.

In this commentary, a meta-analytic review by D. Westen and K. Morrison (2001) (see record 2001-05666-001) is put in a historical context of the controversies over the effects of psychotherapy. It is suggested that recalculations of the effects of psychotherapy have been common in past debates and that Westen and Morrison's estimates understate the effects of therapy. Data are summarized that suggest that outcomes in clinical practice are equivalent to clinical trials research, but only when patients receive similar levels of treatment and regardless of whether empirically supported therapies are offered. Treatment gains are generally maintained. It is suggested that outcomes management strategies would be far more efficient than efficacy and effectiveness research in maximizing patient outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Next Generation of Psychotherapy Research: Reply to Ablon and Marci (2004), Goldfried and Eubanks-Carter (2004), and Haaga (2004).

The commentaries on D. Westen, C. M. Novotny, and H. Thompson-Brenner's (2004; see records 2004-15935-005; 2004-15935-006; and 2004-15935-007) review suggest a number of questions, such as how an empirically informed clinician can integrate both applied and basic science into practice. The authors suggest recommendations for design and funding of psychotherapy research, including expanding the targets of intervention beyond categorical DSM-IV diagnoses, routinely comparing short- and longer- term variants of experimental treatments, revising funding mechanisms to facilitate the study of treatments and follow-up assessments of appropriate duration for the problems they are targeting, requiring at least one "dissenter" on every research team, discouraging exclusion criteria other than those a reasonable clinician would use in everyday practice, creating funding mechanisms for developing and testing treatments in the community, and including practicing clinicians among reviewers of grant proposals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beyond brand names of psychotherapy: Identifying empirically supported change processes.

There is considerable debate about which empirical research methods best advance clinical outcomes in psychotherapy. The prevailing tendency has been to test treatment packages using randomized, controlled clinical trials. Recently, focus has shifted to considering how studying the process of change in naturalistic treatments can be a useful complement to controlled trials. Clinicians self-identifying as psychodynamic treated 17 panic disorder patients in naturalistic psychotherapy for an average of 21 sessions. Patients achieved statistically significant reductions in symptoms across all domains. Rates of remission and clinically significant change as well as effect sizes were commensurate with those of empirically supported therapies for panic disorder. Treatment gains were maintained at 6-month follow-up. Intensive analysis of the process of the treatments revealed that integrative elements characterized the treatments: Adherence to cognitive-behavioral process was most characteristic, adherence to interpersonal and psychodynamic process, however, was most predictive of positive outcome. Specific process predictors of outcome were identified using the Psychotherapy Process Q-Set. These findings demonstrate how process research can be used to empirically validate change processes in naturalistic treatments as opposed to treatment packages in controlled trials. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials.

This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments (notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Empirically certified treatments or therapists: The issue of separability.

Forms of psychotherapy treatment are not neatly separable from one another in actual practice. They differ behaviorally in what they emphasize, but nevertheless they overlap and so cannot be unambiguously compared for effectiveness. Furthermore, forms of psychotherapy are not separable in practice from the therapists who apply them, so apparent differences in effectiveness between forms of treatment are always confounded by differences in effectiveness between therapists. Therapists, however, are separable from one another, and it is therapists not treatment forms that actually treat patients. Therefore, what should primarily be given preference in practice is not treatments empirically certified on the basis of their results in randomized clinical trials but psychotherapists empirically certified to practice on the basis of their results in actual practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Boulder model: A dream deferred—or lost?

Argues that contrary to the vision of the Boulder model for clinical training and practice, few clinicians undertake research or even read about it. The author contends that the infrequency with which clinical practitioners use clinical research continues to be a disappointment and an embarrassment to the discipline. It is concluded that the choice is not between empirically supported treatments and practice guidelines or the old days. It is between empirically supported treatments and practice guidelines developed by and for psychology or empirically supported treatments and practice guidelines developed by and for psychiatry. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the Need for a New Psychotherapy Research Paradigm: Comment on Westen, Novotny, and Thompson-Brenner (2004).

Basic, process, and outcome research have the potential to inform clinical practice. However, as D. Westen, C. M. Novotny, and H. Thompson-Brenner (2004; see record 2004-15935-005) observed in their timely analysis, the current dominant paradigm for psychotherapy outcome research--the randomized clinical trial--is not fulfilling this potential. The field's reliance on the medical model and manual-based interventions has contributed to the gap between research and clinical practice. Greater collaboration between practitioners and researchers, a focus on therapeutic principles rather than treatment packages, and systemic changes in how scholarly efforts are reinforced are needed to shift the current research paradigm. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies.

The authors report a meta-analysis of high-quality studies published from 1990-1998 on the efficacy of manualized psychotherapies for depression, panic disorder, and generalized anxiety disorder (GAD) that bear on the clinical utility and external validity of empirically supported therapies. The results suggest that a substantial proportion of patients with panic improve and remain improved; that treatments for depression and GAD produce impressive short-term effects; that most patients in treatment for depression and GAD do not improve and remain improved at clinically meaningful follow-up intervals; and that screening procedures used in many studies raise questions about generalizability, particularly in light of a systematic relation across studies between exclusion rates and outcome. The data suggest the importance of reporting, in both clinical trials and meta-analyses, a range of outcome indices that provide a more comprehensive, multidimensional portrait of treatment effects and their generalizability. These include exclusion rates, percent improved, percent recovered, percent who remained improved or recovered at follow-up, percent seeking additional treatment at follow-up, and data on both completer and intent-to-treat samples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Practice guidelines: Not yet ideal.

Efforts to identify empirically supported psychological treatments over the past half century have been strongly influenced by the development of more potent treatments and more effective outcome research methods. Practice guidelines incorporating empirically supported treatments proposed by the Agency for Health Care Policy and Research, the American Psychiatric Association, and the Division of Clinical Psychology of the American Psychological Association are described and critically assessed. Advocates for practice guidelines assert that they promote therapeutic accountability and motivate adoption of the best current practices; critics question their empirical bases, diverse standards of proof, and potential to constrain clinical decision making. These claims are critically examined, and when appropriate, solutions are suggested. It is clear, however, that the one solution that will not work is a return to the preguideline era. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Canadian professional psychology and empirically supported treatments": Commentary.

The impact on Canadian professional psychological treatment practices of the American Psychological Association's Division 12 (Clinical Psychology) Task Force's development of criteria and listings for empirically supported psychological treatments, along with other industrial efforts to standardize the identification of treatments with established efficacy is described in the article by J. Hunsley et al (see record 1999-01869-001). D. L. Chambless comments on the importance of having empirically supported treatments (ESTs) because many clients will not have the specific problems for which ESTs have been developed. In such cases, clinicians need to decide whether they are warranted in generalizing from the samples on which an EST is based, or whether they need to devise a novel approach. Also of importance is the therapeutic relationship or working alliance: a focus on ESTs should not be taken to mean that foundational issues such as the alliance can be forgotten. Training therapists should first learn basic therapeutic skills before learning more specialized ESTs. Other comments concern traditional training in Canada and a US trend of rejecting ESTs until more efficacy studies are completed of research-to-treatment generalizability. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality disorders.

There are effective psychotherapy treatments for personality disorder, and they come from a variety of theoretical and practical perspectives. No single approach has proved to be superior to any other, but all those empirically examined to date are superior to no treatment. There are essentially no data available from studies that directly measure the role of the therapy relationship in determining outcome. However, many successful treatments place the therapy relationship at the center of treatment for personality-disordered individuals. Empirically informed, rational analysis of successful treatments suggests that there must be a strong alliance supported by therapist respect for and validation of the patient. Clear structure that includes reasonable limit setting also is required. M. Linehan (1993) aptly called the simultaneous delivery of validation and blocking maladaptive patterns, the dialectic between acceptance and change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bridging the Gap Between Posttraumatic Stress Disorder Research and Clinical Practice: The Example of Exposure Therapy.

There are notable challenges in translating empirically supported psychosocial treatments (ESTs) into general routine clinical practice. However, there may be additional unique dissemination and implementation obstacles for ESTs for trauma-related disorders. For example, despite considerable evidence from randomized clinical trials that attests to the efficacy of exposure therapy for posttraumatic stress disorder, front-line clinicians in real-world settings rarely use this treatment. Perceived and actual barriers that interfere with adoption include clinician misconceptions about what exposure entails and complex cases to which ESTs may not be readily applicable. Specific suggestions for bridging the science-into-service gap in trauma ESTs (in general) and in exposure therapy (in particular) are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Deny nothing, doubt everything: A comment on Westen and Morrison (2001).

It is remarkable that so many important issues in psychotherapy research are touched on and, in some cases, more thoroughly explored in D. Westen and K. Morrison's (2001) meta-analysis (see record 2001-05666-001) and its discussion. Although no previously unanswered questions are resolved on the basis of their findings, original approaches to familiar questions are attempted and intriguing data are presented. Westen and Morrison's capacity to "think outside the box" while they seek to answer very familiar questions is most impressive. In the final analysis, the most significant outcome of Westen and Morrison's laudable effort can be that it might lead other psychotherapy researchers to do important things differently in the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Limitations of the dodo bird verdict and the role of clinical trials in psychotherapy research: Comment on Wampold et al. (1997).

B. E. Wampold et al.'s (1997) meta-analysis provides a useful and methodologically sophisticated summary of the results of comparative psychotherapy outcome research. Despite its strengths, some limitations of the meta-analysis that may have biased the results against finding differences between treatments are pointed out in this article. In addition, the types of treatments and patient populations to which the results can be generalized are clarified through an analysis of the studies contained within the meta-analysis. The importance of exceptions to the Dodo bird verdict is emphasized. Disagreements with Wampold et al. on the implications of the their meta-analysis for research and practice, in particular the role of clinical trials in psychotherapy research and the need for identifying treatments that are "empirically supported," are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Determining the pertinence of psychotherapy outcome research findings for clinical practice: Comment on Westen and Morrison (2001).

D. Westen and K. Morrison's (2001) article (see record 2001-05666-001) is a challenge to advocates of empirically supported therapies (ESTs) and to the research enterprise that has determined which therapies are given the EST designation. Their concern that the long-term effects of ESTs are understudied and, apparently, weak is valid. However, their pessimistic conclusions about the generalizability of the results from outcome studies of ESTs are based on a serious logical error. The authors of the present article described an alternative research method that can address important and appropriate questions about the generalizability of ESTs. Continued dialogue between proponents and opponents of contemporary trends in psychotherapy outcome research is encouraged. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improved treatment outcome associated with the shift to empirically supported treatments in an outpatient clinic is maintained over a ten-year period.

Recent years have seen an increase in emphasis on the use of psychological treatments that are supported by empirical data, as advocates have argued these treatments lead to better patient outcomes. We have previously shown that a shift to use of empirically supported treatments in a training clinic led to significant improvement in patient outcomes over four years (Cukrowicz et al., 2005). In the current study, we examined whether average patient outcomes at termination continued to be favorable over the six-year period following the initial shift. We examined data from 549 patients (M age = 25.78, SD = 10.08; 322 females and 227 males) treated prior to and after the shift to empirically supported treatments, all of whom were rated after termination using the Clinical Global Impression rating scale to track their improvement during treatment. The current study found that improvements in patient outcomes continued over the six-year follow-up period. Patients treated during the follow-up period had superior outcomes when compared to those treated following the initial shift to empirically supported treatments (effect size = .28, p