Issues and Controversies that Surround Recent Texts on Empirically Supported and Empirically Based Treatments

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<ul><li><p>This article was downloaded by: [UOV University of Oviedo]On: 24 October 2014, At: 04:47Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK</p><p>Child &amp; Family Behavior TherapyPublication details, including instructions for authors and subscription information:</p><p>Issues and Controversies that Surround Recent Textson Empirically Supported and Empirically BasedTreatmentsDr. Howard A. Paul PhD and ABPP and FAClinP a b c da American Board of Professional Psychologyb American Academy of Clinical Psychologyc Department of Psychiatry , Robert Wood Johnson Medical School, University of Medicineand Dentistry of New Jerseyd Graduate School of Applied and Professional Psychology, Rutgers UniversityPublished online: 08 Sep 2008.</p><p>To cite this article: Dr. Howard A. Paul PhD and ABPP and FAClinP (2004) Issues and Controversies that Surround Recent Textson Empirically Supported and Empirically Based Treatments, Child &amp; Family Behavior Therapy, 26:3, 37-51, DOI: 10.1300/J019v26n03_03</p><p>To link to this article:</p><p>PLEASE SCROLL DOWN FOR ARTICLE</p><p>Taylor &amp; Francis makes every effort to ensure the accuracy of all the information (the Content) containedin the publications on our platform. However, Taylor &amp; Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor &amp; Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.</p><p>This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms &amp; Conditions of access and use can be found at</p><p></p></li><li><p>Issues and Controversiesthat Surround Recent Textson Empirically Supported</p><p>and Empirically Based Treatments</p><p>Howard A. Paul</p><p>ABSTRACT. Since the 1993 APA task force of the Society of ClinicalPsychology developed guidelines to apply data-based psychology to theidentification of effective psychotherapy, there has been an increasingnumber of texts focussing on Empirically based Psychotherapy and Em-pirically Supported Treatments. This manuscript examines recent keytexts and comments on the issues and controversies surrounding thismovement. Possible reasons for limited transfer to the clinical setting ofmany psychotherapists are noted. [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: 2004by The Haworth Press, Inc. All rights reserved.]</p><p>KEYWORDS. Empirically Supported Treatments (EST), EmpiricallyBased Psychotherapy (EBP), psychotherapy outcome, clinical efficacy</p><p>Howard A. Paul, PhD, ABPP, FAClinP is Diplomat, American Board of ProfessionalPsychology; Fellow, American Academy of Clinical Psychology; Clinical AssociateProfessor, Department of Psychiatry, Robert Wood Johnson Medical School, Universityof Medicine and Dentistry of New Jersey; Field Supervisor, Graduate School of Appliedand Professional Psychology, Rutgers University.</p><p>Address correspondence to: Dr. Howard A. Paul, 1 Wedgewood Drive, North Brunswick,NJ 08902 (E-mail:</p><p>Child &amp; Family Behavior Therapy, Vol. 26(3) 2004</p><p> 2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J019v26n03_03 37</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>UO</p><p>V U</p><p>nive</p><p>rsity</p><p> of </p><p>Ovi</p><p>edo]</p><p> at 0</p><p>4:47</p><p> 24 </p><p>Oct</p><p>ober</p><p> 201</p><p>4 </p></li><li><p>In 1993, a task force of the American Psychological Associations (APA)Society of Clinical Psychology developed guidelines, aiming to applydata-based psychology to the identification of effective therapy. As anoutgrowth of that Task Force, the first book aimed at identifying Empir-ically Supported Treatments (ESTs) by Nathan and Gorman (1998) waspublished leading to a virtual explosion of similar works. EST guide-lines and handbooks have been published for geriatric patients, adults(Barlow, 2001) and of importance to readers of this Journal, children(Kazdin &amp; Weisz, 2003). The Division of Counseling Psychology ofAPA developed their own guidelines and resultant book (Norcross,2002) as did the other APA (American Psychiatric Association). ABest Practices Manual has recently been released in Behavioral Medi-cine, a two volume tome of 758 pages on neuropsychiatric and othermedical disorders (Gordon &amp; Trafton, 2003). Nathan and Gormansgroundbreaking first edition already needed to be updated into its sec-ond edition (Nathan &amp; Gorman, 2002). Texts not entirely addressingthemselves to an overview of ESTs have used the guidelines publishedfor ESTs to format their presentations. Many of the above cited texts havebeen reviewed in this Journal and some are in print.</p><p>Recent books such as Barlows Clinical Handbook of PsychologicalDisorders, third edition (2001) and Kazdin and Weiszs Evidence BasedPsychotherapy for Children and Adolescents (2003) utilize a critical re-view of the literature and presentation of material with a strong mind to-wards empirically based support. A related text by Lilienfeld, Lynn andLohr (2003) dealing with Science and Pseudoscience in Clinical Psychol-ogy is, in essence, a critical overview of EST and a broader application ofEST guidelines to many of the myths and sacred cows of psychologistsand psychotherapy belief. Their book, rather than being a book onESTs, used the EST guidelines to highlight those many areas and pro-cedures of mental health service delivery that do not measure up to theguidelines.</p><p>Roberts and Yeager (2004) have just released their Evidence-BasedPractice Manual: Research and Outcome Measures in Health and Hu-man Services, aimed at broadening the scope of Evidence Based Prac-tice (EBP) research and applying it to the field of Social Services. Thisis a far reaching and expansive volume covering a broad band of SocialService delivery issues. Roberts and Yeagers book contains over 100chapters broken into 11 sections. Even though it is titled a Manual, it ismore a resource compendium. Due to its scope, chapters are short andhighlight the selected field. Using this text, readers will be guided tomore extensively covered material in their particular area of interest.</p><p>38 CHILD &amp; FAMILY BEHAVIOR THERAPY</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>UO</p><p>V U</p><p>nive</p><p>rsity</p><p> of </p><p>Ovi</p><p>edo]</p><p> at 0</p><p>4:47</p><p> 24 </p><p>Oct</p><p>ober</p><p> 201</p><p>4 </p></li><li><p>This name imprecision extends to many of the other books on ESTsand EBPs. Barlows Clinical Handbook is more a resource text, eventhough it represents itself as a step-by-step treatment manual. Each ofits many chapters gives a concise overview of the literature and expla-nation of the treatment. Each chapter presents a summary of the treat-ment process. It is wise to keep in mind that each chapter represents atopic covered by textbooks dedicated to that area alone. Readers wouldbe remiss if they believed they had sufficient knowledge to providetreatment of a specific disorder from reading a summary chapter alone.While the same is true for the text by Kazdin and Weisz, their more ex-tensive presentations would give readers with a previous background inthe area increased capacity to utilize the information therapeutically. Acomplete review of Kazdin and Weisz is in press and will appear in thisJournal shortly.</p><p>Even books published within the last year, are 3-4 years behind thetimes. By virtue of the lag between writing and publication, even themost recently released book will have citations that are a few years old.Journals and conventions remain the best vehicle to stay on top of thelearning curve.</p><p>This article will look at many of these books (taking some informa-tion from book reviews prepared for this Journal) and will note theirstrengths and weaknesses. With some of the more recent and criticalbooks, extra care will be given to detail some of their highlights. Men-tion will be made of important chapters and interesting features, foci,and significant points. This paper will also look critically at the issuesand controversies surrounding EST and EBP guidelines, their usage,and impact on therapists.</p><p>With the advent of WWII, the scope and breadth of clinical practicefor those who were not psychiatrists began to grow exponentially.Along with this growth of service delivery there occurred a parallelgrowth of non-empirically based therapies both in and outside of psy-chiatry. Tavris (2003) uses the term social contagions to describewhat others have termed hysterical epidemics or moral panics to de-scribe the reasons behind the various therapies that proliferated in theU.S.A. and elsewhere. Cultures which are intolerant of ambiguity andhuman foibles, began to develop quick and, unfortunately, un-provenstrategies to deal with the myriad problems of living. Many ideas be-came popularly supported and a part of a cultural or pop-psychology.Researchers who tried to go up against many of these popularly sup-ported ideas found significant resistance to their research and, in somecases, both approbation or loss of academic position or funding. One</p><p>Howard A. Paul 39</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>UO</p><p>V U</p><p>nive</p><p>rsity</p><p> of </p><p>Ovi</p><p>edo]</p><p> at 0</p><p>4:47</p><p> 24 </p><p>Oct</p><p>ober</p><p> 201</p><p>4 </p></li><li><p>example, highlighted in a review of ODonohue et al.s A History of theBehavioral Therapies: Founders Personal Histories (2001) previouslypublished in this Journal, recounts the story of Albert Bandura, a world re-nowned researcher best known for his Social Learning Theory. Bandurawas invited to join an NIMH study section with one of his assigned dutiesto review research grants. Prior to Banduras presence on this NIMH panel,behavioral investigations were not funded, seemingly due to the fear ofsymptom substitution and the prevailing psycho-dynamic belief that itwould somehow be immoral to subject human beings to proceduresthat would inevitably harm them. After Bandura joined the panel,funding for Lovaas now well-known studies on autism and Bijouand Baers studies of the developmentally disabled were able to re-ceive long-overdue Federal support.</p><p>Until lately, it took both fortitude and perseverance to be a researcherin the field of psychotherapy efficacy. This was true not only because ofthe public hue and cry, but also because of the fact that no treatment pro-vided compelling data as to its efficacy. While today there is consensusthat there are specific treatments for specific problems that are empiri-cally supported, there remain significant rifts between researchers andpractitioners and practitioners and policy makers. The pendulum hasswung in favor of ESTs, however the prudent practitioner needs tomaintain a scientific mind, even towards ESTs and EBPs. Key ques-tions need to be addressed, including the pragmatic validity of the ESTguidelines, the purpose and use of EST findings and the real world ap-plicability of the findings, including their acceptance and transfer intothe therapeutic process. Nathan and Gorman, in both their initial andnow, Second Edition, as well as Norcross, are careful to look at the ESTguidelines and delineate their strengths and weaknesses. ESTs follow amedical model of double-blind studies. Nathan and Gorman outline thenow classic 6 levels of research study detailed in their volume and de-veloped by the APA task force. Type 1 studies are the most rigorous andinvolve randomized prospective clinical trials (RCT) with comparisongroups including a valid placebo, random assignment and blind assess-ment. Studies must also define clear exclusion and inclusion require-ments, detail their diagnostic criteria, be of sufficient size to have statis-tical power and have clearly specified and valid statistical processing.Interestingly, within the behavioral tradition, many studies of high re-search caliber are excluded as they utilize small group or single casestudies using ABAB designs. Applied behavioral analysis was a corner-stone of early behavioral research and literature. Multiple baseline de-signs became the foundation of much of the behavioral strategies now at</p><p>40 CHILD &amp; FAMILY BEHAVIOR THERAPY</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>UO</p><p>V U</p><p>nive</p><p>rsity</p><p> of </p><p>Ovi</p><p>edo]</p><p> at 0</p><p>4:47</p><p> 24 </p><p>Oct</p><p>ober</p><p> 201</p><p>4 </p></li><li><p>the very core of behavioral management of children. Early ground-breaking studies such as Zeilberger, Sampson and Sloans (1968) studydetailing the procedures of Time Out, and Pauls (1971) study on reduc-tion of extreme deviant behavior in a developmentally disabled childwould not be considered as reaching the level of proof needed to qualifyfor EST research. Ironically, Type 2 studies, which lack some of the as-pects of a Type 1 study and are of lesser power than an ABA study, havefound their way into the EST literature where no Type 1 study exists. In-terestingly, as patient pathology becomes more profound or, more typi-cally, represents the type of patient found in real-world out-patientpractice, being based on Axis II variables or V code problems, fewerType 1 studies exist.</p><p>Most EST research is targeted to a single diagnosis with dual diagno-sis being an exclusionary factor. This may be one of the reasons for thetepid acceptance of EST data into the treatment office as few patientscome into therapy with singular disorders as addressed in the EST andEBP literature. In reality, a large percentage of patients presenting fortherapy come with challenges not addressed in the literature. In areaswhere a vast HMO (such as Kaiser-Permanente in California) is theprime provider and individuals have access to treatment independent ofdiagnosis, more than 40% of clients are given V codes, rather than aDSM Axis I diagnosis. In areas where more traditional insurance willnot pay for V code disorders, almost 100% of clients will be given anAxis I disorder. The validity of diagnosis is a prime contaminant of ESTcarryover into treatment. It is clear that in many areas, diagnosis isdriven as much by payment method as it is driven by DSM IV criteria.The reader is well advised to remember that general angst and solutionsto problems of living are not addressed in the EST literature,...</p></li></ul>


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