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

Child & Family Behavior TherapyPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/wcfb20

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.

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 & Family Behavior Therapy, 26:3, 37-51, DOI: 10.1300/J019v26n03_03

To link to this article: http://dx.doi.org/10.1300/J019v26n03_03

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & 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 & 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.

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 & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Issues and Controversiesthat Surround Recent Textson Empirically Supported

and Empirically Based Treatments

Howard A. Paul

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:<docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2004by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Empirically Supported Treatments (EST), EmpiricallyBased Psychotherapy (EBP), psychotherapy outcome, clinical efficacy

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.

Address correspondence to: Dr. Howard A. Paul, 1 Wedgewood Drive, North Brunswick,NJ 08902 (E-mail: emphap@optonline.net).

Child & Family Behavior Therapy, Vol. 26(3) 2004http://www.haworthpress.com/web/CFBT

2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J019v26n03_03 37

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

In 1993, a task force of the American Psychological Association’s (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 & 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 & Trafton, 2003). Nathan and Gorman’sgroundbreaking first edition already needed to be updated into its sec-ond edition (Nathan & 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.

Recent books such as Barlow’s Clinical Handbook of PsychologicalDisorders, third edition (2001) and Kazdin and Weisz’s 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 onEST’s, used the EST guidelines to highlight those many areas and pro-cedures of mental health service delivery that do not measure up to theguidelines.

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 Yeager’s 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.

38 CHILD & FAMILY BEHAVIOR THERAPY

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

This name imprecision extends to many of the other books on ESTsand EBPs. Barlow’s 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.

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.

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.

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

Howard A. Paul 39

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

example, highlighted in a review of O’Donohue 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 Bandura’s 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 Baer’s studies of the developmentally disabled were able to re-ceive long-overdue Federal support.

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

40 CHILD & FAMILY BEHAVIOR THERAPY

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

the very core of behavioral management of children. Early ground-breaking studies such as Zeilberger, Sampson and Sloan’s (1968) studydetailing the procedures of Time Out, and Paul’s (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.

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, yet thisrepresents a significant percentage of the practitioner’s caseload. An-other area of practitioner concern is addressed by Norcross in his book,representing the APA counseling division’s answer to Nathan and Gor-man. In order to qualify for a Type 1 study, treatment must be deliver-able at multiple sites by multiple practitioners in a similar fashion. Thisled to the development of manualized treatment, which has become thebane of many practitioners. One problem of manualized treatments isthat they exclude what many believe to be the prime ingredient in psy-chotherapy–the therapeutic relationship. Norcross was given the daunt-ing challenge to develop an evidence based rebuttal to the EST data,putting therapist and patient variables back into the context of effectivetreatment. Norcross sees the use of the “medical model” and the adher-ence to the drug model with RCTs as flawed and limited as it pertains to

Howard A. Paul 41

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

psychotherapy, given its ignoring of both process and interpersonaldata. Few therapists would take umbrage with Norcross’ goals. Alas,Norcross’ volume has its own flaws and only questionably reaches itsgoals, much to the chagrin of practitioners who earnestly believe in thereality of therapeutic experience and interpersonal processes. Norcrossnotes that his volume is composed of “practice friendly” research. Re-search can be neither friend nor foe and this bias is a fatal flaw in his ed-ited work. The criteria used for inclusion of supported work are alsoquestionable. To the scientifically bent practitioner, the most importantchapter in his book is the Appendix, which is not a narrative chapter,but, is a compilation of the data upon which the various rankings of effi-cacy used for his book are based. Meta-analyses were used to discrimi-nate effective vs. promising factors. A 5 point scale was developed with1 being studies with low relationship demonstrated, to 5 meaning a highand significant relationship was found. Studies with only an averagerating of 3 were deemed to merit the finding of effective. Those with rat-ings below 3 were labeled as promising. Norcross’s book, which repre-sents the findings of the APA’s Division of Psychotherapy’s Task Forceconcludes that their findings support the statement that the therapyrelationship makes a “substantial and consistent” contribution to efficacyoutcome. Many share the belief in the reality of their quest; however, acareful scrutiny of their data notes, at best, only moderate support. Whensupport does not even reach the moderate level, their euphemistically call-ing it promising, is troublesome. One can only hope that, as the challengesof psychotherapy process research are better addressed, clearer support willbe shown.

Even with these criticisms, Norcross’ work is important. The limita-tions are more a statement about the difficulties of psychotherapy pro-cess research than a negative reflection on the Editor and the variouscontributors to the Division of Psychotherapy’s Task Force. Norcross,an internationally recognized authority on behavior change and psycho-therapy, makes many valid points. He notes that the ESTs developedwithin the behavioral tradition are not mutually exclusive of compli-mentary data on interpersonal variables and would be additive, increas-ing the degree of control over outcome variance. An anecdote regardingthe potency of therapist variables can be found in a recent review (Paul,2003) of Norcross’ book. In the early 1960s when Thermal Biofeedbackwas being researched, scrupulous attention to detail and the followingof manualized protocol was maintained. All researchers tried to mini-mize therapist variables by wearing white lab coats, stood behind theexperimental subjects and read the experimental instructions from

42 CHILD & FAMILY BEHAVIOR THERAPY

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

prepared notes without expression or enthusiasm. No one was able toproduce any experimental effect and it was concluded that Thermal Bio-feedback could not be supported as an effective control modality. Oneday, due to the unavailability of a principal researcher, an inexperiencedlab assistant was called to run the experiment. This young graduate stu-dent, not being fully aware of the strictures of the protocol, stood infront of the subjects, had eye contact and spoke with enthusiasm. Whileall else had failed to demonstrate any feedback-assisted change, this in-dividual had success! Clearly, non-specific effects were at work.Manualized treatments aim again to eliminate these “confounds.” Wedo not have sufficient evidence to conclude that all treatment can be de-livered by less trained individuals using a manualized approach. Somefear that insurance companies, not used to scientific examination of re-sults would make mistaken bureaucratic conclusions and mandate treat-ment protocols based on the current state of EST research. Having saidthat, no practitioner can ignore the fact that some treatment protocolshave been developed with sufficient power to repeatedly prove their ef-ficacy, even when therapist variables are eliminated. Not using theseprocedures in cases where they are germane is, likewise, not therapeuti-cally appropriate.

We must keep in mind that EST research is in its infancy. It is of dra-matic importance that we have been able, using RCTs to demonstrateefficacy of some procedures for some diagnoses and some populations.The fact remains, however, that 50-80% of “cured” patents still retain re-sidual symptomatology. Empirically supported treatments impact at best,on only 50-70% of patients participating in the studies. The 30% left un-changed and the 20-50% left with significant residual symptomatologystill require further, and by definition, non-manualized treatments.

Barlow, in his excellent Clinical Handbook, makes the ongoing casefor both the art and science of psychotherapy. ESTs can focus only onthe science. Norcross attempted to focus on the art and as noted above,more work on that elusive domain needs to be done. While it is impor-tant to work within the context of clinical standardization where empiri-cal support has been demonstrated, working with individual differencesis a theme common to many of the newer texts on EST and EBP.Barlow’s Clinical Handbook is also unique for a behavioral text in thatit uses previously eschewed formats and is organized around DSM IVdiagnoses. Each chapter presents epidemiological data regarding thepathology being addressed and also addresses patient and therapist vari-ables as well as treatment settings (in-patient vs. out-patient). Co-mor-bidities with other disorders are also detailed. Prior to this work, most

Howard A. Paul 43

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

behaviorally-based books used a behavioral analysis, not a diagnosisbased analysis. Barlow and the many contributing authors in his volumewere able to show that in addition to behavioral assessment, a diseaseassessment was able to identify distinct treatment plans for many listedpathologies. Adherence to the DSM format and medical model makesthis a text valuable for not only psychologists and social workers, butalso makes his Handbook well suited for psychiatrists and medical resi-dency training programs. In Barlow’s Handbook, Miklowitz’s chapteron OCD also leans heavily on the medical model, with medication be-ing a key ingredient in the treatment protocol. Barlow, staunchly behav-ioral, includes non-behavioral treatments such as Gillies chapter onInterpersonal Psychotherapy (IPT), given its demonstrated clinical effi-cacy. Linehan, Cochran and Kehrer wrote the chapter on Dialectical Be-havior Therapy (DBT) for Borderline Personality Disorder. This chapteris one of the best and clearest presentations of Linehan’s theories.Linehan describes her theory as biosocial rather than biological or cog-nitive and the contextual base and empirical, heuristic distinctions arewell laid-out. Equally well done is her description of the dialectic pro-cess and its role in both understanding patients’ paradoxes and the de-velopment of treatment for dealing with dialectic polarities. As inAcceptance and Commitment Therapy (Hayes, Strosahl & Wilson, 1999)metaphor, parable, myth, analogy and storytelling are well presented.The section on validating the patient and providing a sense of under-standing and acceptance, is a gem, important reading for all therapistsregardless of orientation or modality.

Kazdin and Weisz’s book on Evidence-Based Psychotherapies forChildren and Adolescents is a recent and excellent example of how re-search on EST/EBP has influenced books now being written on psycho-therapy. This book is extremely relevant to readers of this Journal, givenits thorough covering of the child psychotherapy literature. This booksets a new standard for rigor, clarity and level of expertise. A world-class group makes up the panel of invited contributors. Each authorpresents information regarding how, why and for whom treatmentswork. Carrying the flame lit by Norcross, interpersonal, therapist andpatient variables are addressed. In stating the problem area, each authorwas asked to address the saliency of the disorder, both in clinical andhuman perspectives. The treatments presented are carefully detailedand in many cases where manuals can be purchased or obtained, sourcesfor their acquisition are provided. Directions for further research are in-cluded in each chapter. The first chapter of Evidence Based Psychotherapiesfor Children and Adolescents is by the Editors, Kazdin and Weisz. They

44 CHILD & FAMILY BEHAVIOR THERAPY

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

note that psychotherapy can be dated to as early as about 350 BCE. Theformal delineation of psychotherapy as a distinct area of study datesback about 100 years. Almost all discussions of the development oftherapy focused on adults. Freud’s early work on children was indirectand developed from his interviews with their parents, or in his workwith his own daughter. Anna Freud was a major contributor to the litera-ture on child psychotherapy by her direct studying of children and heradaptation of psychoanalytic concepts in child psychotherapy. Re-search on psychotherapy with children enjoyed a history of about 50years when Levitt (1957) identified 18 studies focusing on children andadolescents. By his 1963 review, 22 studies were identified. The resultsof those studies were not encouraging as no treatment, i.e., the passageof time, seemed equally effective to the treatments of the time. Thesedata were consistent with other adult findings of the time (Eysenck,1952) that about two-thirds of patients improved as did two-thirds ofthose on waiting list controls. As noted previously, the 1960s experi-enced a large number of studies utilizing the experimental analysis ofbehavior and single case, multiple baseline paradigms. Proof of efficacybegan to be developed, has grown exponentially and now includesRCTs and Type 1 studies.

Up to the last 100 years, culturally, children were simply seen assmall adults. This, fortunately, is no longer the case as researches writ-ing about child therapy are, more and more, sensitive to developmentalissues as well as developmental neuropsychiatric issues to which thera-pists would best attend. Within Kazdin and Weisz’s book, certain chap-ters and authors deserve special comment. Clark, Debar and Lewinsohnare to be commended for making their treatment manual available viathe internet and providing the URL for readers to acquire the manual.They, like others within the behavioral field, now acknowledge the roleof biological and developmental factors in the understanding, diagnosisand management of childhood disorders. ITP, mentioned in Barlow’sHandbook, also finds its way into Kazdin and Weisz’s book with achapter by Mufson and Dorta. They utilize a DSM approach to diagno-ses and, importantly, provide evidence how such diagnostic realities as“double depression” are moderators of treatment outcome. As Mufsonand Dorta present a style of treatment not know to many, more clarify-ing examples of therapy dialogue would have been helpful as wouldhave been an expansion and greater coverage of the background andframework of their theory.

Kazdin and Weisz asked each contributor to provide a section ad-dressing mediators and moderators of treatment outcome. Weisz, one of

Howard A. Paul 45

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

the Editors, along with co-authors Southam-Gerow, Gordis andConnor-Smith, in their chapter on depression provide detailed coverageof the moderating effects of skill deficits which are detailed and com-prehensive. Their detailing the importance of identifying individual dif-ferences and tailoring treatment procedures to fit the behavioral anddevelopmental characteristics of youth is exemplary.

In Kazdin and Weisz’s book, chapters are separated by recent nosologybasing disorders on internalizing and externalizing disorders. This is inagreement with recent neuropsychological data, which had identifiedtypologies of excessively inhibited and excessively excitable nervous sys-tems as the polarities of a continuum. Those with excessive cerebral inhibi-tion to stimulation are more vulnerable to develop externalizing behavioraldisorders such as ADHD and acting out disorders while those who are low incentral inhibition and therefore are reactive to external stimulation are sub-ject to various anxiety disorders. Anastopoulous and Farley provide uswith a well done chapter on ADHD reflecting current thinking, including notonly behavioral but neurobiological data in their discussion of moderators.They give an objective appraisal of the long-term efficacy of behavioraltreatment and integrate medical management and the efficacy of medicationinto their discussion.

Nathan and Gorman’s second edition highlights the rapidity with whichnew findings are now being generated. Even though this is a relativelynew edition, one must keep in mind that most of its citations are prior to2000, with a few from 2000. As noted, even in current texts, there is alag between findings and publication and even newer data exist thanthose presented in the latest volume or edition. Between 1998, the dateof the first edition and 2002, the date of publication for this second edi-tion, approximately 30% of the text was updated with new information.Nathan and Gorman kept the format of the first edition and juxtaposebehavioral and medical findings for the disorders presented. As inBarlow’s Handbook, a medical classification following the DSM is uti-lized making this a text for both medical and non-medical providers.Nathan and Gorman’s text is encyclopedic in its coverage as a referencevolume. It does not represent itself as a handbook, but the reader canreadily find an area of interest and be provided with citations and infor-mation regarding the state of the art at the time of that chapter’s writing.One is struck with the thoroughness of all the chapters and the care anddetail of presentation. Contrasted to the volume by Norcross which putsa summary of the data in an appendix at the end of the book, Nathan andGorman begin the book with a summary of the data on treatments thatwork and identify the standard of proof utilized and refer to the chapter

46 CHILD & FAMILY BEHAVIOR THERAPY

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

and its authors. Unlike Kazdin and Weisz, who provide a rationale for theorder and sequence of their chapters, Nathan and Gorman start withchildren, then geriatrics and then various pathologies without an apparentplan to their presentation. While their presentation may be random, it is cer-tainly thorough and covers Behavioral Disorders, various Anxiety Disorders,Psychoses, Affective Disorders, Obsessive Compulsive Disorders (OCD),Dissociative Disorders, Attention Deficit Disorders (ADHD), Eating andSleep Disorders, Sexual Dysfunction, Personality Disorders, Post TraumaticStress Disorders and Conduct Disorders including Substance Use Disorders andAlcohol Use Disorders. The author list is a “Who’s Who” of the various spe-cialty fields. Pharmacological management is paired with psychotherapeutic in-terventions in almost half of the covered topics.

Hinshaw, Klein and Abikoff provide a chapter on non-pharmacologi-cal treatments for Attention Deficit Hyperactive Disorder (ADHD).They review the pros and cons regarding comorbid anxiety as a modera-tor of treatment. While insufficient data exist, it does appear that chil-dren with anxiety do respond more favorably to behavioral manage-ment than low anxious children. This does make sense and fits withmore current thinking that as anxiety decreases, the severity of ADHDworsens and low anxious children tend to not respond to negative con-sequence, needing primarily reinforcement programming. Carefullylooking at the data, we encounter the sobering fact that 20-35% of chil-dren are non-responders. The literature is clear that a combined treat-ment of medication and behavior therapy produces the most robustgains. Classroom management and direct contingency managementproduce reliable, but situation specific gains with poor carryover toother circumstances. The involvement of family and community sup-port is a reliable mediator of increases in response. Kazdin documentsthe primacy of family input and participation in his review of psycho-logical treatments for Conduct Disorder. Greenhill and Ford deal withthe pharmacological treatments of childhood ADHD. They, too, dealwith anxiety comorbidity and note that data are mixed. They impor-tantly note that, at present, there are no neurological, physiological orpsychological predictors of medication success. Success of medicationin treatment of ADHD ranges from 70-90%. The data clearly supportmedication along with behavioral treatment in ADHD.

Another juxtaposition of behavioral and pharmacological chaptersplaces Franklin and Foa’s Cognitive Behavioral Treatment (CBT) ofOCD along with Dougherty, Rauch and Jenike’s chapter on Pharmaco-logical Treatment of OCD. The “gold standard” of exposure and re-sponse prevention (EX/RP) as the key behavioral intervention is well

Howard A. Paul 47

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

documented. The first line medical management of OCD with SelectiveSerotonin Reuptake Inhibitors (SSRI’s) is detailed. The data at this timeis described as “overwhelming” in support of SSRI usage. While bothCBT and SSRI’s produce identifiable gains, only behavioral and com-bined protocols lead to sustained gains. Barlow, Raffa, and Cohen notea very robust response to exposure presented as in-vivo desensitizationin the management of Panic Disorder (PD). A positive response rate of86% for in-vivo exposure plus CBT is noted.

Nemeroff and Schatzberg, dealing with Pharmacological Treatmentsfor Unipolar depression and Craighead, Hart, Craighead and Ilardi’schapter on Psychosocial Treatments for Major Depressive Disorder(MDD) present another medical-psychological face. Nemeroff and Schatz-berg’s chapter deserves careful reading. They note that, as with ADHD,there are no biological markers which assist in predicting treatment re-sponse to any particular antidepressant. Some initial work with the useof positron emission tomography may, in time, enable more accurateprediction of response to SSRI’s. Nemeroff and Schatzberg note thatwomen of childbearing age are routinely excluded from RCT’s as arethose with co-morbid medical disorders. This excludes over 50% of thepopulation from these studies. These authors look carefully at the crite-ria used for positive response and note than in most studies a 50% de-cline in Hamilton Depression Rating (HAM-D) or related scales islisted as a success. They correctly note that even though individuals canbe listed as positive responders, they may be left with significant resid-ual symptomatology. In CBT treatment of MDD typically 50-70% ofparticipants no longer meet DSM criteria for MDD. As with OCD, CBTor CBT plus medication led to more durable results.

Finney and Moos present an important chapter dealing with psychosocialtreatments for Alcohol Use Disorders. Until recently, no RCTs existed utiliz-ing AAs 12-step approach. They present some of the preliminary data, whichdoes support AA and similar 12 step programs as a valid partner to CBTand Motivational Enhancement Therapy (MET). Individual differencesare also emerging noting that skill teaching is a positive moderator in pa-tients with more severe psychiatric dysfunction, while communicationskills training is a positive moderator where individuals have less educa-tion, high anxiety or strong urges to drink.

In summary, we have come a long way, yet we have a long way to go.Researchers can take pride in the gains made over a relatively short pe-riod of time. We cannot, however, lose sight of the unanswered ques-tions and we must be circumspect in our utilization of EST data. ESTand EBP research, by nature of the criteria used to judge effectiveness,

48 CHILD & FAMILY BEHAVIOR THERAPY

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

can cut itself off from psychotherapy providers due to the format of theresearch itself, using manualized approaches and RCTs. While outcomeresearch has developed some robust procedures and findings, processresearch, being toothier, lags behind and is in need of more intensive de-sign and study. Unlike Lilienfeld, Lynn, and Lohr, who adopt a some-what therapeutically nihilistic stance, it appears to be premature to statecategorically that interpersonal variables don’t matter. They seem to takeus back to the conundrum of the Dodo bird, concluding that almost noth-ing works, so all must be equal. For those not familiar with psychotherapyresearch this reference will need some explanation. The term was put intouse in 1936 by Rosenzweig (1936) and alluded to the Dodo bird in LewisCarroll’s Alice in Wonderland (fitting for child and family therapists).The Dodo bird remarked that “All have won and all must have prizes.” Atthe time of Rosenzweig’s writing, there was no demonstrably superiorform of therapy and, in fact, no demonstration that therapy had efficacy,and therefore “all have won” as the Dodo bird remarked. For many years,this remark was still supportable. We do now have specific proceduresfor specific problems which are potent. This is a decided advance in thescience of psychotherapy. It is now incumbent on all who deliver treat-ment to be aware of and knowledgeable of these techniques and proce-dures and use them when appropriate. These ESTs tend to focus onanxiety disorders, including OCD and phobic behaviors as well as de-pressions. ESTs do not guide us as well with much of what adult patientsand clients present in a typical outpatient setting. It is here that interper-sonal and therapist variables remain important, if not yet fully docu-mented. More work is clearly needed. The recent concern regarding thetransfer of information from EST research into standard clinical prac-tice needs to be addressed by training institutions and the various fieldguilds and organizations who try to keep their members current andmaximally effective. The texts highlighted in this article are meant tobring what is known to the forefront so that the spirit of science and em-piricism can flourish and lead to more accurate treatments and greaterimpact in the field of psychotherapy.

SUMMARY OF PROS AND CONS OF EST/EBPS

Pros:

• Emphasizes utilization of protocols with proven efficacy.• Enhances use of scientist-practitioner model.

Howard A. Paul 49

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

• Enables the clear explication of treatment methods.• Emphasizes the reproducibility of results among various treatment

sites.• Encourages research into efficacy and component analysis of criti-

cal procedures.• Enables comparison of diverse treatments• Leads therapists to look at supported treatments from alternative

schools of therapy.

Cons:

• Even where EST/EBP has shown efficacy, there remains a sub-stantial (approximately 30%) number of individuals who are non-responders and of responders, many who are still symptomatic.

• Manualized presentation eliminates patient and therapist variablesfrom treatment variance.

• Presentation of EST data can inadvertently lead to an overzealouspresentation of real world efficacy and potentially can lead to un-toward insurance company demands for specific procedures whenthey are not appropriate.

• Reliance on RCT occasionally leads to ignoring of alternative re-search strategies with documented efficacy.

• The impact of EST’s has limited impact on “problems of living,”personality disorders and V code complaints.

REFERENCES

Barlow, D. (2001). Clinical Handbook of Psychological Disorders, Third Edition: AStep-by-Step Treatment Manual. New York: Guilford Press.

Eysenck, H.J. (1952). The effects of psychotherapy: An evaluation. Journal of Con-sulting Psychology, 16, 319-324.

Gordon, W. & Trafton, J. (2003). Best Practices in the Behavioral Management ofChronic Disease. Los Alton, CA: Institute for Disease Management.

Hayes, S.C., Strosahl, K.D. & Wilson, K.G. (1999). Acceptance and CommitmentTherapy: An Experiential Approach to Behavior Change. New York: GuilfordPress.

Kazdin, A.E. & Weisz, J. R. (Eds.) (2003). Evidence-Based Psychotherapies for Chil-dren and Adolescents. New York: The Guilford Press.

Levitt, E.E. (1957). The results of therapy with children: An evaluation. Journal ofConsulting Psychology, 21, 189-196.

Levitt, E.E. (1963). The results of therapy with children: A further evaluation. Behav-ior Research and Therapy, 60, 326-329.

50 CHILD & FAMILY BEHAVIOR THERAPY

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4

Lilienfeld, S.O., Lynn, S.J. & Lohr, J.M. (2003). Science and Pseudoscience in ClinicalPsychology. New York: Guilford Press.

Nathan P.E. & Gorman, J.M. (1998). A Guide to Treatments That Work. New York:Oxford University Press.

Nathan, P.E. & Gorman, J.M. (2002). A Guide to Treatments That Work, Second edi-tion. New York: Oxford University Press.

Norcross, J.C. (2002). Psychotherapy Relationships That Work: Therapists Contribu-tions and Responsiveness to Patients. New York: Oxford University Press.

O’Donohue, W.T., Henderson, D.A., Hayes, S. C., Fisher, J.E. & Hayes, L J. (2001). AHistory of the Behavioral Therapies: Founders’ Personal Histories. Reno, Nevada:Context Press.

Paul, H.A. & Miller, J. R. (1971). Reduction of extreme deviant behaviors in a severelyretarded girl. The Training School Bulletin, 67-4, pp. 193-197.

Paul, H.A. (2003) Book Review of: J. C. Norcross (Ed.) (2001). Psychotherapy rela-tionships that work: Therapist contributions and responsiveness to patients. NewYork: Oxford University Press. In Journal of Child & Family Behavior Therapy,25-4, 65-69.

Roberts, A.R., & Yeager, K. (2004). Evidence-Based Practice Manual: Research andOutcome Measures in Health and Human Services. New York: Oxford UniversityPress.

Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psycho-therapy. American Journal of Orthopsychiatry, 6, 412-415.

Tavris, C. (2003) The widening scientist-practitioner gap. In Lilienfeld, S.O., Lynn,S.J. & Lohr, J.M. (2003). Science and Pseudoscience in Clinical Psychology. NewYork: Guilford Press.

Zeilberger, J., Sampsen, S., & Sloan, H. Jr. (1968) Modification of a child’s problembehavior in the home with the mother as therapist. Journal of Applied BehaviorAnalysis, 1-1, 47-53.

RECEIVED: 02/01/04ACCEPTED: 03/01/04

Howard A. Paul 51

Dow

nloa

ded

by [

UO

V U

nive

rsity

of

Ovi

edo]

at 0

4:47

24

Oct

ober

201

4