What is going on with psychotherapy today?

Carolyn R. Fallahi, Ph. D.

Empirically Supported/Empirically Supported/Validated TherapyValidated Therapy APA’s Division 12 Task Force on the

Promotion and Dissemination for Psychological procedures has published a list of empirically validated treatments illustrating that there are efficacious treatments for specific psychological problems.

Is this list premature? What about therapies not included?

Randomized control Randomized control trialstrials

Randomized control trials (RCTs) The gold standard of research. Controversy surrounding this.

Efficacy vs. Efficacy vs. EffectivenessEffectiveness

Consumer Reports study in 1995 by Seligman.

Why are efficacy studies ideal? Efficacy studies versus effectiveness

studies. The Consumer Reports study led to debate

about how research could possibly help clinicians make informed decisions about therapy.

Evidence-based Evidence-based practice (EBP)practice (EBP)

EBP is similar to Evidence Based Medicine. Cochrane Collection.

Steps recommended Steps recommended by an Evidence-based by an Evidence-based

approachapproach 1) Pose a clinically relevant and specific

focused question about the care of a particular patient (e.g. which is the better treatment for major depression – therapy or medication?

2) Search on the internet for the evidence that best answers the question (or ascertains that there is no research available). The literature sources are multiple, but some are evidence-based reviews, such as the cochrane collaboration.

3) Select an article (or more) that contains the information that can answer your question.

Steps recommended Steps recommended by an Evidence-based by an Evidence-based

approachapproach 4) Evaluate and bring the research study to

the level of direct patient care. Validity: is the study valid? How sure can we be

that the results are due to the treatments and not to some other, uncontrolled variable? From most likely to least likely to be valid are systematic reviews and general information about therapy; meta-analysis, randomized controlled studies; cohort studies; cross-control studies; cross-sectional studies; case reports.

Outcomes: what were the result of the study? Based on outcome measures and rating scales used, can you calculate magnitude of improvement? Did the patient move into the normal range of functioning?

Steps recommended Steps recommended by an Evidence-based by an Evidence-based

approachapproach 5) Evaluate and bring the research study to

the level of direct patient care. Safety: is the treatment safe? Meaningfulness: are the results clinically

meaningful/ an the results of the clinical trial be applied to the individual patient?

Applicability: is the result applicable to the patient? Is the patient represented in the research sample? How were the outcomes measured? Can I apply the treatment in my practice?

Proponents of EBPProponents of EBP Those in favor of EBP

We can’t remember what we learned in graduate school.

We need to be knowledgeable about treatments. Learning EBP provides you with tools you need

to find the information conveniently and quickly. Amount of information available grows

exponentially; it is impossible to keep up with all of it. Errors will continue; know how to find what is needed to know where patients need the treatment.

Proponents of EBPProponents of EBP Those in favor of EBP

Total information available in the literature is far more powerful than expert opinion only.

Patient confidence will increase b/c the clinician can back up judgments with empirical findings in the literature.

The therapist can point to the evidence and use it to justify treatment to payers.

Close the gap between research and practice and the false dichotomy between them.

Proponents of EBPProponents of EBP Those in favor of EBP

Evidence goes hand-in-hand with clinical judgment.

The clinician learns how to evaluate evidence. Keep searching and eventually you will find

the most efficacious and effective elements of treatment.

Opponents of EBPOpponents of EBP Graduate school gives the basics; stay current on

your own. New treatments have always been publicized in

major journals and conferences, and word gets out when an effective treatment has been found.

Mental health should not be based on MEDLINE, cochrane, pschARTICLES, PSYCHINFO.

Most professionals can keep up by attending conferences and ordering key journals. They do not have to be researchers themselves.

Opponents of EBPOpponents of EBP Clinical expertise is the most important part of

treating, diagnosing, or assessing. The clinician is the one expert.

Payers should accept expertise as the bottom line. The patient is an individual who has faith in what

the therapist says, not in statistics and articles. The patient expects the therapist to use expert judgment.

There is too much reliance on pure research. Clinical judgment and expertise is superior to research findings on paper; the clinician is there, but the researcher is not.

Opponents of EBPOpponents of EBP There is a difference between research and

practice, and until researchers make the research meaningful, it is not of value to clinicians.

There is too much reliance on pure research. Clinical judgment and expertise is superior to research findings on paper; the clinician is there, but the researcher is not.

These tasks are too time-consuming. Clinician time is better spent working with patients.

One form of therapy is not necessarily superior to another. Look for common factors.