Big Squeeze No research? No reimbursement
by Jay Lebow
In the last year, the influence of psychotherapy outcome research, not as something to be discussed only within obscure journals or to decorate an academic rZsumZ, but as a source of vital information having a crucial bearing on what actually goes on in therapists' offices, seems to have passed a tipping point. What was once a matter of interest only among a small circle of academics whose careers hinged on publishing little-read studies on treatment outcome has now become part of the national debate about healthcare reform, not to mention the focus of increasing scrutiny by multibillion-dollar insurance companies looking to exert more and more control over the procedures for which they'll make reimbursements. It seems likely that in the not too distant future, only research-supported treatments will qualify for insurance reimbursement. The fact that President Obama himself refers regularly to "evidence-based" healthcare is a clear indicator of the growing role research results will play in the future of psychotherapy.
The first major effort to list what were then called "empirically validated" psychotherapies--the official term has since morphed, first to empirically supported, and now to research-supported--was undertaken by a task force headed by University of Pennsylvania professor Dianne Chambless within the Division of Clinical Psychology of the American Psychological Association in 1996. To be officially recognized as effective, the task force decided that an approach needed to yield results beyond no treatment, or at least at the level of proven existing treatments, in at least two randomized clinical trials, each originating from different groups of investigators. Chambless and her colleagues chose the disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association as the focal problems about which to assess the impact of treatments. The task force produced two initial lists of approved treatments: one labeled "well established," and one more tentatively called "probably efficacious." Both lists consisted almost entirely of behavior therapies, the kind that had then been most studied within academia. Accordingly, most nonacademic clinical practitioners regarded the lists as irrelevant to their work and livelihoods, and largely ignored them.
Since 1996, the short list of empirically validated treatments originally provided by the Division of Clinical Psychology (although never endorsed by the American Psychological Association as a whole) has been vastly expanded and augmented by numerous other such lists, provided by organizations such as the Society of Clinical Child and Adolescent Psychology, The Cochrane Collaboration in Great Britain, the American Psychiatric Association, and evidence-based medicine websites such as Uptodate.com. The lists from these sources mostly agree about which treatments qualify; most are cognitive-behavioral approaches. Today, lists of treatments that have achieved the status of "well established" have grown exponentially, with groups of approved approaches now established for almost all DSM disorders, including agoraphobia, generalized anxiety disorder, depression, borderline personality disorder, sexual dysfunction, and alcohol abuse. Several states, including Washington, have taken the next step of mandating the use of only research-supported therapies in some of their mental health and juvenile justice programs. In addition, several countries, including Germany and the Netherlands, have tied payment of service to the practice of research-based treatments. Not surprisingly, increasing numbers of insurance companies are requiring, or considering requiring, practitioners to use research-supported methods to be reimbursed.
The good news in all this for psychotherapy is that our field has established a track record of broad empirical legitimacy, which will be crucial if we're to continue to have a place in the healthcare system. …