FROM RESEARCH TO PRACTICE; Therapy by the Numbers?: Critics Claim ESTs Undermine Clinical Creativity

Article excerpt

The uncertain relationship between the art and science of psychotherapy has for decades been at the heart of many clinical researchers' misgivings about their therapist colleagues. According to these critics, too many therapists practice without the slightest attention to the research literature and the decades of findings regarding which therapeutic methods have proven effective for which kinds of problems. Rather than following the model of medicine, in which what is considered acceptable practice is shaped and refined by rigorous research procedures, the therapy field, its critics contend, has been shaped far more by persuasive innovators and intellectual fashions than by anything resembling scientific inquiry. As a result, important distinctions between untested methods and empirically proven approaches have been obscured.

In 1995, a task force acting under the auspices of the Division of Clinical Psychology of the American Psychological Association, a group that included many of the most prominent therapy researchers in the country, decided it was finally time to establish the scientific foundations of clinical practice. Under the direction of Diane Chambless of the University of North Carolina, they set out to establish clear, objective criteria to distinguish those treatment procedures that had been scientifically proven to be effective with specific psychological conditions from those that had not. Ever since, this ongoing task force has been responsible for issuing and updating a list of empirically supported treatments (ESTs), a kind of Good Housekeeping Seal of Approval for psychotherapies.

To  join the elite ranks of "well-established" therapies, a treatment method has to satisfy the following criteria:

* To make sure that approval of a treatment is not determined by the enthusiasm of a single investigator, two different and independent studies, each undertaken by a different researcher, must show the treatment to be more effective than no treatment, a placebo or an alternative treatment.

* To avoid any ambiguity about the therapeutic factors accounting for an approach's effectiveness, the method itself must be guided by a treatment manual that makes explicit the exact procedures and interventions to be used with each client.

* To establish with which specific treatment group a particular approach is effective, all the clients being studied must be shown to be suffering from the same psychological disorder (e.g. depression, anxiety, schizophrenia, chemical dependence, etc.).

Cognitive Therapy for Depression, developed by Aaron Beck of the University of Pennsylvania and colleagues, offers a clear example of the  typical stages of development involved in becoming recognized as an EST:

- A specific disorder was identified as the focus of treatment. Beck aimed the therapy at a distinct diagnostic category--depression and its specific symptoms. He also created a number of valid and reliable measures (most prominently, the Beck Depression Inventory) to quantify and assess the impact of his interventions.

- A step-by-step treatment strategy was developed. Beck and his colleagues identified a number of typical ways depressed people think, centered on their amplifying negative thoughts while minimizing their sense of competence. They then created a clear and replicable  treatment aimed at altering these thought patterns by teaching clients to logically examine their thoughts, develop more balanced self-talk, track their depressed feelings and behaviors  and increase their activity.

- A treatment manual was created to explicitly direct clinicians' interventions and decision-making. Beck and colleagues developed a treatment manual that purported to describe what interventions to deliver and when during the various phases of therapy.

-  Treatment effectiveness was clearly demonstrated. Beck and colleagues first showed that clients treated with Cognitive Therapy for Depression had fewer symptoms of depression than those who received no treatment. …