Empirically Supported Psychological Treatments: A Natural Extension of the Scientist-Practitioner Paradigm
Morin, Charles M., Canadian Psychology
This paper by Hunsley, Dobson, Johnston, and Mikail (1999) presents an excellent summary of a recent initiative from Division 12 (Clinical) of the American Psychological Association (APA) to identify and disseminate psychosocial treatments with adequate empirical support (Task Force on Promotion and Dissemination of Psychological Procedures, 1995). After presenting a historical overview of this initiative and a summary of the main concerns it has raised thus far, potential implications of this movement for Canadian professional psychology are discussed in relation to training, credentialing, practice, and research. Overall, this is an excellent working document providing a balanced coverage of the main arguments in favour of and against this initiative. Also, the recommendations made for the Canadian scene are reasonable. As I am generally in favour of any effort to develop and promote evidence-based practice in professional psychology, I have very few issues of disagreements with this paper. The comments that follow will focus primarily on why such initiative is necessary, what is (or should be) an empirically supported treatment (EST) and, what is the potential impact of this emerging trend.
Why is this initiative inevitable and necessary?
In this time of cost-containment and rationalization of health services, EST and evidence-based practice in general are both inevitable and necessary. We can no longer afford to use whatever seems to work; we must rely on psychological interventions that have some empirical support, even though they provide no guarantee to be effective with all patients and under all circumstances. We have an obligation to inform both the consumers and providers (students, trainees, clinicians) of psychological services about treatment modalities that have been evaluated in outcome research. Because of the growing number of alternative and sometimes esoteric interventions, it is particularly important to develop mechanisms to protect the public against inappropriate or premature usage of interventions lacking adequate empirical support.
The EST initiative is also critical to ensure that psychological treatments become part of the mainstream of the health care delivery system (Barlow, 1996). There is a growing trend to medicalize mental health problems (e.g., depression) and to promote pharmacological treatments, sometimes to the detriment of equally or more effective psychological treatments. This is often done on the basis of the apparent greater cost-effectiveness ratio of drug therapy. With the EST initiative, our profession could be in a better position to advocate a stronger place for psychological treatments in health care reforms and in clinical practice guidelines. Behavioural medicine is another area that would benefit from this initiative because several health-related problems (e.g., pain, insomnia) are treated predominantly, and sometimes exclusively with traditional medical treatments, even though significant advances have been made in the behavioural management of those conditions (Morin, 1996; National Institutes of Health, 1995).
An important concern raised against the identification of EST is that it may be too restrictive, and that a very limited number of therapies for very specific psychiatric disorders are on the "official list." The potential implication is that this information could be misused by insurance or government agencies to deny reimbursement and access to psychological care for treatment modalities that are not yet on this "official list." Although this is a valid concern, suggesting that we must proceed cautiously, an equally important question is whether the advantages outweigh those risks. I would argue that a greater danger would be to ignore such information on EST and that patients be treated with clinical methods that are not validated.
What is (should be) an empirically supported treatment?
Although it is difficult to argue against the merits of promoting evidence-based practice, several issues can be raised about the criteria used by the APA Task Force to define an EST. …