The Partners for Change Outcome Management System (PCOMS), otherwise known as CDOI, has jumped the first hurdle and is officially under review by NREPP (SAMHSA’s National Registry of Evidence-based Programs and Practices), and will soon be so designated on the NREPP website. This doesn’t guarantee that it will make the approved list but it looks very good given the research we have done, especially the RCTs (all three RCTs are available on the website). This will be, of course, quite a boon to the use of the ORS and SRS in everyday clinical practice and from my perspective quite a boost for involving clients as full partners in decisions that affect their care.

Speaking of research, there are several research projects that are in process: an RCT with returning veterans with PTSD related problems and substance abuse concerns is in the writing phase; an RCT with children with behavioral problems in the schools is in its second year of data collection; a comparison trial of residential treatment services with and without CDOI for clients with the “SMI” moniker is underway; an RCT with prescribers of psychotropic meds is in the planning stages; and a component study addressing why the feedback intervention works is also in the planning stages. I’ll keep you informed of the progress.

Along the lines of Sami Timimi’s “No More Psychiatric Labels” campaign to abolish diagnostic systems like ICD and DSM (Check it out at http://www.criticalpsychiatry.net/?p=527  Support the campaign at http://www.causes.com/causes/615071-no-more-psychiatric-labels/about), another project is underway that calls attention to the many pitfalls of the psychiatric diagnosis. I just signed their petition. Check it out: “Open Letter to the DSM-5″
http://www.ipetitions.com/petition/dsm5/?utm_medium=email&utm_source=system&utm_campaign=Send%2Bto%2BFriend

I really think this is an important cause, extremely well articulated, and I’d like to encourage you to add your signature, too. It’s free and takes just a few seconds of your time.

And, I want to call your attention to the Training of Trainers Conference in West Palm Beach, Florida from January 30 to February 3, 2012. There are still a few spots left so don’t miss out on this intense CDOI/PCOMS immersion as well as the fun and sun. I am convinced that the difference between successful and unsuccessful agency implementation boils down to having someone on site that knows the ins and outs of not only CDOI, but also the nuts and bolts of making it happen on an organizational level. Hope to see you there.

Finally, join me for this month’s webinar on ensuring data integrity and therapist understanding on November 23rd at 1PM Central. Join the member site to watch.

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A special issue of the Journal of Clinical Psychology: In Session (February, 2011) addressed a topic near and dear to the hearts of CDOI therapists: Adapting Psychotherapy to the Individual Patient (sic). Here are some highlights.

Preferences: In this meta-analysis, we summarize results from 35 studies that have examined the preference effect with adult clients. Overall, clients who were matched to their preferred therapy conditions were less likely to drop out of therapy prematurely (OR=.59, p<.001) and showed greater improvements in treatment outcomes (d=.31, p<.001). Type of preference (role, therapist, or treatment type) was not found to moderate the preference effect. These results underscore the centrality of incorporating patient preferences when making treatment decisions. Swift, J.K., Callahan, J.L. & Vollmer, B.M. Preferences. Journal of Clinical Psychology: In Session, 67, 155–165.

Matching client preferences or privileging client ideas is what CDOI is all about in general, and what exploring the client’s theory is about specifically–the client’s view of the problem and how it may be best addressed including the role of therapist and the choice of any given explanation of and remedy to the problem.

Expectations: Patients’ expectations have long been considered a contributory factor to successful psychotherapy. Expectations come in different guises, with outcome expectations centered on prognostic beliefs about the consequences of engaging in treatment. Our research review includes a comprehensive meta-analysis (N =8,016 patients across 46 independent samples) of the association between pretherapy or early-therapy outcome expectations and posttreatment outcomes. The overall weighted effect size was d=.24, p<.001, indicating a small but significant positive effect of outcome expectations on adaptive treatment outcomes. Constantino, M.J., Arnkoff, D.B., Glass, C.R., Ametrano, R.M., & Smith, J.Z. (2011). Expectations. Journal of Clinical Psychology: In Session 67, 184–192.

Enhancing client expectations for success is part and parcel to CDOI clinical work. Monitoring outcome and conveying that the therapy is about change builds on expectancy effects as does matching client preferences about intervention. The alliance, expectancy, and model/technique are interdependent and overlapping. Technique is the alliance in action, carrying an explanation for the client’s difficulties and a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of engendering the same response in the client. Indeed, you cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, you cannot have a positive expectation for change without a credible way for both the client and therapist to understand how change can happen. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes therapist-client fit and client participation, and is itself a core feature of therapeutic change

Culture: We present an original meta-analysis of 65 experimental and quasi-experimental studies involving 8,620 participants. The omnibus effect size of d = .46 indicates that treatments specifically adapted for clients of color were moderately more effective with that clientele than traditional treatments. The most effective treatments tended to be those with greater numbers of cultural adaptations. Mental health services targeted to a specific cultural group were several times more effective than those provided to clients from a variety of cultural backgrounds. We recommend a series of research-supported therapeutic practices that account for clients’ culture, with culture-specific treatments being more effective than generally culture-sensitive treatments.  Smith, T.B., Domenech Rodríguez, M., & Bernal, G. (2011). Culture. Journal of Clinical Psychology:In Session, 67, 166–175.

And of course, we believe that being outcome informed allows one to be more culturally sensitive. Privileging the client via practice based evidence levels the counseling process by inviting collaborative decision making, honoring client diversity with multiple language availability, valuing local cultural and contextual knowledge, and amplifying the voice of the disenfranchised.

Don’t forget the upcoming webinar: Become a CDOI Member!
Title: Barry Duncan – Therapeutic Work: It’s Not Just for Clients Anymore; Date: Monday, March 28, 2011;  Time: 12:00 PM – 1:00 PM CDT

The first annual Heart and Soul of Change Project Training of Trainers Conference occurs next week in West Palm Beach. It looks like a talented group of participants and I am excited to be a part of it. Bob Bohanske and Jacqueline Sparks, Project Leaders, will be joining in toward the end of the week. As I have reflected about what I thought the six most important things that the TOT should cover and what people should understand, I came up with the following list:

• Dodo Verdict: Implications for Psychotherapy as well as the EBT v. EBP Controversy
• Common Factors: The Heart (the Client) and Soul (the Alliance) of Change
• Rationale for Practice Based Evidence and the Power of Feedback
• The Predictors of Ultimate Outcome (Early Change and the Alliance)
• The Clinical Nuances of Using the Measures and Making them Meaningful to the Work
• The Keys to Agency Implementation including Culture Building, Integration at All Levels, and especially, Supervision

There are more to be sure and client privilege is built in to each of the above. But this seems to capture the stuff that forms the foundation of an understanding of client directed, outcome informed clinical work.

Speaking of the EBT v, EBP controversy, I did a webinar last Friday for the CDOI Members (now over 300 and growing). Here is the description:
In this seventh of seven webinars corresponding to the seven chapters of On Becoming a Better Therapist, Barry discusses the fifth and final step to keep your development on the front burner and accelerate your growth as a therapist, the Treasure Chest. This collection of client comments about your work with them and your own articulations of the experiences that meant the most to your development help you to re-remember why you became a therapist while tracking your development as a therapist through narrative accounts of the clients who taught you the most. Barry will also discuss the controversial issues of the day–managed care, evidence based practice, psychiatric drugs, and the medical model–and encourage you to take a stand to protect the aspects of your identity as a therapist that you hold dear.

Why am I telling you this if you not a member? Because I messed up when I presented it the first time and didn’t record the video portion of the presentation. Chalk it up to old age or whatever. So I had to do it over for the members but the good news is that it left me with an audio recording that I can make available to anyone interested. So here it is.

And speaking of the book, here is a review that appeared in Psychotherapy in Australia, by experienced clinician Bill Robinson.

The trend toward describing, researching, teaching, practicing, and regulating psychotherapy in the terms of the medical model (simplified by the equation: diagnosis plus prescriptive treatment = cure or symptom amelioration) began long ago. George Albee (2000) suggested that psychology made a Faustian deal with the medical model over fifty years ago. The deal was sealed, he asserted, at the famed Boulder conference in 1949, where psychology’s bible of training was developed with a fatal flaw:
[The fatal flaw]…was the uncritical acceptance of the medical model, the organic explanation of mental disorders, with psychiatric hegemony, medical concepts, and language (Albee, 2000, p. 247).

Later, in the 1970’s, with the passing of freedom of choice legislation guaranteeing parity with psychiatrists, psychologists (and later others) learned to collect from third-party payers using only a psychiatric diagnosis for reimbursement. Thereafter, drowning any possibilities for other psychosocial systems of understanding human challenges, the National Institute of Mental Health (NIMH), the leading source of research funding for psychotherapy, decided to apply the same methodology used in drug research to evaluate psychotherapy (Goldfried & Wolfe, 1996)—the randomized clinical trial (RCT) requiring both diagnosis and manualized treatments. Diagnosis reached its pinnacle. Now both reimbursement and research funding depended on it. Funding for studies not related to specific treatments for specific disorders precipitously dropped as both research and psychotherapy itself became more and more medicalized, and dependent on diagnosis, manualization, and RCTs for credibility.

Diagnosis is the beginning point, the foundation of the both the medical model’s simple equation as well as the RCT. Unlike with medical treatments, diagnosis is an ill-advised starting point for psychotherapy. Diagnosis simply lacks reliability. In an interview, Robert Spitzer, the architect of the DSM III, admitted:
“To say that we’ve solved the reliability problem is just not true…It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem” (Spiegel, 2005, p. 63).

In addition to underwhelming reliability, psychiatric diagnosis lacks validity. Allen Frances, lead editor of the fourth edition of the DSM, recently confessed, “there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it” (Greenberg, 2010, p. 1). Psychiatric diagnoses fail the most basic definition of validity—they lack empirical standards to distinguish the hypothesized pathological states from normal human variation or other disorders. Consequently, diagnosis always begs numerous, unanswered questions concerning cultural expectations and the role that power, privilege, gender, and race play in the identifying, cataloguing, and addressing client distress. The result is a set of murky over-inclusive criteria, often disadvantaging those who are racially or ethnically different, for an ever growing list of disorders (Duncan et al., 2004).

Finally and particularly germane to practitioners, diagnosis tells little about a person that is relevant to therapeutic change. Diagnosis in mental health is not correlated with outcome or length of stay (Brown et al., 1999; Wampold & Brown, 2005), and given the dodo verdict (see below) cannot provide reliable guidance to clinicians or clients regarding the best approach to resolving a problem. Diagnosis does not address what is most relevant to the helping process, namely the impact of the “disorder” in the client’s life and what can be done about it. Diagnosis also does not cover the range of reasons for which people seek therapy—relational, situational, and quality of life related, not symptom oriented. Nevertheless, the DSM, in spite of a long history of detailed critique (Carson, 1997; Duncan et al., 2004; Kirk & Kutchins, 1992), poor reliability and validity, and limited power to predict treatment outcome, lives on. It remains a fixed part of graduate training programs, a prominent feature of ESTs, and a prerequisite for funding in most mental health and substance abuse delivery systems—all engendering an illusion of scientific aura and clinical utility that far overreaches the DSM’s deeply flawed infrastructure.

Turning to the second part of the equation, that psychotherapists might possess the psychological equivalent of a “pill” for emotional distress resonates strongly with many, and is nothing if not seductive as it teases the desire to be helpful as possible to clients. A treatment for a specific “disorder,” from this perspective, is like a silver bullet, potent and transferable from research setting to clinical practice. Any therapist need only to load the silver bullet into any psychotherapy revolver and shoot the psychic werewolf stalking the client. Perhaps in its most unfortunate interpretation, clients are reduced to a diagnosis and therapists defined by a treatment technology—both interchangeable and insignificant to the procedure at hand

Consider the RCT. It was designed to compare the effects of a drug (an active compound) to a placebo (a therapeutically inert or inactive substance) for a specific illness. The basic assumption of the RCT is that the specific (unique) ingredients of different drugs (or psychotherapies) will produce different effects, superior over placebo, with different disorders. In effect, this assumption likens psychotherapy to a pill, with discernable unique ingredients that can be shown to have more potency than other active ingredients of other drugs.

There are three empirical arguments that cast doubt upon this assumption. First is the dodo bird verdict, which colorfully summarizes the robust finding that specific therapy approaches do not show specific effects or relative efficacy. In 1936, Saul Rosenzweig first invoked the dodo’s words from Alice’s Adventures in Wonderland, “Everybody has won and all must have prizes,” to illustrate his observation of the equivalent success of diverse psychotherapies. Almost 40 years later, Luborsky, Singer, and Luborsky (1975) empirically validated Rozenzweig’s conclusion in their now classic review of comparative clinical trials. The dodo bird verdict has since become the most replicated finding in the psychological literature, encompassing a broad array of research designs, problems, and clinical settings.

Three classic comparative clinical trials illustrate the dodo verdict. Ushering in the RCT in psychotherapy research was the Treatment of Depression Collaborative Research Program (TDCRP) (Elkin et al., 1989). The TDCRP randomly assigned 250 depressed participants to four different conditions: CBT, interpersonal therapy (IPT), antidepressants plus clinical management (IMI), and a pill placebo plus clinical management. The four conditions—including placebo—achieved about the same results, although both IPT and IMI surpassed placebo (but not the other treatments) on the recovery criterion. Project MATCH is the “largest and most statistically powerful clinical trial” in the history of alcohol and drug treatment (Project MATCH Research Group, 1997). Three widely divergent approaches were included: motivational enhancement therapy (MET), 12-Step facilitation (TSF), and CBT. The results revealed considerable improvement, but no differences in outcome emerged among the three approaches. Follow up ten years later (Tonigan et al, 2003) found no support for differential outcomes among the three therapies on percent days abstinent, drinks per drinking day, and total standard drink measures. In the Cannabis Youth Treatment (CYT) Study (Dennis et al., 2004), considered by many to be the largest and most methodologically sound investigation of adolescents to date, 600 adolescents were assigned either to treatment with MET plus CBT ( 5 or 12 sessions), family education and therapy, Adolescent Community Reinforcement Approach, or Multidimensional Family Therapy (MDFT). Comparisons between conditions found roughly equivalent significant pre-post treatment effects that were stable in terms of days of abstinence and percent in recovery by the end of the study.

Meta-analyses have yield similar results. A meta-analysis, designed specifically to test the dodo bird verdict (Wampold et al., 1997), included some 277 studies conducted from 1970 to 1995. This analysis verified that no approach has reliably demonstrated superiority over any other. At most, the effect size (ES) of treatment differences was a weak .2. “Why,” Wampold et al. ask, “[do] researchers persist in attempts to find treatment differences, when they know that these effects are small?” (p. 211).

The preponderance of the data, therefore, indicate a lack of specific effects and refute any claim of superiority when two or more bona fide treatments fully intended to be therapeutic are compared. If there are no specific technical operations that can be reliably shown to produce a specific effect, then prescriptive treatments in psychotherapy (i.e., mandating specific models and techniques for particular disorders) seems to make little sense.

The second argument shining a light on the specific ingredients assumption comes from component studies. Component studies, which dismantle approaches to tease out unique ingredients, have similarly found little evidence to support any specific effects of therapy. For example, a meta-analytic investigation of component studies (Ahn & Wampold, 2001) located 27 comparisons in the literature between 1970 and 1998 that tested an approach against that same approach without a specific component. The results revealed no differences. These studies have shown that it doesn’t matter what component you leave out—the approach still works as well as the treatment containing all of its parts.

A final empirical argument challenging the assumption comes from estimates regarding the impact of specific technique on outcome. After an extensive, but non-statistical analysis of decades of outcome research, Lambert (1986, 1992) suggests that model/technique factors account for about 15% of outcome variance. An even smaller role for specific technical operations of various psychotherapy approaches is proposed by Wampold (2001). His meta-analysis assigns only a 13% (derived from a .8 ES) contribution to the impact of therapy, both general and specific factors combined. Of that 13%, a mere 8% is portioned to the contribution of model effects. Of the total variance of change, only 1% can be assigned to specific technique. A consideration of Lambert’s and Wampold’s estimates of variance reveals that specific treatments do not account for 85% and 99%, respectively, of the variance of outcome. Other variables–the client, the therapist, and their relationship–account for far more of outcome variance. When taken in total–the equivalent results of comparative clinical trials and meta-analytic investigations, component studies, and analyses of the amount of variance attributed to specific effects –the evidence points in the same direction. There are no significant unique ingredients to therapy approaches and therefore little justification for basing psychotherapy on prescriptive or empirically supported treatments. Psychotherapy, therefore, has been shoehorned into the medical model.

But The Medical Model is not the Borg, nor am I Captain Picard fighting for the survival of therapists. Psychotherapy, however, is not a medical endeavor, it is a relational one. There is nothing wrong with the medical model. But it is not empirically supported nor an apt description of our work.

On another note, the last free webinar about my book, On Becoming a Better Therapist is coming up on January 21. Of course you can catch all the free webinars anytime here, but attending live allows you to ask that question you always wanted to ask or make a comment that occurred to you while you were reading the book. In any event, I hope you join me. Here is the info:

Dr. Barry Duncan – On Becoming a Better Therapist: Chapter Seven Discussion
On Becoming presents a five-step method of integrating outcome management with therapists’ long-term professional development. In this seventh of seven webinars corresponding to the seven chapters of the book, I present the fifth step to keep your development on the front burner, the Treasure Chest. I’ll also discuss the controversial issues of the day as they pertain to your identity as a therapist: managed care, evidence based practice, psychiatric drugs, and the medical model. We’ll begin with a 25 minute overview followed by your questions, comments, and reflections. My hope is that the book and these discussions will inspire you to rediscover purpose in your work and become a better therapist.
Friday, January 21, 2011, 6:00 to 7:30 PM
Reserve your Webinar seat now at: https://www2.gotomeeting.com/register/595664219

I have a presentation coming up soon at the Vatican at a conference about equitable health care. I am presenting about social justice, kids, and psychiatric drugs so I have been researching, with my colleague Jacqueline Spark’s help, the latest information. I found some pretty disturbing stuff regarding the differential prescription rates of poor kids. A study of 11,700 children under age 18 covered by Medicaid found that the number of children newly treated with antipsychotics increased from 1,482 in 2001 to 3,110 in 2005 (Mathak, West, Martin, Helm, & Henderson, 2010). In other words, a staggering 26% of kids in this sample were taking antipsychotics. Another study found that children covered by Medicaid were prescribed antipsychotics at a rate four times higher than children with private insurance, and were more likely to receive antipsychotics for unapproved uses (Crystal, Olfson, Huang, & Gerard, 2010), or in other words, for reasons of control, not treatment. A study of foster care children found that 57% received three or more drugs (Zito et al., 2008), six times the national average in spite of the fact that no research supports more than one drug for kids. Finally, the use of antipsychotics with privately insured children, aged 2 through 5, has doubled between 1999 and 2007 (Ofson, Crystal, Huang, & Gerhard, 2010). About 1.5% of all privately insured children between the ages of 2 and 5, or one in 70, received some type of psychiatric drug in 2007 despite the fact that there is little to no evidence in this age group.

When you consider the research of antipsychotics with kids (the TEOSS study found that only 12% of kids benefited from antipsychotics and that serious adverse events were all but guaranteed), this is quite a distressing situation. My presentation and the resulting paper will call for a higher standard of prescriptive care. Where children are concerned, the stakes are higher. They are, essentially, involuntary patients—most do not have a voice to say no to treatments or devise their own, and depend on adults to safeguard their wellbeing (Sparks & Duncan, 2008). Moreover, poor children often have fewer adults watching over them and are vulnerable to dangerous drugs used as interventions of control rather than therapy, and therefore require more care to ensure equitable treatment. The evidence demands that the trend of rising prescriptions and lower psychosocial intervention be stopped and a higher standard of care implemented: 1) psychosocial intervention should be considered first–families and youth should have a voice in decisions about their care, especially the disenfranchised; 2) no off label prescribing; 3) no polypharmacy; 4) immediate separation of the pharmaceutical company influence from science and practice; and 5) monitoring treatment response with consumer rated measures. My presentation will call for a higher standard of care for our most vulnerable and precious commodity, our children, that invites unity among all concerned health professionals. It is time to no longer accept prescriptive practices that do not follow the evidence and increasingly put clients at perilous risk for serious health consequences, dependence, and disability. Read more about psychiatric drugs here and watch a video here.

On another note, we have applied for evidence based treatment status with SAMHSA thanks to the Norway Feedback Trial (congrats to Morten Anker on his Ph.D., just conferred this week) and the two RCTs by Jeff Reese. I’ll keep you posted.

Finally, don’t forget the free webinar this month about my book, On Becoming a Better Therapist: November 23rd at 6:00 PM Central. Register now!

The diagnosis du jour is Post Traumatic Stress Disorder (PTSD). If you want to know what really works best, check out:

Benish, S., Imel, Z. E., & Wampold, B. E. (2007). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review, 28, 746-759.

This study is pretty cool for a lot of reasons. CBT has been demonstrated to be effective and is widely believed to be the treatment of choice, but several approaches with diverse rationales and methods have also been shown to be effective: eye-movement desensitization and reprocessing, cognitive therapy without exposure, hypnotherapy, psychodynamic therapy, and present-centered therapy. The above meta-analysis comparing these treatments found all of them about equally effective. What is remarkable here is the diversity of methods that achieve about the same results. Two of the treatments, cognitive therapy without exposure and present-centered therapy, were designed to exclude any therapeutic actions that might involve exposure (clients were not allowed to discuss their traumas because that invoked imaginal exposure). Despite the presumed extraordinary benefits of exposure for PTSD, the two treatments without it, or in which it was incidental (psychodynamic) were just as effective.

To punctuate the point that it is the more powerful general effects of delivering a model of treatment v. the specific effects of a given model, consider “present centered therapy” mentioned above as a treatment that works for PTSD. Researchers testing the efficacy of CBT for (PTSD) wanted a comparison group that contained curative factors shared by all treatments (warm empathic relationship) while excluding those believed unique to CBT (exposure). This control treatment, present centered therapy (PCT), contained no treatment rationale and no therapeutic actions. Moreover, to rule out any possibility of exposure, even covert in nature, clients were not allowed to talk about the traumatic events that had precipitated therapy. PCT was, of course, found to be less effective than CBT—it wasn’t really a treatment with professed “active” ingredients. However, when later a manual containing a rationale and condition-specific treatment actions was added to facilitate standardization in training and delivery, few differences in efficacy were found between PCT and CBT in the treatment of PTSD (McDonagh et al., 2005). In fact, significantly fewer clients dropped out of PCT than CBT. Thus, when PCT was made to resemble a bona fide treatment, that is, it added placebo, expectancy, and allegiance variables, it was not only as effective but also more acceptable than CBT.

Speaking of evidence based treatments, just got back from a debate about it in Wilmington, NC which was great fun. But even better was that I ran across list member Chris Hall who has written a beautiful article that deconstructs evidence based practice from a practitioner’s point of view. Even beyond the dodo verdict and all the other empirical arguments, Chris presents an elegant argument about why it just does not make clinical sense. Check it out:

Although certainly holding sway over many and unfortunately many states and governing bodies are still holding on to idea that some approaches should be implemented, I believe the whole idea is on the downturn and will be soon looked at as an unhelpful fad. Consider an article just published in Journal of Consulting and Clinical Psychology by Webb, DeRubeis, and Barber, a meta-analysis examining the relationship between adherence to and competence in delivering a particular approach and outcome. The conclusion (drum roll please): “neither adherence nor competence was…related to patient outcome and indeed that the aggregate estimates of their effects were very close to zero.” They also discuss how most studies of competence are confounded by the alliance, a point made by Littell in her chapter in the Heart and Soul of Change and evident to anyone that reads a treatment manual.

Also check out David Elliott’s new video describing the ASIST program. While many if not most of you already understand what ASIST offers, it will be a great introduction for folks just getting their feet wet. And as I am finding out, many will look at a video long before they will read!

Finally, I am very pleased to announce that Brian DeSantis has joined the Project as a Leader. Brian and I go way back—we were graduate students together. His area of expertise is integrated health care, and Brian has been applying CDOI in primary care for some time. And as he recently posted, he was also instrumental in getting the University of the Rockies on board with the ORS/SRS. Read about Brian here.

All approaches have valid explanations and solutions for the problems that clients bring to us. It makes sense to expand our theoretical horizons and learn multiple ways to serve client goals. Similarly, it also makes good clinical sense to be “evidence based” in our work. In truth, no one says, “Evidence, smevidence! It means nothing to my work—I fly by the seat of my pants, meander Willy Nilly through sessions, and rely totally on the wisdom of the stars to show the way.” Saying you don’t believe in the almighty evidence in tantamount to not believing in Mom or apple pie, or whatever your sacrosanct cultural icons happen to be. So what is the controversy about?

On the heels of the American Psychiatric Association’s development of practice guidelines in 1993, to ensure their continued viability in the market, psychologists rushed to offer magic bullets to counter psychiatry’s magic pills—to establish empirically supported treatments (EST). With all good intentions, the task force of Division 12 (Task Force on Promotion and Dissemination of Psychological Procedures, 1995) reviewed available research and catalogued treatments of choice for specific diagnoses based on their demonstrated efficacy in two RCTs. On one hand, the Division 12 Task Force effectively increased recognition of the efficacy of psychological intervention among the public, policymakers, and training programs; on the other hand, it simultaneously promulgated gross misinterpretations—that ESTs have proven superiority over other approaches, and therefore, should be mandated and exclusively reimbursed. Unfortunately, many now believe, to paraphrase Orwell, that some therapies are more equal than others.

The notion, however, that any approach is better than another is indefensible in light of the evidence covered extensively throughout The Heart and Soul of Change that support the outcome equivalence of the different models (the “dodo verdict”) as well as the relative influence of other factors than model and technique. I encourage you to dig a little deeper and bolster your ability to respectfully counter statements that suggest mandates for practice. Littell’s (2010) scathing commentary of ESTs in The Heart and Soul of Change is a good place to start. Littell provides a useful template for understanding the varied ways that findings can be distorted and evidence constructed from underwhelming results.

Like understanding anything else, there is a language involved here and it takes a bit of wading through tedious material. But it is worth it if you desire to counter mandates for specific approaches and promote the freedom for therapists to practice as they see fit according to client preferences and benefit. Our necessary pluralism, the theoretical breadth so important to resonating with clients and accentuating our development, is at stake, as well as our identity—ESTs suggest a therapist identity based on technical acumen in administering manualized, cookie cutter interventions (Duncan & Miller, 2006).

Efficacy over placebo, sham, or no treatment is not efficacy over other approaches, or what is called differential efficacy. In the minority of studies that claim superiority over treatment as usual (TAU) or another approach, you need only to ask one question of the investigation (see Duncan et al., 2004 and Sparks & Duncan, 2010 for a full discussion and examples): Is it a fair contest? Is the study a comparison of two valid approaches intended to be therapeutic administered in equal amounts by therapists who equally believe in what they are doing and who are equally supported to do it—are the therapists from the same pool with equal caseloads or is the experimental group specially selected, trained, and supervised by the researcher/founder of the approach, and have reduced caseloads?

I have never seen an advantage of any approach over another (or TAU) that wasn’t a lopsided contest that had its winner predetermined. Consider Trauma Focused (TF)-CBT, an approach to child sexual abuse that is getting a lot of press as the preferred approach that should be implemented across the board. Let’s look at their “definitive study:” Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.

SSDD all the way! It is always the same when you scratch below the surface of superiority claims—they just don’t hold up to critical scrutiny. First let me say that there is nothing wrong with TF-CBT. It has good ideas and good possibilities, and is surely helpful for some kids and parents. I just wish they would present it that way; i.e., if you work with kids and families where abuse and trauma are involved, you might consider adding these ideas and interventions to your repertoire—they probably will make some sense to some of your clients. But, of course, that is not what they say and instead they claim superiority and folks get the crazy idea that it should be mandated or practiced exclusively.

As always, you gotta consider whether or not it is a fair contest or one in which the winner is pre-determined by the design (imagine the porpoise and the cow in a swimming contest), the pet approach of the researcher pitted against a less than equal opponent. Child Centered Treatment (CCT), the comparison treatment in this study, is not a fair comparison—it is a sham treatment. Therapists did not see the kids and parents together at all, whereas the TF-CBT therapists saw kids and parents together 3 times out of the 12 possible sessions. It just is not reasonable care of a kid who has been sexually abused without meeting with both the child and parent (or caring adult) together to make sense of what has happened. That’s one thing, and then there is the real kicker: Therapists in the CCT condition did not provide advice or suggestions to kids or parents. This is not a real treatment. In the face of such serious concerns, even the most died in the wool “client centered” therapist would address client requests for suggestions and guidance.

Given this mock therapy, one might also suspect that the therapists likely believed that the TF-CBT offered some advantages over CCT given there was at least some structure and ideas offered to these struggling families. Enter allegiance factors. Therapists served as their own controls (performed both TF-CBT and CCT) and were monitored for fidelity, or other words to ensure they didn’t offer guidance (beyond processing feelings and finding client solutions) in the CCT condition. It doesn’t say who provided the “intensive supervision” but that probably means it was the researchers.

So given that it was an unfair comparison of an active treatment model to one unlikely to ever happen in the real world, and given the therapists in the study could hardly help but like to offer some guidance to clients when asked and therefore likely were more committed to TF-CBT, the results are particularly underwhelming. First off, there was a main effect for both conditions. Both treatments worked, which is a real testament to client factors given the CCT didn’t provide any structure or practical intervention. There were 16 measures for the kids and 4 for the caregivers. 3 of the 16 were clinician rated measures (diagnostic interview by folks trained by the researchers). Of the 16, 8 found a significant advantage for TF-CBT. But 3 of those were the from the clinician’s point of view. Only 5 of 13 client rated measures found an advantage for TF-CBT. All 4 of the adult measures found an advantage for TF-CBT. An inspection of the results table reveals that many of the “significant” findings arise from pretty small differences in the means at post-treatment, challenging at least some of the clinical significance of the findings. Finally, it seems that the measures chosen were reactive, or selected to reflect the very things that TF-CBT directly address while the comparison treatment does not address these aspects at all.

In summary, as always you have to ask yourself when superiority is claimed, “as compared to what?” This is study does not provide compelling evidence that TF-CBT is superior to anything else but rather that TF-CBT has demonstrated that it is a viable way to approach children and families who have suffered the trauma of sexual abuse. Regarding superiority claims, the TF in TF-CBT means totally false!

A summary of the problems often found in such claims can be found at http://heartandsoulofchange.com/resources/handouts/

Thankfully, there is a sanctioned argument to help efforts to rescind mandates for particular approaches. In the face of growing criticism, 2005 APA President Ronald Levant appointed the Presidential Task Force on Evidence-Based Practice (hereafter Task Force). The Task Force defined evidenced based practice (EBP) as “the integration of the best available research with clinical expertise in the context of patient (sic) characteristics, culture, and preferences (Task Force 2006, p. 273). This definition transcends the “demonstrated efficacy in two RCTs” mentality of ESTs and finally makes common clinical sense.

The Task Force also said:
The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280).

Proponents from both sides of the common v. specific factors aisle recognized that outcome is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist (Anker et al., 2009). Practice based evidence must become routine. The new definition supports an identity of plurality, essential attention to client preferences, a focus on therapist expertise, and the importance of feedback.

Bottom Line: There is nothing wrong with ESTs or evidence based practice. Challenge statements, however, that use evidence based practice to justify mandates, exclusive reimbursement, or dictates about “the” way to address client problems. Know about the dodo verdict and unfair contests in research. Educate others about APA’s definition and the importance of measuring the client’s response to any delivered treatment—advocate for practice based evidence as an evidence based practice.

Next Blog: The Recovery Revolution

Rebecca just posted this article on the Heroicagency Listserv, and as she said, it begged a response.

Ignoring the Evidence
Why do psychologists reject science?
By Sharon Begley | NEWSWEEK

Published Oct 2, 2009

From the magazine issue dated Oct 12, 2009

It’s a good thing couches are too heavy to throw, because the fight brewing among therapists is getting ugly. For years, psychologists who conduct research have lamented what they see as an antiscience bias among clinicians, who treat patients. But now the gloves have come off. In a two-years-in-the-making analysis to be published in November in Perspectives on Psychological Science, psychologists led by Timothy B. Baker of the University of Wisconsin charge that many clinicians fail to “use the interventions for which there is the strongest evidence of efficacy” and “give more weight to their personal experiences than to science.” As a result, patients have no assurance that their “treatment will be informed by science.” Walter Mischel of Columbia University, who wrote an accompanying editorial, is even more scathing. “The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment,” he told me, and there is a “widening gulf between clinical practice and science.”

The “widening” reflects the substantial progress that psycho-logical research has made in identifying the most effective treatments. Thanks to clinical trials as rigorous as those for, say, cardiology, we now know that cognitive and cognitive-behavior therapy (teaching patients to think about their thoughts in new, healthier ways and to act on those new ways of thinking) are effective against depression, panic disorder, bulimia nervosa, obsessive-compulsive disorder, and -posttraumatic-stress disorder, with multiple trials showing that these treatments—the tools of psychology—bring more durable benefits with lower relapse rates than drugs, which non-M.D. psychologists cannot prescribe. Studies have also shown that behavioral couples therapy helps alcoholics stay on the wagon, and that family therapy can help schizophrenics function. Neuroscience has identified the brain mechanisms by which these interventions work, giving them added credibility.

You wouldn’t know this if you sought help from a typical psychologist. Millions of patients are instead receiving chaotic meditation therapy, facilitated communication, dolphin-assisted therapy, eye-movement desensitization, and well, “someone once stopped counting at 1,000 forms of psychotherapy in use,” says Baker. Although many treatments are effective, they “are used infrequently,” he and his coauthors point out. “Relatively few psychologists learn or practice” them.

Why in the world not? Earlier this year I wrote a column asking, facetiously, why doctors “hate science,” meaning why do many resist evidence-based medicine. The problem is even worse in psychology. For one thing, says Baker, clinical psychologists are “deeply ambivalent about the role of science” and “lack solid science training”—a result of science-lite curricula, especially in Psy.D. programs. Also, one third of patients get better no matter what therapy (if any) they have, “and psychologists remember these successes, attributing them, wrongly, to the treatment. It’s very threatening to think our profession is a charade.”

When confronted with evidence that treatments they offer are not supported by science, clinicians argue that they know better than some study what works. In surveys, they admit they value personal experience over research evidence, and a 2006 Presidential Task Force of the American Psychological Association—the 150,000-strong group dominated by clinicians—gave equal weight to the personal experiences of the clinician and to scientific evidence, a stance they defend as a way to avoid “cookbook medicine.” A 2008 survey of 591 psychologists in private practice found that they rely more on their own and colleagues’ experience than on science when deciding how to treat a patient. (This is less true of psychiatrists, since these M.D.s receive extensive scientific training.) If they keep on this path as insurers demand evidence-based medicine, warns Mischel, psychology will “discredit and marginalize itself.”

If public shaming doesn’t help, Baker’s team suggests a new accreditation system to “stigmatize ascientific training programs and practitioners.” (The APA says its current system does require scientific training and competence.) Two years ago the Association for Psychological Science launched such a system to compete with the APA’s.

That may produce a new generation of therapists who apply science, but it won’t do a thing about those now in practice.

Find this article at
http://www.newsweek.com/id/216506

My Response
There are many inaccuracies in this story—not the least of which is the distortion of APA’s definition of evidence based practice, which unequivocally does not give equal weight to the personal experiences of the clinician and scientific evidence—but I will focus here on the “evidence” claiming that the noted approaches are the most effective. Perhaps clinicians are ignoring the researchers quoted in the article because the brand of evidence they are selling is not credible or relevant to their work. They fail to mention the most replicated piece of evidence in the psychological literature: Namely, that no one treatment model, including the cognitive and cognitive behavioral models canonized in the article, have reliably shown any superiority over other treatments. Moreover, treatment models account for a very small amount of the variance of change. As just one example of these robustly demonstrated findings, consider the landmark NIMH study of depression in which cognitive behavioral therapy was compared to interpersonal therapy and antidepressants. No differences emerged between the treatments—they all worked about the same (although the talk therapies did better at follow-up). Treatment model differences accounted for only 2% of variance of change. What did explain the changes achieved by the clients? The quality of the relationship/alliance between the clinician and the client accounted for 21% of the variance. The person of the clinician, not what treatment was delivered explained another 8%. This is why clinicians don’t rally around the flag of different treatments making false claims about superior effectiveness. They know that other factors are far more important—psychotherapy is a richly nuanced interpersonal event that defies being reduced to a diagnosis and treatment model.

The much ballyhooed models have only shown themselves to be better than sham treatments or no treatment at all, which is not exactly news to write home to mom about. Think about it. What if one of your friends went out on a date with a new person, and when you asked about the guy, your friend replied, “He was better than nothing—he was unequivocally better than watching TV or washing my hair.” (Or, if your friend was a researcher: “…he was significantly better, at a 95% confidence level, than watching TV or washing my hair). How impressed would you be?

Finally, the success of any treatment is not guaranteed regardless of its evidentiary support or the expertise of the therapist. As the APA Task Force noted, the response of the client is variable and therefore must be monitored and treatment tailored accordingly to ensure a positive outcome. Monitoring outcome with clients, what has been called practice based evidence, has been shown to significantly improve treatment outcomes regardless of the treatment administered, a far more powerful influence on outcome that the specific approach administered.