Evidence Based Therapies

Evidence-Based Treatment
from Medscape General Medicine [TM]

Are Non-EST Therapies Invalid?

One might think from the way in which ESTs are being promulgated by psychiatric and psychological training programs, HMOs, and insurance companies that their superiority to other familiar forms of treatment has been proven. Here are some relevant facts: study after study, meta-analysis after meta-analysis,[1,2] and even meta-analyses of meta-analyses (called mega-analyses)[3,4] have repeatedly produced the same result: there are very few differences among bona fide therapies. By bona fide, I mean therapies that are guided by a coherent theoretical structure, have been widely practiced for a long time, and have a research foundation,[5] even if this foundation does not include the randomized control trials or single-case design sanctioned by the Task Force on ESTs of the American Psychological Association's Division of Clinical Psychology.[6] Examples are the psychodynamic, client or person-centered, and family or marital therapies.

There is an important distinction to be drawn between a therapy that is in validated by research and one that has not yet been validated. Given the results of the meta-analyses, there is every reason to believe that bona fide therapies will perform as well as the current ESTs in head-to-head comparisons for many diagnostic disorders. It happens that the ESTs are largely behavioral or cognitive-behavioral (CB), but when direct comparisons to other bona fide therapies have been made, typically the behavioral or CB therapies have not been found to be more efficacious. These analyses are not cited in the EST literature because the meta-analyses are often conducted on studies that have not targeted a specific Diagnostic and Statistical Manual of Mental Disorders (DSM)-based disorder but may include in the same study, for example, adjustment disorders, major depression, and anxiety disorders.

Even where it appears at first that there is an advantage to the behaviorally based ESTs, on closer inspection, this has turned out to be incorrect. For example, Wampold and colleagues[7] meta-analyzed therapies for depression and found CBT to be superior to the noncognitive and nonbehavioral therapies. However, when they separated these therapies into 2 groups -- those that were bona fide treatments and those that were not (such as "supportive counseling" with no theoretical framework) -- the superiority of CBT turned out to be an artifact of including non-bona fide therapies in the comparisons. That is, CBT was not significantly more beneficial than noncognitive and nonbehavioral treatments that were intended to be therapeutic rather than merely serving as a foil or convenient control group for the researchers' favored therapy.

Replies:

Re:Evidence Based Therapies, by McFall , 12/22/02

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