Efficacy effectiveness and the clinical utility of evidencebased practice a reprise

The past three decades have witnessed clear, evidence-based gains in the effectiveness of psychological treatments for both mental and physical disorders.

Advocates for behavioral and cognitive-behavioral treatments can now assert their documented effectiveness as treatments of choice for the anxiety and mood disorders (Chambless & Ollendick, 2001; Roth & Fonagy, 1996), while cognitive-behavioral treatments for alcohol abuse, eating disorders, and several other common psychopathologic conditions are also widely studied and well-accepted (Nathan & Gorman, 2002). More recently, the efficacy of psychological treatments for certain physical disorders has also been established empirically (e.g., Barlow, 2004). Marked advances in outcome research methodologies, including intensive efforts to integrate the effectiveness and efficacy research models, have energized efforts to promote empirically supported treatments.

Regretfully, despite these clear advances, many of the theories and therapeutic approaches used by clinicians today remain unsupported empirically (Beutler, Williams, Wakefield, & Entwistle, 1995; Castonguay & Beutler, 2006; Plante, Andersen, & Boccaccini, 1999). In provocative recent articles that raised questions about the empirical basis for empirically-supported treatments, Westen and his colleagues (2001, 2004) argued that "the attempt to identify empirically supported therapies imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments ... but substantially violated for others" (2004, p. 631). Accordingly, they suggested that the field "shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies" (2004, p. 631). Of relevance to the focus of this chapter, Westen and his colleagues clearly believe that psychotherapy researchers' reliance on RCTs as the "gold standard" of efforts to identify empirically supported treatments unduly restricts the kinds of settings and patients in such studies to those more characteristic of efficacy trials than of effectiveness studies.

Crits-Christoph, Wilson, and Hollon (2005) and Weisz, Weersing, and Henggeler (2005) took issue with this position, arguing that Westen and his colleagues selected only research findings that supported their position and ignored voluminous data attesting to the heterogeneity of research participants, settings, and procedures incorporated into contemporary effectiveness studies using randomized clinical trials. Of relevance to this matter as well, Stirman, DeRubeis, Crits-Christoph, and Rothman (2005) recently tested the validity of Westen and Morrison's claim (2001) that the exclusion criteria for the disorders studied in RCTs "often eliminated more troubled and difficult-to-treat patients" (2001, p. 880), reporting instead that "most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT" (2005, p. 127).

There is also widespread, growing support for the view that research on empirically supported treatments ought to be augmented by studies of other factors affecting therapeutic outcomes, primarily including therapist variables and common factors (Wampold & Bhati, 2004). Most recently, Castonguay and Beutler (2006) have proposed an additional factor they think influences therapeutic outcome, principles of therapeutic change, which they believe transcend techniques and treatments.

future prospects

Our field's intense preoccupation over the past decade and more with heightening the clinical utility of psychotherapy research by resolving the efficacy/effectiveness paradox, however frustrating it may have been, may nonetheless ultimately prove to have been a success. A number of solutions to the paradox posed by internal and external validity have been proposed, although none has yet proven ideal (Addis, 2002; McCabe, 2004). We believe, however, that, within a shorter rather than a longer time, a solution will be found and the evidence base underlying psychological treatments for a number of disorders will become more widely accepted. Exclusive endorsement of either the efficacy or the effectiveness research models alone will likely not be sufficient; efforts to date along those lines haven't yielded much encouragement. Similarly, tinkering with both models simultaneously to achieve some more optimal balance of the two does not seem to be the answer either; experience does not suggest it will be.

Serious doubts must also be expressed about whether it will be possible to develop new conceptual and statistical methods to permit integration of the two models that NIMH and others envision. Instead, the most likely solution seems to be to take findings from the best efficacy studies and use them to design the most robust effectiveness studies. Then, in bootstrap fashion, alternating between the two, meaningful and clinically relevant findings might well emerge. This back-and-forth variant of the Onken Stage/Hybrid Model of Behavioral Therapies Research makes the most sense to us and seems to have generated the most productive research to date. That this approach has recently been endorsed by NIDA, NIAAA, and NIMH (Gotham, 2004) to guide their efforts to diffuse technological innovations to the field attests to the attractiveness of this model.

Resolution of the efficacy/effectiveness controversy would nonetheless be but the first step, albeit a substantial one, toward solution of the fundamental unresolved issue of when and how psychotherapy researchers and clinicians will feel comfortable enough with each other to benefit from each others' contributions. Perhaps this will occur when research on therapy outcomes comes close enough to actual clinical practice to enable practitioners to recognize themselves and their patients in the research settings in which effectiveness research takes place.

There are encouraging signs of progress. In particular, as we have already observed, the Stage/Hybrid Model of Behavioral Therapies Research has generated more and more research that subjects efficacy findings to effectiveness trials. Moreover, recent reports suggest that clinicians and researchers have been able to come together to make decisions about empirically supported treatments that bridge the efficacy/effectiveness gap (including Chorpita et al., 2002; and Zapka, Goins, Pbert, & Ockene, 2004). Notable in this regard is the report by Chorpita and his colleagues (2002) describing the large-scale, successful implementation of empirically supported treatments for children by the Hawaii Empirical Basis to Services Task Force. Chorpita and his colleagues describe the process by which a broad-based group of administrators, providers, consumers, and researchers—"health administrators, parents of challenged children, clinical service providers, and academicians from the areas of psychology, psychiatry, nursing, and social work" (2002, p. 167)—reviewed findings on treatment efficacy "... through a systematic cataloguing of effectiveness parameters across more than one hundred treatment outcome studies" (2002, p. 165) and ultimately agreed on a set of treatments meeting efficacy and effectiveness standards that were then recommended to providers throughout an entire state. What accounts for the apparent success of this effort? Three factors: (1) most of the work was done by dedicated, committed volunteers who cared enough to do much of the work on their own time; (2) the effort was open to anyone with a stake in the system, so a diverse group of interested persons came together to develop the standards; (3) once the State of Hawaii recognized what the group had achieved, it decided to invest funds in the initiative, thereby making its dissemination and implementation possible.

It seems clear that this effort presages more such efforts in the future.

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