The practice of classifying treatments as empirically supported (ESTs) has been widely debated for a long time. Recently Jessica Nasser published an article in the Journal of Contemporary Psychotherapy named “Empirically Supported Treatments and Efficacy Trials: What Steps Do We Still Need to Take?”. In the article the author raises several concerns and suggestions regarding the current use of EST criteria—which can be summarized as the current criteria being too lenient, something that I wholeheartedly agree with. Currently a treatment is regarded as “probably efficacious” if two different experiments show the treatment’s superiority over a wait-list condition. At least according the criteria proposed by Division 12 (Clinical Psychology) of the American Psychological Association.
In the article, Nasser outlines three main concerns and suggestions regarding the current criteria for ESTs, which are:
1) Wait-list and placebo control condition does not provide useful information. Instead active control conditions should be used.
2) The EST criteria do not take negative findings into considerations, nor do the criteria provide any provisions for removing treatments from the list. Nasser argues that this could be remedied by including all published findings in a meta-analysis, which would also provide a means of systematically updating the EST lists.
3) ESTs identified in RCTs lack external validity and clinical utility. Nasser’s concern is that trials are neglecting outcomes related to patients’ quality of life, interpersonal and work functioning and so on. The author’s suggestion is that more trials should link “… outcome measures, effect sizes, and statistical and clinical significance to real-life functioning and practical significance”.
I think these points are fair. However, I would like to add that the criteria should take into serious consideration if there is evidence for the proposed mechanism of change. Currently, treatments can claim to be working by magic and still qualify as an EST, even though the improvements seen in patients are obviously mediated by some other mechanism. The classic example of this is Eye Movement Desensitization Therapy--which Nasser mentions--were the active mechanism probably is traditional desensitization. Moreover, I believe that the raw data should be made public before a treatment is considered empirically supported, so that the analyses can be validated and replicated.
Despite the shortcomings of the current EST criteria, I do believe that it is a worthy pursuit—mostly as a type of research synthesis to inform clinicians and decisions-makers. But in the criteria’s current form it is hard to not get the feeling that the epithet of “well-established” is basically meaningless.
Nasser, J. (2013). Empirically Supported Treatments and Efficacy Trials: What Steps Do We Still Need to Take? Journal of Contemporary Psychotherapy DOI: 10.1007/s10879-013-9236-x