Empirically Supported Treatments in Psychology: Recommendations for Canadian Professional Psychology
Force on Empirically Supported Treatments (Section on Clinical Psychology of the Canadian
History of American Psychological Association Task Force on Promotion and Dissemination of Psychological Procedures In the United States, the late 1980s and early 1990s saw (i) growing concerns with the future of psychological services in the context of managed health care and (ii) an increasing emphasis on accountability and cost containment. These concerns, along with a desire to emphasize the scientific basis of psychological treatments, were the motivating forces in the origin of the APA task force on empirically supported procedures. In 1993, as president of Division 12 (Clinical Psychology) of APA, and acting upon the initiative of Section III (Society for a Science of Clinical Psychology), Dr. David Barlow appointed Dr. Dianne Chambless to chair a Task Force on the Promotion and Dissemination of Psychological Procedures. This Task Force was charged with developing criteria for empirically evaluating psychological treatments, and with making recommendations as to the best methods for educating psychologists, the public, and mental health service payers about these treatments. The original report included criteria for evaluating treatments, a short list of example treatments that met criteria as either well-established or probably efficacious (along with citations of evidence supporting the classification), and a list of recommendations for the promotion and dissemination of this material to clinical psychologists, the public, and health insurers.
To serve the widest possible interests, membership on the Task Force was selected to represent a breadth of theoretical orientations (e.g., cognitive-behavioral, psychodynamic, interpersonal) and a range of occupational settings (e.g., academic psychology departments, medical schools, private practice). Rather than evaluating treatments without reference to particular disorders, or evaluating treatments as they applied across various disorders, the Task Force opted for a strategy of evaluating treatments according to their application to specific mental health disorders (e.g., exposure/guided mastery for specific phobia, brief psychodynamic therapy for depression). The Task Force also chose to set the boundaries of what would define a treatment according to the availability of a treatment manual. Recognizing the arbitrary and subjective nature of any set of criteria for evaluating treatments, the Task Force opted for two categories of support: treatments classed as well-established and those that are probably efficacious. These criteria have changed only slightly since the initial report, and the current version (Chambless et al., 1998) is presented in Table 1.
The Task Force presented a preliminary version of its findings at the APA convention in the summer of 1993 and the document was adopted by APA's Division 12 in October of 1993. The report generated considerable controversy, and in 1994 the Task Force added an epilogue to their report addressing what they felt were common misconceptions in the interpretation of the initial report. Among other things, this epilogue clarified that the list of treatments was preliminary and incomplete, that a range of formats was acceptable for treatment manuals, and, especially, that the list was not intended to guide payment for psychological services. In February, 1995 the Task Force report was adopted by APAs Council of Representatives and, also in 1995, the report (including the epilogue) was published in Division 12s newsletter, The Clinical Psychologist (Task Force on Promotion and Dissemination of Psychological Procedures, 1995).
Since its inception, the Task Force report has been conceptualized as a dynamic process, with both the criteria for evaluating treatments, the treatments meeting criteria, and the methods of dissemination in need of constant revision to reflect empirical developments. In 1995, the Task Force was renamed the Task Force on Psychological Interventions, and Dr. Dianne Chambless was again appointed as chair. In 1996, this group published an updated version of the report (Chambless et al., 1996). This version began with a series of caveats regarding the use of the list of empirically supported treatments, as well as discussion of issues such as the treatment of ethnic minority clients and aptitude by treatment interactions. In addition, it ended with an addendum by Division 12 disclaiming any intention for the list of empirically supported treatments to be seen as treatment guidelines and urging that the list not be misused in deciding payments for psychological services. The Task Force continues to review treatments on a yearly basis and the most recent update to the report was presented in June, 1997 (Chambless et al., 1998). As of June, 1997 Dr. Paul Pilkonis is the chair for the Task Force. It is intended that the list of empirically supported treatments (as well as accompanying lists of manuals and graduate course syllabi) will be updated yearly and published in The Clinical Psychologist, as well as made available through the Division 12 office of APA (Division 12 Central Office, P.O. Box 1082, Niwot, CO, USA, 80503).
The initial Task Force report (Task Force on the Promotion and Dissemination of Psychological Procedures, 1995) listed 18 treatments as empirically supported and 7 as probably efficacious. The most recent update of the report (Chambless et al., 1998) lists 16 empirically supported treatments and 56 treatments that are probably efficacious. This list, along with efficacy citations, is presented in Appendix A. The empirically supported treatments represent a range of orientations including behavioral, cognitive, interpersonal, and family, although cognitive-behavioral and behavioral treatments are the most common. Each years report has included a preamble that deals with issues related to the mandate of the Task Force or with reactions to its work. For example, the 1996 report acknowledged that the term empirically validated may not be the most appropriate descriptor, and that the term "empirically supported" was preferable. Accordingly, the term "empirically supported" is used throughout the present document. The most recent report commented on the fact that only the efficacy of treatments, not their effectiveness was evaluated by the existing criteria (i.e., that the treatment has a demonstrated clinical impact in controlled trials, but that the generalizability of these findings to clinical settings is unknown). This most recent report also extended its review to include couples and family treatments for disorders, treatments for the severely mentally ill, and treatments within the field of health psychology.
The initial Task Force and its report had several impacts on psychology in the United States and beyond. One project, undertaken as part of the initial report, was the provision of a list of treatment manuals and training opportunities for the well-established treatments. Sanderson and Woody (1995) provided an initial list of these and, as with the list of treatments, the list of manuals and training opportunities is to be updated on a yearly basis (this list is also available from the APA Division 12 office). Within Division 12 of APA, in 1994, then president Dr. Martin Seligman, charged Dr. Peter Nathan with preparing an edited book reviewing empirically supported treatments (Nathan & Gorman, 1997). Numerous other articles, books, and conferences have focused on the issue of empirically supported treatments and the Task Force report (e.g., review and commentaries in Clinical Psychology: Science and Practice, Volume 3, 1996; a special section of Journal of Consulting and Clinical Psychology, Volume 66, 1998; CPA Convention Conversation Hour in 1995 and subsequent report in the Newsletter of the Clinical Section of CPA, November, 1995; and the 1996 Banff Conference on Behavioural Science and its resulting volume [Dobson & Craig, in press]). Parenthetically, although initiated within the profession of psychology, the push for the use of empirically supported treatments has already begun to spread to the profession of social work (Myers & Thyer, 1997).
The Task Force report also encouraged efforts at evaluating other aspects of psychological treatments or procedures. For example, in 1995, Dr. Martin Seligman as chair of APAs Division 12, appointed a Task Force to established criteria and empirically evaluate psychological assessment procedures. In 1996, then Division 12 president, Dr. Gerald Koocher, appointed a Task Force on Effective Psychosocial Interventions: A Life Span Perspective to concentrate on evaluation of treatments for children and for the prevention of mental health problems. This Task Force, chaired by Dr. Suzanne Bennett Johnson, presented a preliminary report at the APA convention in 1996. It is expected that the full report of this Task Force will soon be published in the Journal of Clinical Child Psychology.
In addition to its development of criteria and evaluation of psychological treatments, the initial Task Force also devoted considerable attention to issues of training. As part of the initial report, APA-accredited doctoral and internship training programs were surveyed concerning the amount of training they provided in empirically supported treatments. The findings of this survey indicated wide variability across programs in the coverage of this material, and formed the basis for the Task Force reports recommendations on the need for more systematic coverage of these treatments in training (Crits-Christoph, Frank, Chambless, Brody, & Karp, 1995). Thus, recommendations from the Task Force report formed the basis of some changes to the APA accreditation criteria for graduate and internship training programs. These criteria now include training in empirically supported treatments, although the extent and level of this training is not clearly specified. In support of this change, the Council of University Directors of Clinical Psychology Programs has also encouraged training in empirically supported treatments at all levels. Under the auspices of the Task Force, a set of syllabi for graduate psychology courses in empirically supported treatments has been compiled and made available. In addition, the Society for a Science of Clinical Psychology (Section 3, APA Division 12) publishes a directory of internship training sites that includes information on the availability of training in empirically supported treatments at each site (Blanchard, 1994).