Fact and Fiction about Evidence-Based Treatments (EBTs)
When there is scientific evidence demonstrating that a specific treatment (e.g., cognitive-behavioral therapy) for a specific problem (e.g., depression, obsessive-compulsive disorder) leads to the reduction symptoms and/or the improvement of functioning of individuals who receive the treatment, the treatment is called an evidence-based treatment. Prior to the 1990s, there were no specific guidelines for either therapists or mental health consumers regarding which treatments to select for which conditions among children, adolescents, and adults. That changed in the 1990s, as scientists and policymakers worked to identify criteria for understanding and summarizing the scientific data about psychological treatments, in an effort to help guide public policy, to inform training of new and current professionals, and to provide information to consumers. Although all professionals providing mental health services are united in their efforts to provide the best possible services to children, adolescents, and their families, there are disagreements about how to identify EBTs (and even whether it is necessary to do so). The Society of Clinical Child and Adolescent Psychology (SCCAP) has been a longstanding advocate of such standards and is a leader in providing information about EBTs to professionals and the public. In 1998 and then again in 2008, SCCAP's scientific journal, Journal of Clinical Child and Adolescent Psychology (JCCAP) has published important review articles that summarize the evidence related to the treatment of specific childhood and adolescent problem areas, including a listing of EBTs. The treatment recommendations provided in this website are based on these reviews and more recent updates of those as part of JCCAP's Evidence-based Update series.
The push to develop lists of EBTs has been controversial and has been met with fierce resistance in some quarters. Although several of the criticisms of EBTs may have merit, several others appear to reflect a general misunderstanding of EBT criteria. Below are some of the most widespread misconceptions regarding EBTs (see Chambless & Ollendick, 2001; Weisz, Weersing, & Henggeler, 2005, for further discussions of these and other misconceptions).
1. Randomized controlled trials (RCTs), on which the EBT list is based, are fallible and no more informative than other sources of evidence. This claim is problematic on two fronts. First, the EBT list does not require treatments to be tested using RCTs; as noted above, a series of rigorous single-case designs can also suffice. Second, the assertion that RCTs are no more valuable than other sources of evidence is misinformed; RCTs currently represent the "gold standard" of evidence in that they control for a host of sources of error, such as placebo effects, spontaneous remission, regression to the mean, and demand characteristics.
2. The EBT list is unfair because some treatments that have yet to be studied may turn out to be efficacious. The effective child therapy website is only as good as the current scientific literature. Thus, it is true that not all treatments have been tested. Thus, the lists on the website are not viewed as the final answer. Instead, they are viewed as guidance based on the best available information. That said, it is important for therapists and consumers alike to know the relative amount of scientific evidence supporting different treatments. For example, given a choice of treatments for Problem A, it is important for the family to understand that Treatment 1 has scientific evidence to support it and Treatment 2 does not. A therapist and family may still choose to try Treatment 2, but being clear about the extent of the evidence for different treatments is an essential aspect of evidence-based practice (EBP).
3. The EBT list is unnecessary because research shows that all psychotherapies work equally well. In criticizing the EBT list, some researchers have invoked the "Dodo Bird verdict," named after the Dodo Bird in "Alice and Wonderland," who famously said (following a race) that "Everybody has won and all must have prizes." Some researchers have claimed that all therapies work equally well and, therefore, EBT lists are unnecessary. Recent research has clearly demonstrated, however, that this characterization is false. Numerous studies have shown that specific therapies work better for specific problems (e.g., CBT for child anxiety) than other therapies.
4. Some of the studies on which the EBT list is based are flawed. Although this contention is almost certainly true, it should be remembered that virtually all research studies are flawed in certain respects. The goal of the EBT list, like that of all advances in science, is to reduce uncertainty. Without this list, there would be little or no explicit guidance to clinicians regarding which treatments should be administered for whom and with which conditions. Imperfect but informative scientific evidence is almost always better than no evidence at all.
5. EBTs are not generalizable to the "real world." Some critics have charged that research on "efficacy" (i.e., how well treatments perform in carefully controlled settings) do not generalize to research on "effectiveness" (i.e., how well they perform in real-world situations). In part, the rationale behind this criticism is based on the fact that EBT efficacy studies often exclude severely disordered patients or patients with "comorbid" (co-occurring) conditions. Although it is true that many studies to date have been conducted in controlled settings, more recently there has been an increase in studies conducted in community settings. These studies have added to what we know about which treatments work (and which do not) across a variety of settings. Because the evidence base is always evolving based on new studies, EffectiveChildTherapy.com is working to keep the EBT lists posted here up to date with the latest science.
6. Because EBTs are manualized, they necessarily constrain clinical creativity. This criticism is based on a few misunderstandings of EBTs. First, treatment manuals are not meant to be rigidly adhered to nor do they, for example, prescribe fixed responses to patients' behaviors in therapy. Instead, most manuals provide flexible guidelines for how to proceed at different stages of treatment.
7. The EBT list is fixed and cannot change in response to new evidence. This criticism is untrue. As noted, the evidence base is constantly evolving. As a result, the EBT list is always a work in progress, subject to continual updating as new data become available. Indeed, as noted above, this website was explicitly created to provide revised treatment recommendations for children and adolescents based on JCCAP's Evidence Base Updates.
EBTs: Future Directions
Thus, although many of the concerns with the American Psychological Association's approach to defining, identifying, and cataloguing EBTs are based on fundamental misunderstandings, there are alternative and complementary approaches that appear to have merit for connecting the research on children's mental health treatments to clinical practice. For example, some researchers have noted that many EBTs appear to differ only in their superficial features, and that a number of seemingly different treatments may work for the same underlying reasons. They have argued that a list of "empirically supported principles of change," such as the exposure to feared stimuli in many effective treatments for anxiety disorders or the restoration of hope in many effective treatments for depression, may ultimately be more fruitful than a list of EBTs (Rosen & Davison, 2003). There is considerable merit to this suggestion, a stronger consensus among clinical scientists regarding the underlying mechanisms of change that cut across many therapies is needed.
Similarly, other researchers have argued that the specific clinical techniques that comprise most EBTs appear to draw from a relatively limited number of procedures, and that there is merit to mapping the relationship between specific clinical procedures (e.g., cognitive restructuring, relaxation training) and client or contextual features (e.g., clinical problem, age, gender, setting) (Chorpita & Daleiden, 2009). This paradigm is seen as one that potentially complements a "list" approach, offering detail about the specific procedures that commonly characterize the numerous EBTs often applicable to a given area and pointing out what most EBTs do and do not have in common with one another.
Several research groups have begun to consider the question of how to define evidence for real-world systems, with some systems developing an expanded number of "levels of evidence" (Chorpita et al., 2002), and with some researchers emphasizing the importance of repeated measurement of client outcomes as a primary source of evidence (Bickman, 2008; Daleiden & Chorpita, 2005; Lambert, 2005). That is, one important evidence base consists of data that therapists collect about how well their treatment works for their clients.
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