Psychology Should List Empirically Supported Principles of Change ...

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10.1177/0145445503253829 BEHAVIOR Rosen, Davison MODIFICATION / EMPIRICALLY / July SUPPORTED 2003 PRINCIPLES

Psychology Should List Empirically Supported Principles of Change (ESPs) and Not Credential Trademarked Therapies or Other Treatment Packages GERALD M. ROSEN University of Washington

GERALD C. DAVISON University of Southern California

Current systems for listing empirically supported therapies (ESTs) provide recognition to treatment packages, many of them proprietary and trademarked, without regard to the principles of change believed to account for their effectiveness. Our position is that any authoritative body representing the science and profession of psychology should work solely toward the identification of empirically supported principles of change (ESPs). As challenging as it is to take this approach, a system that lists ESPs will keep a focus on issues central to the science and practice of psychology while also insulating the profession from undue entrepreneurial influences. Keywords: empirically supported; therapy; behavior principles; EMDR; treatment outcome.

When the effectiveness of psychotherapy is questioned, a lively debate is certain to follow. Eysenck (1952) reviewed available data a half century ago and questioned if any psychotherapy was effective for any problem. His conclusions reverberated through the literature until some 20 years later, when Luborsky, Singer, and Luborsky (1975) introduced the “dodo bird verdict” and concluded that all therapies

AUTHORS’ NOTE: The current committee is considering empirically based treatments (EBTs) rather than empirically supported treatments (ESTs), a further move away from what were originally termed empirically validated treatments (EVTs). Regardless of this terminology, a focus on principles of behavior change (ESPs or EBPs) is recommended to replace the current focus on treatment packages (ESTs or EBTs). Address correspondence to Gerald M. Rosen, 2825 Eastlake Avenue East, Suite 205, Seattle, WA 98102; e-mail: [email protected]. BEHAVIOR MODIFICATION, Vol. 27 No. 3, July 2003 300-312 DOI: 10.1177/0145445503253829 © 2003 Sage Publications

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were effective and equivalent. Beutler (1991) revisited Luborsky et al.’s verdict and asked, “Have all won and must all have prizes?” Now, more than 20 years after the dodo bird verdict, a Task Force for Division 12 of the American Psychological Association has concluded that some psychotherapies are empirically supported, whereas others are not. Based on a number of criteria established by the Task Force, a list of empirically supported therapies (ESTs) has been compiled and revised over time (Chambless et al., 1996, 1998; Task Force, 1995). It is around this list of ESTs and other, similar efforts (see Chambless & Ollendick, 2001) that debates on psychotherapy outcome now turn.

HOW THE CURRENT SYSTEM WORKS

Any system that identifies ESTs must specify criteria that will determine a procedure’s status. In this context, numerous commentators have raised important issues and concerns (Beutler, 1998; Beutler, Kim, E. H. Davison, Karno, & Fisher, 1996; Borkovec & Castonguay, 1998; G. C. Davison, 1998, 2000; Drozd & Goldfried, 1996; Eisen & Dickey, 1996; Garfield, 1998; Goldfried & Wolfe, 1998; Kendall, 1998; Persons & Silberschatz, 1998; Silverman, 1996). Should a method be more effective than placebo controls to receive recognition or simply more effective than no treatment? Should established criteria take into account the clinical significance of measured change or simply consider statistical significance? How can one judge if a particular study provides a fair test of a method without considering the training of therapists, treatment fidelity, and therapist allegiance effects? What are the consequences of tying randomized controlled trials (RCTs) to specific diagnostic categories within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), thereby “medicalizing” the use of psychotherapy, compartmentalizing diverse problems faced by individuals, downplaying idiographic functional analysis, and possibly ignoring the importance of patient and therapist interactions? One of the most recent attempts to deal with these issues (Chambless & Ollendick, 2001) holds to criteria proposed by

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Chambless and Hollon (1998). Within this system, a treatment method is given the title “possibly efficacious” if it is found more effective than no treatment in a single RCT. If the same procedure is found more effective than no treatment in a second RCT conducted by an independent research team, the method is given the less ambiguous label of “efficacious.” Procedures shown to be better than nonspecific processes or another established treatment are referred to as “efficacious and specific.” Other decision rules have been proposed, but all have led to essentially similar results (Chambless & Ollendick, 2001). Chambless and colleagues understood a practical consequence of listing ESTs; namely, once an official listing exists to certify, recognize, or otherwise officially sanction a treatment, then those who promote a particular method will want to be listed. In a sense, the various levels of listings can be thought of as “prizes.” Unlike Luborsky’s dodo bird verdict, these prizes are selective and do not go to all. Consider, for example, the title “efficacious and specific” as proposed by Chambless and Hollon (1998): “Treatments found to be superior to conditions that control for such nonspecific processes (placebo) or to another bona fide treatment are even more highly prized and said to be efficacious and specific in their mechanisms of action” (p. 8; emphasis added). One other point is important when discussing how the current system works for listing ESTs. The current system allows for listings based on principles of change as well as for listings that reference specific “brand” or trademarked methods. This point is illustrated by the current classification of treatments for posttraumatic stress disorder (PTSD). On one hand, various procedures such as systematic desensitization, flooding, and guided imagery have been lumped under the single term “exposure therapies” and listed as probably efficacious in the treatment of civilian PTSD. The listing is based on a principle of change whereby properly managed exposure to an aversive stimulus leads to anxiety reduction. The principle, in actuality, likely enjoys as much experimental support with both animals and humans as any in psychology (cf. Wilson & G. C. Davison, 1971). At the same time, eye movement desensitization and reprocessing (EMDR) was provided the same level of recognition as the exposure therapies—in this case, referring to a proprietary, trademarked method.


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TRADEMARKED THERAPIES SHOULD NOT BE LISTED

The core purpose of this article is to argue that any authoritative body representing the science of psychology should work toward the identification of “empirically supported principles of change” (ESPs); it should not list empirically supported treatments (ESTs); and it certainly should never list proprietary, trademarked methods. To understand the importance of this argument, one only has to consider the listing of EMDR by the Division 12 Task Force as a probably efficacious treatment of civilian PTSD. A full exploration of the science and politics that went into listing EMDR as an EST is beyond the scope of this article, as is an analysis of the science and pseudoscience of the entire EMDR phenomenon (Herbert et al., 2000; Rosen, 1999). Suffice it to say, the method has been aggressively promoted with several claims that have not received empirical support (DeBell & Jones, 1997; Lohr, Tolin, & Lilienfeld, 1998; Muris & Merckelbach, 1999) and rest on assumptions outside the mainstream of science (see F. Shapiro, 1995; also see reviews by Lohr, 1996 and O’Donohue & Thorpe, 1996). The original claim made on behalf of EMDR, that eye movements facilitate anxiety reduction, has not been supported in the majority of dismantling studies (e.g., Pitman et al., 1996; Sanderson & Carpenter, 1992). An accompanying claim that EMDR is more effective or works more rapidly than traditional forms of exposure therapy has also failed several tests (e.g., Devilly & Spence, 1999; Goldstein, deBeurs, Chambless, & Wilson, 2000; Muris, Merckelbach, Holdrinet, & Sigsenaar, 1998). These conclusions were recently borne out in a meta-analysis of 34 studies examining EMDR (Davidson & Parker, 2001) in which the authors concluded that “EMDR appears to be no more effective than other exposure techniques, and evidence suggests that the eye movements integral to the treatment, and to its name, are unnecessary” (p. 305). If one takes eye movements out of EMDR (the first two letters), one is left with the previously known and empirically supported treatment components of exposure and cognitive therapies (the last two letters). This realization led McNally (1999a) to conclude, “What is effective in EMDR is not new, and what is new is not effective” (p. 619). Never-

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theless, because EMDR has been demonstrated to be more effective than no treatment (Rothbaum, 1997; Wilson, Becker, & Tinker, 1995), it can meet criteria for an EST and achieve the listing of “probably efficacious.” McNally (1999b) commented on this turn of events in a fascinating historical comparison between EMDR and Mesmerism: Despite the many similarities between the history of Mesmerism and the history of EMDR, there is at least one important difference. A prestigious committee of scientists (including Benjamin Franklin) concluded that the effects of Mesmer’s therapy were attributable to the power of suggestion, not the power of “animal magnetism,” thereby discrediting the Mesmerism movement. In contrast, the American Psychological Association’s (APA) committee on empirically validated treatments recently startled many psychologists by proclaiming EMDR as “probably efficacious for civilian PTSD.” EMDR has earned the approbation of this committee because it was statistically superior to no treatment at all in two controlled trials. Had Franklin and Lavoisier applied these criteria, they might have arrived at similar conclusions about the “probable efficacy” of animal magnetism therapy. (p. 235)

K. G. Wilson (1997) referenced earlier discussions in the 1970s on what would be required to demonstrate the safety and efficacy of psychotherapies. At that time, it was estimated that it would take 500 years to carry out all the studies that would be required to determine what treatment should be used on which problem. Wilson applied this analysis to the contemporary phenomenon of EMDR and observed, Eye movement desensitization and reprocessing (EMDR) provides a recent example of a treatment lacking any credible linkage to psychological science . . . We need to stick to solid science or else risk taking on the impossibly large task described in the 500-year problem: brute force empirical evaluation of each and every treatment that has and will be dreamed up. (p. 553)

Experience with EMDR demonstrates that current decision rules for determining ESTs are inadequate. Furthermore, the current system makes psychology vulnerable to any treatment innovator or savvy charlatan who puts a novel method through a single randomized controlled trial with a no-treatment comparison. Hypothetically, a doctor could ask clients with driving phobias to wear a large purple hat while


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applying relaxation and cognitive coping skills to in vivo practice. The practitioner places a band of magnets in the purple hats, claiming that particular algorithms for positioning the magnets are determined by age, sex, and personality structure of the client. When properly placed, so the practitioner claims, the magnets reorient energy fields, accelerate information processing, improve interhemispheric coherence, and eliminate phobic avoidance. The inventor might call his method “purple hat therapy” (PHT) or “electro Magnetic Desensitization and Remobilization” (eMDR), conduct a single RCT against no treatment, and apply for listing as an EST. If all this sounds too silly for words, the reader is encouraged to consider recent developments among the “power therapies” (Rosen & G. C. Davison, 2001), the aggressive promotion of EMDR (DeBell & Jones, 1997; Herbert et al., 2000; Metter & Michelson, 1993; Muris & Merckelbach, 1999), and the scientific status of neuropsychological explanations advanced on behalf of EMDR (Lohr, 1996; O’Donohue & Thorpe, 1996).

EMPIRICALLY SUPPORTED PRINCIPLES OF CHANGE

The central problem in the hypothetical just provided and in the real life example of EMDR is that proprietary, trademarked therapies can receive recognition without regard to any meaningful principle of change. By creating this possibility, the Division 12 Task Force on Empirically Supported Therapies has set aside concepts central to the study, practice, and teaching of our field (Borkovec, 1997; Borkovec & Castonguay, 1998; G. C. Davison, 1998) while exposing psychology to entrepreneurial influences not unlike those currently afflicting academic medicine (see Angell, 2000; Bodenheimer, 2000). Herbert (2000) recognized the problems that result “when novel treatments begin with an established procedure and add functionally trivial bells and whistles” (p. 118). He argued that it was consistent with scientific parsimony to apply the null hypothesis and assume new treatments were not different until proven otherwise. Herbert observed that the opposite approach now applies, whereby treatments are first assumed to be distinct, even when there is little or no basis for the assumption. In effect, the Task Force has provided a prize that can motivate interest

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groups to fund narrowly defined RCTs on trademarked therapies that ride piggyback on established principles of change. This situation makes for poor science and, at best, inefficient practice. The solution to this troublesome situation is, of course, for psychology to get out of the business of listing proprietary, trademarked therapies. Instead, psychology needs to return to the core issues facing those concerned with the development of effective therapies—the identification of ESPs. Others have provided similar direction. G. C. Davison and Lazarus (1995) addressed the need for psychologists “to apply general principles (a goal of science) to individual cases,” (p. 95). D. A. Shapiro (1995) suggested, “The central goal of psychotherapy research is to achieve an understanding of the change mechanisms giving rise to clients’ clinical improvement” (p. 1). G. C. Davison (1998) noted that “rather than focus on brand-name treatments, it is important . . . to underscore the psychological principles assumed to underlie their effectiveness” (p. 165). In a detailed analysis of these concerns, Borkovec and Castonguay (1998) observed, The criteria for empirically supported treatments merely allow conclusions about whether treatments cause any change . . . Creating increasingly effective therapies through between-group designs is best done by controlled trials specifically aimed at basic questions about the nature of psychological problems and the nature of therapeutic change mechanisms. (p. 136)

Readers familiar with the very beginnings of behavior therapy (e.g., Eysenck, 1960; Skinner, 1953; Wolpe, 1958) will recognize this call to apply experimentally established principles to the amelioration of clinical problems. There is, indeed, little new under the sun, but sometimes we need to be reminded of valuable lessons and exhortations from the past. One benefit that results from a focus on ESPs is the likely impact this system would have on the education of future clinicians. Rather than students learning a list of cookbook methods that are tested and marketed for the treatment of a specific DSM-IV category, psychologists in training would learn basic principles of change and the range of their applications. This endeavor speaks to a level of professional and scientific analysis worthy of a student’s attention (G. C. Davison, 1998; G. C. Davison & Lazarus, 1995).


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While it is beyond the scope of this article, this issue raises questions about the appropriateness of the professional school movement in applied psychology as well as the philosophy and structure of education and training in clinical and other applied areas. Briefly put, when the focus of theory and research is on principles of change, then doctoral education can be serious about following the Boulder Model (G. C. Davison, 1998), whereby advanced study concentrates more on the science of psychology and less on the acquisition of specific practical skills that may be favored at a given time or by a particular program. Another benefit that results from listing ESPs instead of ESTs is that it provides a logical basis and simple decision rule for resolving the thorny issue of what should constitute a minimum standard for recognition. At the present time, the minimal standard for achieving recognition is that a method is better than no treatment. As Herbert (2000) has observed, “Unless one went out of one’s way to design an iatrogenic intervention, any treatment that provides a believable rationale, attention from a trusted professional, and expectations of positive change will almost certainly perform better than nothing” (p. 116). We should have learned this much from Jerome Frank’s classic book, Persuasion and Healing (1961). When the focus of attention shifts away from ESTs to principles of change, then decision rules become clearer. Once it has been established that a placebo intervention is better than no treatment for a particular problem, then a principle of change has to perform better than placebo to receive separate recognition.

COMPLEX ISSUES REMAIN EVEN WITH ESPS

Listing ESPs creates its own difficulties. For starters, principles of change may be in dispute. One can ask whether “social skills training” is better listed as “graduated practice,” “exposure,” or “behavioral rehearsal.” Should “exposure therapies” be listed as “extinction,” “habituation,” or perhaps Wolpe’s (1958) original “reciprocal inhibition”? G. C. Davison and Lazarus (1995) observed that techniques can be effective for reasons having nothing to do with the theoretical ideas from which they were derived. They proposed, “The active ingredi-

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ents of techniques as diverse as the empty chair, projected imagery, cognitive restructuring, relaxation, assertiveness training, abreaction, biofeedback, flooding, structured daydreams, and so forth, are explainable by social and cognitive learning principles” (p. 107). A listing of ESPs does not solve these issues and may, in fact, heighten the intensity of debates on the matter. We welcome this state of affairs and consider such debates healthy for our field. Debates that concern principles of change, rather than specific trademarked therapies, will return our attention to what psychology is about. There are instances when active principles of change have not been specified but a treatment package, nevertheless, has been shown effective. Dialectic behavior therapy (DBT) for the treatment of borderline personality disorder is one example. Linehan (personal communications, 2001) has clarified that DBT likely involves a number of principles of change, but there is no empirical basis for determining exactly which ones are critical or if there is a particular combination of factors that produces change.1 How then would a system based on ESPs handle DBT? The current approach proposed by Chambless and Hollon (1998) is to simply ignore the matter of change mechanisms. As they explained, “Simply put, if a treatment works for whatever reason, and if this effect can be replicated by multiple independent groups, then the treatment is likely to be of value clinically, and a good case can be made for its use” (p. 8). We take the opposite view and suggest that listing proposed principles of change, on the basis of the best scientific information available, is far preferable to the alternative of simply ignoring the matter. A system focused on ESPs would list the multiple change principles thought to be operative in DBT while noting that dismantling studies aimed at elucidating process mechanisms were yet to be conducted. If future research demonstrated that some components of DBT were not necessary to produce positive outcome, these components would be dropped from the ESP list. (Linehan has always seen the need for and advocated such research on DBT.) On the other hand, an investigator could not add a new component until it first was demonstrated that the addition meaningfully contributed to treatment. The resulting list of ESPs would still allow case managers to approve practitioners who applied the best available methods. In this context, DBT becomes a


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shorthand label to describe the application of certain empirically supported change principles. A system that lists ESPs also leaves open for debate the value of RCTs, the questionable merits of linking treatment methods to DSM categories, and a host of associated issues first stirred up by Eysenck (1952) a half century ago. No single framework will resolve all these controversies, including our proposal on ESPs. Nevertheless, a focus on identifying ESPs does move us forward by redirecting the attention of academic psychologists, practicing clinicians, and students to where it should be—on mechanisms of change. A system focused on ESPs also is less likely to be influenced by proprietary concerns and the undue influence of particular interest groups. Principles of behavior change, after all, cannot be trademarked, for they belong to science.

NOTE 1. The situation of DBT differs from EMDR in that empirically supported treatments had not been established for the treatment of borderline personality disorder before the development of Linehan’s method, while effective methods for the treatment of anxiety disorders had been developed years before the striking claims for EMDR.

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Gerald M. Rosen, Ph.D., has a private practice in clinical psychology in Seattle and holds an appointment as clinical professor in the Department of Psychology, University of Washington. Dr. Rosen received his Ph.D. from the University of Wisconsin, Madison, in 1972. Gerald C. Davison is professor of psychology and department chair at the University of Southern California. His research involves the application of articulated thoughts in simulated situations think-aloud paradigm to a variety of emotional and behavioral phenomena, including anxiety, aggression, and hate crimes.