Demystifying Therapy: What on earth is an Evidence-Based Treatment or Empirically- Supported Therapy?
If you have read a few Psychology Today profiles (or scrolled through my website), you probably came across the terms “evidence-based treatment” or “empirically supported therapy.” As you choose a therapist, it is important to learn if they use these therapies, the training they have received in these approaches, and if they integrate these therapies or stick to one type. This post provides information about what evidence-based treatments/ empirically-supported therapies are, their strengths and limitations, and the benefits of integrating them. In the psychology field, the terms empirically supported therapy (EST) and evidence-based treatment (EBT) are used (almost) interchangeably. For this post, I will use the acronym EBT.
What’s evidence-based treatment?
Simply put, EBTs are psychotherapy treatments that are backed by scientific research. Technically, to be considered an EBT, at least two rigorous, quantitative studies -called “randomized control studies” or RCTs- must have demonstrated that a therapy is effective or is at least as effective as another therapy that research has already shown works.
Why is evidence-based treatment important?
There are many benefits of using EBTs with clients. First and foremost, when a therapist uses an EBT, they know that they are utilizing a treatment that has been scientifically demonstrated to be effective with a large group of people. That is, the therapist knows that the therapy they are using works for most folks! Additionally, when researchers examine these therapies using rigorous studies, they can start to understand why therapy works. For example, researchers can look at what the therapy actually is targeting (e.g., thoughts, interpersonal skills, behaviors) and what specific process accounts for the positive change clients experience (called mechanisms of change). Researches can also use what are called dismantling studies, to see if certain parts of the therapies are more effective than others. Taken together, when a therapist elects to use an EBT, they have access to information about the innerworkings of a treatment; they can know what they are doing and why it works.
EBTs also provide a framework that therapists can use to conceptualize, or make sense of, a client’s difficulties. For example, if research has demonstrated that a therapy that helps change client’s thinking patterns can help decrease depression (as is the case in cognitive therapy), a therapist who uses this therapy may focus on a clients’ thinking patterns and belief systems when trying to understand why a particular client may be feeling depressed.
Downsides of evidence-based practice in psychology
One might ask, “Why wouldn’t all therapists want to use treatments backed with science?” The answer is that there are several limitations to these therapies and the research that backs them. For example, some therapeutic approaches simply do not easily lend themselves to being researched in the manner necessary to be designated as an EBT and so they are not studied. For example, some approaches to therapy (for example, some forms of psychodynamic therapy) cannot be easily manualized. These therapies may be incredibly effective but they are just not studied in a way sufficient to be an EBT.
A huge critique of EBTs is that the research supporting them may not actually apply to folks in the real world! In order to see if a therapy is effective, researchers design highly controlled studies in order to decrease the likelihood that a variable other than the therapy is actually what is driving client’s improvement. Let’s say that a research psychologist wants to see if cognitive behavioral therapy (CBT) improves depression. They need to make sure that all the therapists in the study are actually doing CBT and in the exact same way. In order to do this, researchers will create a manual that therapists must follow strictly, sometimes with exact wording therapists must use. However, in the real world, it is not likely that a therapist would follow a script or manual verbatim. The researchers would also choose participants that are very similar to each other. For example, researchers may only select participants that are only struggling with moderate depression. In the real world, folks coming to therapy for depression may be experiencing mild or severe depression and could also be coping with a number of other things like anxiety on top of their depression. It leads critics of EBTs to argue that, perhaps, an EBT is actually not effective in treating all severities of depression but we just don’t know that since it was only studied with moderate depression. Another major critique is that oftentimes study participants have similar demographic backgrounds and BIPOC folk tend to be underrepresented in these studies. Critics worry that EBTs may not be culturally sensitive.
The good news is, once EBTs receive initial empirical support, psychologists from many academic institutions tend to jump onboard and start performing studies with different populations, different presenting problems or symptom severities, and in different settings. Psychologists then start to learn if the therapy is actually going to be effective outside of a highly controlled, laboratory setting. Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Dialectical Behavior Therapy (DBT) are examples of treatment approaches that have been shown by thousands of studies to be effective with folks from different backgrounds and presenting problems.
What is an integrative or evidence-based approach?
Given concerns about EBTs and an acknowledgement that no two people (including therapists) are exactly alike, many psychologists adopt an integrative approach. Technically speaking, an integrative approach means using a conceptual framework and selecting interventions from different therapies in which the psychologist must have had intensive training and competence. An integrative approach, therefore, is not like simply throwing spaghetti at a wall and seeing what sticks. Rather, the therapist makes intentional choices about what aspects of a therapy to use in order to best each unique client. When a therapist draws from EBTs as part of their integrative approach, they are engaging in evidence-based practice, which many therapists see as the best of both worlds. Not only can a therapist harness science, but they can also attend to clients’ cultural and contextual factors as well as client’s own preferences. An integrative approach also can make room for a therapist to be authentically themselves in the therapy room and to draw on what they have learned over the years through their clinical experience.
The good news is that there is also a wealth of research that demonstrates that integrative approaches are effective. In one of many examples, in a metanalysis of 66 well-designed studies that varied in respect to population, presenting problems, and treatment approach, researchers found no significant differences in terms of outcome when psychologists used the standard protocols or adapted approaches. Moreover, these authors even found that an integrative approach lead to higher rates of therapy completion and effect sizes.
So, what is the takeaway?
EBTs aren’t the only “right” way to do therapy; folks benefitted from therapy for decades before the psychology field even started completing the rigorous research necessary to design and validate an EBT. We know that other processes, such as the therapeutic appliance, drive improvement in therapy and therefore are just as important to attend to as empirically-based interventions. However, many therapists, including myself, find it important to know that part of their approach with clients is based on what science has demonstrated works.
Sources:
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of consulting and clinical psychology, 66(1), 7.
Bell, E. C., Marcus, D. K., & Goodlad, J. K. (2013). Are the parts as good as the whole? A meta-analysis of component treatment studies. Journal of Consulting and Clinical Psychology, 81(4), 722–736. https://doi.org/10.1037/a0033004
