Clinical Child Psychology's Progress in Disseminating Empirically Supported Treatments

Advances have been made over the past decade in identifying, evaluating, and disseminating empirically supported treatments (ESTs). Progress with adult ESTs, compared to child treatments, however, has differed. This article highlights areas of advancements, reviews literature related to specific training methods (i.e., treatment manuals, graduate education, continuing education, and EST protocols), discusses issues relevant to adult versus child treatment dissemination, and provides recommendations for enhancing the dissemination of ESTs.     

Achieving Successful Dissemination of Empirically Supported Psychotherapies: A Synthesis of Dissemination Theory

Although psychotherapy researchers have begun to recognize the benefits of applying dissemination research to their efforts to disseminate empirically supported treatments into community settings, to date no model has been proposed specifically for the dissemination of psychological interventions. We therefore summarize the key elements of three dissemination models and propose an integrated plan that may be useful in promoting wider and more effective dissemination of empirically supported psychotherapies. Barriers to dissemination are also discussed in the context of these models.     

Empirically Supported Treatments for Children and Adolescents: Where to From Here?

In this commentary, we provide additional detail about the movement to identify, evaluate, and disseminate empirically supported treatments (ESTs), suggest a Web-based strategy that might prove useful in disseminating ESTs, and comment on professional and ethical issues associated with the use and failure to use ESTs. We provide a series of Web-based recommendations and then assert that the ongoing practice of invalidated treatments not only is bad practice, but also may be unethical. The children, adolescents, and families the profession serves deserve the very best it has to offer them. It is our responsibility as practicing professionals to keep abreast of developments about which treatments work and which ones do not. Further, if we are not proficient in those strategies that do work, then we need to refer children with these problems to professionals who are. We recognize the boldness of our assertion but suggest that if we stay the course and are successful in disseminating these interventions, they will become "treatment as usual" over time.     

Bringing Identification of Empirically Supported Treatments Into the 21st Century

The author applauds the plan proposed by Tolin, McKay, Forman, Klonsky, and Thombs (2015) for bringing the methodology for identifying empirically supported treatments (ESTs) into the 21st century. She suggests that further attention is required to operationalize (a) what sorts of designs for effectiveness studies will be acceptable to the Committee on Science and Practice, (b) how data on improvement in functioning will be incorporated in the context of brief treatments, and (c) how complications in obtaining clean follow‐up data for long‐term outcomes will be addressed, and to specify (d) whether noninferiority to an existing EST is acceptable evidence of efficacy. She further cautions that meta‐analyses can mask poorly designed studies and bias in their implementation that will require the Committee's careful scrutiny.     

Empirically Supported Treatments for Specific Phobia in Children: Do Efficacious Treatments Address the Components of a Phobic Response?

Empirically supported treatments for childhood specific phobias are reviewed and critiqued using bioinf ormational theory ( Lang, 1979 ). Treatments in these trials have been based on different underlying principles of change and have placed different priorities on altering the tri-partite components of the pathological fear response (i.e., physiology, behavior, cognition) as well as the overall subjective experience of fear. Some studies place greater emphasis on altering behavior, others on cognition, and still others on physiology. However, these priorities have not always been attended to in guiding the evaluation of treatment outcome. It is suggested that future studies incorporate, in addition to individuals' subjective fear, a theoretically based multimethod approach to assessment. Research is needed to examine the purported principles of change associated with treatment outcome and to determine the clinical utility of such an approach.     

Employing Empirically Supported Treatments: A Research-Informed Clinical Practitioner Perspective

Ruscio and Holohan (2006 ) offer many excellent ideas for improving research on empirically supported treatments (ESTs) applied to complex cases. They hope that, as more empirical findings are accumulated, clinical practitioners will be more willing to use ESTs in their clinical work with such patients. This commentary suggests additional research strategies that are necessary to acquire information more useful and relevant to clinical practitioners. These include (a) integrating information from research on empirically supported relationship factors with findings from EST outcome research, (b) studying longer term therapies attempting to address issues beyond the symptoms of diagnostic and statistical manual of mental disorders (DSM)-defined disorders, and (c) investigating the efficacy and effectiveness of integrative forms of psychotherapy. The author's successes and difficulties of incorporating ESTs in his integrative therapy for anxiety disorders are highlighted.     

The Role of Empirically Supported Treatments in Evidence-Based Psychological Practice: A Canadian Perspective

This article offers a Canadian perspective on the empirically supported psychological treatments initiative. As a context for the comments, we begin with an overview of the structure of professional psychology in Canada and comments regarding the logical fit of an evidence-based approach to practice within Canadian professional psychology. The history and recommendations of the Task Force on Empirically Supported Treatments commissioned by the Clinical Psychology Section (CSP) of the Canadian Psychological Association are outlined. Two themes are identified in the recommendations of the Canadian Task Force: an encouragement of collaboration among various professional, regulatory, and accreditation bodies in promoting evidence-based psychological practice, and an approach to dissemination that explicitly recognizes the complexities of clinical practice and the limitations of existing empirical knowledge. The commentary ends with discussion of the current CSP report, with particular attention to similarities and differences between the approach outlined here and the recommendations of the Canadian Task Force.     

Applying Empirically Supported Treatments to Complex Cases: Ethical, Empirical, and Practical Considerations

Among the factors contributing to the underutilization of empirically supported treatments (ESTs) are practitioners' concerns about the appropriateness of ESTs for complex patients who are thought to differ in significant ways from the samples in clinical trials. Such patients may challenge our best available treatments and may raise important ethical, practical, and empirical questions. The present article reviews features that may make a case complex and considers influences on the clinician's decision to provide, modify, or abandon an EST with such cases. Given a dearth of data to inform this decision, we highlight several questions faced by clinicians that are in need of investigation. We suggest avenues for future work that may enhance efforts to disseminate and effectively provide ESTs.     

Severe Mental Illness Needs Empirically Supported Assessment and Treatments

This commentary describes the prevailing mental health-care paradigm as hindering the advantageous and sensible utilization of psychologists in the treatment of individuals with severe mental illness (SMI). The commentary suggests that the failure to utilize clinical psychology in treating SMI is part of a longstanding trend toward the narrow viewing of SMI as exclusively biological conditions requiring medical treatment exclusively. In neglecting a host of treatment interventions, a broad knowledge base of empirically supported treatments, and specific assessment skills available to clinical psychologists, an opportunity is missed to better enhance the lives of the individuals with SMI and even facilitate the effectiveness of biological interventions. This commentary raises the troubling implications of the underutilization of psychologists in the care of those with SMI, including the moral imperative raised by our absence, the neglect of the development and implementation of effective psychological interventions, and the erroneous message this absence sends about what it is that psychologists practice and who they are able to help. This commentary describes some of the ways in which clinical psychologists have contributed to the care of SMI and argues that the expertise of clinical psychologists in empirically supported assessment and treatment is a resource that should not be deprived to members of society desperately in need of treatments if we are to continue to reduce suffering and enhance quality of life. This commentary elucidates some ways in which members of the profession of clinical psychology can meet their ethical obligation to take part in the treatment of SMI.     

The Empirically Validated Treatments Movement: A Practitioner/Educator Perspective

In this commentary, I discuss the empirically validated treatments movement from the perspective of a practitioner and educator. I review the American Psychological Association (APA) Division 12 Task Force report ( APA, 1995 ) on empirically validated treatments, its effects, and its critics. I also consider the APA Division 29 Task Force report ( Norcross, 2001 ) on empirically supported therapy relationships and Westen and Morrison's (2001) metaanalysis of a set of efficacy studies. After highlighting the dilemmas that the empirically validated treatments movement creates for practitioners, I discuss how the endeavor of clinical practice differs from that of science and close by considering the definition of evidence-based practice adopted by the Institute of Medicine (2001) .     

The Role of Instructional Design and Technology in the Dissemination of Empirically Supported, Manual-Based Therapies

The principles, processes, and tools of instructional design and technology (IDT) can facilitate the translation of paper-based, text-intensive Manual-Based Therapies (MBTs) into media-rich, interactive, Web-based training (WBT) applications. This article outlines available technology-based mechanisms for delivering instructional content, provides examples of how each can be used for effective dissemination of MBTs, and outlines the advantages that may accrue from this approach. Clinical researchers and IDT professionals can collaborate to increase adoption of treatment manuals by employing user-friendly, instructionally sound Web applications that incorporate video role-plays, audio narration, graphics, animation, and dynamic, interactive content.     

The Process and Product of the Felix Decree Review of Empirically Supported Treatments: Prospects for Change

The report by Chorpita et al. on the Hawaii Empirical Basis to Services Task Force details a significant effort to improve services and enhance children's lives. Several elements distinguish this particular project to identify empirically supported treatments, notably the multi-disciplinary and consumer composition of the review committee and the mandated application of treatments identified in the process. The context of the lawsuit with the resulting Felix decree and the process of decision-making are important for public policy as well as for the science and practice of mental health service delivery. These considerations will likely enlarge the impact of this project.     

A Tool to Advance the Effectiveness and Dissemination of Empirically Supported Psychotherapies and the NIMH Public Health Research Agenda

Carroll and Nuro's (this issue) stage model will likely hasten the availability of more educationally effective and clinically complete therapy manuals for both research and practice. The model is an important and concise tool for broadly disseminating knowledge about psychotherapy manual development that has accrued over the 20 years since manuals became required for federally funded therapy outcome research. The current paradigm shift to a public health research agenda, spearheaded by the National Institute of Mental Health (NIMH), is evident in the model's specifications for stage III manuals. The immense challenge for researchers to truly meet the scientific demands of stage III manuals (and the NIMH's research charge) is briefly discussed. An autobiographical case report is also presented to illustrate that manuals for empirically supported therapies are not, in all cases, as "unfriendly" to practice and practitioners as much contemporary literature suggests, and as the stage model is intended to remedy.     

The Idiographic Application of Nomothetic, Empirically Based Treatments

Empirically supported treatments are nomothetically based and often operate by affecting causal variables for a behavior problem. Clients can have multiple behavior problems that are complexly interrelated, and different configurations of causal factors can affect the same, behavior problem across clients. Empirically based treatments vary in the degree to which their causal mechanisms are congruent with the idiographic networks of causal relations extant across clients. Consequently, the applicability of an empirically supported, nomothetically based treatment to a client is a function of the degree of congruence between the causal relations relevant to the client's behavior problem and the causal relations targeted by the treatment.     

Exploring Empirically Supported Treatment Options for Children: Making the Case for the Next Generation of Cultural Research

In the last decade there has been increasing interest in empirically supported treatments for children. Chorpita et al. present an attempt to synthesize the knowledge base in the field and implementation of services. Placing the results in context, the authors make clear the need for an increased awareness of culture by researchers interested in empirically supported treatments. The construct of culture is explored as an active participant in the outcome literature. Furthermore, reasons for the lack of research into culture's influence on treatment outcomes is considered. Lastly, the importance of maintaining a dialog between the scientific and clinical service community is discussed.     

Empirically Supported Treatment: A Commentary

Generating and updating lists of empirically supported treatments serves the public interest. Such lists force advocates to test the accuracy of their claims and serve to inform the public regarding the relative benefits of different interventions. Such efforts should cover the full array of types of interventions used to treat a given disorder and be multidisciplinary in nature to guard against bias related to guild identification. I wholly endorse the authors' call for Division 12 to update their list of empirically supported treatments.     

Empirically Validated Treatments: Reality and Resistance

Although not free from methodological problems, the Task Force report represents an important step toward identifying effective treatments for major clinical disorders. The commitment to empirical research that this report embodies is part of what could be an overdue move toward greater accountability in clinical training and practice. The time-honored reliance on therapists' clinical judgments in formulating individual treatment plans needs to be critically examined in the light of their well-documented limitations and the informed use of empirically supported, manual-based treatments. The reality of common factors across different treatments does not conflict with the effectiveness of specific treatments for particular disorders.     

Facilitating Practitioner Flexibility Within an Empirically Supported Intervention: Lessons From a System of Parenting Support

[Clin Psychol Sci Prac 17: 238–252, 2010] Reluctance by practitioners to follow manuals is often cited as a reason for the lack of adoption of empirically supported treatments (ESTs). We contend that rigid adherence to the therapeutic techniques described in a manual is neither necessary nor desirable. Rather, practitioners should flexibly deliver interventions to meet the diverse needs of consumers, but in such a way that the intervention is not moved beyond its evidence base. This tension between adherence and flexibility is reframed as an issue of practitioner generalization. The present article draws on the authors’ experiences from disseminating the Triple P‐Positive Parenting Program to describe a number of strategies that can both safeguard the fidelity with which ESTs are delivered and encourage their flexible delivery.     

Four Considerations for Dissemination of Intervention Innovations

The current paper offers four considerations related to Stirman, Crits-Cristoph, and DeReubis' (this issue) insightful review on general theories relevant to the dissemination of psychological interventions and major obstacles associated with the dissemination effort. Readers are asked to consider (a) the notion that the dissemination of a psychological intervention is not equivalent to unidirectional product delivery, (b) the importance of examining local uncontrolled evidence alongside controlled research evidence, (c) design strategies to facilitate adapting evidence-based interventions for community settings, and (d) fostering working partnerships between laboratories and the communities.