ESTs and EBP

What are Empirically Supported Treatments and How Do They Related to EBP?

In 1993, the American Psychological Association (APA) Task Force on the Promotion and Dissemination of Psychological Procedures delineated three categories of for classifying the empirical support for psychological treatments. (The "promotion" role may well be worth noting!) These three categories have remained fairly stable over time, though they were initially called 'Empirically Validated Treatments." After major discussion about what validity means in research and practice, they were renamed 'Empirically Supported Treatments" or ESTs.

(In social work, the term "Empirically Supported Interventions" or ESIs is also used - though there is no clear, standard, definition of an ESI.)

The APA propose the following three (or perhaps really four) categories related to the empirical support found, or not found, for a given psychological treatment.

1) Well-established treatments, the report said, required two studies or more using between group research designs done by different researchers that demonstrated the superiority of the treatment under study to a placebo or a different treatment OR its equivalence in outcome to another established empirically supported treatment. That is, two experimental studies demonstrating superiority to no treatment or alternative treatments OR equivalence to an empirically supported treatment. Such treatments employed must also be manualized to permit replication of the treatments in other settings.

2) Probably efficacious treatments require at least two studies with superior outcomes compared to untreated control groups, two studies completed by the same researchers meeting the criteria for a well-established treatment, or a series of single-case or single-system design withdrawal studies (which are the single system design equivalent of an experimental design - the multiple replications indicate some likelihood that the treatment cause the changes noted in varied settings and with treatment done by different providers).

3) Experimental treatments which are newly developed and awaiting study but do not meet criteria for inclusion in well-established or probably efficacious categories.

4?) All other treatments lack empirical validation, though keep in mind that this may simply be a matter of not enough research being done or lack of a treatment manual. This does not mean the treatment does not work - just that we don't know yet. Be cautious.

ESTs and EBP: Key Differences

APA's ESTs differ from the criteria used in EBP for a systematic review in that they require manualized treatments and at least two experiments (or several single subject withdrawal designs). Both ESTs and EBP privileges experimental research results in its hierarchy of research yield, but EBP methods does not require any specific number of studies or any specific type of research design for systematic review. Of course, where good quality research is limited or lacking, the summary results of an EBP review will likely report it is of unknown quality. Most EBP reviews do not include or highlight single-system or single-case research design (based in replication logic), but instead look for large scale studies using sampling logic. EBP reviews also do not require manualized treatments, though many studies employ them.

Another requirement of an ESTs is that some of the research must be completed by people who are not also the creators of the treatment under study. It has been found that people who develop treatments may consciously or unconsciously, bias studies of the effectiveness. This is known as "attribution bias." Thus an EST must have some research done by researchers who are not the creators of the treatment under study to avoid attribution bias.

In short, APA's EST's are based on empirical support of two or more experimental studies and discount all other research using other research designs, as well as any non-manualized treatments. One report in the New York Times noted that this report and similar efforts generated a rather deep divide in psychology. Critics noted the requirements for ESTs were very much linked to behavioral or cognitive behavioral theories. Some said the EST movement promoted a "cookbook approach" to treatment. A number of psychologists took the position that the EST movement was heavily ideological. Some also note that such research does not answer the question of how the treatment works - which they view as a requirement of a scientific understanding of treatment. Instead, superior results are honored without full understanding - which may have practical utility but is not truly scientific. Further, the interpersonal interaction between client and therapist is discounted - as are the personal characteristics of the client - which may run from opposed to treatment to unsure to open and invested. (The view that factors other than the treatment are important sources of treatment effectiveness is called the "common factors" approach.)

EBP allows for wider inclusion of varied types of research than does the EST approach. Even within psychology, EBP includes qualitative research as well as a wide variety of quantitative research designs types. Of course, the yield of the different types of research will be differentially appraised. More studies are generally sought in a EBP systematic review before efficacy is claimed. Systematic reviews used in EBP (by the Cochrane Collaboration and the Campbell Collaboration, and potentially some qualitative research syntheses) use wider and perhaps better documented review criteria.

Note that it is possible for researches or administrators to claim a treatment is empirically supported using these standards even if a larger, more inclusive systematic review questions the efficacy of the treatment.

Note, too, that it may be useful for program evaluation for researchers, administrators and practitioners to evaluate their work using experimental designs to begin to establish the efficacy of their work - even if it only in a specific city or state program serving what is arguably a very specific and likely non-replicable population (such as people referred by courts for services based on local legislation). Doing such work - and using empirically supported" logic and language may be helpful to promoting and marketing a program or treatment. Yet it may also be confusing to practitioners and consumers (despite good intentions).

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text copyright by J. Drisko - page begun 4/9/10 updated 9/4/12