Summary and Keywords
Research in psychotherapy has developed a number of treatments, numbering well over 300, that have a strong evidence base. These treatments can be applied to a broad range of psychiatric disorders (e.g., depression, anxiety, schizophrenia, and others) as well as other sources of impairment in psychological functioning among children, adolescents, and adults. This article provides an overview of evidence-based psychotherapies, including current advances in how treatments are applied. Examples of treatments for depression and autism spectrum disorder are provided to illustrate the diversity of procedures in use and how they are applied. Key challenges related to evidence-based psychotherapies are highlighted, and these include disseminating the research findings, so that effective treatments are being used in clinical practice, and devising novel ways of delivering treatment to reach the large number of individuals who are in need of psychological services but do not yet receive care.
Psychosocial interventions refer to a broad range of techniques and strategies that are directed toward reducing psychological sources of dysfunction (e.g., symptoms of mental disorders and substance abuse disorders) and improving functioning and well-being (England, Butler, & Gonzalez, 2015; Knapp, Soares, Farrell, & Silva de Lima, 2007). These interventions encompass a range of interpersonal techniques, or strategies, including the full panoply of psychotherapies (for example, psychodynamic therapy, cognitive-behavioral therapy, interpersonal psychotherapy, problem solving therapy), community-based treatments, peer support services, and integrated-care interventions. The broad term of psychosocial intervention is needed because of the expanded range of interventions, contexts in which treatment is administered, and methods of delivery. Thus psychologically based interventions can be delivered in a variety of settings (such as outpatient clinics, individual provider offices, primary care clinics, schools, hospitals, community settings, and virtual settings such as video conferencing).
Psychotherapy is a subcategory of psychosocial interventions and typically consists of a special interaction between two (or more) individuals in which one person (the patient or client) has sought professional help for a particular problem and in which another person (the therapist) provides conditions to alleviate that person’s distress and to improve functioning in everyday life. Psychotherapy draws on psychological theory and research on the development and nature of adaptive and maladaptive functioning and methods that can be used to affect change. The means used to achieve therapeutic change rely on verbal interaction as well as other techniques, such as problem solving, practicing new ways of thinking and behaving, engaging in “homework” activities to develop behavior outside of the treatment sessions, being exposed to special experiences in and out of the sessions, and others. These means are structured and readily distinguish psychotherapy as a more formal enterprise from talking with a friend or relative in everyday life. The emphasis and focus of this article is on psychotherapies broadly conceived as treatments based on the interaction of two or more individuals (e.g., marital therapy, group therapy).
Psychotherapeutic interventions have been the subject of considerable research. A key part of that research has focused on the development, evaluation, and dissemination of evidence-based psychotherapies (EBPs) (Nathan & Gorman, 2015; Weisz & Kazdin, 2010).1 These are interventions that have been evaluated in research and have been shown to lead to therapeutic change. This article provides an overview of EBPs including current advances and trends in research and clinical practice. Examples of treatments will be highlighted to convey the diversity of procedures and their applications. Key issues and challenges for psychotherapy research and extensions to clinical practice are highlighted; these include disseminating the research findings, so that effective treatments are being used in clinical practice, and devising novel ways of delivering treatment, to reach the large number of individuals who are in need of psychological services
Evidence-Based Psychosocial Interventions
Overview of Current Status
Impetus for much of psychosocial intervention research can be traced to early evaluations of what was once a rather weak and sparse empirical literature on psychotherapy. In 1952, Hans Eysenck, a prominent psychological researcher, evaluated the sparse research literature on psychotherapy that was available at the time. The conclusion he reached was that treatment was effective (i.e., was associated with therapeutic change) for approximately two thirds of patients who received treatment. This initial conclusion seemed promising until the disconcerting punch line, namely, that among patients who did not receive any treatment, approximately two thirds improved. Eysenck was not alone in the general claim that the evidence, such as it was, did not firmly support the view that psychotherapy could surpass the changes that occur over time without treatment (e.g., Levitt, 1957, 1963). Updating of the reviews did not change the conclusion very much, but generated vibrant discussion and controversy (Eysenck, 1966).
We have learned that the passage of time includes many influences that can be associated with therapeutic change. That is, people often improve over time, sometimes due to maturational and healing processes, repeated testing on a set of measures designed to assess symptoms, and the tendency of extreme scores (high levels of symptoms at the beginning of treatment) to revert toward a less extreme level (statistical regression). Controlled trials of therapy must take these changes into account by providing some control or comparison condition, such as no treatment or serving on a wait-list to receive treatment later. Now, with many controlled studies, we are long past the challenge of whether psychotherapy leads to change. By the mid-1970s and early 1980s, extensive reviews of the evidence involving hundreds of controlled studies concluded, in fact, that psychotherapy was effective (Smith & Glass, 1977; Smith, Glass, & Miller, 1980).
Currently, many interventions have been delineated as evidence-based, and these can treat a wide range of psychiatric disorders and sources of impairment in psychological functioning among children, adolescents, and adults (e.g., Lambert, 2013; Nathan & Gorman, 2015; Weisz & Kazdin, 2010). The criteria used to designate treatment as evidence-based vary among multiple disciplines (e.g., psychology, psychiatry, social work), diverse professional organizations within and among countries (e.g., in the Americas, the European Union), and private and public agencies within a given country. Although there is no single consensus definition about what it means to be an EBP, for the most part, the following criteria are commonly invoked:
• Careful specification of the patient population (e.g., the disorder or problem and how the clinical problem is measured);
• Random assignment of participants to intervention and comparison or control conditions;
• Use of treatment manuals that specify in detail what the therapeutic procedures are;
• Multiple measures of therapeutic change, including measurement of the problem or disorder targeted in treatment;
• Statistically significant differences at the end of the intervention period between treatment and control or comparison conditions; and
• Replication of outcome effects, ideally by an independent investigator or research team that can reproduce the findings obtained in the original study.
These criteria require at least two independent studies that attest to the effectiveness of treatment as applied to a particular problem. The studies required are randomized controlled clinical trials (RCTs), in which clients who are to participate in a study are assigned randomly to conditions.
Given some variations in the criteria, there is no single count of EBPs. Even so, as an instructive guide, a federal agency in the United States monitors these psychosocial treatments in an ongoing fashion. In the most recent count, over 350 psychosocial interventions are listed as evidence based, and that number continues to grow (U.S. Department of Health and Human Services, 2015). With so many treatments, it is of course impossible to list, much less describe, the many options that are available. Two illustrations are provided to convey variations of treatment as applied to significant clinical dysfunctions.2
Two Illustrations of EBPs Briefly Noted
Cognitive Therapy for Depression
One of the most well studied EBPs is cognitive therapy (CT) for depression. The underlying conceptual view is that depressed persons often have negative cognitions or beliefs about themselves, the world, and the future. These three areas, referred to as the negative cognitive triad, are captured by other terms including low self-esteem, pessimism, and hopelessness, respectively. Among the key tenets is that negative cognitions critically influence and promote depression and lead to the pervasive behavioral, affective (mood related), and motivational symptoms (e.g., sad affect, loss of interest in activities).
CT focuses on beliefs and negative cognitive processes that promote depression (Beck, 2011; Beck, Rush, Shaw, & Emery, 1979). Sessions are conducted individually. Within and outside of the sessions, assignments are provided in which the client is encouraged to identify negative thoughts and to record alternative explanations that might be generated in their place. The therapist and client together examine these negative beliefs and point to disconfirming evidence or challenges. For example, extensive self-criticism may be identified as a problem. The therapist will challenge that the individual is responsible for a particular event or that the event reflects on the individual’s self-worth.
Behavioral tasks and assignments outside of the treatment session help disconfirm the negative cognitive beliefs. For example, a client who says he or she cannot do something or will be no good at an activity (some hobby or sport) will be given an assignment to engage in the activity. The experience will help the client identify the negative cognitions that hold him or her back and disconfirm the particular cognition (“I can’t do anything”; “It’s useless to try anything new”). The activities are viewed as a way to change cognitions and depression.
CT is the most well studied EBP for depression, but there are other treatments as well (Cuipers, Berking, Andersson, Quigley, Kleiboer, & Dobson, 2013; Hollon & Beck, 2013). Among the many interesting findings is that, when compared to medications, the effects of CT are much more enduring. CT began as a treatment for depression, but extensions have conveyed that it is effective well beyond that focus (e.g., anxiety, schizophrenia, personality disorders) and can be adapted for use with children, adolescents, and adults. In addition, now there are computerized and self-help versions of treatment that extend its use, as this article mentions later.
Early and Intensive Behavioral Intervention for Autism Spectrum Disorder (ASD)
ASD includes deficits in social interaction, verbal and nonverbal behaviors, delays in cognitive development and adaptive functioning, and repetitive or ritualistic behaviors. The disorder is referred to as a spectrum disorder to convey that symptoms and severity can vary in degrees. ASD is evident in approximately 1 in 88 children. In its most severe form, children may have pervasive delays and deficits in their development.
Early and intensive behavioral intervention focuses in one-to-one situations where children are taught basic language and communication skills, play, social interaction, and other skills. Children participate in sessions that allow a trainer to closely monitor performance, prompt, guide, shape, and provide multiple opportunities for reinforced practice (e.g., the use of praise and food reward to build skills). Parents are trained in the procedures so the intervention of developing, shaping, and reinforcing behavior is supported beyond the individualized sessions.
The intervention is intensive and includes 20–40 hours per week of individualized training and continues for two or more years. The number of hours and years are determined by the child’s progress. During the first year of treatment, the intervention takes place mainly in the child’s home with one-to-one sessions with a trainer. As the child progresses, training is conducted more in naturalistic situations and focuses on behaviors such as communication, academic skills, play, and other activities. Parents are very actively involved in the child’s training and spend 3–4 months (5 hrs/week) working alongside of one of the trainers to learn the procedures, participating in team meetings, recruiting peer play dates for the child, and negotiating school placements.
Training includes various stages, each of which can be an extended period of months or more depending on the child’s progress (Smith, 2010). The stages begin with teaching simple commands (e.g., sit, come here) and reducing behaviors that may interfere with learning (e.g., tantrums), then imitating the trainer, identifying objects, dressing oneself, playing with toys, then focusing on imitative speech, labeling objects, then finally concentrating on more complex interactions with others, working independently, and comprehending stories. The interventions then focus on recognizing emotions (e.g., I want), playing with peers, entering preschool, and expanding self-help skills. The intervention ends at age 5, and children proceed from preschool to kindergarten if they show the skills expected for their developmental level at this time. If not, they can repeat preschool and continue training. If they are still delayed at this point, the students are likely to need ongoing services.
Several studies have attested to the impact of treatment on children with ASD (see Dawson & Burner, 2011; Wong et al., 2015). Gains from treatment often are reflected in increased intelligence quotients, improvements in communication, and placement in regular education classes. The intervention is not a “cure” for ASD, but it is an EBP that has impact on daily functioning of many children.
This article has briefly highlighted two of the hundreds of EPBs to convey procedures that are well studied but that depart from the most familiar and media-fostered stereotypes about psychotherapy, namely, that two people sit and chat and focus on the individual’s past emotional life. Therapy takes many different forms and often involves direct activities designed to change emotions (affect), thoughts (cognitions), and actions (behaviors) that can change the clinical problems. Often active practice is involved, in which clients are provided with exercises and activities, in and outside of the session, designed to build new ways of thinking, acting, processing information, and regulating emotions.
I noted that the criteria to be designated as an EBP require at least two studies conducted by independent research teams that support the effectiveness of treatment. Actually, for many techniques there are many—even hundreds of—studies. Needless to say, treatments that have a strong evidence base do not work with everyone, something true of evidence-based treatments in general (such as surgery or medication). Among the challenges is to identify variables that differentiate responsiveness to treatment (moderators), to understand how they operate (mechanisms), and to utilize that information showing that, in fact, the knowledge translates to more effective treatment.
Many of these studies focus on extending treatments to diverse populations or psychiatric disorders, or they elaborate whether there are some indices before treatment (e.g., characteristics of personality, brain functioning) that might identify who responds well or poorly. For example, culture and ethnicity can make a difference in responsiveness to treatment, and it is possible that some treatments may be more or less applicable across different groups. Among the many tests that are needed are those that ensure effective treatments can be used, adapted, or replaced if needed for specific groups. In short, once effectiveness of a treatment is established, there remains much to learn about how and why it works and for whom.
Current Trends in Treatment Development
EBPs have continued to flourish with a constant flow of well-controlled studies that evaluate novel applications of treatment. There are significant changes in the conceptualization of EBPs and in how they are applied, and these reflect important trends that characterize current work. Two salient trends are highlighted here.
Transdiagnosis and Transtreatment: Changing the Focus of EBPs
The development of EBPs has focused on matching treatments to specific clinical dysfunctions that form the basis of psychiatric diagnoses. Psychiatric diagnoses include distinct syndromes (sets of symptoms) such as anxiety disorders, major depression, bipolar disorder, and attention-deficit/hyperactivity disorder. There are over 400 such disorders and subtypes that are identified in the manuals used to delineate psychiatric dysfunction (American Psychiatric Association, 2013; World Health Organization [WHO], 2010). That means, that individuals are considered to meet criteria for major depression, or anxiety, or schizophrenia or possibly two or more disorders. In developing EBPs, treatments were (and continue to be) developed with a disorder focus. Yet, this is changing and reflects a new emphasis.
An alternative view to disorder-specific treatments has emerged and involves two related areas of research, transdiagnosis and transtreatment, which serve as a model for understanding clinical dysfunction, underlying processes, and treatment development. Transdiagnosis refers to the study of processes that span many different manifestations of clinical dysfunction (e.g., Harvey, Watkins, Mansell, & Safran, 2004; Kring & Sloan, 2009; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015). Several factors have served as impetus for a transdiagnostic conceptualization of clinical dysfunction including these empirical findings:
• Individuals (children or adults) who meet criteria for one psychiatric disorder are likely to meet criteria for at least one other disorder as well (e.g., Kessler et al., 1994; Wichstrøm, Berg-Nielsen, Angold, Egger, Solheim, & Sveen, 2012), so perhaps disorders are not discrete and unrelated;
• Many disorders also share several psychological processes, such as reactivity to stress, or sleep characteristics (e.g., Conway, Slavich, & Hammen, 2014; Dolsen, Asarnow, & Harvey, 2014; Eaton, Rodriguez-Seijas, Carragher, & Krueger, 2015).
The findings indicate that there are many commonalities among different disorders. Disorders no doubt still have specific and unique features that make it so. Schizophrenia is not the same thing as depression or anxiety disorders. Even so, the commonalities have been surprising and have had many implications including those related to treatment. On the diagnostic side, the findings have inspired efforts to search for core psychological processes (e.g., working memory, cognition), environmental influences and experiences (e.g., exposure to trauma, violence, parent with depressed affect), and biological factors (e.g., neuromarkers, genetics), and to locate the interrelations that unite several paths leading to clinical dysfunction (e.g., Caspi et al., 2014; Harvey et al., 2014).
Transdiagnostic conceptualizations have altered treatment and treatment research. Rather than adding to the burgeoning list of EBPs for specific disorders, attention is now being directed to the search for treatments than can be effective across a multiple disorders. These are referred to generally as transtreatments, although many specific terms are used such as transdiagnostic treatment, unified protocol, and unified and enhanced cognitive behavior therapy (e.g., Barlow et al., 2011; Fairburn et al., 2013). The treatments draw on and distill core practices of EBPs such as restructuring maladaptive cognitive appraisals, changing maladaptive behaviors associated with emotions, preventing avoidance, and using exposure procedures to help reduce emotional reactions. Transtreatments with these foci have been effective across many different disorders (Greeson, Garland, & Black, 2014; Hofmann & Smits, 2008; Johnston, Titov, Andrews, Dear, & Spence, 2013, McEvoy, Nathan, & Norton, 2009; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015). In the coming years, advances are likely to continue in developing treatments for specific disorders and in transtreatments that have wider applicability.
Increased Use of Technology
The vast majority of therapy, whether or not based on EBPs, consists of one-to-one treatment sessions, in person with an individual mental health professional. Increasingly, treatments involve the use of technology that draws on advances in both hardware (e.g., smart phones, tablets, smart watches) and software (e.g., Web resources available 24/7; application software or “apps”). The use of technology to deliver treatment is not new. Telemedicine, telehealth, and telepsychiatry have been around for a long time in some form—at least 40 years (see online here for information on telemedicine). Telepsychiatry consists of providing treatment via phone or computer to areas (e.g., rural, developing countries) where mental health professionals or services are not usually available (e.g., Wooton, 2003). The current impetus for using technology is much broader. In everyday life, many people are actively involved with social media, connected to the Internet in one or more of the many available ways (e.g., smart phone, smart watches, various tablets, and that now seeming old fashioned device, laptop computer).
Among the technological options, there is a rapidly growing literature on the use of the Internet. The ability to reach a large segment of the population in need is nicely illustrated in an application to cigarette smoking, which often is a target of psychological interventions. A series of Web-based intervention studies for smoking cessation, conducted in English and Spanish, have shown significant smoking termination rates through a standard smoking cessation guide and mood management course (Muñoz et al., 2006). An individualized, password-protected Website provided access to the smoking cessation intervention to consenting eligible individuals and was used to obtain assessment data throughout the intervention. Initial applications of the program reached more than 4,000 smokers from 74 countries and was carefully evaluated (e.g., RCTs, follow-up assessments). In a recent extension, the online program was available in Spanish and English and was visited by over 290,000 individuals from 168 countries (Muñoz et al., 2016). Online treatment conveys the potential reach. In fact, this particular program advanced the notion of Massive Open Online Interventions as a model for reaching many people in need of services and for a variety of clinical problems.
Smartphones also are being used to provide therapeutic services, and they provide new opportunities for methods of intervention and assessment in real time as the client functions in everyday life. For example, one smartphone application, known as Mobile Therapy, prompts users to report their mood levels throughout the day by indicating their mood on a touchscreen “mood map” and to report their levels of happiness, sadness, anxiety, and anger (Morris et al., 2010). The application provides mobile therapeutic exercises based in cognitive behavioral techniques (such as visualization, physical relaxation, and cognitive reappraisal exercises) as needed to cope with their stress and mood.
The use of technology overlaps with another treatment advance, namely, self-help techniques. Self-help interventions vary in the extent to which they are done completely by individuals on their own or they utilize some assistance in varying degrees. Many of these treatments are versions of EBPs that have been well established as individual, in-person therapies. For example, Beating the Blues is one such treatment that is interactive, multiple media, and computerized, and draws on cognitive behavior treatments that have been well studied. Treatment begins with a 15-min introductory video; then weekly sessions are provided by computer. The sessions assign activities to do at home. Separate modules are presented (e.g., automatic thoughts, core beliefs, attributional style), and treatment can be individualized by additional modules that may also apply (e.g., graduated exposure if the patient has anxiety).
Self-help treatments include resources available for a wide variety of conditions, including anxiety and depression, eating disorders, addictive behaviors, and personality disorders. Evidence suggests their effects are comparable to those obtained with individual in-person therapy (e.g., Cuijpers, Donker, van Straten, Li, & Andersson, 2010; Harwood & L’Abate, 2010). Yet, they get lost in a sea of countless self-help books and websites that are have no basis in theory or research. There is no easy way for the public to tell which self-help treatments have evidence in their behalf.
The use of technology to deliver and provide effective treatment is clearly a wave of the present and is likely to proliferate. Among the reasons is that technology is more familiar and used in multiple ways; people are “connected” to the Internet, friends, and so on. Also, more “apps” are available that focus on mental health, including interventions to treat anxiety, prevent suicide, help with eating and sleep disorders, help with controlling and reducing substance use and abuse, and many other domains of clinical dysfunction (e.g., Singh, 2014). Texting also is used where questions, reminders, and activities are provided to combat problems (e.g., depression, anxiety) (Ben-Zeev, Davis, Kaiser, Krzsos, & Drake, 2013). The vast majority of “apps” and texting programs are not evidence-based; studies have not been completed to evaluate their effects. Yet the pervasive development of these techniques illustrates how technology is being used.
More hardware and more advanced versions of what we already use (e.g., smartphones, smart cars, smart clothing to detect biological reactions, smart watches, smart wrist bands and bracelets, social robots, etc.) are on the rise, and these will increase the options for delivering treatment methods. Many of these devices can detect and measure biological states associated with psychological dysfunction (e.g., arousal due to stress or anger, diminished activity related to depression, restlessness, and disturbed sleep). Interventions can be delivered in real time, while the person is confronting anxiety, or an urge or impulse, and can provide immediate strategies to cope. At present, the evidence has not caught up with the range of options, so we know technology-based treatments can be applied; now we need to show to whom (e.g., children, adolescents, adults), with what sorts of dysfunction (type and severity), and with what effects.
Integration of Traditional Therapy Topics
Highlighting the use of technology for therapy conveys significant shifts in how treatment is administered. At the same time, traditional topics and foci continue in psychotherapy research but with somewhat new perspectives. This section considers three illustrations to convey the point.
Guiding Question for Psychotherapy Research
For decades, a guiding, if not dominant, question of psychotherapy research has been a variation of “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?” (Paul, 1967, p. 111). The question continues to receive prominence as the treatment agenda to guide research (e.g., DeRubeis, Cohen, Forand, Fournier, Gelfand, & Lorenzo-Luaces, 2014; Fonagy, Cottrell, Phillips, Bevington, Glaser, & Allison, 2015; Maric, Prins, & Ollendick, 2015). The different conditions under which treatment might vary in effectiveness are referred to as moderators, that is, variables that influence the direction or magnitude of a relation between two other variables. The focus on multiple moderators in the question is of even greater interest now in light of broader attention in physical health care about personalized medicine, for instance, in targeting treatment to key biomarkers that influence responsiveness to treatment. The goal of identifying moderators of psychologiical treatment also is in keeping with clinical practice where the interest invariably has been to “individually tailor treatment” or to “meet the individual’s needs.”
In research and clinical practice, we do not have valid and reliable information that allows us to routinely tailor treatment. By valid in this context, I refer to evidence that tailoring treatments improves clinical outcome compared to the best (untailored) treatment available. By reliable, I refer to consistency among therapists in agreeing on what that tailoring would be for patients with similar subject and demographics characteristics and presenting conditions. Currently, we do not have evidence-based information to guide clinical practice for individual tailoring.
There has been a long tradition of studying moderating variables that influence treatment outcome, and these include a variety of client, therapist, and relationship variables (e.g., Bergin & Garfield, 1971; Lambert, 2013). We have not reached a place where information is very useful for guiding treatment for at least three reasons. First, when moderators are studied (e.g., comorbidity, severity of dysfunction, culture), they often exert a small influence on treatment outcome (Kraemer, 2013). This relatively weak impact as a general rule suggests, perhaps mistakenly, that they are not very critical.
Second, when a moderator is demonstrated in research, rarely is the same moderator studied across clinical problems or treatment techniques. That means we do not know the extent to which that particular moderator applies to any treatment, or just the treatment used in a particular study that focused on a particular clinical problem. That is, the generality of a particular moderator is not known. This means we cannot use the information to direct clients to a different treatment to which they might better respond in light of their standing on a given moderator.
Third, there has been very little attention in studying precisely how and why a moderator exerts its influence. Without that knowledge, we do not know if the moderator itself makes a difference or is a proxy (stand-in) for some other construct. Examining why and how a moderator works might entail looking at core psychological processes (e.g., perception, attention) and neurological processes (e.g., changes activated or not activated) that underlie moderator effects and relate to clinical dysfunction.
The ways in which moderators are studied are likely to change in the coming years. Moderators usually are studied one at a time in any individual study. Recently, methods for integrating and combining multiple moderators have been elaborated (Kraemer, 2013). When multiple moderators are combined, moderator x treatment interactions emerge that otherwise would not be evident (e.g., Frank et al., 2011; Wallace, Frank, & Kraemer, 2013). Combining moderators in principle might generate multiple variables that could be used to “profile” (select) clients who vary in responsiveness. Then we would need to evaluate whether that responsiveness might be improved by triaging individuals to different treatments and generating a treatment that is more individualized (personalized).
The overall question mentioned to guide psychotherapy research is of unclear value. With approximately five decades of research, it is not clear we have advanced in ways that the question promotes. Clearly, we want to learn about moderators, but to study them in ways that translate to better patient care. That said, the question that has guided research has not generated major breakthroughs in understanding treatment. Moreover, the question may be unanswerable for many reasons. One cannot begin to examine the range of moderators (culture, comorbidity) across techniques, clinical problems, and age groupings (children, adolescents, adults, the elderly). The combinations that are possible require an enormous number of studies that could not be completed, executed, or funded (see Kazdin, 2008).
Therapeutic Alliance and Treatment Outcome
A long-standing topic for research and practice has been the client-therapist relationship and its role in treatment. The relationship served as a central role in conceptual models and actual practice of treatments (e.g., psychoanalysis, client-centered therapy) as psychotherapy was formally developed and studied. The study of the relationship has spanned the full range of psychotherapies. Literally thousands of studies have been conducted on the therapeutic relationship, mostly in the context of adult psychotherapy, with much less attention on therapies with children and adolescents (e.g., Elvins & Green, 2008; Horvath & Bedi, 2002; Norcross, 2011).
The most well studied facet of the relationship has been the therapeutic alliance. This refers to the collaborative nature of the patient-therapist interaction, their agreement on goals, and the personal bond that emerges in treatment. Studies that evaluate alliance during (e.g., early, middle) treatment often show that quality of alliance predicts improvement in symptoms at the end of treatment. This is an important finding in its own right, because prediction of change or lack of it might well guide the therapist in decision making about intervention strategies. The relation of therapeutic alliance and treatment outcome is relatively small (r = 0.27; Horvath, Del Re, Flückiger, & Symonds, 2011), but has been reliable across many studies.
Showing that alliance predicts later symptom change by itself does not show that alliance plays a causal or mediational role in therapeutic change. In the vast majority of studies, alliance is measured somewhere during treatment and then used to predict symptom change at the end of treatment. Without assessing both symptom change and the alliance at multiple points during treatment, it is quite possible that alliance is the result of early symptom change, changes along with symptoms, or precedes symptom change. Several studies have now clarified the relation to show that symptom change early in treatment can improve alliance, and alliance contributes to symptom change at the end of treatment, even after controlling for symptom change (e.g., see Castonguay, Constantino, Boswell, & Kraus, 2011; Crits-Christoph, Gibbons, & Mukherjee, 2013). Thus the relation does make a difference in outcome, but symptom change early in treatment actually predicts alliance as well as the other way around.
Several advances in research have altered the way we think about the alliance, or at least the centrality of that to change. First, the role of alliance extends to a diverse range of treatments beyond the traditional one-to-one in-person therapy, including, for example, treatments delivered over the Internet or by phone (e.g., Sucala, Schnur, Constantino, Miller, Brackman, & Montgomery, 2012). Second, the relationship may be important for many reasons other than contributing to outcome. Satisfaction with treatment, adhering to treatment prescriptions, and remaining in treatment are also favorably influenced by the quality of the client-therapist relationship. Third, we know the relationship is not essential to therapeutic change. This is suggested by well-replicated findings that some patients make rapid or sudden gains in treatment, as early as the first and second session, and that these changes predict treatment outcome (e.g., Aderka, Nickerson, Bøe, & Hofmann, 2012; Busch, Kanter, Landes, & Kohlenberg, 2006). Presumably, the alliance (e.g., bonding that develops over time) may not have emerged at this early point or at least in the usual sense. However, that possibly instant alliance may still be important. More tellingly, we know the relationship is not essential because there are many treatments (e.g., self-help, technology based) with little or no professional involved in the treatment delivery (e.g., Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010; L’Abate, 2007).
Treatment research on alliance continues. Arguably the most outstanding question is understanding the mechanisms through which treatment alliance operates. That is, we do not understand how alliance alters core psychological or biological processes that relate to symptoms, precisely what alliance does to those processes, and how that action leads to symptom change. Increasingly, neuroimaging studies are used to elaborate the correlates of change in psychotherapy including the therapeutic alliance (Frewen, Dozois, & Lanius, 2008; Levy, Beeney, Wasserman, & Clarkin, 2010). The research is largely descriptive and correlational, but elegant description of those changes associated with alliance could readily lead to understanding how treatment works more broadly.
Treatments as Usual and Evidence-Based Psychotherapies
Development and evaluation of EBPs has been based on RCTs. Increasingly, the control or comparison condition in these trials has been the treatment that is routinely used in a clinical setting in which the study is conducted. The treatment usually is referred to as treatment as usual (TAU) and can include a variety of procedures, but most often some unspecified form of traditional individual therapy as administered in a particular clinic, hospital, or community setting. As a control condition, TAU affords many advantages, such as averting ethical issues associated with delaying or withholding treatment, and by controlling many of the so-called common factors or nonspecific treatment factors that are now well established as influencing therapeutic change (e.g., Lambert & Ogles, 2013; Wampold & Imel, 2015).
The use of TAU helps address a key question, namely, whether a new treatment or an EBP really surpasses in outcome effects what is ordinarily achieved at a given clinic. There now have been several reviews (meta-analyses) that look at the impact of TAU (see Kazdin, 2015). One type of review includes RCTs that directly compare EBPs with TAUs (e.g., Wampold et al., 2011; Weisz, Kuppens, Eckshtain, Ugueto, Hawley, & Jensen-Doss, 2013). Another type of review looks at the effectiveness of TAUs as applied and evaluated in many clinics but are not part of controlled trials (e.g., Cahill, Barkham, & Stiles, 2010; Minami, Wampold, Serlin, Hamilton, Brown, & Kircher, 2008). In these latter studies, the impact of treatment is “benchmarked,” compared to the effects of EBP that have been achieved in controlled trials.
The main findings from both types of reviews are rather provocative (see Kazdin, 2015). From direct comparisons of EBPs and TAUs, the effectiveness of EBPs is only slightly better in producing therapeutic change. Moreover, the slight effects often diminish or are lost (are not statistically significant) once confounding factors are controlled (e.g., EBPs often include more sessions or longer treatments). From the benchmark reviews, the findings are similar. The effect sizes obtained across a wide range of clinics and psychotherapies show little or no outcome differences between TAUS and EBPs. Overall, the reviews do not show any stark difference in outcome effects among EBPs and TAUs.
Ambiguities about TAUs limit interpretation of the overall findings. TAUs include a large range of interventions that are rarely well specified and usually cannot be replicated, at least beyond the individual setting of a particular study. Also, TAUs often include a variety of community treatments that are routinely available, including individual therapy, group therapy, medication, natural remedies, and others. TAU participants occasionally are instructed to select services they prefer among those available in the community. Finally EPBs and TAUs are large classes of treatment and analogous to other large classes (e.g., surgery, medication). The meaningfulness of comparing overall classes (e.g., is surgery better than medication?) without specifying what type of intervention (e.g., type of surgery), and as applied to what type of problem (e.g., ruptured appendix, tumor removal, hip replacement). It is easy to combine studies (effect size) and create these super classes of interventions (TAUs), but this does not establish their meaningfulness. In clinical care and research, we want to know what treatments have impact on clinical dysfunction; that treatment is a specific intervention or some combination of specific interventions. Even so, the notion that TAUs can be and often are, as a class, as effective as EBPs is important to note. Among the reasons are the efforts to disseminate EBPs and to introduce them into training (e.g., in clinical psychology, social work). Those efforts assume that what is going on clinically in many settings is inferior in the outcomes they produce. The reviews of TAUs merely raise the matter and the need for studies, about what specific TAUs seem to be as good as or better than specific EBPs.
Advances in the development of EBPs are important to underscore. Equally important is that many enduring topics of psychotherapy research continue to be studied. The therapeutic alliance is a prime example. Apart from the pervasive influence of the alliance across techniques, new lines of work are evident. Advances in assessment (e.g., full range of neuroimaging techniques) may be able to refine what is known in terms of psychological processes that are influenced by alliance and how that translates into therapeutic change. Also, there is an ever-increasing collection of treatments (e.g., computerized, self-help) in which no therapist is actually involved. From this, we have learned that alliance may well facilitate therapeutic change with clinical problems, but there are many instances in which alliance is not relevant.
Another enduring topic has been the effectiveness of traditional treatments. These have taken a back seat, although meta-analyses support a variety of these too. Yet, treatments in clinical practice have been assumed to need rather large revamping because EBPs are infrequently used, and when used, are often diluted in procedures and outcomes. Reviews of TAUs bring the matter to the fore by showing that EBPs and many of the treatments as usually practiced are not all that different in the outcomes they produce. There are hundreds of psychotherapies leaving aside the combinations that clinicians in clinical practice are wont to use. Sorting out when one treatment surpasses the effects of others in clinical work is a major task with its own research priorities (see Kazdin, 2015).
More profitable is greater attention to understanding precisely how treatments work. There are endless studies on correlates, predictors, and mediators of therapeutic change. These still leave unanswered the process mechanisms (more fine-grained processes) at the level of core processes (psychological, social, biological) that explain precisely what happens in treatment, what intervening processes are affected, and precisely how these lead to symptom change. The best long-term investment in developing effective interventions will be to understand mechanisms of action (Kazdin, 2014).
Major challenges remain and have become more evident now that we have a set of effective interventions. Two salient challenges include disseminating treatments so they are used in clinical practice settings, and providing treatments to reach more of the people in need of services.
Dissemination of EBPs to Clinical Practice
Psychotherapy is in use in many different settings, including in private practice offices, clinics, hospitals, health maintenance organizations, schools and universities, business and industry, the military, and religious organizations, among others. Perhaps surprisingly, most of the psychotherapies in use are not evidence based. It is often the case that advances in scientific research do not move quickly into clinical practice, whether in medicine, public health, or psychology (e.g., Brownson, Fielding, & Maylahn, 2009). The problem is exacerbated if there is no industry or business model behind the novel intervention to promote, build demand, and disseminate the procedures. For example, if a new medication is developed for depression, the pharmaceutical company often has extensive marketing efforts to reach doctors who see patients with the pertinent condition and to reach the public (e.g., via television, Internet advertising) so that individuals will ask their doctors for the treatment. Obviously, it is in the interest of the business to sell the medication, to recover development costs, and to make a profit. That incentive helps the treatment enter medical practice and everyday life. In the case of EBPs, a major challenge is to move treatments from research settings where they are investigated to clinical settings where psychotherapy is routinely conducted. There are no marketing or financial incentives for psychotherapies that are parallel to those available with medications. No therapy company develops, patents, markets, and sells a treatment. One can learn about most treatments from books, professional conferences, and workshops, or from journal articles where research on the treatments is reported. Yet, there is no established method that can be scaled up to train clinicians in practice in EBPS or to inform potential patients about what treatments might be preferred for a given clinical problem.
The challenge of getting the techniques into clinical practice has multiple components, beginning with the diverse disciplines that administer therapy (e.g., psychologists, psychiatrists, social workers), the hundreds of clinical problems they treat (e.g., anxiety, depression, autism spectrum disorders, bipolar disorder), and the broad age range of individuals in need of psychological services (from children through the elderly). Add to those challenges the availability of more than 350 EBPs. Which of those treatments ought to be extended to clinical practice? At best, a clinician in practice might learn one or a few treatments. One can see the attractiveness of transtreatments, mentioned earlier. If there were one or a few treatments that had wide applicability to many clinical problems, dissemination of effective treatment would be more manageable.
The task of learning a new treatment is part of the challenge as well. Whether a specific EBP or transtreatment is to be learned, that task is not a matter of reading a book or attending a workshop or two. Many of the treatments require mastery of concrete procedures that have to be done in a particular way. There might be some academic instruction, but hands on instruction and supervision are likely to be essential. Rarely can an individual in clinical practice take the time to learn a treatment in any formal way. Also graduate training (e.g., doctoral programs in clinical psychology, residency programs in psychiatry, master’s degree programs in social work) still do not routinely include EBPs as part of their training.
With these considerations in mind, several efforts are underway to disseminate treatment and train clinicians so they can use a particular technique or components of a technique (Chorpita & Daleiden, 2010). One model has been to adopt a modular approach to treatment. Modules or components of treatment are selected that are likely to have wide applicability, and can be trained and applied clinical use. For example, in one demonstration, three modules (cognitive therapy for depression, for anxiety, and behavioral parent training) were used and applied as needed to children referred for treatment in 10 outpatient services (Weisz et al., 2012). Depression, anxiety, and conduct problems constitute frequent bases for child referrals. Also, children may experience more than one of these. Therapists were trained in three modules and could then apply each module as needed. Early research suggests that the approach is an effective way to extend a few treatments in a clinically feasible way for treatment. A modular approach is very much like transtreatments, by extracting from different EBPs a few components that might be used widely.
A main challenge is scaling up dissemination approaches so they are integrated into health care services and among multiple clinicians. Promising efforts along those lines require integrating evidence-based treatment with systems of care. This can begin by training individuals to train clinicians (training the trainers). Already some models are in place to show that dissemination can be accomplished (e.g., Southam-Gerow et al., 2014). It is still the case that large-scale dissemination is needed, with procedures in place to show that treatments maintain their effectiveness.
Reaching People in Need of Mental Health Care
The usual model of delivering psychological services is one-to-one, in person treatment, with a mental health professional. The vast majority of EBPs, including the newer transtreatments and modular treatments, are in this model. Yet, this model by itself cannot begin to address the challenge of reducing the burdens of mental illness (see Kazdin & Blase, 2011; Kazdin & Rabbitt, 2013).
Consider different facets of the challenge, beginning with the scope of clinical dysfunction in the population. In the United States, approximately 25% of children, adolescents, and adults in the community meet criteria for at least one psychiatric disorder (Kessler et al., 2009; Kessler & Wang, 2008). With a U.S. population of approximately 320 million people, that would amount to approximately 80 million people currently with a psychiatric disorder at a given point in time. Apart from prevalence, the personal, social, and financial burdens of mental disorders are astounding. Mental disorders are more impairing than common chronic medical disorders (Druss, Hwang, Petukhova, Sampson, Wang, & Kessler, 2009). For example, in 2004, the burden of depressive disorders (e.g., years of good health lost because of disability) was ranked third among the list of mental and physical diseases worldwide (World Federation for Mental Health, 2011). By 2030, depression is projected to be the number one cause of disability, ahead of cardiovascular disease, traffic accidents, chronic pulmonary disease, and HIV/AIDS (WHO, 2008b).
The monetary costs of the full range of psychiatric disorders, including substance use and abuse, are in the billions in a given year in the United States alone. Alcoholism and substance abuse, for example, which affect more than 20 million Americans and are the most prevalent mental disorders in the United States, cost approximately $500 billion annually (Jason & Ferrari, 2010). The main costs include medical and criminal justice costs, accidents, and loss of earnings. For anxiety disorders, annual health-care expenditures in the United States are approximately $42 billion (Greenberg et al., 1999). The costs encompass health-care utilization, including medical and psychiatric treatment and decreased work productivity. These examples note just two types of dysfunctions and their costs. Clearly a major challenge is how to reduce the burdens that mental illnesses reflect.
This article mentioned the challenge of disseminating EBPs so they are used in clinical practice. Yet, that alone will not have significant impact on reducing the burdens. In the United States, approximately 70% of individuals in need of treatment do not receive services (Kessler et al., 2005). That means if all professionals providing services switched to EBPs, it would not really affect the majority of individuals in need of care. The answer is not simply adding more mental health professionals so there is a larger workforce (Hoge, Morris, Daniels, Stuart, Huey, & Adams, 2007). Mental health professionals in the United States tend to be concentrated in urban areas, underrepresent the diverse ethnic and cultural groups in need of treatment, and underrepresent key areas of services (e.g., children, the elderly) that are needed. The dominant model of delivering treatment (one-to-one, in person, with a mental health professional) will not be sufficient by itself to reduce the burdens of mental illness. New ways of delivering services are sorely needed. The increased use of technology and self-help treatments, as ways of delivering psychological treatment, are promising lines of work to extend the reach of treatment. Much more will be needed.
Interventions are needed that can be extended to people who do not come for or do not have access to individual psychotherapy. Treatments would need to have many of several characteristics, as summarized in Table 1. Individual psychotherapy can provide effective treatment, but typically does not include any of these characteristics. Additional models of delivery (how treatment is provided) as well as a broader set of interventions (what is actually done to achieve therapeutic changes) are needed to complement individual psychotherapy.
Table 1. Key Characteristics of Models of Treatment Delivery to Reach People in Need of Services
Capacity to reach individuals not usually served or well served by the traditional dominant service delivery model
Capacity to be applied on a large scale or larger scale than traditional service delivery
Relatively low cost compared to the usual model that relies on individual treatment by highly trained (master’s, doctoral degrees) professionals
Acceptability to consumers (potential clients and as relevant therapists):
Views that the treatment is appropriate and reasonable as an intervention
Expansion of settings where interventions are provided
Bring interventions to locales and everyday settings where people in need are likely to participate or attend already
Feasibility and flexibility of intervention delivery
Ensure the interventions can be implemented and adapted to varied local conditions, to reach diverse groups in need
Flexibility and choice of alternatives for clients within a particular type or class of effective interventions
Allow options or choices for how services are delivered, because no single model will be suitable for all.
Expansion of the nonprofessional work force
Increase the number of providers who can deliver interventions
Novel models of delivery and novel treatments have emerged from physical health care and treatment of disorders (e.g., HIV/AIDS, malaria, tuberculosis, cardiovascular disease, cancer). In many developing countries in particular, treatment is needed, under a variety of conditions (e.g., enormous resource constraints, geographical obstacles), and where people in need of services were not receiving them. One model of delivering is referred to as task shifting or task sharing and consists of expanding the healthcare work force by redistributing the tasks of delivering services to a broad range of individuals with less training and fewer qualifications than traditional healthcare workers (e.g., doctors, nurses) (see WHO, 2008a). Lay and community members are trained in basic procedures and deliver needed services. Empirical evaluations show that task shifting rapidly increases access to services, reaches large numbers of individuals in need, yields good physical health outcomes, and has high levels of patient and counselor satisfaction (WHO, 2008a). Extensions to mental health have been made by having lay individuals trained to administer EBPs. Controlled studies have shown that lay individuals can deliver effective treatment for significant clinical problems including depression, anxiety, and schizophrenia (e.g., Balaji et al., 2012; Patel et al., 2010).
Another way of intervening that departs from the traditional model of providing psychological services is referred to as best-buy interventions. This model derives from economic considerations to help decide what procedures in a given country, or area within a country, can have impact in reaching people and can lead to improved health. Characteristics of best-buy interventions are that they are feasible, low cost, and acceptable to individuals within the culture (Chisholm & Saxena, 2012). Best-buy interventions emerged out of efforts to address physical disease, but many diseases are directly related to behavior, lifestyle, and mental health, as reflected in substance use and abuse (e.g., alcohol and tobacco).
Best-buy models began to be extended to mental health by analyzing options (using math models) likely to be feasible and affordable and other criteria in relation to how many people could be reached. Multiple treatment options are identified and then recommended for use. The intervention is then implemented and evaluated to see if, in fact, the intended effects and predictions were correct. For example, for alcohol abuse, best-buy interventions include enhanced taxation of alcoholic beverages and comprehensive bans on advertising and marketing, based on their favorable cost-effectiveness, affordability overall, and feasibility. Treatment for excessive alcohol use was identified as a successful best-buy intervention for reducing the incidence of cardiovascular diseases and cancers, but extends to other burdensome conditions (e.g., cirrhosis of the liver, depression, traffic injuries, and deaths; WHO, 2011). Best buy in this case clearly had implications for reducing personal suffering from both mental and physical health conditions and, in the process, reducing the enormous financial costs that these create for society.
There are many other models that are unfamiliar within the context of mental health services but are very likely to help reduce the burden of mental illness and complement the benefits achieved with the EBPs (Kazdin & Blase, 2011; Kazdin & Rabbitt, 2013). Not all of the options are esoteric or unfamiliar. For example, encouraging life-style changes can have a huge effect on both mental and physical illness (Jorm, 2012). Perhaps the most familiar example is exercise, which is well known to have enormous physical health benefits. As it turns out, exercise has mental health benefits including reduction of symptoms of mental disorder (e.g., depression and anxiety), although evidence is sparse and not always consistent (Rosenbaum, Tiedemann, Sherrington, Curtis, & Ward, 2014; Stanton & Happell, 2014). The effects of exercise are broad, extending to improvements in people’s evaluation of the quality of life, in addition to mental and physical health benefits (Alexandratos, Barnett, & Thomas, 2012; Richardson, Faulkner, McDevitt, Skrinar, Hutchinson, & Piette, 2005). An interesting feature of exercise is that it can take many different forms (e.g., chores around the house, walking, games and sports, use of exercise equipment) to suit individual tastes and preferences and can vary across the developmental spectrum (e.g., children through the elderly). Because the benefits of exercise on mental and physical health are broad, this is likely to be a best-buy intervention in terms of impact and cost savings.
I have sampled some novel ways to extend mental health services (see Kazdin & Blase, 2011; Kazdin & Rabbitt, 2013 for others). The purpose is to reduce the burden of mental illness. EBPs can play a role. In many cases, the interventions can be extended by having nonprofessionals deliver them. In other cases, entirely new methods, such as those I have sampled, will be needed. To have impact on mental illness, we will need a portfolio of ways to reach people and deliver services. Perhaps the specific interventions well studied as part of EBPs can serve as a backbone for many new ways of reaching people.
Summary and Conclusions
Psychotherapy has advanced remarkably for the treatment of a broad range of psychiatric disorders and related sources of impairment among children, adolescents, and adults. At this time, over 350 forms of therapy have been established as having a strong evidence base. Depression and anxiety disorders, each with many subtypes, are the common bases for which patients are referred to psychological treatment. Multiple EBPs are available to reduce these dysfunctions and improve functioning in everyday life. There are important qualifiers to keep in mind. In many cases, treatments to do not eliminate the disorders. For example, treatments are available for schizophrenia and autism spectrum disorders. Individuals receiving EBPs for these disorders often show significant and enduring improvements in symptoms and in their ability to function in everyday life. Yet, both of these are considered to be significant brain disorders and with a broad range of symptoms that can be enduring.
Contemporary research continues to focus on enduring themes in psychotherapy research. The therapist alliance was discussed as one of those. The quality of the client-therapist alliance makes a small but reliable contribution to outcome and across many different treatment techniques. After decades of research and thousands of studies, we do not know precisely how the alliance produces change, whether by altering fundamental facets of affect, cognition, or behavior. Also discussed was how advances in research may help to combine and understand the role of moderators, in order to individualize treatment better, or at least to provide them with a more defensible empirical base.
Two trends in psychotherapy research were discussed. First, there is increased interest and research in developing treatments that can be applied to many different disorders. This is a departure from the traditional approach in psychotherapy research, which has sought to develop specific treatments for each of the different psychiatric disorders. Research on disorders reveals many commonalities (e.g., genetic, brain, psychological processes), and that suggests a great deal of overlap rather than completely distinct entities. This has led to the development of transtreatments, that is, psychotherapies that can be applied to many disorders. Evidence continues to support the effectiveness of transtreatments across a range of disorders.
Second, psychotherapy research and applications have very much been influenced by technology and social media. Treatments often can be administered on-line through the Internet and have been effective. Computers, smartphones, tablets, smart watches, smart cars (to detect alcohol consumption of the driver), and more on the way (smart clothing to detect bodily states) help bring treatment (e.g., coping activities to help regulate stress, emotional reactions, or mood) to clients in everyday life. Application software (“apps”) has increased to help assess the functioning of individuals in real time as they go through their days and provide immediate treatment exercises if and as needed (e.g., through text messages). No doubt EBPs that rely on technology will increase even further in the coming years.
This article highlighted two major challenges in intervention research. The first challenge is the dissemination of EBPs so they are implemented in clinical practice. Currently, most psychotherapy that is provided routinely is not based on the most effective treatments. Major efforts are underway to try to disseminate EBPs to clinicians for their routine use. This has multiple obstacles because there are few opportunities and little funding available to train many individuals (psychologists, psychiatrists, social workers, and others) who carry out therapy. Also, what treatments ought to be trained among the hundreds of EBPs available? Perhaps transtreatments and modular treatments will facilitate the task by providing one or two treatments that can be learned and widely applied to clients who come for treatment.
The second challenge mentioned was the need to reach people in need of services. Most of the people in need of psychological services in the United States (and worldwide) do not receive any services at all, leaving aside the matter of receiving EBPs. To reduce the burden of mental illness, novel methods are needed to reach more people. EBPs that rely on technology and self-help are two broad lines of research that can help. Also, the use of lay counselors, in addition to mental health professionals, can help reach many more people in need of services. Finally, novel interventions that we do not routinely view as therapeutic can to be implemented and evaluated. Life-style changes (e.g., exercise, meditation), as one example, can have enormous benefits on physical and mental health and perhaps ought to be fostered more as part of health care, but also as part of everyday life.
Psychotherapy research continues to make advances in refining techniques, improving treatment effects, and extending treatments to many different populations in need of care. There are now EBPs for clinical problems that children, adolescents, and adults experience. Armed with effective interventions, we need to pay major attention to ensure that they reach the people who could profit from them and have broader impact on reducing the personal, social, and financial burdens of mental illness.
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(1.) Different terms have been used to refer to psychosocial interventions with evidence on their behalf including empirically validated treatments, empirically supported treatments, evidence-based treatments, evidence-based practice, and treatments that work. The term “evidence-based psychosocial interventions” is adopted here and will be used throughout. The term “evidence-based” is in keeping with a broader movement that pervades many disciplines (e.g., evidence-based medicine, law, social work, social policy).
(2.) The term “clinical dysfunction” is used in this article to refer to a broad range of domains where psychological functioning (e.g., affect, cognition, behavior, social interaction) is associated with impairment in everyday life. This term includes mental and substance-use disorders as specified in various diagnostic systems, subclinical (subsyndromal) dysfunctions, and other areas of functioning (e.g., reactions to stress) that fall outside of these domains but still lead to impairment.