I. Introduction
Although we are not certain about what goes on in the real world
practice of psychotherapy, what hints we have suggest that there is a
substantial discrepancy between the availability of psychotherapies with
evidence for efficacy (based on controlled clinical trials) and their use in
clinical practice by the three professional groups providing most of the
psychotherapy; psychiatrists, psychologists and social workers (e.g., Taylor,
King, & Margraf, 1989; Goisman, Warshaw, & Keller, 1999; Plante,
Andersen, & Boccaccini, 1999; Addis & Krasnow, 2000; Sanderson, Hiatt,
& Schwartz, 2001). The discrepancy
between research evidence and clinical practice begins with the education and
training of practitioners. In part,
this is due to the recency of the evidence base for psychotherapy. However, if research advances in the
practice of psychotherapy are to be translated into improving treatment
services on a large scale, an accelerated change in the education and training
of practitioners is needed.
This paper will make the following points: (1) There have
been significant advances in the technology and testing of psychotherapy; (2)
Evidence-based psychotherapeutic treatments (EBT) exist for the range of
psychiatric disorders; (3) These treatments are somewhat different than
traditional psychodynamic or supportive approaches in that they are usually
time-limited, specified in manuals and tested in clinical trials; (4)
Psychotherapists are not using evidence-based approaches, mainly because many,
perhaps the majority, of clinical graduate/residency training programs do not emphasize
training in them; (5) Training programs
are not emphasizing treatments endorsed by Clinical Practice Guidelines which
have been developed to increase quality of care; (6) The failure to train
students, the future practitioners, in EBT will leave psychotherapy vulnerable
in the new health care environment, where accountability is paramount; (7) Improvement in the dissemination of
evidence-based approaches needs to begin with the education of the next
generation of health professionals.
Current practitioners can “catch up” with guided continuing education
programs. However, no criteria for the
content or quality of these programs in EBT exist.
II. Definitions and Rationale for Focus
We use the term psychotherapy to refer to a host of different approaches with
differing theoretical and conceptual underpinnings conducted by a range of
professionals with differing educational backgrounds and training. By psychotherapy, we mean an intervention in
which a verbal exchange between therapist and a patient or client is the main
mode of treatment. By evidence-based
treatment (EBT), we mean psychotherapy that has been defined in a manual and
tested for efficacy in a controlled clinical trial. When we describe EBT we also include the systematic diagnostic
and clinical monitoring assessments that are part of EBT.
While the Macy Conference entitled
the program “Modern Psychiatry,”
challenges in educating health professionals was the full topic. We will follow their implicit lead and focus
not only on psychiatrists but also on psychologists and social workers.
As of the year 2000, the mental health
worker data indicated that there were approximately 40,000 psychiatrists,
58,000 psychologists and 155,000 social workers. While we realize that not all of these mental health
professionals practice psychotherapy, there is evidence to suggest that a large
number of adults receive psychotherapy from all three. The evidence comes from a national survey
(Medical Expenditure Panel Survey-MEPS) which was conducted by the Agency for
Health Care Research and Quality (AHRQ). The survey was based on a national
probability sample of approximately 35,000 individuals in 14,000 households (An
expanded description of Methods and relevant Results of our analysis of the
survey data can be found in the Appendix.).
The survey found that 3.2% of the adult population reported receiving
psychotherapy in 1987 and 3.6% reported receiving psychotherapy in 1997 (no significant
difference between years). However,
visiting a medical doctor (psychiatrists were not separated out in the survey
in 1997) or social worker became more common; seeing a psychologist remained
the same and seeing another type of non-M.D. provider became less common. Although the “popularity” of psychotherapy
(as reflected by the number of persons seeing a professional for psychotherapy)
did not increase from 1987 to 1997, those receiving psychotherapy in 1997 (as
compared to 1987) had significantly fewer visits (see Table 1 in the
Appendix). The likelihood of
psychotherapy users receiving psychotropic medication nearly doubled (31% in
1987 to 58% in 1997) (see Table 2 in the Appendix). These data, to the extent they reflect current practice, suggest
that short-term psychotherapy administered by non-M.D.s combined with
medication is the new trend in treatment.
Since psychiatrists were not separated out from medical doctors it is
likely that the increase in psychotherapy sought from M.D.s reflects an
increase in use of primary care physicians.
The data suggest that training M.D.s and non-M.D.s in EBT is needed if
the scientific advances are to be effectively translated into scientifically
sound therapeutic and preventive programs.
III. Advances in Psychotherapy
The increased availability of efficacy data on psychotherapy
has largely been due to developments over the last 15 years in the
specification of the essential treatment strategies in manuals and the
development of programs to standardize the training of therapists providing treatment
in these trials. While some
practitioners in the field who received adequate training use some of these
procedures, training in these procedures have not become an integral part of
most educational programs (e.g., graduate school, residency). As a result, in many cases, the availability
of these treatments is limited to clinical research centers where the treatment
is being evaluated.
Specifying Treatment in Manuals.
At one time, the diversity of psychotherapists’ approaches to patients
discouraged research on psychotherapy.
Each therapist and patient was considered unique. There was no way to define what was going on
in the office with a given patient.
Psychotherapy was considered an art that could not be addressed by
science. Treatment manuals constitute a
marked departure from this thinking and a small revolution in the ability to
conduct clinical trials. Manuals
operationalize the procedures in that they provide technical specifications
with scripts for interventions and guidelines on what should be covered (Hibbs
& Jensen, 1996; Luborsky & DuRubeis, 1984). Treatment manuals can teach experienced psychotherapists to adapt
their styles to a particular approach.
Audiotaping or videotaping provides an objective record of how the
therapist delivers the treatment allowing raters to review and score for
treatment adherence. A manual can make
psychotherapy a relatively uniform, and thus testable, treatment.
Manuals have become a virtual requirement for psychotherapy
studies. Some studies have shown that
the therapist’s degree of adherence to the manual is significantly associated
with patient improvement. In order to
facilitate dissemination of EBT, a list of manuals and information on how to
obtain them has been compiled (Woody & Sanderson, 1998). While over 100 EBT manuals for adult
psychiatric disorders have been identified (cf. Chambless & Ollendick,
2001), a large majority of them are adaptations of cognitive behavioral therapy
(CBT) and to a lesser extent, interpersonal psychotherapy (IPT). The modifications were made in order to
apply the treatment to a clinical presentation of a particular disorder or age
group. CBT and IPT will be described
later.
Training Therapists.
Procedures for training therapists to administer these “manualized”
treatments have been developed in order to accelerate their testing in clinical
trials (Shaw et al., 1999; Weissman et al., 2000). Typically, training programs involve: (a) the reading of the
manual, (b) attendance at a didactic course, (c) supervision of several cases
by a clinician trained in the approach using actual video or audio tapes of the
sessions, and (d) evaluation of competence.
There is evidence that reading a manual alone is not a substitute for
psychotherapy training and that supervised clinical experience is
critical. From a practical perspective,
this is best accomplished in graduate or residency programs when therapists in
training are being supervised regularly.
It is possible to develop well-planned continuing education programs to fill
this need for practitioners in the field.
A manual does not teach therapists basic psychotherapy skills such as
how to listen, hear, empathize, and handle one’s own feelings and distortions. Manuals teach trained therapists a
particular strategy. It is relatively
easy for experienced therapists to learn specified therapies. The limitations are usually only ideologic.
Evaluating Treatments.
Treatment manuals, training programs, and therapist competency criteria
maximized internal validity and were necessary technologies to begin testing
the efficacy of psychotherapy in controlled clinical trials. As a result of these efforts, there has been
a substantial increase during the past 15 years in the number and quality of
studies supporting the efficacy of several psychotherapies. These EBTs cover the full-range of
psychiatric disorders. Efficacy
studies evaluating treatment manuals is an essential link in determining how well
a treatment works for a given disorder (cf. Chambless et al., 1998; Nathan &
Gorman, 1998; Weissman et al., 2000).
The next challenge is determining how
well these treatments generalize to clinical practice where patients often do
not have a single diagnosis, where practitioners in the community must be used,
and where training programs must be simple and cost-efficient (effectiveness
research). While effectiveness research
is in its infancy the existing data generated thus far support the use of EBT
in clinical practice (Wade, Treat, & Stuart, 1998; Sanderson, Raue, &
Wetzler, 1999; Franklin, Abramowitz, & Kozac, 2000; Tuschen-Caffier, Pook,
& Frank, 2001; Antonuccio, Thomas, & Danton, 1997; Otto, Pollack, &
Maki, 2000). Nevertheless, much
research remains to be done to modify treatment manuals and training
procedures. For example, treatment
manuals must be modified to take into account comorbid diagnoses. In addition, training procedures used in
efficacy studies must be modified to improve their efficiency and then the
validity of streamlined training needs to be determined. This work is underway and will have
considerable relevance to the psychotherapy training of practitioners in the
future.
IV. An Overview of Evidence-Based Psychotherapy
Comprehensive reviews exist which have
identified psychotherapies that have been specified in a manual, have specific
criteria for training and competence evaluations, and have supporting data from
controlled clinical trials (e.g., Chambless et al., 1998; Nathan & Gorman,
1998; Weissman et al., 2000). Chambless
and Ollendick (2001) recently completed the most extensive review in that they
integrated the efforts of eight workgroups (from the U.S., U.K., & Canada)
focused on identifying empirically supported psychotherapies. Although the criteria used to define EBT
were not the same for each workgroup, overall, the criteria used tended to be
conservative. For a treatment to be
defined as empirically supported by any of the workgroups, support from at
least one rigorous randomized clinical trial was necessary.
Based upon Chambless and Ollendick’s
(2001) “review of reviews” it is accurate to say that at least one evidence
based treatment (and sometimes several) exist for the full spectrum of
psychiatric disorders including:
Anxiety
and Stress
Agoraphobia/panic disorders with
agoraphobia
Blood injury phobia
Generalized anxiety disorder
Geriatric Anxiety
Obsessive-compulsive disorder
Panic disorder
Post-traumatic stress disorder
Public speaking anxiety
Social anxiety/phobia
Specific Phobia
Chemical
Abuse and Dependence
Alcohol abuse and dependence
Benzodiazepine withdrawal
Cocaine abuse
Opiate Dependence
Depression
Bipolar disorder
Geriatric Depression
Major Depression
Other
Disorders
Anorexia
Binge-eating disorder
Borderline personality disorder
Bulimia
Chronic Pain
Irritable-bowel
syndrome
Marital
Discord
Migraine Headache
Obesity
Schizophrenia
Smoking Cessation
Sexual Dysfunction
(Because
of space limitations, many other less common disorders have been left off, see
Chambless & Ollendick (2001) for a complete list).
Evidence-based psychotherapies are not
efficacious for all conditions (for example, interpersonal psychotherapy has
been shown to be ineffective in two clinical trials with opiate abusers). However, for several disorders psychotherapies
have been shown to be as effective as psychotropic interventions (e.g., panic
disorder, major depression, bulimia-nervosa). Thus, having psychotherapy
available as an alternative to medication is important for patients who do not
want to take medication (e.g., pregnant or lactating women), who cannot
tolerate medications (e.g., side-effects, adverse reactions), as well as for
patients who are not responsive to medications. For other disorders, psychotherapy is an invaluable adjunct (but
not a solo treatment) to medication (e.g., bipolar disorder, schizophrenia),
enhancing medication compliance, reducing residual symptoms, and decreasing
relapse.
In this section we highlight data on the
efficacy of specific EBT for several commonly occurring psychiatric disorders.
Depression.
Both IPT (Weissman et al., 1979; Elkin et al., 1989) and CBT (cf.
Glaoguen, Cottraux, & Cucherat, 1998; Elkin et al., 1989)
have been shown to be as
effective in reducing symptoms as psychotropic medication for acute treatment
of major depression (Depression Guideline Panel, 1993). However, the onset of action is slower for
psychotherapy. An amalgam of CBT and
IPT (cognitive behavioral-analysis system of psychotherapy) has been shown to
be effective in the treatment of chronic depression, and when combined with medication,
increased the response rate from 55% to 85% (Keller et al., 2000).
Depression is associated with a high
relapse rate. When administered less
intensively (approximately once a month) following an acute phase of weekly
treatment, both IPT and CBT have been shown to decrease the rate of relapse and
recurrences (Frank et al., 1990; Jarrett et al., 1998).
Although not as extensive, controlled
trials have also supported the use of IPT and CBT for the treatment of
adolescent depression (Brent et al., 1997; Rosello & Bernal, 1998; Mufson
et al., 1994, 1999) and late-life depression (Sloane et al., 1985; Reynolds et al., 1999).
Psychotherapy has also been shown to be
an efficacious treatment for depression secondary to other problems. For
example, IPT has been shown to reduce depression for depressed HIV-positive
patients (Markowitz et al., 1995), and both IPT and CBT have been shown to be
effective in reducing depression in patients with marital dysfunction (O’Leary
& Beach, 1990; Foley et al., 1989).
Bipolar Disorder.
IPT and CBT for bipolar disorder target: 1) social/interpersonal events
that may be triggers or consequences of bipolar episodes (e.g., interpersonal
disputes) and/or 2) mediating mechanisms (such as distorted cognitions,
disrupted circadian rhythms). A social rhythm regulation component was added to
standard IPT (Interpersonal and Social Rhythm Therapy – IPSRT) to address the
specific issues in treating bipolar patients (Frank, Kupfer, Ehlers et al.,
1994; Basco & Rush, 1995; Miklowitz & Goldstein, 1997). These treatments are considered adjuncts in
combination with medication (e.g., Lam, Bright, Jones et al., 2000). The effectiveness of these psychotherapies in
combination with medication for bipolar disorder is currently being tested in a
large-scale, multisite study.
Anxiety Disorders. Treatment manuals based upon the
principles of CBT exist for each of the anxiety disorders and include several
common components: psychoeducation, cognitive restructuring, relaxation
strategies, and exposure procedures.
These strategies are tailored to address the specific psychopathology
associated with each disorder.
There is a considerable body of evidence
from controlled studies supporting the efficacy of CBT for the range of anxiety
disorders (cf. Nathan & Gorman, 1998 for a comprehensive review):
agoraphobia (e.g., Chambless, Foa, Groves, & Goldstein, 1979), generalized
anxiety disorder (e.g., Barlow, Rapee, & Brown, 1992), obsessive-compulsive
disorder (e.g., Fals-Stewart, Marks, & Schafer, 1993), panic disorder
(e.g., Barlow, Gorman, Shear, & Woods, 2000), social phobia (e.g.,
Heimberg, Liebowitz, Hope, et al., 1998), and posttraumatic stress disorder
(e.g., Foa, Rothbaum, Riggs, & Murdock, 1991).
Schizophrenia. Efficacy studies of psychotherapy for
schizophrenia typically compare two or more treatments in patients who are also
receiving antipsychotic medication. Psychotherapy is seen as an adjunct to
medication. The focus of outcome is
relapse prevention rather than symptom reduction at post-treatment. EBT of schizophrenia can best be viewed as
attempts to decrease the patient’s vulnerability to relapse by remediating
deficits (e.g., social skills training); increasing medication compliance
(e.g., providing patients with skills to discuss side-effects with their doctor
rather than just discontinuing medication); and reducing stress in the family
(e.g., decreasing expressed emotion, providing problem-solving strategies for
resolving family conflicts).
Social skills training can lower relapse rates in patients
with schizophrenia. In a study by
Hogarty, Anderson, and Reiss (1986), patients being treated with medication who
received social skills training had a significantly lower relapse rate than
those who received individual supportive psychotherapy (20% vs 41%). Overall, when compared to treatment as
usual, behavioral, supportive, and systems based family intervention strategies
were efficacious in reducing relapse rates in patients with schizophrenia
(e.g., Falloon, Boyd, & McGill, 1984; Leff et al., 1985; Schooler et al.,
1997). The efficacy of the various
family interventions (behavioral, supportive, & systems) appear to be
equivalent (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). Indeed, the only direct comparison of two
evidence-based family interventions found that supportive family therapy and
behavioral family therapy were not significantly different. These findings are not surprising
considering the family intervention strategies across the three theoretical
orientations share many common essential treatment components (Baucom et al.,
1998). There is evidence that family
therapy involving the use of insight-oriented techniques and focusing on the
past is not beneficial in reducing relapse (Kottgen, Sonnichsen, Mollenhauer,
& Jurth, 1984) and can be associated with negative outcomes (McFarlane,
Link et al., 1995).
Description of Two Evidence-Based
Psychotherapies
There are a variety of psychotherapies
that have been shown to be efficacious for at least one disorder. However, most are variants or modifications
of two modes of psychotherapy– interpersonal therapy (IPT) and cognitive
behavior therapy (CBT), which have had the most testing.
Cognitive
Behavioral Therapy. CBT is based
upon the premise that emotional disorders stem from distorted, negative
thoughts (cognitions) and maladaptive behaviors. The theoretical and empirical source of CBT based on a cognitive
model of emotional disorder and on learning theory have been discussed (Beck et
al., 1975; Beck, Emery, Greenberg, 1985; Lewinsohn et al., 1986). CBT utilizes strategies to change cognitions
(e.g., to reduce harsh self-criticism that may lead to depression, and
catastrophizing about events that may lead to anxiety) and behaviors (e.g.,
decrease phobic avoidance, increase assertiveness) related to the patient’s
psychopathology. While cognitive and
behavioral methods are aimed at different psychopathological processes, in
fact, they have an overlapping effect (i.e., cognitive methods may produce a
change in behavior, and behavioral methods may produce a change in
cognition). Thus, in CBT, the therapist
focuses directly on modifying thoughts and behaviors. CBT is relatively brief (usually four to eight weeks) and CBT
differs from traditional forms of psychotherapy in the following ways:
(1) A focus
on symptoms. The goal is to improve the
patient’s quality of life and restore social and occupational functioning by
remediating symptoms that the patient and therapist mutually agree upon as
problematic.
(2) An
emphasis on the present and future. In
CBT the therapist works to help patients deal more effectively with problems or
symptoms that they are currently experiencing, as opposed to examining their
early childhood.
(3) Explicit,
ongoing assessment. In order to assess
for progress (or lack thereof), symptoms are evaluated throughout treatment
using objective patient and/or therapist rating scales, thus increasing the
therapists’ accountability.
(4) A high
level of therapist activity. In
addition to structuring the sessions and maintaining the symptom focused
direction, the therapist is responsible for introducing and implementing
systematic cognitive and behavioral strategies which will allow the patient to
change his/her distorted cognitions and maladaptive behaviors.
(5) An
emphasis on generalizing therapy skills.
In CBT, progress depends largely upon the patient’s use of time outside
the therapy session. Therefore, every
effort is made facilitate the transfer of learning from the session to the
patient’s environment (e.g., patients are initially given “homework
assignments” to carry out between sessions).
Theoretically, if patients use the techniques introduced in session to reduce
emotional distress outside of the session, the techniques will be reinforcing
to the patient, and thus, continue to be utilized. Thus, in CBT patients are empowered to cope with their problems,
and dependence upon the therapist is minimized.
Interpersonal
Psychotherapy (IPT). IPT was
first developed as a time-limited based treatment for depression by Klerman et
al., 1984 and has been subsequently modified to deal with different types of
mood and non-mood disorders (see Weissman et al., 2000 for an update). The theoretical and empirical source is
based on Bowley’s attachment theory and the body of research showing the
relationship loss of attachment, stressful life events and development of
symptoms (Klerman et al., 1984). These
clinical findings are now under investigation using modern techniques of
neuroscience such as studies on the long lasting effects of stress exposure on
physiology, brain structure, function, and a growing body of animal research on
behavioral and biological effects on potent stressors occurring at specific
point in development (Costello et al., In press). The basic premise of IPT is that, irrespective of their cause,
psychiatric disorders usually occur within a social and interpersonal context. Thus, in IPT therapists teach patients to
understand the relationship between the onset and fluctuation of their symptoms
and current problems and to find ways of dealing with their interpersonal
problems. IPT treatments differ from
traditional forms of psychotherapy in a number of ways as follows:
(1)
Time-limited and focused. IPT is time
limited, usually eight to 12 weeks; weekly sessions or monthly in case of
maintenance treatment. After the
initial diagnostic evaluation, which involves systematic assessment and is
discussed openly with the patient, the patient and therapist agree on one or
two areas of focus. The therapist
focuses one or two problem areas in the patient’s current interpersonal
functioning (grief, role disputes, transitions, role deficits).
(2) An
emphasis on current interpersonal relationships. While a brief review of the patient’s past relationships and
interactions does occur (to enhance the therapist’s understanding of the
patient’s patterns of interpersonal relationships), the focus of the sessions
is on the patient’s current social functioning.
(3)
Interpersonal instead of intrapsychic.
In IPT, the therapist does not attempt to see the current situation as a
manifestation of an internal conflict.
Instead, the patient’s behavior is explored in terms of disputes in
interpersonal relationships.
(4)
Personality is recognized, but not focused on.
While personality is considered important and is believed to affect
several aspects of treatment (e.g., outcome, patient-therapist relationship),
in IPT the therapist does not explicitly set out to alter the patient’s
personality. It should be noted that
one exception to this is in IPT for Borderline Personality Disorder - but even
here, the patient is not confronted directly.
(5) A
moderate level of therapist activity.
The therapist acts as an ally, and fosters the patient’s positive
expectations about the therapeutic relationship. The therapeutic relationship is not seen as a reenactment of the
patient’s previous relationships with others, and the therapist may use both
reassurance and direct advice whenever they seem most helpful (but generally
keeps them to a minimum in order to foster the patient’s own sense of
competence). The therapist can also be
selectively self-revealing in interactions with the patient and, when relevant
to the issues at hand, may express personal opinions or give brief examples of
problems from his or her own life.
While the therapist does not assign formal homework, homework is
implicit in solving focal interpersonal problems during time-limited
treatment. As with CBT, the emphasis is
on planning and preparing the patient to make (interpersonal) changes in life
outside of the therapist’s office.
V. Learning Evidence-Based Treatment
Results of our efforts
to learn about current educational curriculum, training and continuing
education as it pertains to psychotherapy will be presented. Clearly, a comprehensive review is needed.
In principle, the majority of providers
of psychotherapy (i.e., social workers, psychologists, and psychiatrists) would
probably agree on the necessity of providing empirical support for their
interventions. The public expects to
receive an effective treatment from these licensed professionals. Hence, one would expect that training
programs would embrace evidence-based treatments. However, we will show that one major obstacle to the use of
evidenced-based treatments is their near absence in many training programs for
psychologists and social workers and in residency training programs for
psychiatrists. This lag may be due in
part to the recency of the evidence, although some is due to ideologic
differences. Training efforts are more
vigorous in Canada, Great Britain, Holland, Iceland, Germany and Spain where
calls for workshops, individual training and supervision in EBT by
psychiatrists, general practitioners (in Canada) and psychologists have been
overwhelming. This view is based on
personal experience and not systematic survey.
Residency
and Graduate Training
Psychiatrists.
Accreditation criteria for psychiatry residency programs set forth by
the Accreditation Council for Graduate Medical Education (2000) does not
emphasize training in evidence-based psychotherapy but is further along than
the other professions in that CBT will be included in the new accreditation
criteria. The psychotherapy criteria
emphasize training toward competency
in brief therapy, cognitive-behavioral therapy, combined psychotherapy and
psychopharmacology, psychodynamic therapy, and supportive therapy. Thus, manualized evidence-based
psychotherapies, such as those identified in clinical practice guidelines, are
not emphasized and psychotherapy that has not been subjected to clinical trials
testing is included. According to Dr.
Lisa Mellman (personal communication, 7/2/01) who is a member of the American
Association of Directors of Psychiatry Residency Training, the plan is to
continue to move in the direction of defining and standardizing competency
criteria rather than emphasizing training in specific psychotherapies. This approach has some value in that general
therapeutic skills will be emphasized.
With this background learning manualized psychotherapy is considerably
easier if such a mechanism to do so was in place. We could not find any surveys of actual residency training
practice in psychiatry. It will be
interesting to see how these new criteria are implemented.
Psychologists. Guidelines set forth by the Committee on
Accreditation (1996) of the American Psychological Association state that
training should be based upon “the science of psychology” but allow programs to
state their own “philosophy of training.”
As a result, programs may choose to ignore evidence-based approaches
that are not consistent with their philosophy of training. The guideline does not mention training in
manualized, evidence based approaches as a priority, although it does note that
“students should be trained in implementing intervention strategies (including
training in empirically supported procedures).” Thus, while there is mention of scientifically evaluated
treatments, overall, the document is vague and does not emphasize the
importance of training in the specific empirically supported approaches defined
above.
One would expect psychologists to be
particularly receptive to EBTs since a large portion of the development and
testing of these treatments was initiated by psychologists. However, a survey
of clinical psychology doctoral programs and internship programs revealed that
training in most EBTs is lacking (Crits-Christoph, Frank, Chambless, Brody,
& Karp, 1995).
For example, two
of the first-line treatments for depression listed by the AHCPR Depression
Treatment Guideline, CBT and IPT, are not universally taught in graduate and
internship training. Specifically,
among clinical psychology internship
programs - the place where clinical psychologists receive the bulk of
supervised clinical experience - only 59% of programs provided supervision in
CBT for depression, and a mere 8% of programs provided supervision in IPT. University doctoral programs were somewhat better, with 80% offering
supervision in CBT and 16% in IPT.
Having
supervision available does not mean that students are required to
receive it. As a result, these numbers
do not indicate that 80% of students
are, in fact, receiving training in cognitive therapy. For example, based upon personal experience
as a faculty member at Rutgers University, although training in cognitive
therapy for depression is available, only about one-quarter of the students
seek supervision in this modality. Thus, the percentages are likely an
overestimation of the total number of clinical psychology students actually
receiving training in these approaches.
If one
examines the training in EBTs for other disorders, the numbers are even lower
(Crits-Christoph et al., 1995). For
example, the survey revealed that only 22% of adult focused internship sites
provide supervision in IPT for bulimia and only 3% required it, 14% (2%
required) in CBT for social phobia, 22% (4% required) in Exposure/Response
Prevention for OCD, 25% (3% required) in family education programs for
schizophrenia, 26% (4% required) in exposure treatment for phobias, and 54% (8%
required) in CBT for panic disorder.
The numbers
reflecting psychotherapy training students receive in graduate school are not
very different from internship training: 21% provide supervision in IPT for
bulimia, 19% in CBT for social phobia, 48% in Exposure/Response Prevention for
OCD, 22% in family education programs for schizophrenia, 59% in exposure
treatment for phobias, and 70% in CBT for panic disorder. (The survey did not
ask doctoral programs to note if they required the treatment, thus those
data are not available, but as noted above, the actual number of students
receiving training in these approaches is likely to be considerably lower).
Since most of
these treatments represent a first-line intervention for the respective
disorder (with some of the treatments being the only empirically
supported psychotherapy, such as exposure/response prevention for OCD), it is
not as though training in that approach is being eschewed because of training
in another evidence-based approach.
Social
Workers. The Educational Policy
from the Council on Social Work Education (1999) does not prescribe any
particular curriculum for psychotherapy or counseling (Mullen, personal
communication, 2001). Students are
expected to become competent and effective practitioners and to evaluate research
studies and apply relevant findings to their practice. There are no guidelines on including
empirically based approaches in the training.
Since most clinical training occurs through fieldwork, it is unlikely
that students receive any training in EBTs.
We could not find data on actual training in EBT or on the use of
guidelines in social work graduate programs.
However, the writing of Mullen & Bacon, both social workers, on the
adoption and implementation of evidence-based effective treatments and quality
control in social work practice are relevant (Mullen & Bacon, In press-a
and b). They conducted a pilot survey
of a large urban voluntary mental health/social service agency, which they
stated was known for its quality of services and training. While social workers were the main providers
of service, the staff included psychiatrists and psychologists. The sample survey was small (N=124) and the
response rate poor so results must be viewed cautiously. A survey of a large sample of social workers
that are members of the national organization is underway. In light of the absence of other data, the
preliminary observations drawn by the authors are interesting. The authors focused on practice guidelines
as they believed these were central to the implementation of EBT. The three mental health professions
represented in this survey were strikingly different in their knowledge of
practice guidelines and EBT.
Psychiatrists were relatively well informed whereas social workers were
poorly informed, typically not even aware of the existence of practice
guidelines. Psychologists were
somewhere in-between. Once told what
practice guidelines were, social workers were inclined to be open to their use. Social workers generally were not using
research findings or research methods in their practice. Psychiatrists and to a lesser extent
psychologists were using findings and methods of assessment. Many social workers did not read the
research literature or even other professional literature. Psychiatrists read this literature
frequently. Social workers were heavy
users of consultation, much more so than the other professionals who functioned
more autonomously. Social workers
frequently sought guidance from supervisors and other consultants who were
viewed as repositories of knowledge based on experience. Given the low use of research methods and
infrequent reading of professional literature, Mullen & Bacon conclude that
it is unlikely that social work practitioners will be influenced significantly
through these routes. Rather,
supervisors and consultants seem to be the most promising conduit for knowledge
regarding practice guidelines and other forms of evidence-based practice for
social workers. Social workers appear
to be open to guidelines so long as they are perceived as helping to improve practice,
but their preference is for guidelines that represent professional consensus
rather than research evidence. A few
social work practitioners deviated from this norm, appearing to function more
autonomously through behaviors similar to those of the psychiatrists in the
sample. These social workers expressed
preference for evidence-based guidelines and they had higher frequencies of
reading research articles and professional publications. They concluded that these social workers may
be important resources for dissemination of evidence-based practice knowledge
within social work organizations. It is
likely that their training has provided them with research skills relevant to
practice. These findings, they
conclude, have implications for technologies needed to assist practitioners in
identification and use of evidence-based guidelines; for quality control and
accountability; and for education.
Continuing
Education. No formal process
exists to disseminate and train practitioners in the use of EBTs (Calhoun,
Moras, Pilkonis, & Rehm, 1998).
Clinicians trained ten years ago are unlikely to be up-to-date with the
newer, evidence-based psychotherapies, since the data supporting EBTs have
appeared in the past 10 to 15 years.
Continuing Education (CE) Programs have the potential to fill this
void.
Workshops
are given on EBT at the annual National meetings of psychiatrists and
psychologists. Periodically CE
workshops outside the professional organizations are offered. However, none of the mental health groups require
updated training in EBT. The decision
is left to the individual. There is no
way to insure the transfer of these treatments to established practitioners or
to set standards or monitor quality.
Since experienced clinicians are already overworked by changes in
healthcare delivery they may feel negative about yet another requirement, time
burden or a possible restriction in practice.
Other
obstacles to updated training exist.
While there is a dearth of information on this topic, those that exist
are primarily limited to psychologists but may apply to social workers and
psychiatrists. For the most part
practicing psychologists tend not to believe that evidence based
treatments (and related procedures such as practice guidelines, structured or
validated assessment procedures) are useful in their clinical practice (Addis
& Krasnow, 2000; Plante et
al., 1999).
The most frequent reasons stated are that EBT limits creativity and does
not take individual patient needs into account.
VI. Implications
in the Evolving Health Care System
The gap in the
transfer of EBTs from research to clinical practitioners will impact on the
viability of psychotherapy as the healthcare system evolves. The National MEPS
data presented above show a decrease in visits for psychotherapy and a dramatic
increase in the use of psychotropic medication (see Appendix). The increasing penetration of managed care
and the proliferation of clinical practice guidelines and treatment consensus
statements have raised the stakes for accountability. The failure to train practitioners in EBT so that they are
available to the general public may lead to the disappearance of psychotherapy
as a treatment despite data supporting its efficacy.
Managed Care.
Managed care organizations (or any other system monitoring the
utilization and cost of service such as HMOs, captivated contracts with
providers, etc.) are reshaping the practice of psychotherapy. In the traditional fee-for-service model,
decisions about the cost and length of treatment were primarily functions of
choices made by the doctor and patient, with the allocation of resources (i.e.,
cost of psychotherapy) being of less concern to the clinician. In fact, the fee-for-service model encouraged the provision of service, as
more service created more income.
However, in response to the increased costs of psychotherapy and, in
particular, to the perceived “endless” nature of psychotherapy, managed care
organizations are pressuring clinicians to allocate decreasing amounts of service.
To date, the focus of managed care organizations’ cost
cutting has been almost entirely on limiting the number of sessions a patient
receives. However, in order to compete, managed care organizations will also
have to focus on the quality (effectiveness) of psychotherapy, as they strive
to satisfy both the consumer (i.e., patient), and payer (e.g., employer
providing health benefits). In essence,
managed care organizations must balance their motivation to cut costs with
effective clinical outcomes. Simply
reducing the length of treatment may not accomplish this goal and lead in turn
to both consumer dissatisfaction and increased costs down the road (as the
severity of the disorder may increase and become less responsive to
treatment). Thus, concern for the
effectiveness of an intervention will eventually temper the managed care
organizations’ focus on economics.
Ultimately, managed care organizations will be interested in clinicians
providing the “optimal intervention: ...the least extensive, intensive,
intrusive and costly intervention capable of successfully addressing the
presenting problem.” (Bennett, 1992).
Clinical Practice Guidelines. Clinical practice guidelines and treatment
consensus statements have also impacted upon the practice of psychotherapy. As
noted by Smith and Hamilton (1994) “Guidelines are now being developed because
there is a perception that inappropriate medical care is sometimes provided and
that such inappropriate care has both health and economic consequences” (p. 42). Guidelines are developed to ensure that
patients uniformly receive the optimal intervention (whether it is a type of
medication, surgical procedure, or psychotherapeutic intervention).
The Agency for Healthcare Policy and
Research (AHCPR) with the Public Health Service is a federal agency involved in
clinical guideline development. Only
treatments with documented efficacy from randomized controlled trials are
emphasized. As a result, the
recommendations of the clinical practice guidelines are quite clear. For example, consider the wording from the
AHCPR guideline for Depression (Depression Guideline Panel, 1993), which states
that, “[when psychotherapy is to be selected as the sole treatment], the
psychotherapy should generally be time-limited, focused on current problems,
and aimed at symptom resolution rather than personality change as the initial
target. Since it has not been
established that all forms of psychotherapy are equally effective in major
depressive disorder, if one is chosen as the sole treatment, it should have
been studied in randomized controlled trials.”
In addition to endorsing specific treatments for depression that have
sufficient empirical evidence (e.g., cognitive behavioral therapy [CBT] and
interpersonal psychotherapy [IPT]), the report goes on to state: “Long-term
therapies are not currently indicated as first-line acute phase treatments”
(p.84).
Consensus statements are also
influential in determining which treatments should be delivered. In 1991, a Consensus Development Conference
on the Treatment of Panic Disorder sponsored by the National Institute of
Mental Health and the Office of Medical Applications of Research, National
Institutes of Health was held. The
available scientific evidence from clinical trials determined the merit of
various treatments (Wolf & Maser, 1994).
A number of specific treatments were judged to be effective for panic
disorder, including several pharmacological compounds and CBT (cf., Panic
Consensus Statement published in Wolf & Maser, 1994). The Panic Consensus Statement is clearly
negative on the use of treatments not supported by empirical evidence. “One risk of maintaining individuals in
nonvalidated treatments of panic disorder is that misplaced confidence in the
therapy’s potential effectiveness may preclude application of more effective
treatment.” The statement also spells
out a specific concern about the use of psychotherapies without demonstrated
effectiveness for panic disorder: “The
nature of the therapeutic relationship makes it difficult for the patient to
seek additional or alternate treatment.”
As clinical guidelines and treatment consensus statements
continue to emerge for a wide array of emotional disorders, they will have a
significant impact upon the way clinicians practice psychotherapy. In effect, these documents set standards of care, which if ignored,
leave the clinician both ethically and legally vulnerable. Health insurance companies and managed care
plans are now providing their practitioners with copies of guidelines and
asking that they be followed. For
example, Merit Behavioral Care Corporation, in a letter to their providers
(July 14, 1997), stated the following: “Consistent with national standards, the
Medical Affairs Committee of MBC endorses clinical practice guidelines.” They then provided references to specific
treatment guidelines created by the American Psychiatric Association for
schizophrenia, major depression, substance abuse, and bipolar disorder.
Managed care and clinical practice
guidelines are placing increasing pressure to deliver psychotherapies that are
cost-effective and empirically supported (Sanderson, 1995). Practitioners have not been concerned about
scientific testing and accountability.
As practice guidelines become the "standard of care,"
accountability will be essential.
Ultimately, treatments without supporting efficacy data are less likely
to be reimbursed (Trabin, 1994).
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APPENDIX
Psychotherapy Use in the U.S. Civilian
Non-institutionalized Population in 1987 and 1997
Marc J. Gameroff
Myrna M. Weissman
Rates of
Psychotherapy Use
The percentage of the population
receiving psychotherapy in 1987 and 1997 was on average 3.4%, with no significant
difference between years (see Table 1). However, visiting a medical doctor or
social worker for psychotherapy became more common, and seeing another type of
non-M.D. provider became less common. Although the overall “popularity” of
psychotherapy did not decrease, those receiving psychotherapy in 1997 had fewer
visits. This trend was essentially limited to therapy provided by psychologists
and other non-M.D.’s. However, visiting another type of non-M.D. provider was
also less common in the population in 1997, while psychologists provided
therapy to an equal proportion of the population in 1987 and 1997.
|
Table
1. Percentage of the Civilian U.S.
Population With Psychotherapy Usea, and Mean Number of Visits Per
User, 1987 and 1997
|
|
|
%
With
Psychotherapy
Use
|
|
Mean
Number of
Visits
Per User
|
|
|
|
|
|
|
|
|
Psychotherapy
Provider
Typeb
|
1987
(N=34,459)
|
1997
(N=32,636)
|
|
1987
(n=993)
|
1997
(n=1,136)
|
|
|
|
|
|
|
Medical doctor (M.D.)
|
1.6
|
2.3****
|
|
4.0
|
3.9
|
|
Psychologist
|
1.1
|
1.3
|
|
3.4
|
2.5*
|
|
Social worker
|
0.3
|
0.5*
|
|
0.7
|
1.2
|
|
Other non-M.D.c
|
0.9
|
0.5***
|
|
2.7
|
1.3**
|
|
|
|
|
|
|
Any provider type
|
3.2
|
3.6
|
|
10.8
|
8.9*
|
|
|
|
|
|
|
|
|
Note. Figures are national estimates based on
weighted data from the 1987 National Medical Expenditures Survey (NMES) and
the 1997 Medical Expenditure Panel Survey (MEPS). SUDAAN software was used to
account for the complex survey design. Year effects are tested with c2
analysis (% with psychotherapy use; df
= 1) or linear regression (mean number of visits per user; df = 1).
aPsychotherapy
users were those who made at least 1 visit to a provider in an office-based
practice or a hospital outpatient unit where “psychotherapy/mental health
counseling” was the main reason for the visit (NMES) or where
“psychotherapy/counseling” was among the services received (MEPS). bRows labeled with particular
provider types are not mutually exclusive, as a portion of psychotherapy
users (16.4% in 1987 and 23.6% in 1997) saw more than 1 provider type. cThe most commonly given titles
included: “therapist,” “counselor,” “mental health counselor,” “occupational
therapist,” “physical therapist,” and “nurse/nurse practitioner.”
*P
< .05. **P < .01. ***P < .001. ****P < .0001.
|
Rates of
Receiving a Psychotropic Medication
While
for psychotherapy users the mean number of visits decreased between 1987 and 1997,
the likelihood of receiving a psychotropic medication almost doubled, from 31%
in 1987 to 58% in 1997 (see Table 2). Naturally, this trend was pronounced
among individuals receiving psychotherapy from medical doctors (47% in 1987 to
71% in 1997), however rates also increased sharply for individuals seeing
psychologists, social workers, and other types of non-M.D. providers, from
about 25% in 1987 to 50% in 1997. Among those in the population who did not
receive psychotherapy, the likelihood of receiving a psychotropic prescription
was below 7% in both years but showed a statistically significant increase.
|
Table
2. Percentage of the Civilian U.S.
Population With At Least One Psychotropic Prescription During the Year, Among
Psychotherapy Usersa and Non-Users, 1987 and 1997
|
|
Psychotherapy
Use and Provider Typeb
|
%
Receiving
Psychotropic
Rx
|
|
|
|
|
1987
|
1997
|
|
|
|
Received psychotherapy…
|
|
|
|
|
|
…from a medical doctor
|
46.5
|
71.4****
|
|
…from a psychologist
|
24.9
|
47.3****
|
|
…from a social worker
|
27.6
|
54.2**
|
|
…from another type of non-M.D.c
|
24.9
|
52.1****
|
…from any provider type
|
31.2
|
58.1****
|
|
|
|
Did not receive psychotherapy
|
5.5
|
6.8****
|
|
Note. Figures are national estimates based on
weighted data from the 1987 National Medical Expenditures Survey (NMES) and
the 1997 Medical Expenditure Panel Survey (MEPS). SUDAAN software was used to
account for the complex survey design. Year effects in this table are tested
with c2 analysis (df = 1).
aPsychotherapy
users were those who made at least 1 visit to a provider in an office-based
practice or a hospital outpatient unit where “psychotherapy/mental health
counseling” was the main reason for the visit (NMES) or where
“psychotherapy/counseling” was among the services received (MEPS). bRows labeled with particular
provider types are not mutually exclusive, as a portion of psychotherapy
users (16.4% in 1987 and 23.6% in 1997) saw more than 1 provider type. cThe most commonly given titles
included: “therapist,” “counselor,” “mental health counselor,” “occupational
therapist,” “physical therapist,” and “nurse/nurse practitioner.”
*P
< .05. **P < .01. ***P < .001. ****P < .0001.
|
Demographic Characteristics of
Psychotherapy Users
The demographic profile of
psychotherapy users in the U.S. did not change considerably between 1987 and
1997 (see Table 3). For instance, the ratio of females to males was roughly
3:2, and the racial/ethnic distribution of users was fairly stable within and
across provider types. Across years, the vast majority (86%) of users were
non-Hispanic Whites, and about two-thirds of users were middle to high income.
However, the average user in 1997 was somewhat older, with this trend most
pronounced among people who saw medical doctors and social workers. In 1997,
psychotherapy users had more public and less private health insurance coverage,
which was reflected sharply among those who saw psychologists. Psychologists
were also the only provider group to be seeing a increased percentage of
lower-income clients in 1997.
Payment Sources
for Psychotherapy Visits
