Study casts doubt on ‘gold standard’ psychological treatments

In my salad days, I was a therapist. I confess that I placed no faith in any particular therapeutic method.

I believed, even then, that human beings were driven by the need to form supportive relationships and that most mood disorders (depression, anxiety etc.) were the result of relationships that had gone wrong in some way—or genetics.

A paper appearing in the Journal of Abnormal Psychology questions much of the statistical evidence underpinning therapies designated as “Empirically Supported Treatments”, or ESTs, by the American Psychological Association (of which I am a member) and shows that I might have been right to eschew particular therapy methodologies.

For years, ESTs have represented a “gold standard” in research-supported psychotherapies for conditions like depression, schizophrenia, eating disorders, substance abuse, generalised anxiety and post-traumatic stress disorder. But recent concerns about the replicability of research findings in clinical psychology prompted the re-examination of their evidence.

The new study concluded that while underlying evidence for a small number of empirically supported treatments is strong, “power and replicability estimates were concerningly low across almost all ESTs, and individually, some ESTs scored poorly across multiple metrics”.

What the researchers say

“By some accounts, there are over 600 approaches to psychotherapy, and some are going to be more effective than others,” said a co-lead author. “Since the 1970s, people have been trying to figure out which are most effective using clinical trials just like in medicine, where some subjects are assigned to a therapy and some to a control group. The APA has a list of therapies with strong scientific evidence from these trials, called ESTs. Ours is the first attempt anyone has made using this broad suite of statistical tools to evaluate the EST literature.”

The researchers analysed 78 ESTs with “strong” or “modest” research support, as determined by more than 450 published articles. Among their key conclusions:

• 56 per cent (44 of 78) of ESTs fared poorly across most metric scores.
• 19 per cent (15 of 78) of ESTs fared strongly across most metric scores.
• 52 per cent (26 of 50) of ESTs deemed by the APA as having Strong Research Support fared poorly across most metric scores.
• 22 per cent (11 of 50) of ESTs deemed by the APA as having Strong Research Support fared strongly across most metric scores.
• 64 per cent (18 of 28) of ESTs deemed by the APA as having Modest Research Support fared poorly across most metric scores.
• 14 per cent (4 of 28) of ESTs deemed by the APA as having Modest Research Support fared strongly across most metric scores.

“Our findings don’t mean that therapy doesn’t work; they don’t mean that anything goes or everything is the same,” said a second co-lead author. “But based on this evidence, we don’t know if most therapies designated as ESTs do actually have better science on their side compared to alternative, research-supported forms of therapy.”

According to the authors, the field of clinical psychology may be ripe for a broad-scale reassessment of therapies that were thought to be supported by rigorous scientific evidence until now.

So, what?

As a result of this study, I would advise clinicians and patients to continually evaluate progress in therapy and adjust therapeutic approaches based more on patient progress than research evidence of a given therapy’s effectiveness.

The truth is that there is no pharmaceutical or talk psychotherapy that has been proved to be more successful than a placebo in the medium to long term. Some studies have in fact shown that all therapies are just placebos. This is largely because there is no one cause of depression or other “mood” disorders. There may, in fact, be hundreds of them.