Are Evidence-Based Psychological Interventions Practiced by Clinicians in the Field?

Column Editor: William C. Sanderson, PhD, Rutgers University, Piscataway, New Jersey.

Disclosures

Introduction

During the last 15 years there has been considerable progress in the development of specific, time-limited psychotherapy protocols (eg, exposure and response prevention for obsessive-compulsive disorder, interpersonal psychotherapy for depression, cognitive therapy for panic disorder) and then testing them in controlled clinical trials.

As a result, there is an increased availability of specific psychotherapeutic evidence-based treatments (EBT) for the full range of psychiatric disorders,[1] and an increased recommendation for their use in official treatment guidelines, such as the American Psychiatric Association's Practice Guidelines for the treatment of psychiatric disorders.[2]

It is very difficult to track the kinds of psychotherapeutic methods actually being practiced in the field; however, it has been suggested that EBTs are not typically used by the 3 primary professional groups that provide psychotherapy -- psychiatrists, psychologists, and social workers.[3,4,5,6,7] Unfortunately, it appears as though research advances in the practice of psychotherapy have not translated into improving treatment services on a large scale. Consider the treatment of panic disorder as an example: The effectiveness of specific psychotherapeutic procedures is well documented by a number of controlled research studies, and the National Institute of Health Panic Consensus Statement fully endorses behavioral (exposure) treatment as an effective therapy.[8] However, only a small percentage of patients with panic and phobic disorders (estimated between 15% and 38%) actually receive an evidence-based psychological intervention, such as exposure therapy and cognitive restructuring.[3,9] An identical survey conducted 5 years later[10] revealed that, unfortunately, the use of psychosocial treatments had declined overall, and that dynamic psychotherapy was still the most frequently used therapeutic approach. The percentage of patients receiving cognitive and behavioral treatment had decreased,[4] which is surprising since an increase -- not a decrease -- in the use of EBTs would be expected, given the growing body of research on this topic.

Although there have been some concerns about how well the treatments -- which are studied under highly controlled conditions, such as those employed in clinical research centers -- actually work in the field, effectiveness studies, aimed at evaluating how well these treatments generalize to "real world" settings, are beginning to appear. Existing studies continue to support the value of EBTs in real practice settings.[11,12,13,14]

Thus, effective psychosocial treatments are available for treating a wide range of commonly encountered disorders in both controlled-research trials and real-world settings. Unfortunately, these treatments do not appear to be widely used by clinicians in the field. The logical conclusion is that the development of EBTs does not necessarily lead to their use. The dissemination of treatments from research settings to actual clinical practice is a vital step -- without which EBTs will be used only by clinical researchers -- thus, the general public will not benefit from psychotherapeutic advances.

In principle, the majority of psychotherapy providers (ie, social workers, psychologists, and psychiatrists) likely agree on the necessity of providing empirical support for their interventions. Additionally, the public expects to receive effective treatment from licensed professionals. Therefore, one would expect clinicians to embrace EBTs. However, as mentioned above, the few data that exist on this topic reveal that this is not the case.

Given this paradoxical finding, an important question emerges: Why is it that clinicians are not utilizing advances in the field? Several factors have been identified. First, the psychotherapy training that psychiatrists, psychologists, and social workers receive as part of their graduate (or medical) education does not require that they receive comprehensive training in EBTs; consequently, when they enter practice, they do not have the skills to administer these treatments.[15,16,17] Second, continuing-education programs do not require training in EBTs; therefore, there is no way to insure the transfer of these treatments from research settings to clinical practice. Third, many clinicians in the field are negatively biased toward evidence-based treatments and, presumably, are not likely to seek continuing-education training and adopt for use in practice.[5,6,17]

The poor record of disseminating EBTs from research settings to clinical practitioners in the field has resulted in the lack of availability of many of these treatments. Ultimately, this may have a disastrous impact on the viability of psychotherapy as the healthcare system evolves. The increasing proliferation of managed care, as well as the continued development of clinical practice guidelines and treatment consensus statements, has raised the stakes for accountability,[18] and the failure to train practitioners in EBTs may lead to the fall of psychotherapy as a first-line effective treatment -- even though considerable data support its efficacy. If psychotherapy providers are not trained to provide EBTs, where do they fall in this new healthcare scheme? All psychotherapists should be concerned with this issue, as it is paramount to the survival of psychotherapy as a viable treatment.

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