Wednesday, October 25, 2006

Do "Evidence Based" Psychotherapies Work Best for Youth?

Yeah, I know I’ve spent a lot of space discussing psychiatry but this post deals with psychological treatments for youth. The new issue of American Psychologist contains a meta-analysis by Weisz, Jensen-Doss, and Hawley, comparing so-called evidence based treatments to usual community care. Evidence based treatments (EBTs) are those that have been shown efficacious in comparison to some sort of control group, even a control as unimpressive as a group of individuals who receive no treatment. So the claim to fame of many alleged evidence based treatments is that they are better than nothing.

A debate has raged for about 15 years over whether these EBTs are better than what is actually being done by mental health practitioners in the community. Weisz and colleagues, to make a long story short, basically found a small difference (effect size of d = .30 at endpoint and d = .38 at followup) favoring EBTs over usual care. Through moderator analyses, they ruled out different amounts of treatment received as explaining the difference (i.e., the EBT group didn’t just turn out superior because they received more sessions). They also generally ruled out another few potential extraneous variables.

The most interesting moderating variable to me was that when the EBT was delivered/supervised by the developer of the therapy, the advantage was d = .33, but when the EBT was not delivered/supervised by the developer of the therapy, the advantage was a paltry d = .09.

My View: As the authors pointed out aptly, it was pretty unclear what “community treatment” meant in most studies. On one hand, there is a very well described EBT, and on the other is whatever clinicians are doing. This makes it very difficult to pin down why this small advantage exists for EBT, as all that is known is that it is being compared to some mishmash of various techniques. I also wonder if therapists in community care being overwhelmed with patients (high caseloads) may have something to do with their lesser performance.

Then again, it may all just be that therapists trained to do EBT are aware that it is supposed to be superior and just work harder since they know that they are under a microscope, so to speak. There are not many psychologists who would take the time to design a therapy then not attempt to make sure it is being implemented to its fullest when it is being compared to an alternative treatment. The therapists giving the EBT are aware that there is some pressure to achieve results. I would think this makes them work harder because they feel a great sense of accountability whereas in usual practice, there may not be as great a sense of accountability on day to day basis. I’m not saying that your typical clinician does not at all feel accountable, but that there is not as much pressure on her or him to achieve results as measured on a variety of questionnaires. This got a little longer than I expected – sorry about that. Please comment to add your two cents on the topic.

Update: I noticed that some of the "usual clinical care" conditions to which these EBTs were compared were pretty bogus. Many of them were case management only controls. The EBT therapists generally got extra training and supervision whereas the usual care therapists were on their own. So what we can take away from this is that well-trained therapists with small caseloads and tons of supervision do better than some combination of case management and/or overloaded therapists performing treatment without supervision. Hopefully the EBT crowd will see the results for what they are instead of proudly (but wrongly) proclaiming superiority over a legitimate alternative form of treatment. I'm pretty sure that non-EBT psychotherapies administered with the same advantages EBT had in terms of training, supervision, and low caseloads would also prevail in a contest with bogus therapy.

Link to American Psychologist website here.

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