"Canadian professional psychology and empirically supported treatments": Commentary.
The authors have provided an excellent overview of issues in the debate over identifying and disseminating empirically supported treatments (ESTs) as played out in the United States and have set this debate in an international context. They have cogent suggestions for why and how Canadian professional psychology should be involved with this movement. This is, of course, for Canadians to decide, but I am confident that Canadian participation would be welcomed by the Society for Clinical Psychology (Division 12 of the American Psychological Association), the central group working on the EST question in the u.s. The authors raise a number of intriguing issues for discussion. I will limit my comments to four of these.First, the authors advocate for the inclusion of basic research in the scientific foundation of clinical practice. This is of critical importance, because many clients whom psychologists treat will not have the specific problems for which ESTS have been developed. In such cases, clinicians need to decide whether they are warranted in generalizing from the samples on which an EST is based, or whether they need to devise a novel approach. If the latter, what is the basis for selection? Similarly, what is the basis for treatment when ESTs have failed? The clinicians' general theoretical orientation, unsystematic observations from practice, or, we hope, interventions drawn from the clinician's basic training in psychological principles? I commend the authors for including this point, which has not heretofore been emphasized in discussions of ESTs.A second issue concerns the importance of the therapeutic relationship or working alliance. Garfield (1996), among others, castigated the Division 12 Task Force for ignoring the importance of the alliance in favour of specific treatment interventions. The focus on ESTs should not be taken to mean that foundational issues such as the alliance can be forgotten. Psychotherapy occurs within an interpersonal context, and there is evidence that in ESTs (e.g., Williams & Chambless, 1990), as well as in less structured psychological treatments (see meta-analysis by Horvath & Symonds, 1991), this context needs to be a positive one. Training students in ESTs is thus only part of the process of teaching them to be effective clinicians. Authors of many EST treatment manuals explicitly highlight the importance of the alliance (e.g., Beck, Rush, Shaw, & Emery, 1979; Klerman, Weissman, Rounsaville, & Chevron, 1984), but some give it only a brief mention. Typically, the assumption is that protocol therapists already have these skills, rather than they are unimportant. Nonetheless, this needs to be made explicit (see Waltz, Addis, Koerner, & Jacobson, 1993). In my view, students' training should begin with training in basic therapeutic skills before they learn more specialized ESTs. This training may be facilitated by the use of organized, research-based approaches to interviewing and relationship skills (e.g., Ivey, 1988).Third, the authors note that training directors in Canada may see no need for emphasizing ESTs because most programs are cognitive-behaviourally oriented. Given the traditional emphasis of the cognitive and behavioural approaches on their scientific bases, this may indeed make the EST movement less urgent in Canada. However, a CBT orientation does not ensure that a clinician is well informed about ESTs. In my own field of anxiety disorders, I have seen numerous clients who had considerable ineffective treatment at the hands of cognitive or behavioural therapists who failed to use well-established ESTS and, instead, treated obsessive-compulsive disorder with systematic desensitization or panic disorder with biofeedback, two treatments with no empirical support for these problems. …
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