PURPOSE

SCOPE

Psychosocial Treatment Focus
The focus of TherapyAdvisor is on effective psychosocial treatments for various mental health conditions. Effective medication treatments also are available for many of these conditions but are not addressed in TherapyAdvisor. A large and well-developed marketing infrastructure already exists for promoting medication treatments, and a variety of web sites provide information on medications for various mental disorders. The treatment summaries in TherapyAdvisor address comparative efficacy of psychosocial and medication treatments if known. In addition, a brief review of medications is included for each disorder covered by TherapyAdvisor (“Medical Corner” for practitioners, “What about Medications” for consumers). The focus of TherapyAdvisor, however, is on effective psychosocial treatments.

Empirically-Supported Treatments
TherapyAdvisor focuses on those treatments which have received adequate scientific research support (empirically validated). The treatments addressed in TherapyAdvisor are based on a recent review of empirically supported psychological treatments: Chambless, D.L. & Ollendick, T.H. (2001). Empirically supported psychological interventions: Controversies and Evidence. Annual Review of Psychology , 52, 685-716. This review utilized the most recent lists of empirically supported treatments from a number of sources including:

• Division of Clinical Psychology, American Psychological Association’s (APA) Task Force on the Promotion and Dissemination of Psychological Procedures Link to Division 12 APA
• Division of Clinical Psychology, American Psychological Association’s (APA) Task Force on Effective Psychological Interventions: A LifeSpan Perspective; published in Spirito, A. ed. (1999). Empirically supported treatment in pediatric psychology. Journal of Pediatric Psychology, 24, 87-174.
• Journal of Clinical Child Psychology (1998). Special Issue: Empirically supported psychosocial interventions for children, 27, 138-226.
• Nathan, P.E., & Gorman, J.M. eds. (1998). A Guide to Treatments that Work . New York: Oxford University Press.
• Roth, A.D. & Fonagy, P. (1996). What Works for Whom? A Critical Review of Psychotherapy Research . New York: Guilford.
• Kendall, P.C. & Chambless, D.L. eds (1998). Empirically supported psychological therapies. Journal of Consulting and Clinical Psychology , 66, 3-167.
• Wilson, J.J., & Gil, K.M. (1996). The efficacy of psychological and pharmacological interventions for the treatment of chronic disease-related and non-disease-related pain. Clinical Psychology Review , 16, 573-597.
• Gatz, M., Fiske, A., Fox, L.S., Kaskie, B., Kasl-Godley, J.E. et al. (1998). Empirically validated psychosocial treatments for older adults. Journal of Mental Health and Aging, 41, 9-46.

All treatments considered “well established” or “probably efficacious” based on this review were included as empirically supported treatments in TherapyAdvisor. To be considered a "well-established" or "probably efficacious" treatment, the treatment had to have at least two well-controlled trials demonstrating superiority compared to waiting list control (probably efficacious) or to a placebo or alternative treatment (well established). A treatment also could be included if a number of well controlled, single subject studies demonstrated efficacy. For more information on the criteria for defining empirically supported treatments, see: Chambless, D.L. & Hollon, S.D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7-18.

Atheoretical
TherapyAdvisor focuses on those psychosocial treatments with adequate research support for their efficacy, regardless of the theory from which the treatment was developed. Many of the treatments listed in TherapyAdvisor are consistent with cognitive-behavioral theories because more research has been performed on these treatments than on treatments based on other theories. The predominance of cognitive-behavioral treatments among empirically-supported treatments is due to many factors including the relative ease with which research can be conducted on well-defined, circumscribed approaches, and the integral nature of research within cognitive-behavioral theory and practice. Although cognitive-behavioral treatments have considerable scientific support, any treatment meeting the criteria of an empirically-supported treatment, regardless of underlying theory, is included in TherapyAdvisor.

EVIDENCE-BASED PRACTICE

General Psychotherapeutic Effect
All of the specific treatment approaches described in TherapyAdvisor are delivered within the context of a therapeutic relationship between the practitioner and the client or patient. A substantial body of research has shown that a number of factors in the therapeutic relationship including positive regard (the practitioner values the client), empathy (the practitioner understands how the client feels), and genuineness (the practitioner’s interactions appear real, not fake or contrived) contribute to the effectiveness of psychosocial treatments. Most forms of psychotherapy also share common factors such providing support, feedback, and direction. The therapeutic relationship and these common psychotherapeutic factors are necessary requisites for any psychosocial treatment. TherapyAdvisor includes a section on General Psychotherapy to address the therapeutic relationship and the effects of psychotherapy generally.

These general psychotherapeutic effects, however, are not always sufficient to produce the desired outcome. For some problems such as adjusting to common stressful events, a general supportive therapy alone may be sufficient. For the problems and disorders covered by TherapyAdvisor, however, specific psychosocial treatments are likely to provide better outcomes than general or supportive therapy alone. For a few of these specific treatments, the additional benefits compared to supportive therapy alone are modest. Many of the psychosocial treatments listed in TherapyAdvisor, however, have been shown to produce effects that are clearly superior to supportive therapy alone for specific disorders.

An Unvalidated Treatment is not an Invalidated Treatment
If a treatment is not included in TherapyAdvisor based on the empirically supported criteria used to select the treatment covered, it does not mean that it has been proven ineffective (invalidated). Because of the limited amount of outcome research in psychosocial interventions, many treatment approaches simply have little to no research on their efficacy (unvalidated). Therefore, some of these unvalidated treatments may be effective, but there is insufficient research to establish their efficacy at the time these treatments were last reviewed.

How should an evidence-based practice utilize these unvalidated treatment approaches?

• Unvalidated treatments should be utilized only when: a) there is no validated treatment for the disorder being treated, b) the validated treatments have been tried for a particular client and have not been effective, or c) there are clear contraindications for using the validated treatment.
• When there is insufficient research to support the effectiveness of a particular treatment for a particular disorder, preference should be given to treatment approaches that: a) have been shown effective for a similar disorder, or b) are based on a theory that has research support. Some unvalidated treatment approaches have considerable scientific support but have not yet been adequately evaluated to determine effectiveness for a specific disorder. This is particularly true for general psychotherapeutic approaches that are based on sound theory and research but were not developed to address a specific disorder or condition (e.g. Acceptance Treatment, Supportive-Expressive Treatment).
• All psychosocial treatments, but particularly unvalidated treatments, should be carefully monitored and evaluated with each client.

Disorders also are seldom seen in isolation. Clients can come in with multiple problems that require treatment. In these cases, communalities between the treatment approaches for each disorder may be combined and merged. It also may be appropriate to stagger treatment focus and prioritize the order in which problems are addressed (e.g. easiest to hardest to treat, core to ancillary problems, most impact to least impact on client’s functioning).

Evidence-based practitioners, however, should be cautious not to “over-tailor” the treatment. Most studies that have attempted to match treatments to patients have generally found no difference between matched and unmatched treatments. Treatment research also generally shows that the more practitioners deviate from the specified treatment, the less effective the treatment. Therefore, it is best to tailor treatments only to the degree necessary to fit the client’s presentation and situation.

APPROACH

• Poor Dissemination. Despite considerable research funding, publications, reviews, and books on empirically supported treatments, many of these treatments are not known to the vast majority of practitioners or their clients. In contrast to psychosocial treatments, medication treatments for specific disorders are much better disseminated to physicians and consumers, driven primarily by the substantial advertising and promotional budgets of pharmaceutical companies. Mental health practitioners do not receive reams of free information on the latest treatments, and “psychosocial treatment salesmen” do not visit their offices to promote specific psychosocial treatments. Mental health consumers are not inundated by “psychosocial treatment” advertisements on television, radio, and print media as they are with medications. Many of these psychosocial treatments are as effective or more effective than medications for treating the same disorder, but there is no profit motive driving the dissemination of psychosocial treatments.
• Poor Accessibility to Research. The sources of information on empirically supported psychosocial treatments are generally scattered and not concisely tailored to the needs of practitioners. Research publications are typically written for other researchers, not for treatment providers. Practitioners need to be able to quickly obtain research information that is relevant to their practice and to the types of problems their clients have. Practitioners have busy practices and need to be able to access relevant and succinct research information.
• Poor Accessibility to Training. Even when the research on the effective psychosocial treatments for a specific disorder are known and accessible, the practitioner may need specific training resources to become competent to provide these treatments. The training background and theoretical orientation of the practitioner may not fit with the therapeutic skill set required for a specific treatment. In these situations, treatment manuals, training materials, training institutes, and supervision resources must be available to practitioners willing to learn a new treatment approach.
• Minimal Reward. With few exceptions, practitioners receive the same reimbursement for services regardless of the empirical support for the psychosocial treatments they provide. Failure to deliver the most effective psychosocial treatment available has never been grounds for regulatory or civil sanction. Mental health consumers are generally unaware of the evidence supporting specific psychosocial treatments and, therefore, are unlikely to demand these services from their mental health practitioners or health providers. Professional and consumer satisfaction remain the primary rewards for practitioners to practice empirically.

TherapyAdvisor attempts to bridge these barriers by providing information on empirically supported psychosocial treatments to mental health practitioners that is easily accessible, concise, and relevant to practice. TherapyAdvisor also provides information and links to treatment manuals, training materials, and training institutes to provide practitioners with the training they need to utilize treatment approaches that may be unfamiliar to them. TherapyAdvisor also has information on empirically supported treatments for mental health consumers so they can become more knowledgeable of the most effective treatments available and be more selective and proactive in obtaining empirically supported psychosocial treatment.

FEATURES AND MEMBERSHIP

Mental Health Consumers
TherapyAdvisor access is free and anonymous for mental health consumers. The consumer site offers mental health consumers with a range of information about each disorder:

• What Is . . . ? provides a description of the disorder and how prevalent it is.
• What Therapies Work? provides a list of psychosocial therapies that are empirically supported to treat the disorder. Clicking the treatment name provides a PDF file (Adobe Acrobat) with a consumer-oriented description of the treatment.
• What About Medications? provides basic information on the medications and other medical approaches used to treat the disorder as well as information about medical conditions that should be considered and evaluated by their physician.
• Self-help Resources provides a list of books and other materials that are consistent with the empirically-supported treatments for the disorder.
• Information and Advocacy provides links to organizations that provide information and advocacy for the disorder.

Practitioners
TherapyAdvisor provides free and anonymous access for practitioners to all of the consumer information above and to the disorder pages for each disorder. To access the treatment pages within each disorder, however, practitioners must register and provide a small membership fee. Registration information allows TherapyAdvisor to track and monitor who uses the site to obtain practitioner treatment information and to provide alerts to members when the site is updated. No registration information will be provided to any other party or used for any other purpose. There is no advertising or paid links on TherapyAdvisor to ensure that the information provided is independent and free of commercial conflict. The small membership fee is used to support maintenance and updates to TherapyAdvisor.

Disorder Pages.
There are 40 disorders covered by TherapyAdvisor, grouped in adult, child, geriatric, chemical dependency, and health behavior disorders. Only disorders with empirically supported treatments are addressed. Each disorder page includes the following features:

• Introduction provides a diagnostic description of the disorder and basic information on prevalence. At the end of each introduction are listed the empirically supported treatments for that disorder. TherapyAdvisor members can select each treatment to obtain additional information about the treatment.
• Medical Corner provides a brief synopsis of the physical conditions that should be considered and ruled out in making the diagnosis, as well as the medications that are effective and commonly used to treat the disorder.
• Assessment Tools provides the title and brief description of measures that can be used to assess outcomes for that particular disorder. Assessment tools which are commonly used in the outcome research for that disorder and which are easily incorporated in a practice setting are included. A link is provided if the measure is available on the web or was provided by the copyright owner as a PDF file. These assessment tools are an important part of an evidence-based practice. Outcomes of each treated client can be assessed and results compared to the outcomes literature for that disorder (i.e. benchmarking).
• Contributors lists the experts who provided information on the treatments for the disorder. An asterisk denotes those experts who authored treatment summaries. The development of TherapyAdvisor would not have been possible without the contribution of these experts, many of whom are foremost authorities in their area and developed the empirically supported treatment approaches covered in TherapyAdvisor.

Treatment Pages.
Practitioner members can select a specific treatment and obtain additional information about each treatment. Each treatment page includes the following features:

• Treatment Summary Statement provides the practitioner with a description of the disorder, a comparison of the effects of the specific treatment to no treatment and/or to other treatments, and a detailed treatment description. These treatment summaries, many authored by the developers of the treatment, provide the practitioner with a clear and concise understanding of the treatment steps and procedures.
• Key References lists a compilation of books, chapters, and articles considered by the treatment experts to be “must reads” for the practitioner. These key references include seminal articles, literature reviews, and practical descriptions of each treatment. The abstract for each key reference can be viewed by selecting “View Abstract”. If the full text document is available on the web, a link is provided to access or purchase the key reference.
• Recent References lists books, chapters, or articles which have been recently published (within the last two years). Most of these recent references were also recommended by experts, but some are recent publications selected by the TherapyAdvisor team as highly relevant to the treatment of the disorder.
• Treatment Manuals and Training Materials lists books, treatment manuals, or training materials such as audio tapes, videotapes, and treatment checklists which are available to assist practitioners in becoming competent to provide the specific treatment. The list includes a brief description or abstract, and also provides a link if the material can be accessed or purchased via the web.
• Training Institutes provides a link to programs and institutes which provide workshops, supervision, and/or intensive training for the specific psychosocial treatment.

NAYSAYERS

TherapyAdvisor is based on the belief that most practitioners have the desire but have limited opportunity to utilize empirically supported psychosocial treatments and engage in evidence-based practice. Some practitioners, however, disagree with this approach based on a number of different rationales.

Rationale 1: All therapies are equal. There are no outcome differences between different psychosocial treatments. General supportive psychotherapy skills and therapeutic factors common to all therapies are adequate to treat most conditions.
TherapyAdvisor Response: For some of the empirically supported treatments covered by TherapyAdvisor, there is no evidence that these treatments are superior to other psychosocial treatments or to more general supportive therapy. For many of these empirically supported treatments, however, there is ample evidence that these treatments are superior to other psychosocial treatments. The research clearly indicates that providing supportive therapy to someone suffering from primary insomnia, obsessive compulsive disorder, enuresis, or a number of other disorders will result in inferior outcomes compared to the provision of the empirically supported treatments described in Therapy Advisor. General supportive therapy skills are a necessary requisite for almost all treatments, but they are not sufficient to produce optimal outcomes for the treatment of some disorders.

Rationale 2: Treatments developed and implemented within the necessary constraints of research are unduly constraining for clinical practice. Following a treatment manual is too constraining and technical for clinical practice.
TherapyAdvisor Response: It is accurate that empirically supported treatments are typically more structured and organized than unvalidated treatments. The treatment manuals for these empirically supported approaches, however, often provide considerable leeway and room for professional judgment (e.g. see Dialectical Behavior Therapy as an example of a structured approach that is not a step-by-step guide). Research should serve as the basis for practice, not as a constraint on practice. A practitioner can use one or more of these empirically supported approaches as the basis for the treatment of a specific client without having to adhere perfectly to the manual.

Rationale 3: Treatments validated in research setting are not clinically relevant. Treatments validated on mild forms of a specific condition are not generalizable to the more severe and multiple conditions often seen in clinical practice.
TherapyAdvisor Response: This was a reasonable rationale in the early days of psychotherapy research when college students and sub-clinical samples were sometimes used to test new approaches. Psychosocial treatment research over the past few decades, however, generally has been conducted on clinical samples in clinical settings. Although much of this research has focused on a single disorder (i.e. major depression) by excluding those with certain other comorbid disorders, multiple diagnoses still exist in these populations (e.g. personality disorders were seldom evaluated and excluded from these studies). Once efficacy with a specific condition has been established, subsequent research has been performed to determine the efficacy of these approaches in those with multiple disorders. With very few exceptions, the results of the research on these empirically supported treatments are generalizable to the conditions treated in clinical practice.

CONTACT US

• Do you have other concerns about adopting empirically supported treatments?
• Are there additional features or information which would make it easier to practice empirically?
• Are there additional treatments or resources that you would like considered for inclusion?

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THERAPYADVISOR TEAM

TherapyAdvisor was developed and evaluated by PICS (Personal Improvement Computer Systems) with a Small Business Innovation Research contract from the National Institute of Mental Health (N44MH22041).

• William Riley, Ph.D.; Director of Research, PICS; Project Principal Investigator
• Mary Schumann, Ph.D.; Consulting Research Scientist; Practicing Clinical Psychologist
• Valerie Forman, Ph.D.; Assistant Professor, University of Iowa, Carver College of Medicine
• Bradford Applegate, Ph.D., Behavioral Research Scientist, PICS
• Patti Mihm, M.A.; Consulting Research Associate
• Amy Day, B.S.; Research Assistant
• Ofer Asif, M.S.; Senior Web Developer, PICS
• Albert Behar; M.S.; President, PICS

General Consultants:
In addition to the hundreds of experts who contributed treatment summaries and reference material recommendations for each disorder and treatment in TherapyAdvisor, general consultants provided support and feedback throughout this project.

William Sanderson, Ph.D. is Professor of Psychology at Hofstra University. Dr. Sanderson was recently the Chair of the American Psychological Association Division of Clinical Psychology`s Committee on Science and Practice (a Task Force aimed at identifying and promoting the practice of empirically supported psychological interventions). He has published five books and over 80 articles and chapters, primarily in the areas of anxiety, depression, personality disorders, and cognitive behavior therapy.

Thomas Ollendick, Ph.D. is Professor of Psychology and Director of Training Clinics at Virginia Polytechnic Institute and State University (Virginia Tech). He has chaired a number of committees in Division 12 (Clinical Psychology) of the American Psychological Association. He has published a number of books and over 100 articles and chapters, primarily in the etiology, assessment, and treatment of childhood behavioral disorders.

Richard Elliott, M.D., Ph.D. is Professor of Psychiatry and Behavioral Sciences at Mercer University School of Medicine. He is certified by the American Board of Psychiatry and Neurology, American Board of Forensic Psychiatry, the American Medical Society for Alcoholism and Other Drug Dependencies, and has added qualifications in geriatric psychiatry and forensic psychiatry. He has published over 60 peer-reviewed articles and has made over 100 national and state-wide presentations. He has received five national awards for public service to the mentally ill, and was named Georgia Psychiatrist of the Year by the National Alliance for the Mentally Ill - Georgia.