– Articles by Dr. Stephen Migden –
Common Sense In Judging E.S.T. Programs
The increased use of empirical research methods in psychology and education has been one of the most positive developments that I have witnessed in over 25 years of professional practice. Empirical research methods have helped us to better determine the effectiveness of treatments for troubled youth, including some of those used in residential treatment centers, therapeutic boarding schools and wilderness programs. With such knowledge, a number of Empirically Supported Treatments (E.S.T.s), or treatments that are shown to be effective in scientific research studies have been developed. (Though technically, E.S.T.s assess efficacy, i.e. the benefit of a treatment under controlled conditions, rather than effectiveness, i.e. the benefit of a treatment in the natural clinical setting, in this essay I will use the more generic term of "effectiveness.") These developments have led to many improvements in the mental health and educational services provided to troubled children and teens.
Yet, despite these very positive developments, I am concerned that many of us, consultants and parents alike, have lost some perspective in our understanding of the role of E.S.T.s in the clinical setting. As a result, I fear that we may, at times, risk over-ruling our own good judgment and common-sense, while ignoring important aspects of treatment that don't readily fit into the E.S.T. model.
The Role of the Treatment Relationship
For example, almost any behavioral health or special education treatment is - in fact, must be - applied in the context of a human relationship. Whether client-therapist or student-teacher, the positive relationship between the helping professional and the troubled youth is the all important environment in which any treatment, empirically supported or not, must come to life (Wampold & Bhati, 2004). Without this positive relationship, even the best-supported treatment will come to nothing. A student is much more likely to benefit from a treatment applied by a caring adult with whom he has a positive working relationship than from a cold-fish technician, even if the technician knows and applies the technical details of the treatment proficiently. In fact, as I often remind other professionals who seek my advice, the same type of scientific research that demonstrates the effectiveness of many highly regarded treatments (including, for example, DBT, CBT, anger management, and relapse prevention) also demonstrates the importance of the relationship in treatment (American Psychological Association, 2005).
Even when research shows that a particular treatment is effective in helping troubled youth to improve, the treatment itself often only accounts for a part of this improvement. Other factors that are not specific to the treatment often account for much of the improvement (Wampold & Bhati, 2004). We know this because researchers are able to estimate what percentage of the positive outcome in a treatment study relates to the particular treatment applied and what percentage is due to other factors not specific to the treatment. Frequently, even when a treatment is effective, these other factors will actually account for a large percentage of the positive outcome. Thoughtful researchers and practitioners frequently understand that many of these other, not-specific-to-the-treatment factors are actually aspects of the relationship, and they include such things as the amount of warmth, trust, empathy and openness between the client and the helping professional (Horvath & Bedi, 2002; Lambert & Barley, 2002). As a result, it's important for both consultants and parents to remember the common-sense elements of the human environment when looking at a program for a troubled youth, even as they focus on the technical aspects of the program, such as the use of E.S.T.s.
The Importance of Matching Treatment and Problem in E.S.T.s
When evaluating programs for troubled teens, it's also very important to remember that the empirical support for almost any treatment, be it medical, psychiatric, psychological or educational, is not merely blanket support for the treatment. Instead, the empirical support of the treatment is specific to its use within a particular group of people with a particular set of problems. In the E.S.T. model, the treatment-problem match is very important. To take one obvious example, the E.S.T. for substance abuse is different from the E.S.T. for eating disorders. In this regard, E.S.T.s are prescriptive: "This treatment is used with our troubled youth because research has shown it to be effective with similar youth who have similar problems." Unfortunately, I occasionally come across situations where professionals ignore this match between treatment and problem: "This empirically supported treatment is [routinely] used with all of our youth [regardless of their particular problem]." If parents or consultants hear such statements when looking at a program, it's important to ask a number of clarifying questions. Such questions might include: Do you adjust this treatment for different kids? Have you found this treatment to be helpful with all the youth in your program or just some of them? If the latter, can you describe which ones have benefited most?
Limitations of E.S.T. Research
When considering the use of E.S.T.s, we must also remember that as valuable as scientific research is in measuring treatment effectiveness, this same research may have significant limitations, which may affect research findings. For example, due to a variety of factors, such as funding or time limitations, certain treatment models may attract more research interest than other types. Alternatively, certain types of treatment may fit the empirical research model better than others, with the result that the better fitting treatment may fare better in research trials. For example, humanistic, gestalt and psychodynamic treatments are often much harder to study than behavioral or cognitive treatments. The former typically deal with more subtle, less tangible internal phenomena that, as a result, take longer to change and/or are harder or more expensive to measure. Because of this, it's important to remember that a lack of empirical support for a particular treatment doesn't necessarily mean empirical non-support for it. Instead, it may simply mean that a substantial amount of scientific evidence, pro or con, is not yet available about the treatment (Messer, 2004). In such instances, we must use other sources of knowledge such as the clinicians' experiences and a common-sense understanding of what helps people in psychological distress, not only empirical research data to evaluate the effectiveness of treatments and programs (Davidson & Spring, 2006). However, I believe it is crucial to impress on both researchers and research funding agencies the importance of thoughtful, comprehensive outcome studies for many types of treatment, even those that are difficult or expensive to measure.
In summary, although the use of scientific research methods to enhance our understanding of empirically supported treatments has had a very positive influence on our capacity to help troubled youth, it is important to maintain perspective and balance as we strive to learn about and apply these treatments. We must not ignore the human relationship, the all-important context for any treatment, empirically supported or otherwise. We must remember the importance of the treatment-problem match, and thoughtfully consider whether a proposed treatment is appropriate for this particular youth with this particular set of problems. Finally, we must remember that a treatment's lack of empirical support may be due to limitations in the research rather than limitations in the treatment. Because of this, we should support and encourage comprehensive studies of many types of treatment, even those that are difficult or expensive to measure.
American Psychological Association (2005). Report of the 2005 Presidential Task Force on Evidence-Based Practice. Washington, DC.
Davidson, Karina W., & Spring, Bonnie (2006). Developing an evidence base in clinical psychology. Journal of Clinical Psychology, vol. 62, no. 3, 259-271.
Horvath, Adam O., & Bedi, Robinder P. (2002). The alliance. In John C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.
Lambert, Michael J., & Barley, Dean E. (2002). Research summary on the therapeutic relationship and psychotherapy outcome. In John C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University Press.
Messer, Stanley B. (2004). Evidence-based practice: Beyond empirically supported treatments. Professional Psychology: Research and Practice, vol. 35, no. 6, 580-588.
Wampold, Bruce E., & Bhati, Kuldhir S. (2004). Attending to the omissions: A historical examination of evidence-based practice movements. Professional Psychology: Research and Practice, vol. 35, no. 6, 563-570.
Reprinted, with permission, from Places for Struggling Teens, a publication of Woodbury Reports, Inc. May 2006, Number 141