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Defining the Boundaries of Evidencebased Family Treatments and the Complex Contexts in which they ar


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Title: Defining the Boundaries of Evidencebased Family Treatments and the Complex Contexts in which they ar


Evidence Informed Couple and Family Therapy A
dialogue between empirical and clinical voices
APA Division 43 Committee Work on Defining
Evidence-based Family Treatments
Jay Lebow
  • Defining the Boundaries of Evidence-based Family
    Treatments and the Complex Contexts in which they
    are Practiced
  • AFTA Clinical Research Conference 2007

  • Jay Lebow, Ph.D., ABPP
  • Family Institute at Northwestern
  • 618 Library Place
  • Evanston, Illinois 60202
  • e-mail

Goals for This Presentation
  • Examine evidence based practice in couple and
    family therapy and the interface between EBP and
    systemic practice.
  • Look at how clinicians can improve the process
    and outcome of treatment by informing practice
    with research findings and how researchers can
    make their research more relevant to clinical
  • Describe the dialogue among the Division of
    Family Psychologys Task Force on Evidence Based
    Couple and Family Therapy and the Directions of
    the Committee

Some Questions
  • In what ways and how much does evidence based
    methods add to the quality of the clinical
    practice of couple and family therapy?
  • How does evidence based practice interface with
    systemic thinking? Is evidence based practice in
    the context of a systemic understanding the
    equivalent of an oxymoron?
  • What are the best ways to apply evidence based
    practice in different treatment contexts? Do
    these ways vary across context and client

First Framework-Evidence based Practice applied
to Psychotherapy
  • Practice is evidence based which utilizes
    scientific research findings and/or methods of
    assessing therapy process and outcome in some way
    to inform clinical practice.

Criteria for Effective Treatment
  • The Standard of Common Practice
  • The Principle of the Respectable Minority
  • Scientific Evidence

Rationale for Evidence Based Treatment
  • Improve quality and accountability for health
    care practice
  • Develop shared vocabulary and concepts for cross
    disciplinary, biopsychosocial practice, research
    and health care policy
  • Stimulate development of evidence base for
    behavioral treatments

Kinds of Evidence Based Treatment
  • Idiographic
  • Evidence based practice
  • Focus on decision making about individual clients
  • Research informed practice
  • Client Progress Research
  • Nomothetic
  • Empirically Supported Treatments
  • Empirically Supported Relationships
  • Empirically Supported Principles of Practice

Whats an Empirically Supported Therapy? (EST)
  • Treatment that
  • Aims at a specific disorder or difficulty.
  • Has a treatment manual that specifically
    describes interventions and how decisions are
    made to utilize them
  • Has evidence for efficacy established in a
    randomized clinical trial, much like those to
    establish the safety and effectiveness of drugs.

Ests Who Are Suggesting Practice Guidelines?
  • American Academy of Child and Adolescent
  • Center for Substance Abuse Treatment
  • Various APA Divisions
  • Various authors Nathan Gorman (1998)
    oth Fonagy (1996)

Criteria for Empirically Supported Therapies
Society of Clinical Psychology
  • At least two good between group design
    experiments demonstrating efficacy in one of more
    of the following ways
  • A. Superior to pill or psychological placebo or
    another treatment
  • B. Equivalent to an already established treatment
    in experiments with adequate sample size
  • A large series of single case design experiments
    (more than 9) demonstrating efficacy.
  • These must have good experimental design and
  • Compared the intervention to another treatment.

Strengths of ESTs
  • Therapies have been demonstrated to work.
  • Clear evidence available for impact, not such
    claims of treatment developer or ability to
    present or market the treatment.
  • Therapies are specifically tailored to DSM
    diagnosis and/or population
  • Therapies are clearly described by manual
  • Easily followed and disseminated.
  • When pointing to effective special treatments for
    populations known to be difficult to treat and to
    likely have poor outcomes that are shown to be
    better than treatment as usual ESTs can
    designate special powerful treatments
  • Examples
  • Family based psychoeducation/ medication/
    individual skills training integrative treatments
    for clients with schizophrenia
  • Cognitive behavioral treatments for severe forms
    of panic disorder and obsessive compulsive

Criticisms of ESTs
  • DSM Focus does not speak to why most individuals
    enter psychotherapy
  • DSM focus ignores key client differences
  • Co-morbidity
  • Real clients have multiple problems
  • Disorder focus makes it difficult to evaluate
    overall effectiveness of psychotherapy across
  • Efficacy studies on which they are selected are
    not studies of real world effectiveness in
    typical clinical settings
  • Treatments need to be time limited
  • Treatments can be much more intense than in
  • Clients in studies which exclude those with
    multiple problems are atypical

Criticisms of ESTs-2
  • Manuals limit therapist creativity
  • Not an even playing field Bias favors
    cognitive-behavioral treatments.
  • Too many therapies to learn
  • No acknowledgement of the importance of the
    therapist factors
  • Not likely to be adopted by therapists of
    different orientations

  • Crucial building blocks for the establishment of
    the scientific basis for any endeavor
  • Helpful in suggesting directions for clinical
  • Never should be seen as a panacea or able to
    fully direct clinical practice

Alternatives Other evidence based frameworks
  • Empirically Supported Relationships
  • Focus on common factors at work across
    psychotherapies and enhancing these factors
  • Empirically Supported Principles of Practice
  • Principles that transcend specific treatment
  • Progress Research
  • Monitor client progress during treatment. Utilize
    information of progress in relation to other
    similar clients to assess whether treatment is
    effective/needs to be altered.

Second framework-History of Evidence in Couple
and Family Therapy
  • Couple and family therapy originally developed
    based principally in the brilliance of systemic
    understandings and the writing and presentations
    of its charismatic early leaders.
  • Research has shown them to be right about some
    ideas-e.g. the power of circular family
  • And wrong about others the double bind
    hypothesis of schizophrenia the value of
    affectively charged treatments for treating
    families with members with severe mental illness.
  • Evidence for most approaches followed the
    development of those approaches.
  • A paradox-center of systemic view was about
    change in the family system but these approaches
    have mostly been utilized to improve the
    functioning of the individual (e.g. the
    schizophrenic client) or sub-system in focus
    (e.g. the couple relationship) as well
  • Question-Is the move toward a greater focus on
    achieving outcomes in client focal problems
    progress or regression?

Evidence for the Impact of Couple and Family
  • Reviews of the literature and meta-analyses have
    established that couple and family therapies are
    effective methods for intervening with a wide
    array of difficulties
  • Gurman/Kniskern/Pinsof early reviews
  • More recent reviews by Lebow/Gurman Alexander
    Holzworth-Monroe Baucom, D. H., Shoham, V.,
    Mueser, K. T., Daiuto, A. D., Stickle, T. R.
    Sexton Alexander, Snyder, Heyman, and Haynes
  • AAMFT Projects Effectiveness research in marriage
    and family therapy edited by Pinsof Wynne and
    by Sprenkle
  • Meta-analyses by Shadish and others

History of Evidence in Couple and Family Therapy-2
  • Shadish and Baldwin report effect sizes typically
    are in range of .65 at end of treatment and .52
    at follow-up. Effect sizes for marital therapy
    average at .85 and for family therapy at .58.
  • Some couple/family therapies now have
    considerable support in evidence
  • Especially cognitive-behavioral marital therapy,
    emotion-focused couples therapy, multi-system
    family treatments for adolescent
    delinquency/substance abuse, psychoeducational
    treatments for severe mental illness
  • Many other widely disseminated approaches have
    yet to be evaluated.
  • Family therapies have primarily been evaluated in
    relation to their impact on individual disorders
  • A by-product of funding priorities
  • Impact of treatments on family is a secondary
    consideration in research. Where assessed, family
    therapies impact on family process as well as on
  • Yet to be research on the impact of couple and
    family therapies on family problems as primary
    target (e.g. intergenerational conflict) except
    for marital distress.

ESTs Marital distress
  • Behavioral marital therapy Neil Jacobson Gayla
  • Emotionally focused couples therapy Les
    Greenberg and Sue Johnson
  • Insight oriented couples therapy Doug Snyder
  • Integrative behavioral couples therapy Andy
    Christenson Neil Jacobson
  • Forgiveness based integrative couple therapy for
    infidelity-Don Baucom, Kristi Gordon, Doug Snyder

ESTsAdolescent substance use
  • Brief strategic therapy Jose Szapocznik, Dan
    Santiesteban et al
  • Functional family therapy Jim Alexander and Tom
  • Multi-dimensional family therapy Howard Liddle,
    Gayle Dakof, Cynthia Rowe et al
  • Multi-systemic family therapy Scott Henggeler

ESTs Other Child and Family Issues
  • Parent Training Programs For Children With
    Oppositional DisorderGerald Patterson et. al.
  • Applied behavior analysis parent training for
    Childhood Autism-Ivar Lovaas
  • Family psycho-educational intervention for
    schizophrenia and bi-polar disorder Ian Falloon,
    Carol Anderson, Bill McFarland David Miklowitz
  • Behavioral Couple Therapy for depression for
    partners in distressed relationships

Establishing Principles of Practice in Couple and
Family Therapy
  • Client Factors
  • Therapist Factors
  • Relationship Factors
  • Treatment Factors
  • Interactions of these factors

  • Traditional client demographic characteristics
    are typically unrelated to outcome
  • There have been few studies of the kinds of
    characteristics that are related to outcome in
    research on individual therapy such as motivation
    to change. Examples of what we have from this
    kind of research looks more promising
  • Survey of couple therapists found partners
    inability/unwillingness to change, lack of
    commitment to the relationship, and intensity and
    duration of problems to be most frequent factors
    associated with poor outcome (Whisman, Dixon,
    Johnson, 1997)
  • In couple therapy for alcoholism, individuals who
    were highly invested in their relationships and
    perceived high levels of support from their
    spouse showed great improvement as did those who
    reported low investment in their relationships,
    but those with high levels of relationship
    investment and low levels of support did less
    well (Longabaugh, Beattie, Noel, Stout, Malloy

  • Have strong relationship to outcome
  • In a study of Functional Family Therapy therapist
    relationship skills (warmth, humor etc) accounted
    for 45 of outcome variance (Alexander, Barton,
    Schiavo, Parson, 1977)
  • Therapist defensiveness early in treatment
    associated with negative outcome in couples
    (Waldron, Turner, Barton, Alexander, Cline,
  • Emerge as important even in therapies thought to
    have low therapist personal component such as
    strategic therapies (Green Herget, 1991)

  • Numerous studies show the importance of alliance
    to outcome in couple and family therapy
  • Alliance tends to be stronger predictor of
    outcome for men in couple and family therapy than
    for women
  • Longitudinal investigation shows that
    mid-treatment alliance predicts outcome beyond
    that accounted for by early alliance scores
    (Knobloch-Fedders, Pinsof, Mann, 1994)
  • Split alliance when family members dont agree on
    the quality of the alliance and unbalanced
    alliances are related to poorer outcomes
  • For example, Robbins, Turner , Alexander,
    Gonzolo show cases in which fathers and
    adolescents have different alliances with
    therapist have greater drop-out

  • Each subsystem in family therapy has an alliance
    with the therapist that is more than the sum of
    each persons alliance with the therapist
    (Pinsof, 1995)
  • Pinsof Catherall (1986) created the Couple and
    Family Therapy Alliance Scales assess 4
    relationship subsystems as well as dimensions of
    tasks, bonds, and goals
  • Self-therapist
  • Other family members-therapist
  • Entire family-therapist
  • Self-family (within)
  • Confirmatory factor analysis has validated the
    3x4 structure (Pinsof, Mann, Zinbarg,
    Knobloch-Fedders, 2004)

  • Couple and family therapy almost invariably
    involve someone who is lower in motivation to
    enter therapy
  • Assertive methods of engagement that include
    active joining, cultural sensitivity, and a
    willingness to remain flexible in therapy format
    vastly increase levels of engagement and alliance
    (Research on Brief Strategic Therapy)

  • Therapeutic relationship makes a difference
  • Alliance in Family Therapy is more complex than
    in individual therapy
  • Individual alliances with therapist
  • View of other family members alliances
  • Collective alliance with therapist
  • Alliance with one another
  • Need to attend to these multiple alliances
  • Assertive engagement helps

Integrating the findings of basic research into
  • Base of knowledge about family process, social
    psychology, individual personality,
    psychopathology, and social systems

Applying Research findings in Specific Contexts
Marital Therapy
  • Pre-marital skill development has a profound
    effect on the long term success of marriage.
    Therefore, encourage such skill development.
  • The presence of criticism, defense, contempt, and
    stonewalling predicts relationship demise.
    Therefore, if these patterns are evident, advise
    of the likelihood of relationship dissolution and
    prioritize the changing of these patterns.
  • The ratio of positive to negative behaviors in
    happy couples is overwhelmingly slanted toward
    the positive. Therefore, encourage more positive

Applying Research findings in Specific Contexts
Family Therapy
  • Reducing expressed emotion helps in severe mental
  • Assertive engagement is clearly preferable in
    certain client populations
  • Certain family patterns of behavior, such as high
    conflict, ultimately have profound negative
    effects. When present, therapy should at least
    in part focus on their reduction.

Tracking Progress in Psychotherapy
  • Assess gains as each case progresses
  • Utilize appropriate measures
  • OQ-45
  • Compass
  • HDI
  • Systemic Inventory of Change (STIC)
  • Compare with norms for comparable groups
  • Provide feedback to clinicians-Increases

Stages of Therapy Progress Howard
  • Feeling better happens quickly-Remoralization-
  • 10-15 by session 1, 55 by session 2-a few
    sessions if not by session 10, unlikely to
  • Followed by symptom change-remediation
  • 55 at session 2, 80 at session 10
  • typically require 16 sessions
  • Followed by change in current life functioning
  • time depends on kind of problem-typically 6months
    to a year
  • self-esteem slower to change 25 by session 2 but
    only 50 by session 48

Place of Couple/Family Therapies in Efforts to
Designate Evidence Based Practice
  • Typically an afterthought recognizing only the
    couple/family therapies with the most research
  • e.g. Division of Clinical Psychology list which
    ignores several prominent well studied couple and
    family therapies
  • e.g. Division of Child and Adolescent Clinical
    Psychology listing which accentuates individual
    interventions in children and adolescents
  • Some overviews/examinations dont even look at
    couple/family treatments
  • Family concerns and systemic considerations
    typically not mentioned.

Need for A Family Psychology Task Force
  • To examine place of evidence based practice in
    couple/family therapy
  • To establish couple/family therapies place in
    world of evidence based practice
  • To identify those treatments and treatment
    methods that are well established
  • To bring nuances of systemic viewpoint to the
    assessment of evidence based practice
  • To bring a balanced scientist-practitioner view
    to such efforts.
  • To suggest directions for further research on
    couple and family therapy
  • To bring nuances of systemic viewpoint to this

Origin of the Task Force
  • Division of Family Psychology of the American
    Psychological Association appoints task force to
    examine evidence based practice with Kristi
    Gordon as chair.

Criteria for Composition of Task Force and
Advisory Panel
  • Diversity of orientations
  • Diversity of interests
  • Ethnic and Gender diversity
  • Demonstrated commitment to both science and
  • Experience with evaluating and/or conducting
    treatment outcome studies
  • Openness to varying points of views

Members of Task force
  • Kristina Gordon
  • Alan Gurman
  • Amy Holtzworth-Munroe
  • Sue Johnson
  • Jay Lebow
  • Tom Sexton

Advisory Panel Members
  • Andrew Christensen
  • Daniel Santiesteban
  • Don David Lusterman
  • James Dobbins
  • Jaslean LaTaillade
  • Peter Chang

The domain
  • The clinical treatments that fall under the
    domain of Couple and Family Therapy
  • emphasize those aspects of the part of the
    therapy process that focuses on and works through
    the relational systems of couples and families as
    the basis of clinical assessment and intervention
  • focus on multisystemic relational systems for
    intervention and aim for clinically relevant
    changes in individual, couple, and family
    functioning at both broad and specific levels,
    considered from multiple perspectives with work
    often involving multiple systems.

Goal of the Guidelines
  • The purpose of these guidelines is to offer a
    system of organizing the research such that the
    knowledge base can be reviewed and effective
    treatments and interventions in family psychology
    identified that can serve as a resource for
    consumers and practitioners.
  • In a way that orders the reliability of
    empirically findings so that effective
    programs/interventions are identified and attends
    to the complexities of practice by considering
    variations in that evidence due to diverse
    clients, therapists, and contexts.

Important Notes
  • It is important to note that our primary
    assumption is that clients will only be helped
    through the use of both the wisdom of good
    professional practice and the guidance of
    clinical intervention research if effective
    treatments are to be delivered reliably to
    diverse clients across the various settings in
    which Family Psychologists practice.
  • As a group of researchers, practitioners, and
    trainers, the Task Force was sensitive to and
    constructed these guidelines appreciative of the
    need to attend to both the artfulness and
    individuality of effective clinical work AND the
    invaluable role of research at all levels of
    clinical decision-making.

Important Notes
  • We would suggest a more substantial place for
    research in the clinical decision making process.
  • If research evidence exists and that evidence
    comes from quality studies, it should carry the
    primary weight in clients, therapists, and
    systems choosing intervention and/or treatment

Dimensions of Evidence-based Treatments
  • Broad theoretical approach (traditional broad
    theory-based approach)
  • Common factors that are in existence in all good
    therapy approaches (typically considered
    non-specific factors)in couple and family
    therapy common factors are not enough, but only a
    starting point for therapy.
  • Specific clinical interventions (specific
    clinical procedures)
  • Specific Treatment Model (with clearly defined
    model-based principles, systematic approach to
    treatment-manual driven, specific change
    mechanism-based intervention strategies)

Broad/ Non-specific
Dimensions of Evidence-based Treatments
  • 2. A range of research methodologies
  • Family Psychology is a complex endeavor and must
    consider various forms of systematic study in
    order to capture that complexity
  • More important is that type of study fit the
  • Regardless of the type, studies considered must
    be systematic and clinically relevant and of high
    methodological rigor (for that specific type of

Types of Evidence in Evidence-based Treatments
  • Multiple case studies
  • Comparison trials
  • Clinical trials
  • Within these..
  • Efficacy studies
  • Effectiveness studies
  • Process-to-outcome
  • Transportability studies
  • Qualitative and Meta-analytic research reviews

Dimensions of Evidence-based Treatments
  • Scientific evidence must meet high standards of
    methodological rigor
  • no single standard of methodological excellence.
    Instead, the standard used to evaluate evidence
    must match the type of study.
  • should include measures of
  • intervention/model fidelity (therapist adherence
    or competence),
  • clear identification of client problems,
  • complete descriptions of service delivery
    contexts in which the intervention/treatment is
    tested, and
  • use of specific and well accepted measures of
    clinical outcomes.
  • In intervention research important to account
    for dropout (attrition) and follow-up outcome.

Dimensions of Evidence-based Treatments
  • 3. Multiple definitions of clinical outcomes
  • Broad non-specific outcomes (e. g. general
    measure of functioning)
  • Specific defined clinical syndromes usually
    defined by DSM-IV criteria
  • Specific measures, or theory-specific measures of
    individual, couple, or family functioning
    (recidivism changes, relapse levels, cognitive
    changes, object relations changes, etc).
  • Cost benefit analysis for specific models in
    specific treatment delivery settings

Broad/ Non-specific
Dimensions of Evidence-based Treatments
  • Outcomes must be compared to understand nature of
  • Absolute effectiveness is a measure of the
    success of the intervention/treatment compared to
    no treatment. Such a comparison is useful in
    determining if an intervention/treatment can even
    be considered evidence-based.
  • Relative efficacy is comparison of an
    intervention/treatment to a reasonable
    alternative (common factors, a treatment of a
    different modality, or a different
    intervention/treatment). Relative efficacy is
    critical to establish that a treatment is the
    best choice for a specific client/problem.
  • Contextual efficacy, the degree to which an
    intervention/treatment is effective in varying
    community contexts, is a critical third

Standards of Evidence-based Treatment in
Family/Couple Therapy
  • Levels of Evidence informed/based
  • Pre-evidence informed interventions/treatments
  • Level I Evidence-informed interventions/treatmen
  • Level II Promising interventions/treatments
  • Level III Evidence-based Treatments

Standards of Evidence-based Treatment in
Family/Couple Therapy
  • Pre-Evidence Informed Intervention/Treatments
  • Interventions and intervention approaches without
    evidence, or without a basis in empirically based
  • May use basic general principles that are common
    to all models yet the way they do it has yet to
    be systematically evaluated and tested

Standards of Evidence-based Treatment
  • Level I Evidence-informed Interventions/Treatmen
  • Informed by previous research/basic psychological
    research, or common factors perspective.
  • Factors/elements in the treatment are explicitly
    linked aspects of the model that is proposed.
  • Specific treatment programs that have evidence
    for portions of the program to suggest that they
    have an evidence base.
  • Maybe a common factor, or a single intervention,
    however, the intervention needs to be
    specifically defined.

Standards of Evidence-based Treatment
  • Level II Promising Interventions/Treatments
  • Specific interventions (meets the criteria for a
    defined intervention) that have comparison
    studies of high quality but no further evidence
    or specific outcomes with specific populations.
  • Specific intervention/treatment programs (meets
    the definitions above) that have studies with
    specific outcomes with specific populations.
  • Might be either limited number of studies, or
    studies at either at a single site or of less
    methodological rigor.

Standards of Evidence-based Treatment
  • Level III Evidence-Based Treatments
  • Evidence based treatments/interventions have
    different levels of evidence, specificity and
    applicability. Three categories define these
  • To be considered an evidence-based
    intervention/treatment, it is necessary to meet
    the criteria for category 1.
  • Assumption is that to reach this level needs to
    have more than single intervention but to be
    embedded within the conceptual and theoretical
    aspects of a treatment package.
  • Multiple studies, at a single site with high
    level methodological rigor

Standards of Evidence-based Treatment
  • Category 1 Absolute efficacy/effectiveness
  • Specific treatment intervention models/programs
    that meet the criteria above (theoretical
    principles, specific clinical procedures,
    theoretically articulated change mechanisms) that
  • Efficacy studies with comparison, clinical trial
    evidence that shows clinically significant
    effects with specific clinical outcomes that have
    clinical relevance.
  • This would suggest that this treatment is a
    useful treatment for a specific class of clinical

Standards of Evidence-based Treatment
  • Category 2 Relative efficacy/effectiveness
  • Specific treatment intervention models/programs
    that meet the criteria above (theoretical/conceput
    al principles, specific clinical procedures,
    identified change mechanisms) that have
  • Efficacy studies with clinical trial evidence
    that show clinically significant effects with
    specific clinical outcomes with clinical
    relevance as compared to other reasonable
  • This would suggest that this treatment is a
    preferred treatment for a specific class of
    clinical problems
  • Specific evidence of evaluated or verified change
    mechanisms that are expected and proposed by the
    treatment model

Standards of Evidence-based Treatment
  • Category 3 Effective models with verified
    mechanisms of action
  • Specific treatment intervention models/programs
    that meet the criteria above (theoretical
    principles, specific clinical procedures,
    identified change mechanisms) that have
  • Specific evidence of evaluated or verified change
    mechanisms that are expected and proposed by the
    treatment model

Standards of Evidence-based Treatment
  • Category 4 Contextual efficacy
  • Specific treatment intervention models/programs
    that meet the criteria above (theoretical
    principles, specific clinical procedures,
    identified change mechanisms) that have
  • Efficacy studies AND effectiveness studies in
    community settings that show clinically
    significant effects with specific clinical
    outcomes with clinical relevance as compared to
    other reasonable treatment alternatives.
  • Specific evidence of evaluated or verified change
    mechanisms that are expected and proposed by the
    treatment model. Where it is designed to work.
  • Evaluated according to a matrix logic model

Standards of Evidence-based Treatment
  • Logic
  • Criteria should reflect the notion that evidence
    based models have different uses/applications
    based on the evidence
  • Reliable and valid evidence in different areas
    are important for different decisions
  • For example
  • Evidence in different contexts will lead to
    different clinical decisions (what to use with
    what client) and administrative decisions (what
    system the intervention program has demonstrated
  • Evidence with different outcomes will lead to
    different decision regarding confidence/use for
    different clinical/administrative applications
  • Matrix approach allows for the holes in
    research evidence to be identified and thus,
    create needed future research agendas

Decision Making Matrix
Specific Intervention Model
Type of demonstrated Outcomes (e. g. satifaction,
Level of Efficacy/Effectiveness Absolute/Relative
Client factors -gender -Ethnicity -culture Servic
e Delivery/ Settings (e. g. mental health
Center/private practice) Social/Cultural Context
(e. g. urban/rural/ US/International)
(demonstrated evidence)
Final comments
  • Aim to produce more comprehensive guidelines to
    help clinicians better match treatments to
    problems and researchers identify needs and
    present this information in a user friendly
    format via web and print
  • Next step what are cross-cutting therapeutic
    principles and how are these principles used in
    existing treatments?
  • Plan for how to consider evidence over time
  • Be less concerned with which treatments are ahead
    now than place of evidence over time
  • Present accidents of funding priorities exert
    influence in what is known but other evidence
    will fill in over time.

More Questions
  • What to do with evolving methods-How much of a
    treatment needs to be the same for it to count as
    an example of a treatment?
  • An emphasis on principles or on treatments?
  • Different routes to the same therapeutic change
  • Valid key measures for assessing change or
    arbitrary metrics?
  • What status to designate problems never addressed
    in funding priorities-e.g.. relational
  • How much demonstration needed in a specific
    context or culture?
  • How important is the therapist in treatment
  • Whats the balance of client values/clinical
    expertise in relation to research evidence.
  • Perhaps evidence more important when there is a
    specified target problem rather than therapy as a
    multi-faceted process of development e.g.
    overcoming panic attacks vs. decisions about
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