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

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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

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Address

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

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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
  practice
• Describe the dialogue among the Division of
  Family Psychologys Task Force on Evidence Based
  Couple and Family Therapy and the Directions of
  the Committee

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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
  population?

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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.

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Criteria for Effective Treatment

• The Standard of Common Practice
• The Principle of the Respectable Minority
• Scientific Evidence

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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

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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

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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.

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Ests Who Are Suggesting Practice Guidelines?

• American Academy of Child and Adolescent
  Psychiatry
• Center for Substance Abuse Treatment
• Various APA Divisions
• Various authors Nathan Gorman (1998)
  -----------------------R
  oth Fonagy (1996)

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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.

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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
  disorder

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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
  difficulties
• 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
  practice
• Clients in studies which exclude those with
  multiple problems are atypical

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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

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Synthesis-ESTS

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

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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
  contexts
• 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.

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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
  processes
• 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?

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Evidence for the Impact of Couple and Family
therapy

• 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

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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
  disorder.
• 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.

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ESTs Marital distress

• Behavioral marital therapy Neil Jacobson Gayla
  Margolin
• 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

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ESTsAdolescent substance use

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

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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

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Establishing Principles of Practice in Couple and
Family Therapy

• Client Factors
• Therapist Factors
• Relationship Factors
• Treatment Factors
• Interactions of these factors

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CLIENT 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
  1993).

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THERAPIST CHARACTERISTICS

• 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,
  1997)
• Emerge as important even in therapies thought to
  have low therapist personal component such as
  strategic therapies (Green Herget, 1991)

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RELATIONSHIP FACTORS

• 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

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EXPANDED ALLIANCE

• 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)

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ASSERTIVE ENGAGEMENT

• 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)

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SO WHAT DO WE KNOW ABOUT COMMON FACTORS IN FT?

• 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

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Integrating the findings of basic research into
practice

• Base of knowledge about family process, social
  psychology, individual personality,
  psychopathology, and social systems

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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
  exchanges.

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Applying Research findings in Specific Contexts
Family Therapy

• Reducing expressed emotion helps in severe mental
  illness
• 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.

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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
  effectiveness

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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
  improve
• 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

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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
  studies
• 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.

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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
  effort

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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.

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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
  practice
• Experience with evaluating and/or conducting
  treatment outcome studies
• Openness to varying points of views

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Members of Task force

• Kristina Gordon
• Alan Gurman
• Amy Holtzworth-Munroe
• Sue Johnson
• Jay Lebow
• Tom Sexton

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Advisory Panel Members

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

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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.

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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.

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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.

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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
  programs.

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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
Specific
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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
  question
• Regardless of the type, studies considered must
  be systematic and clinically relevant and of high
  methodological rigor (for that specific type of
  research)

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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

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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.

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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
Specific
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Dimensions of Evidence-based Treatments

• Outcomes must be compared to understand nature of
  outcome
• 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
  dimension.

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Standards of Evidence-based Treatment in
Family/Couple Therapy

• Levels of Evidence informed/based
  interventions/treatments
• Pre-evidence informed interventions/treatments
• Level I Evidence-informed interventions/treatmen
  ts
• Level II Promising interventions/treatments
• Level III Evidence-based Treatments

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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
  intervention/models
• 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

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Standards of Evidence-based Treatment

• Level I Evidence-informed Interventions/Treatmen
  ts
• 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.

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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.

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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
  differences
• 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

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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
  have
• 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
  problems

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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
  treatments.
• 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

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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

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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

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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
  outcomes)
• 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

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Decision Making Matrix
Specific Intervention Model
Type of demonstrated Outcomes (e. g. satifaction,
cost/benefit/durability)
Level of Efficacy/Effectiveness Absolute/Relative
Context
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)
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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.

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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
  process
• Valid key measures for assessing change or
  arbitrary metrics?
• What status to designate problems never addressed
  in funding priorities-e.g.. relational
  difficulties
• How much demonstration needed in a specific
  context or culture?
• How important is the therapist in treatment
  success?
• 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
  marriage