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V I E W
E
Review in Advance first posted online
R

S
on December 14, 2012. (Changes may
still occur before final publication
online and in print.)

C E
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N
A
D V A

Evidence-Based Psychological
Treatments: An Update and the
Way Forward
David H. Barlow, Jacqueline R. Bullis,
Annu. Rev. Clin. Psychol. 2013.9. Downloaded from www.annualreviews.org

Jonathan S. Comer, and Amantia A. Ametaj

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Center for Anxiety and Related Disorders, Boston University, Boston,

Massachusetts 02215; email: [email protected]

Annu. Rev. Clin. Psychol. 2013. 9:10.1–10.28 Keywords

The Annual Review of Clinical Psychology is online at psychological treatments, temperament, dissemination, methodology
http://clinpsy.annualreviews.org

This article’s doi: Abstract

10.1146/annurev-clinpsy-050212-185629
Enormous progress in the field of clinical science has been made over the
Copyright  c 2013 by Annual Reviews. past 50 years, with advances in our understanding of psychopathology and
All rights reserved
more sophisticated research methodology leading to the development of
more efficacious psychological treatments for a variety of behavioral disor-
ders. Despite these advances, the public health impact of well-established
psychological treatments is less than it should be. After an overview of the
current status of the field, we identify barriers that must be overcome to
maximize the public health impact and propose that to breach these barriers
we must (a) augment the efficacy of treatments, (b) broaden the impact of
treatments across diagnoses to include temperamental variables, (c) attend
more closely to mechanisms of action of treatments, and (d ) learn the best
methods for disseminating and implementing psychological interventions.
We conclude by proposing new directions in both research and clinical prac-
tice to accomplish these goals.

10.1

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Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2
THE PAST: HOW FAR HAVE WE COME? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2
THE PRESENT: WHERE ARE WE NOW? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.3
Advances in the Understanding of Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.3
Evidence-Based Psychological Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5
Relative Lack of Public Health Impact of Psychological Treatments . . . . . . . . . . . . . . . 10.9
BARRIERS TO EVIDENCE-BASED PSYCHOLOGICAL
TREATMENTS AND THE WAY FORWARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.10
Treatment Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.10
Comorbidity, Temperament, and a Transdiagnostic Perspective . . . . . . . . . . . . . . . . . .10.11
Mechanisms of Action and Idiographic Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.13
Dissemination and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.18
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FINAL REMARKS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10.22

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INTRODUCTION
The notion that psychological practice can actually be influenced by science is a relatively new
phenomenon in psychology, and indeed in all of the mental health professions, with origins in the
1960s and 1970s. Since one of us (D.H.B.) began his career in that era, it is revealing, to say the
least, to reflect back on the state of clinical science at that time.

THE PAST: HOW FAR HAVE WE COME?

Hans Eysenck’s notorious article on the lack of effects from psychotherapy, first published in
1952 (Eysenck 1952) but reprinted more prominently in later years (e.g., Eysenck 1965), had
roiled the largely psychoanalytic establishment. His findings, based on crude actuarial tables from
the records of insurance companies of the day comprise, perhaps, the first primitive quantitative
review or “meta-analysis,” and although the science underlying his conclusions on the relative
ineffectiveness of psychotherapy was weak indeed, there were no objective findings to offer in
refutation. Thus, the most usual response to Eysenck’s assertions at the time was anecdote, as
notably represented by a quote from Hans Strupp (who was later himself to become one of the
pioneers of psychotherapy research): “Clinical observations amply document that many patients
benefit from an interpersonal relationship with a professional person when they are troubled by
difficulties in living and are seeking help. To argue otherwise is simply to close one’s eyes to the
facts” (1964, p. 101).
Nevertheless, there was a growing belief among many, including Strupp, that we should be
striving to move beyond “clinical observation” and demonstrate the effects of psychological in-
terventions through the scientific method, but the fact was that nobody had a good idea of how
to do it. The few clinical trials conducted in those years tended to be extraordinarily ambitious,
with numbers of patients running well into the hundreds. Perhaps the best known of these stud-
ies is one of the first: the Cambridge Somerville Youth Study (Powers & Witmer 1951), which
was designed to explore the effects of a psychosocial intervention on what might today be called
conduct problems in adolescents or, at the very least, adolescents at risk for conduct problems.
In this study, 650 boys were randomized to either active treatment or treatment as usual. The 10

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therapists in the active treatment condition had no formal training and were told to do “whatever
you think is best” for five sessions a year for up to five years. Typically, therapists focused on
arranging physical exams, organizing a stint in a summer camp, or placing the boys in special
education, along with a bit of counseling. The boys were not characterized in any meaningful way,
nor were any measurements systematically collected, but crude outcomes, such as contact with
the law or other kinds of difficulties encountered in subsequent years, revealed, not surprisingly,
no differences between groups at the end of the five-year trial. Despite the initial findings, the
study continued for another 30 years, replicating the finding of no differences between groups at
10, 20, and 30 years after the interventions had taken place.
This study and others like it, such as a large naturalistic study from the Menninger Clinic
that yielded few, if any, meaningful findings (Kernberg 1973), led to considerable despair among
the psychotherapy researchers of the day. Indeed, one the most sophisticated psychotherapy
researchers of that era, Carl Rogers, well known for his early work evaluating psychological
treatments for schizophrenia, advocated abandoning formal research in psychotherapy altogether
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in 1969, since in his view it was yielding nothing of value and had no impact on practice (Bergin
& Strupp 1972).
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But another pioneer in our field, Gordon Paul, suggested that the question, is psychotherapy
effective? was the wrong question to ask in the first place, since any test of a global treatment,
such as psychotherapy, was bound to fail. He urged that clinical researchers begin defining the
independent variable (therapy) more precisely and ask the question, what specific treatment
is effective with a specific type of client under what circumstances? (1967, p. 112). Following
Paul’s guidelines, the early work of pioneers such as Joseph Wolpe and Isaac Marks, but also
Allen Bergin and Hans Strupp, changed the landscape of research on psychological treatments.
This was due to the promise, if not the realization at that time, of translating research from
basic psychological and behavioral science to the applied arena in the service of developing and
evaluating more effective interventions (Barlow 2011a, Hersen & Barlow 1976). Also during the
1970s, conceptualizations of psychopathology became more empirical and specific, facilitating the
development of reliable and valid dependent variables, and both behavioral and psychodynamic
treatments were described in detail, paving the way for more systematic and objectively defined
independent variables (Barlow 2011a).

THE PRESENT: WHERE ARE WE NOW?

Now several generations have passed, and those of us who were trained in that era are approaching
the end of our careers in very different circumstances. At this time, governments around the world
and their health care systems, faced with demonstrably inadequate health care and spiraling costs,
have decided that the quality of health care should improve, that it should be evidence based, and
that it is in the public’s interest that this happen (Barlow 1996, 2004; McHugh & Barlow 2012).
In no area of health care has this development produced more radical change than among the
mental health professions, with psychology most often leading the way in the development and
evaluation of evidence-based psychological treatments. The remainder of this review provides
a brief overview of how we have reached this point, describes the current status of our applied
science, and identifies the barriers we must overcome if we are to continue to progress during the
coming years.

Advances in the Understanding of Psychopathology

Many of the earliest psychological treatments ultimately showed only limited efficacy in the clinic.
Included in this group are early treatments for anxiety disorders, particularly phobias, such as

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Wolpe’s systematic desensitization, and even early in vivo exposure-based procedures (Barlow
1988). But with a new emphasis on the scientific process, investigators began to find out why,
and the process of discovering the answers is illustrative of how new knowledge of the nature
UCS: unconditioned
stimulus of psychopathology can influence and sharpen treatment development across other classes of
disorders. For example, in the 1980s, the centrality of panic attacks to many anxiety disorders was
CS: conditioned
stimulus discovered and, in particular, the realization that internal cues were just as important, if not more
important, in triggering fear and anxiety than situational cues due to the process of interoceptive
conditioning (Barlow 1988). Traditional conditioning theories posited that when an individual
experienced a panic attack in a particular situation or place, he or she would learn that this situation
was a trigger for panic. In essence, any unconditioned stimulus (UCS) paired with a panic attack
can become a conditioned stimulus (CS) that signals the imminent onset of the panic response.
More modern conditioning research (Bouton et al. 2001) includes a focus on interoceptive con-
ditioning, which suggests that lower levels of autonomic arousal can serve as conditioned stimuli
for higher levels of arousal (Barlow 1988). Individuals can learn to associate one interoceptive
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experience with another interoceptive experience, which is precisely what occurs during a panic
attack; small, subtle changes in heart rate or body temperature become associated with the onset of
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a full-blown panic attack. The pairing of interoceptive events has been demonstrated using drug
stimuli: After undergoing conditioning trials that paired a pentobarbital injection with a subse-
quent morphine injection, rats demonstrated better tolerance of the UCS (morphine) when it was
preceded by the CS (pentobarbital) than when the UCS was presented alone (Bouton et al. 2001).
The realization that panic attacks could be triggered by internal cues was an enormous ad-
vancement in our understanding of the pathology underlying panic disorder, an understanding
that soon contributed to more effective treatments (Barlow 1988). We also learned that avoidant
behavior that prevented the full processing of fear and anxiety cues extended beyond gross situa-
tional avoidance to include subtle behavioral avoidance (e.g., avoidance of eye contact, avoidance
of caffeine or alcohol), cognitive avoidance (e.g., distraction, worry, rumination), and reliance on
safety signals (e.g., presence of a companion or “good luck” charms).
There is now a substantial body of empirical research demonstrating that efforts to avoid (or
suppress) thoughts, emotions, or physiological responses actually result in increased physiologi-
cal arousal, greater autonomic instability, and more stress-related symptoms, despite the desire
to down-regulate arousal (Campbell-Sills et al. 2006, Gross 1998). Studies explicitly evaluating
the relationship between this emotional or “experiential” avoidance (i.e., any action to prevent
full emotional experience and arousal) and psychopathology suggest that experiential avoidance
increases the likelihood of substance use relapse, mediates the effect of trauma, and interacts neg-
atively with self-regulatory strategies to result in greater psychological distress (e.g., Chawla &
Ostafin 2007). The construct of experiential avoidance is actually recognized, either explicitly or
implicitly, across all theoretical orientations (Blackledge & Hayes 2001, Chawla & Ostafin 2007).
In our own newly developed Unified Protocol for Transdiagnostic Treatment of Emotional Disorders
described below (Barlow et al. 2011), the identification and prevention of emotional avoidance is
one of five core treatment strategies.
Finally, there was a realization that the methods of exposure-based procedures had failed to
keep up with the advances in the basic science of fear learning and extinction. This was largely due
to, it turns out, a misguided focus on fear reduction within exposure-based sessions, since neither
amount of fear reduction during exposure sessions nor level of fear at the end of the session
predicts therapeutic outcome. This is because extinction does not occur through unlearning the
CS-UCS association as previously thought. Thus, instead of requiring patients to remain in a
fear-producing situation until the fear had diminished, scientists discovered that the creation of
new memories associated with both external and internal cues, if sufficiently established, could

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Table 1 The efficacy of selected specific psychological treatments versus medication or alternative
treatments published in the Journal of the American Medical Association or the New England Journal
of Medicine
Disorder Results Reference
Stress incontinence in the PT > meds + control at acute and Burgio et al. 1998, Goode et al.
elderly/women follow-up 2003
Insomnia PT > meds or placebo at acute + Morin et al. 1999, Sivertsen et al.
follow-up 2006
Depression and physical PT > routine medical care Teri et al. 2003
health in Alzheimer’s
patients
Gulf War veterans’ illnesses PT > usual care or alternative Donta et al. 2003
treatments at follow-up (modest
effects)
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Depression PT alone = meds alone; PT + meds Keller et al. 2000

> than either alone at follow-up
PT = meds at acute—both >
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Panic disorder Barlow et al. 2000

placeboPT > meds (or PT + meds)
at follow-up
PTSD PT > present-centered Schnurr et al. 2007
psychotherapy
Tourette’s disorder PT > supportive therapy and Piacentini et al. 2010
education (effect size = 0.68)

Abbreviations: PT, psychological treatments; PTSD, posttraumatic stress disorder; meds, medication.

override existing fear responses without necessarily eliminating them (Bouton et al. 2001, Craske
et al. 2008). These scientific advances and others like them have led to the refinement of existing
treatments and the development of new treatments for anxiety disorders.

Evidence-Based Psychological Treatments

With similar progress in other areas (e.g., Barlow 1996, 2004, 2008, 2011b), it became clear to
both practitioners and health care policy makers that robust evidence-based psychological treat-
ments exist for a variety of disorders and problems, and these treatments should be disseminated
to those who could benefit from them. Table 1, an update of a table originally published in 2004
(Barlow 2004), presents just a partial listing of some of the disorders for which evidence exists
demonstrating clear efficacy of psychological treatments compared to credible alternative treat-
ments. It is important to note that this table presents a sampling of studies first published in two
of the world’s leading health care journals, the New England Journal of Medicine and the Journal
of the American Medical Association. In North America, and also to some extent around the world,
health care policy is derived from evidence on health care practices first appearing on the pages
of these two journals.
The table presents a mix of studies, with some targeting very specific conditions often found in
health care settings, such as stress incontinence, and others targeting more common psychological
disorders, such as anxiety and depressive disorders. Some of the specific problems, such as treat-
ing depression in patients with Alzheimer’s disease, may have a profound impact. For example,
Teri et al. (2003) demonstrated that psychological interventions for this group not only improved

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depression, but also delayed institutionalization and improved physical health compared to usual
best medical practices. Piacentini et al. (2010) recently demonstrated the efficacy of psychological
treatments for Tourette’s disorder compared to more customary treatments involving support-
ive therapy and education. Both of these disorders are most usually treated by psychologists in
dedicated clinics or community settings specializing in these problems, thus underscoring the con-
tinuing need for specialty psychological clinics where the expertise is available to focus on these
problems ( J.S. Comer & D.H. Barlow, manuscript submitted). But most psychologists, practicing
increasingly in primary care settings as “generalists,” will focus on the more common problems,
and leading evidence for the efficacy of psychological treatments for some of these disorders is also
available in Table 1. Two examples, insomnia and schizophrenia, are highlighted here because
many psychologists and other mental health clinicians, particularly in North America, are still
relatively unaware of the robust evidence base for the psychological treatments of these disorders.

Insomnia. The case of insomnia is especially interesting since the treatment most familiar to
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clinicians and the population at large is sleep medication, due to heavy direct-to-consumer adver-
tisement by pharmaceutical companies. But in fact, a meta-analysis of pharmacological treatments
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for insomnia found that despite receiving approval from the US Food and Drug Administration,
the majority of medications prescribed for the treatment of sleep maintenance have not consis-
tently demonstrated significant efficacy (Rosenberg 2006). Table 1 describes one of the first studies
testing brief psychological treatments compared to these popular sleep medications or placebo
at both posttreatment and follow-up (Morin et al. 1999). Results show very dramatically the su-
periority of a brief cognitive-behavioral treatment compared to medication, which was in turn
superior to placebo at treatment termination. More importantly, beginning at the three-month
follow-up and continuing to a two-year follow-up, medication did not differ significantly from
placebo, whereas the psychological treatment retained its effects. Interestingly, adding medication
to cognitive-behavioral treatment did not enhance effectiveness and, if anything, interfered with
the effectiveness of the psychological treatment. Since this report, a number of additional studies
and reviews have confirmed the efficacy of psychological treatments for insomnia, particularly
over the long term (Mitchell et al. 2012, Morin et al. 2009). As a result of these findings, the
American Academy of Sleep Medicine, as early as 2006, designated this brief psychological treat-
ment for insomnia as the first-line treatment for people with both primary and secondary chronic
insomnia, including chronic hypnotic users (Lambert 2008, Morgenthaler et al. 2006). As of 2008,
because of this demonstrated efficacy, the American Academy of Sleep Medicine began requiring
sleep centers in the United States seeking accreditations to have these psychological treatments
available. But only 136 doctoral-level US sleep specialists were judged to be competent to deliver
these services at that time. Problems of dissemination and implementation, which are taken up
later in the review, are not limited to specific areas such as insomnia and present a major hurdle
to the realization of the potential of psychological treatments in the coming decades.

Schizophrenia. Schizophrenia (not represented in Table 1) presents another interesting example

of evidenced-based psychological approaches. Pfammatter et al. (2006) conducted a meta-analysis
of psychological treatments targeting four major components of schizophrenia: deficits in social
skills, cognitive deficiencies associated with schizophrenia, the demonstrated toxic influence of
expressed emotions in families on relapse, and the effects of psychological treatments, specifically
cognitive behavioral therapy, for positive symptoms, including clusters of delusions, hallucinations,
and associated phenomena. They found moderate to strong effect sizes of existing psychological
treatments for each of these target problems (Pfammatter et al. 2006). Of course, the types of

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25

20
Mean SAPS total score

15

10

ST alone (n = 29)
CT with ST (n = 31)
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Baseline 6 12 18*
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Assessment (months)

Figure 1
The values at baseline are raw means; the values at 6, 12, and 18 months are adjusted means from the
intent-to-treat hierarchical linear models. CT, cognitive therapy; SAPS, Scale for the Assessment of Positive
Symptoms; ST, standard treatment. ∗ P = 0.04 for the mean difference based on the hierarchical linear
modeling interaction of treatment condition × assessment time.

interventions appropriate for remediating cognitive deficits on the one hand, or positive symptoms
on the other, are necessarily very different.
Illustrating approaches to one of these areas, positive symptoms, Grant et al. (2012) took on the
daunting task of treating low-functioning neurocognitively impaired patients with schizophrenia
by adding cognitive therapy to a treatment-as-usual (TAU) standard care package that included in-
dicated antipsychotic medications. Patients receiving cognitive therapy in addition to TAU showed
a clinically significant mean improvement in global functioning from baseline to 18 months, but
particularly interesting were the effects of cognitive therapy on positive symptoms as seen in
Figure 1 (Grant et al. 2012). Values at 6, 12, and 18 months showed a marked and sustained im-
provement in positive symptoms from the addition of cognitive therapy compared to TAU alone.
In fact, psychological treatments for schizophrenia, which are recommended as first-line treat-
ment in the National Health Service in the United Kingdom, evidence a doubling of therapeutic
benefit compared to those patients receiving medication alone (Tarrier 2008).
Another study, this time examining the effects of cognitive enhancement procedures targeting
cognitive deficits in schizophrenia, revealed an increasingly common outcome from studies of
robust psychological treatments when properly measured; that is, demonstrable changes in brain
function and even brain structure. In this case, cognitive enhancement therapy protected against
frontal and temporal gray matter loss when administered early during the course of schizophrenia
compared to a well-construed alternative psychological treatment termed “applied coping.” Cog-
nitive enhancement procedures also improved long-term cognitive outcomes (Eack et al. 2010). TAU:
Evidenced-based psychological treatments for these and other disorders share two common treatment-as-usual
characteristics. First, they are tailored to specific forms of severe and identifiable psychopathol- standard care
ogy. This is particularly evident in the example of schizophrenia, where different psychological
treatments focus on four distinct and identifiable deficits found to some degree in individuals

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suffering from this disorder (Addington et al. 2010). Secondly, these procedures are typically
derived from psychological science, specifically behavioral and cognitive sciences, with heavy in-
put from social cognition and interpersonal approaches. This is very different from the era of
“schools” of psychotherapy of 1960s and 1970s, where techniques were typically derived from
theoretical conceptions of personality rather than the laboratories of cognitive and behavioral
sciences.
Because of these unique qualities, one of us (D.H.B.) proposed (Barlow 1996, 2004, 2006) that
this heterogeneous group of evidence-based interventions, targeting as it does psychopathology or
psychological aspects of pathophysiology in a manner compatible with the objectives of organized
health care systems, should be identified as “psychological treatments (or interventions)” to
distinguish it from the broad and generic term “psychotherapy,” a valuable undertaking that
ranges well beyond problems covered in any health care system, including issues of adjustment
and growth. These two activities would not be distinguished in theory, technique, or even
evidence, but on the problems addressed, which would serve to increase the marketability
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and acceptability of these approaches to health care policymakers. This terminology has now
been widely adopted in, for example, the National Health Service in the United Kingdom
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and the Veterans Affairs Health Care System in the United States (Clark 2012, Ruzek et al.
2012).

Reasons for success. There are several reasons for the success of these interventions. First, as
alluded to above, we have a greater understanding of the nature of psychopathology and patho-
physiology, resulting in new, more precisely targeted treatments. Examples are evident once again
in schizophrenia as described above, but also in more common disorders, such as panic disorder,
where discoveries of internal interoceptive triggers for fear responses (Bouton et al. 2001) facil-
itated the development of interoceptive exposures that directly target symptoms (Barlow 1988,
Barlow & Craske 2007).
Second, clinical research methodologies have improved substantially over the past several
decades as illustrated above. Not only have these improvements occurred in design method-
ologies capable of isolating components of treatment efficacy and ruling out threats to internal
validity, including the contribution of common factors and allegiance, but also in more mundane
procedures such as data management, which can now be effected through direct web-based data
entry from multiple sites in real time. This development makes possible coordinated multisite
clinical trials typically more common in medicine, but increasingly seen in the context of mental
disorders, with minimal loss of data or inaccurate data entry. In other words, the invisible college
of clinical trialists working in the arena of mental disorders has developed reasonable consensus
on best research methods and practices. Finally, health care systems and governments around the
world, noting this strong evidence, are adopting and promoting evidence-based psychological in-
terventions. The two most notable examples of this initiative, each with expenditures of over one
billion dollars thus far, are the aforementioned program in the UK National Health Service titled
“Improving Access to Psychological Therapies” (Clark 2012) and the Mental Health Strategic
Plan of the US Veterans Affairs Health Care System (Ruzek et al. 2012).
Two other developments have attracted attention and facilitated progress. First, psychological
treatments have evolved such that the evidence base of specific procedures is more important
than the theoretical origins of the procedures in schools of psychotherapy. Hence, although many
evidence-based procedures are cognitive-behavioral in origin, procedures and techniques with
developing evidence have been derived from myriad different approaches. Perhaps the best-known
example is motivational interviewing, which was originally validated as effective with addictive

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disorders and was more recently found to contribute significantly to the treatment of anxiety and
mood disorders (Arkowitz et al. 2008). And yet this procedure is very clearly derived from client-
centered Rogerian therapy. It is likely that schools of psychotherapy will become an anachronism
in years to come and theoretical approaches will blur in the face of the development of more
finely targeted treatments based on increased knowledge of psychopathology derived from the
best evidence available.
Second, in every survey taken, consumers prefer psychological treatments to drug treatments
by a wide margin (e.g., McHugh et al. 2012). This factor will become increasingly important as
dissemination and implementation efforts, currently in the early stage of development, become
more widespread (McHugh & Barlow 2012).

Relative Lack of Public Health Impact of Psychological Treatments

Despite these developments and outside of highly regulated health care systems such as the Veter-
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ans Affairs Health Care System, psychological interventions of any kind, let alone evidence-based,
are not penetrating the de facto health care delivery system in North America to the extent that
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they should be.

In fact, recent national service use trends raise great concerns about the quality of mental
health care for affected individuals generally. Specifically, in recent years we have seen a decrease
in the prominence of psychological treatments in the management of mental health problems
(e.g., Marcus & Olfson 2010) and a dramatic increase in the use of unsupported psychotropic in-
terventions with unfavorable side effects. For example, among individuals receiving mental health
care, we saw a significant decrease from 1998 to 2007 in the proportion of individuals receiving
psychological interventions or psychotherapy, dropping from roughly 1 in 6 treated individuals to
1 in 10 treated individuals, and a simultaneous increase in the proportion of individuals receiving
psychotropic medication interventions alone, with rates rising from 44% of treated individuals to
almost 60% in 2007 (Marcus & Olfson 2010). There have been striking expansions in the rate of
antidepressant medication prescribing (Olfson & Marcus 2009) and the prescription of off-label
antipsychotic medication (Comer et al. 2011).
The growth in off-label antipsychotic prescribing in outpatient mental health care is of partic-
ular concern, given the associated metabolic, endocrine, and cerebrovascular risks that have been
well documented (Olfson et al. 2006). Since the introduction of second-generation antipsychotic
medications in the early 1990s, these powerful medications have become increasingly common
in the outpatient management of diverse clinical populations. Sedative properties associated with
antipsychotic medications may help to explain their broadened use in nonpsychotic patients. Of
central relevance to the field of clinical psychology, these off-label prescribing regimens are being
used to treat mental health conditions for which well-established psychological treatments with
empirical support exist. For example, antipsychotic prescriptions by psychiatrists for outpatient
anxiety disorders increased from 10.6% to 21.3% of anxiety disorder visits (Comer et al. 2011). The
largest increases in antipsychotic prescribing for anxiety disorders were among new outpatients, in-
dicating that psychiatrists appear increasingly comfortable prescribing antipsychotic medications
for anxious patients before initiating trials of other medication classes or adjusting current med-
ications. Among the anxiety disorders, the largest increase in antipsychotic prescribing has been
among visits for panic disorder. Of great concern, there have been no controlled trials evaluating
the efficacy of antipsychotic treatments for panic disorder, whereas the psychological treatment
of panic disorder is well established (see Craske & Barlow 2008). Such findings underscore the
tremendous need for effective dissemination and implementation of psychological treatments.

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BARRIERS TO EVIDENCE-BASED PSYCHOLOGICAL

TREATMENTS AND THE WAY FORWARD
DCS: D-cycloserine Why have psychological treatments not been more broadly adopted in the de facto mental health
delivery system in the United States? Some of the reasons for this lack of penetration are deeply
imbedded in the structure of the health care delivery system in North America and elsewhere,
and these policies are continually undergoing scrutiny at various levels. But there are a number
of barriers to the availability of psychological treatments that are more directly amenable to
change by the community of mental health researchers and practitioners. These barriers are:
first, the relative lack of efficacy of psychological treatments for a substantial minority of the
population who are administered the treatments. Second, it is clear that most patients present with
extensive comorbidity among psychological disorders and sometime physical disorders as well. But
psychological treatments administered are typically directed at just one problem or disorder at
a time. Third, the very nature of our research enterprise as it has evolved utilizes a nomothetic
approach that produces results reflecting the average response of large groups and ignores to
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some extent intersubject variability or the response of the individual patient. And yet the object
of health care delivery and mental health care delivery is the well-being of the individual. The
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absence of a more idiographic approach to our research limits to some degree the applicability of
our research findings. Concomitantly, most efforts using randomized controlled trials to establish
efficacy have not mounted a parallel effort to examine purported mechanisms of action through
mediation analyses or the functional analytic strategies of single-case experimental designs (Barlow
2010, Kazdin 2011, Nock 2007). But discovering active mechanisms of treatment is one of the
surest ways to enhance efficacy. Finally, due in part to the relatively recent establishment of
psychological treatments and the lack of concerted marketing efforts that are so much a part of
drug development by large pharmaceutical corporations, efforts to disseminate and implement
psychological treatments have only just begun. Each of these barriers is reviewed in turn, and it is
proposed that better addressing these issues will be necessary as we move forward.

Treatment Augmentation
In response to less-than-desirable treatment effects in some cases, researchers have recently turned
to translational science in search of alternative methods to augment the effect of psychological
treatments. Among many interesting developments, several are highlighted here. First, basic re-
search has revealed that certain pharmacological agents, although not beneficial by themselves,
seem to enhance the effects of psychological procedures. One such example within the treatment
of anxiety disorders is D-cycloserine (DCS), an antibiotic that was first introduced in 1955 for the
treatment of tuberculosis. DCS is a partial agonist for the N-methyl-D-aspartate receptor in the
amygdala, which has been shown in animal studies to enhance the consolidation of memories that
facilitate fear extinction learning (Hofmann 2007, Walker et al. 2002)
In a randomized, double-blind, placebo-controlled trial, patients with panic disorder who re-
ceived 50-mg doses of DCS prior to a brief evidence-based psychological treatment were sig-
nificantly more likely to achieve a clinically significant change status than were participants who
received a pill placebo (Otto et al. 2010). In a similarly designed study of participants with social
anxiety disorder, acute administration of DCS prior to exposure therapy resulted in significantly
greater reductions in social anxiety than did administration of a pill placebo (Hofmann et al. 2011).
There is also preliminary support for the use of DCS as an augmentation strategy for specific pho-
bia (Ressler et al. 2004) and obsessive-compulsive disorder (Wilhelm et al. 2008). Interestingly, a
recent study found that the addition of DCS to exposure therapy for posttraumatic stress disorder in

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veterans returning from Afghanistan and Iraq resulted in significantly poorer outcomes than the ad-
ministration of a pill placebo, leading the authors to hypothesize that DCS may enhance reconsol-
idation of a trauma memory if fear does not sufficiently decrease during exposure (Litz et al. 2012).
Thus, the parameters of DCS require further exploration before routine use in clinical practice.
Oxytocin, an amino acid neuropeptide produced in the hypothalamus, is another example of
a potential cognitive enhancer for exposure-based therapy. In animal research, the administra-
tion of oxytocin to rats results in twice the amount of physical contact with one another (Witt
et al. 1992). When administered intranasally to humans, oxytocin has been shown to decrease
anxiety and promote prosocial or approach behavior (e.g., Heinrichs et al. 2009). In a double-
blind, placebo-controlled study, participants with generalized social anxiety disorder demonstrated
greater activity in the medial prefrontal cortex extending into the anterior cingulate cortex while
viewing an emotionally valenced interpersonal cue (sad faces) compared to a control group. But
this activity reduced to levels comparable to the control group following intranasal administration
of oxytocin. Interestingly, this effect was present only for negative social cues (sad faces) and not
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positive (happy) or neutral faces (Labuschagne et al. 2011). In another randomized, double-blind,
placebo-controlled study, participants with a principal diagnosis of social anxiety disorder who
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received intranasal oxytocin as an adjunct to exposure therapy received more favorable appraisals
of speech performance and physical appearance from judges (Guastella et al. 2008). However,
oxytocin had no effect on broader patterns of symptom reduction in the short term, suggesting
that further research is necessary to determine whether modifications to the frequency or amount
of oxytocin administration results in more substantial clinical change.
In another exciting development, neuroscientists have discovered that fear memories are en-
coded and consolidated with the synthesis of new proteins and that retrieval of these memories,
by means of a cue, provides additional synthesis during a consolidation window (Monfils et al.
2009). In rats this reconsolidation window lasts for approximately three hours, and if extinction
procedures are instituted during this window, new memories seem to be formed and the extinction
process is more complete, thereby preventing reinstatement or spontaneous recovery of fear. In an
important study in humans, Xue et al. (2012) tested extinction procedures among heroin addicts
by cuing intense drug cravings through video clips. The investigators then tested the relative ef-
fects of extinction occurring approximately 10 minutes after the retrieval cue versus 6 hours versus
extinction with no prior retrieval cue at all. Extinction of the heroin urges was substantially greater
during the 10-minute window compared to the other conditions, lending some clinical validity to
this new finding. If confirmed in additional disorders where exposure-based extinction processes
are indicated, then clinical outcomes may well improve. Of course, these developments are just a
sampling of efforts to translate findings from basic research to augment treatment outcomes.

Comorbidity, Temperament, and a Transdiagnostic Perspective

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is now available, and
although improvement is evident, many of the same limitations remain, including high diagnostic
comorbidity (Brown & Barlow 2009). One possible explanation for such high rates of comorbidity
among emotional disorders is the presence of shared etiological pathways and, more importantly a
possible shared underlying diathesis. One such example is triple vulnerability theory (Barlow 1991,
2000, 2002), which emphasizes a common etiological process among a wide range of disorders
of emotion. This model focuses on three vulnerabilities—generalized biological and generalized
psychological vulnerabilities, as well as a specific psychological vulnerability resulting from early
learning that strongly influences the development of one set of specific focal symptoms versus
another (e.g., obsessions versus panic attacks). The generalized vulnerabilities are associated with,

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and may largely comprise, the temperament of neuroticism—an enduring tendency to experi-
ence negative emotions (D.H. Barlow, S.E. Sauer-Zavala, J.R. Carl, K.K. Ellard, & J.R. Bullis,
manuscript submitted).
Indeed, there now exists a substantial body of empirical research utilizing quantitative
approaches, such as structural equation and latent variable modeling, supporting the contribution
of higher-order temperamental constructs, such as neuroticism and the largely overlapping
constructs of negative affectivity and behavioral inhibition, to the etiology and presentation of
emotional disorders (Brown 2007, Clark 2005). In one study conducted with a large sample of
outpatients, higher-order dimensions of positive and negative affect accounted for almost all of
the covariance in the latent variables that corresponded to social anxiety disorder, generalized
anxiety disorder, obsessive-compulsive disorder, panic disorder with agoraphobia, and unipolar
depression (Brown et al. 1998). Although negative affect (neuroticism) contributes to all disorders,
the strongest relationships for (low) positive affect are observed with unipolar depression and
social anxiety disorder, and more recently agoraphobia (Brown et al. 1998, Rosellini & Brown
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2011). There is also evidence to suggest that treatment of the patient’s principal diagnosis results
in some treatment gains, at least initially for comorbid mood and anxiety disorders as well
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(Brown et al. 1995, Newman et al. 2010). Neuroticism also predicts disorder onset and a poorer
prognosis (D.H. Barlow, S.E. Sauer-Zavala, J.R. Carl, K.K. Ellard, & J.R. Bullis, manuscript
submitted; Clark et al. 1994; Griffith et al. 2010). Taken together, the results from research
exploring rates of diagnostic comorbidity, response of comorbid diagnoses to single-disorder
treatment protocols, evidence of shared etiological pathways, and empirical support for the latent
structure of emotional disorders comprise a strong evidence base that highlights the magnitude
of shared features among anxiety and mood disorders, perhaps even eclipsing differences, and the
importance of focusing on temperament, particularly neuroticism and variations in positive affect
(D.H. Barlow, S.E. Sauer-Zavala, J.R. Carl, K.K. Ellard, & J.R. Bullis, manuscript submitted).
On the basis of this renewed emphasis on temperament as a unifying factor across emotional and
related disorders, clinical investigators have begun focusing on the existence of transdiagnostic
processes (e.g., avoidance, cognitive biases, worry and rumination, intolerance of uncertainty,
sleep disturbance) that cut across diagnostic categories and comprise the core facets of emotional
disorders (Harvey et al. 2010, McLaughlin & Nolen-Hoeksema 2011). A treatment protocol
designed to target the shared features of mood, anxiety, and related disorders, if successful, may
offer a solution to the ubiquitous challenge of comorbidity while simultaneously overcoming some
of the barriers to the dissemination and implementation of effective psychological treatments by
reducing the number of protocols that are applicable to only a single diagnosis. One of us (D.H.B.)
developed The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Barlow et al.
2011) with the goal of addressing these challenges by distilling current, empirically supported
treatments and incorporating recent advances in emotion regulation, motivational interviewing,
mindfulness techniques, and exposure-based procedures (Campbell-Sills & Barlow 2007). Most
notably, the Unified Protocol focuses on how an individual responds to intense emotional experiences
and aims to modify unproductive strategies for down-regulating or avoiding these experiences,
thereby extinguishing anxiety and distress associated with intense emotions. Additional details
regarding protocol development can be found elsewhere (Campbell-Sills et al. 2012, Ellard et al.
2010, Wilamowska et al. 2010).
In a randomized controlled trial of 37 patients with a principal (most severe) diagnosis of one of
the anxiety disorders and accompanying comorbidity, 18 sessions of the Unified Protocol produced
significant symptom reduction in depression, anxiety, and functional impairment (Farchione et al.
2012). There is also evidence to suggest that transdiagnostic treatments for anxiety disorders
are effective when administered in a group format (Norton 2008) as well with other families of

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disorders, such as eating disorders (Fairburn et al. 2009). Currently, our group is conducting an
equivalency trial comparing the Unified Protocol to well-established, manualized disorder-specific
treatment for each participant’s primary diagnosis, as well as a wait-list control condition, to
MATCH: Modular
evaluate whether a transdiagnostic treatment is capable of producing treatment effects on both Approach to Therapy
principal and comorbid diagnoses comparable, or even superior, to our best available single- for Children with
disorder treatments. Anxiety, Depression,
Although transdiagnostic psychological treatments are a relatively new area of interest in clin- or Conduct Problems
ical psychology, there is evidence that pharmacotherapy may also effect changes through trans-
diagnostic mechanisms. For example, little is known about how antidepressants mediate changes
in mood or why these changes take so long to occur. Harmer et al. (2009) hypothesize that the
time lag from the administration of an antidepressant to an improvement in mood is actually
not due to a delay in the neuropharmacological drug action (e.g., an increase in serotonin that
then produces downstream neuroadaptive effects), since there is evidence of changes in emotional
processing based on sophisticated cognitive assessment as early as one week into antidepressant
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therapy. Accordingly, the authors propose that antidepressants likely work through reductions
in negative affective biases, which in turn produce more gradual changes over time in mood as
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patients discover that their view of the world has changed. This suggests that antidepressants and
transdiagnostic psychological interventions may, when effective, work for similar reasons, albeit
following very different paths to reach this point. This finding also underscores the importance
of discovering mechanisms of change in all treatments (taken up in the next section). Regarding
clinical utility, if further research confirms the relationship between early changes in emotional
processing and subsequent improvements in mood, it may be possible in the future to predict an
individual patient’s response to antidepressant therapy within the first week of treatment based
on changes in emotional processing.
Another example of a transdiagnostic approach is the development of modular treatment proto-
cols. Perhaps the most successful example of modular approaches to date is the Modular Approach
to Therapy for Children with Anxiety, Depression, or Conduct Problems (MATCH; Chorpita &
Weisz 2009). This effort was also driven by the poor applicability in children of specific single-
problem or diagnosis treatment protocols to the everyday clinic where comorbid presentations are
common (Weisz & Gray 2008). The treatment protocol consists of separate and modular treatment
elements derived from evidence-based treatments for anxiety, depression, and conduct problems,
and it provides clinicians with a decision flowchart for module selection as well as troubleshooting
guidelines to address possible treatment difficulties (Chorpita & Weisz 2009). In a recent random-
ized controlled study comparing modular treatment to standard manual treatment and usual care
for youth with emotional and conduct disorders, modular treatment significantly outperformed
both treatment comparison conditions on multiple clinical outcome measures (Weisz et al. 2012).
Unlike the Unified Protocol for emotional disorders mentioned above, or Fairburn’s transdiag-
nostic approach to eating disorders, this approach is not a theoretically derived set of principles
emerging out of new findings pertaining to the nature of the psychopathology. Rather, MATCH
identifies discrete, practical empirically based treatment modules or components and provides
guidelines for identifying specific presenting problems and then matching the appropriate mod-
ule. In any case, further research is necessary to explore the applicability of modular treatments
in diverse clinical populations, but adapting current evidence-based treatments to follow a more
modular approach may help increase implementation and effectiveness in clinical settings.

Mechanisms of Action and Idiographic Approaches

The primary focus of clinical research should be on the development of effective psychological
treatments, the identification of the mechanisms of change (i.e., mediators and moderators) that

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drive treatment response, and ultimately the specification of individual factors that increase and
reduce treatment efficacy (Kazdin 2011, Nock 2007). Very few studies have examined the latter
two aims for several reasons; one is the complexity of methodology and data analyses required to
evaluate mediation of treatment change. It is only within the past 10 to 15 years that treatment
mediation has been systemically explored, and existing studies are limited in both scope and
number. A second reason is the relative lack of emphasis in extant studies on individual (idiographic)
change as opposed to the average response of groups of individuals (nomothetic), and the tendency
in these nomothetic studies to measure change infrequently during treatment—usually just at
pretreatment and posttreatment.

Mechanisms of change. It is simply not enough to establish efficacy for a particular treatment.
Consistent with the theoretical or empirical identification of core strategies comprising transdi-
agnostic treatments, further research on treatment mechanisms should distill existing treatments
into the most parsimonious models possible and allow us to maximize treatment efficacy by dis-
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carding what doesn’t work and including more of what does work (Nock 2007). In order to assess
effectively for mediation of treatment changes, both clinicians and researchers must include one
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(preferably more) potential mechanism of change, assess proposed mechanisms and treatment out-
comes continuously, and replicate any observed effects in different settings with diverse patient
populations (Barlow 2010, Kazdin 2011).
Many of these hypothetical mechanisms will emerge from basic research. Others will be iden-
tified serendipitously in the clinic and then verified by research. Within the emotional disorders,
for example, we described basic research identifying mechanisms underlying the process of extinc-
tion and accompanying changes in brain function. We have now learned that this process, which
involves the creation of new memories rather than the unlearning of specific fear and anxiety as-
sociations, is optimized during a specific window of opportunity following cued retrieval of these
memories (Monfils et al. 2009, Xue et al. 2012). This information, once translated to the clinic,
should prove to be very useful in augmenting the effectiveness of extinction procedures.
Similarly, Harmer and colleagues (2009) have tentatively identified an important process during
drug treatment of depression involving alteration of cognitive biases that might prove to be a
marker for successful treatment. Confirming this mechanism should contribute substantially to
the development of more effective treatments, both drug and psychological. Finally, based on
contributions from basic science as well as theoretical advances, a purported mechanism of action
of The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders has been identified,
subject to further confirmation, best described as extinguishing anxiety and distress associated with
intense emotional experiences. Progress in identifying and confirming mechanisms of actions will
be one of the most efficient methods for improving treatment efficacy.

Are psychological treatments placebos? The dodo bird interpretation. As described above,
better understanding of the nature of psychopathology and other targets of treatment has al-
lowed the development of very focused interventions designed to remediate specific deficits or
pathologies as diverse as cognitive deficits in schizophrenia or severe tics in Tourette’s disorder.
Nevertheless, an argument has been raised that none of these studies actually demonstrate that
any of these specific treatments are any better than a credible comparison condition and that
any results showing efficacy are really a function of factors that are common to all treatments. In
this conceptualization then, psychological treatments could be considered placebos in the sense
that the therapeutic mechanism of action would not be in the specificity of the treatment for
the condition targeted but rather in the more general credibility of the treatment in the eyes of

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both patients and therapists, and the aforementioned skill with which the therapist develops the
alliance, or other therapist factors (e.g., Wampold 2001).
This debate has been ongoing for decades, but the “common factor” argument has not gained
traction with health care policymakers or other independent bodies around the world tasked with
creating clinical practice guidelines or best practice algorithms for the treatment of psychological
disorders. For example, the National Institute for Health and Clinical Excellence in the United
Kingdom, charged with deciding on treatment approaches with sufficient evidence to be included
in the National Health Service, and the Agency for Healthcare Research and Quality within
the US Department of Human Services, as well as the Veterans Affairs Health Care System,
who provide a similar function in the United States, all using sophisticated analytical methods
and examining hundreds of studies, have produced detailed clinical practice guidelines identifying
specific psychological interventions as recommended first-line treatments that differ from disorder
to disorder. This view of the evidence also meets the test of face validity with clinicians, since few
clinicians believe that you could use exactly the same procedure to treat chronic schizophrenia,
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specific phobia, bipolar disorder, or Tourette’s disorder, as long as the treatment is credible. To
hold this view would imply that client-centered therapy, or even less highly regarded treatments
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such as past-life regression therapy or thought-field therapy, would work as well for any of these
disorders as would the treatments specifically designed for these disorders described above.
Proponents of the common factor account readily dismiss the hundreds of studies (e.g., Nathan
& Gorman 2007, Weisz & Kazdin 2010) that contribute to clinical practice guidelines for one
reason or another, but the most common reason is that comparison procedures are not as credible
as the psychological treatments under evaluation, and furthermore that therapists evaluating these
procedures often have allegiance to these treatments or have some reason to believe that they might
be superior and that this influences the results. Of course, evaluation of psychological treatments
can never be double blind, but recent advances in methodology as represented by the Consolidated
Standards of Reporting Trials Statement outline more rigorous standards of research (Moher
et al. 2001). These standards include the use of independent evaluators, adherence ratings of
therapists delivering treatments, and assessment of credibility and acceptability of all treatments
under investigation, among other procedures, and they have substantially mitigated threats of
allegiance to internal validity (i.e., conclusions on efficacy) and make it highly unlikely that every
single study would be somehow fatally flawed. In addition, at present there is no direct causal
evidence supporting the effects of allegiance, although it is not an unreasonable hypothesis, and
there is some post hoc correlational evidence (Leykin & DeRubeis 2009).
Nevertheless, multisite studies involving sites with different allegiances designed in part to
control for allegiance effects, both between medications and alternative psychological treatments,
have not yielded site-by-treatment interactions that would be expected if allegiance accounted
for most of the effects (Leykin & DeRubeis 2009). For example, Stangier et al. (2011) evaluated
cognitive therapy and interpersonal psychotherapy as treatments for social anxiety in a multisite
study comparing both to a waitlist control condition. One site had clear allegiance to cognitive
therapy whereas the other was a center for the study of interpersonal psychotherapy. Both treat-
ments were efficacious compared to the waitlist control group, effects that were maintained one
year after treatment, but cognitive therapy was more efficacious than interpersonal psychother-
apy at both sites, reflecting the fact that there were no significant treatment-by-site interactions.
Other prospective studies exist that run counter to an allegiance hypothesis. One good example
is found in Shear et al.’s (2001) evaluation of a new emotion-focused treatment for panic disorder
based roughly on psychodynamic concepts. The developer of this procedure, Dr. Shear, had a
strong allegiance to it, had written a treatment manual she was ready to submit for publication,
and had found strong evidence for efficacy compared to a waitlist condition in an initial study.

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But when properly tested in a prospective randomized controlled trial against a well-established
psychological intervention as well as an active drug and a drug placebo condition, this treatment
evidenced significantly less efficacy, roughly comparable to the drug placebo condition, at which
point it was abandoned.
Of course placebo effects do contribute to psychological treatments. But one interesting fact
is that different disorders representing various patterns of psychopathology respond very differ-
ently to placebo interventions, whether drug or psychological, as we have demonstrated elsewhere
(Huppert et al. 2004). Thus, depression with its cyclical pattern of exacerbation and remission is
notoriously responsive to placebo medications in the short term, much to the chagrin of phar-
maceutical companies who have difficulty demonstrating the efficacy of new antidepressant drugs
compared to placebo medications. Panic disorder is also placebo responsive in the short term given
its cyclical nature. In these disorders, and with this specific psychopathology, many treatments will
work well initially, but the question becomes, which treatments work well in the long run and with
more severe patients? In contrast, obsessive-compulsive disorder is not placebo responsive, with
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a placebo effect of close to zero. We have shown elsewhere that in this disorder, the contribution
of specific techniques vis-à-vis other factors, such as therapist effects, is much higher, accounting
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for up to 60% of the variance (Huppert et al. 2007).

Along these lines, more recent and sophisticated analyses examining the issue more directly
have confirmed that nonspecific therapies for depression may well be efficacious at least in the
short term, although less so than powerful and specific evidence-based interventions, but only in
the treatment of less severe depression (Cuijpers et al. 2012). When depression is more severe, the
effects of specific evidence-based interventions become stronger (Driessen et al. 2010). Further-
more, specific psychological treatments evidence an enduring effect when compared with patients
treated by credible alternatives, including effective medications, and this enduring effect is even
larger in magnitude than is keeping patients on continuing medication (P. Cuijpers, S.D. Hollon,
A. van Straten, C. Bockting, M. Berking & A. Andersson, manuscript submitted; Hollon 2011).
Thus, a possible general conclusion is that many psychological approaches, even nonspecific ones,
may be effective with less severe forms of some disorders that are particularly placebo responsive,
such as depression, but this would not be the case with different disorders or even more severe
forms of placebo-responsive disorders (Hollon 2011, Huppert et al. 2004).
In any case, to demonstrate the “dodo bird” thesis, proponents would need to do the hard work
of conducting prospective randomized trials comparing newly constructed “bona fide” treatments
to well-established evidence-based interventions for specific disorders using data analytic proce-
dures more appropriate to the task, such as equivalence or noninferiority analysis. It is not enough
to rely on post hoc correlational reanalyses of groups of studies using meta-analytic procedures,
nor is it enough or even correct to assume that studies showing no difference between specific
procedures (i.e., the null hypothesis) implies equivalence. Indeed, proving the null hypothesis
signifies only a failed clinical trial.
On the other hand common factors do clearly contribute to the outcomes of psychological
treatments even for severe patients, thus constituting one mechanism of action. We now have
new evidence from a large multisite study on the treatment of panic disorder indicating that the
therapeutic alliance as perceived by the patient (but not the therapist) contributes to outcome in
terms of symptom reduction, both early and late in the treatment process ( J.D. Huppert, Y. Kivit,
D.H. Barlow, M.K. Shear, J.M. Gorman & S.W. Woods, manuscript submitted). Of course, it
is certainly intuitive that patients would be more likely to follow through with the procedures
assigned in this therapy, some of them producing temporary distress, in the context of a trusting
relationship. Nevertheless, this finding and many others like it do indicate the importance of
monitoring the therapeutic alliance during treatment.

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But the same study, using more sophisticated multilevel analysis, found no evidence of dif-
ferential therapist effects across 23 therapists of different theoretical orientations treating 258
patients. This was in contrast to an earlier study from our group (Huppert et al. 2001), using less
appropriate analytic procedures, where it was found that approximately 10% of the variance in
efficacy was accounted for by variability in therapist effects. Of course, this simply indicates that
training these therapists to a gold standard of competence was highly successful. This would, of
course, be unlikely in more naturalistic settings where therapists would differ more widely in the
delivery of evidence-based treatments. All of this underscores the need for continuous study of
mechanisms of action that look at the interaction of therapists, patients, and contextual factors
with the specific actions of robust evidence-based psychological treatments.

Idiographic approaches to treatment development and evaluation. At present, clinical sci-

ence focused on interventions is largely based on inferences made about the relations between
variables through the comparison of averages between groups of individuals. This approach, also
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known as the nomothetic approach, has become the gold standard for establishing causal relations
between independent and dependent variables since the 1980s, when the National Institutes of
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Health began to fund large randomized clinical trials on the treatment of behavioral disorders
(Barlow 1996, 2004). Although this approach will continue to yield important findings, there are
limitations in terms of the efficiency and flexibility of this methodology as well as the generaliz-
ability of findings attained (Barlow & Nock 2009). Furthermore, despite the huge influence on
clinical practice exerted by large-scale, randomized controlled trials, many therapists understand-
ably wonder about the applicability of such results to their individual patient.
In fact, variability in behavior is a function of a wide range of factors, and the task of the
researcher and clinician alike is to discover functional relations among independent variables, or
more specifically among treatments and behavior disorders, over and above the welter of environ-
mental and biological variables affecting the patient at any given time. A limitation of a nomothetic
approach is the assumption that much of the variability, including occasional deterioration in some
individuals, is intrinsic to the individual or due to uncontrollable external events; as a result, com-
plex data analytic procedures are used to look for reliable effects over and above these factors,
which are treated as error (Barlow & Nock 2009). An idiographic approach—one that focuses on
the processes of change in the individual or, at the very least, outcomes in individuals—is capable
of supplementing the nomothetic approaches as well as supporting meaningful advances in our
understanding of psychopathology.
The principal idiographic methodology utilized in treatment evaluation research is the single-
case experimental design approach, where well-defined treatment components serving as indepen-
dent variables are systematically manipulated within an individual for the purpose of establishing
causal relationships between the treatment component and aspects of the disorder being treated
(Barlow et al. 2009). It is also possible to take traditional randomized controlled trials and analyze
the data more idiographically. For example, Mayou et al. (2000) reanalyzed the data from a group of
individuals experiencing posttraumatic stress following severe traffic accidents. These individuals
had received a brief intervention called Critical Incident Stress Debriefing immediately following
the accident. Overall, the data showed no effect of the treatment when compared to individuals
who did not receive the treatment. But when the data were broken down based on initial scores on
the Impact of Events Scale (Horowitz et al. 1979), the results showed that individuals experiencing
severe stress actually did worse both immediately and over a three-year follow-up period if they
received the treatment compared to those who didn’t.
Idiographic methodology, particularly single-case experimental designs, is not only useful in
clinical research but in applied settings as well, since the procedures are much closer to what

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happens in the clinic. Thus, clinicians can directly partake in clinical research by using repeated
measurement and carefully documenting response as well as generating hypotheses to explain
individual variation in response (e.g., McCullough 2002), which will likely become more common
as health care policy pushes for greater outcome tracking of treatment progress among all clinicians
(Barlow & Carl 2011).

Dissemination and Implementation

As noted above, despite the development and identification of well-supported psychological treat-
ments, problems to date with the broad availability of treatments in practice settings have seriously
limited their collective public health impact. These barriers interfere with the timely provision of
mental health care (Chorpita et al. 2011, Kazdin & Blasé 2011). Evidence of service utilization
inadequacies is portrayed in reports showing only 40% of Americans with mental disorders over
the past year have received any treatment for their condition in the past 12 months (Wang et al.
Annu. Rev. Clin. Psychol. 2013.9. Downloaded from www.annualreviews.org

2005a). For those who do receive mental health care, the median delay in treatment initiation
after onset of a disorder ranges from 5 to 9 years for substance use disorders, 6 to 8 years for mood
by Cape Breton University on 03/16/13. For personal use only.

disorders, and 9 to 23 years for anxiety disorders (Wang et al. 2005b). Further, those who do
receive mental health care are not necessarily receiving evidence-based treatments. Regrettably,
widely used approaches rarely show strong support (e.g., Ennett et al. 1994), whereas treatments
showing considerable support are rarely disseminated broadly. When supported treatments are
broadly disseminated, they are rarely implemented with fidelity (McHugh & Barlow 2010).
In response to this state of affairs, sizable financial commitments in recent years, totaling bil-
lions of dollars, as well as considerable scholarly attention, have focused on broad dissemination
and implementation efforts aimed at improving the availability and quality of services delivered
throughout practice settings (Spring & Neville 2011). Dissemination efforts constitute the pur-
poseful distribution of relevant information and materials to practitioners, and implementation
efforts constitute the adoption and integration of disseminated information and materials into
actual clinical practice (Beidas et al. 2012). The two processes are complementary; in order to
effect meaningful and sustainable change in practice settings, each is necessary but not sufficient
without the other.
Among the boldest and most far-reaching dissemination and implementation efforts as noted
above are the Improving Access to Psychological Therapies program (Clark 2012) and the Veterans
Affairs Health Care System Mental Health Strategic Plan (Ruzek et al. 2012). Both are nationally
implemented, centralized therapist-training programs that promote competent evidence-based
practice for affected individuals seeking mental health services in very large health care systems.
Other impressive efforts include state dissemination programs that facilitate centralized training
in and use of evidence-based psychological treatments (e.g., Bruns & Hoagwood 2008) as well as
programs directly pursued by the very developers of evidence-based treatments (e.g., Landes &
Linehan 2012, Schoenwald 2012).
As dissemination and implementation efforts move ahead, high-quality programs seem to sep-
arate into two camps: (a) the Intensive Community Training model and (b) the Public Health
model. The Intensive Community Training model entails intensive training of doctoral-level men-
tal health specialists to specific criteria. Examples include the Improving Access to Psychological
Therapies program as well as the extensive training efforts emanating from the Beck Institute for
Cognitive Behavior Therapy and the Dialectical Behavior Therapy Intensive Training Program
(see Landes & Linehan 2012), which all entail structured didactic training followed by extended
consultation with treatment experts. The Public Health model typically entails the remote tele-
training and supervision of large numbers of health workers with little or no formal training in

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mental health care, and although the training is typically less intensive than in Intensive Commu-
nity Training models, this model has the potential to reach larger numbers of affected individuals
in the settings where they commonly present (e.g., primary care settings). For example, the Co-
CALM: Coordinated
ordinated Anxiety Learning and Management (CALM) program uses a computer-based system Anxiety Learning and
to assist nonexpert mental health care providers, such as nurses, in the delivery of evidence-based Management
treatment for a range of anxiety disorders. In a large evaluation of the program, 1,004 primary
care patients with anxiety disorders across 17 geographically diverse primary care clinics were
treated with either the CALM program or TAU, which was determined randomly at the clinic
level. At 12 months, 63.7% of CALM patients showed clinical response (relative to 44.7% of TAU
patients), and 51.5% of CALM patients showed remission (relative to 33.3% of TAU patients)
(Roy-Byrne et al. 2010).
Despite the billions of dollars collectively spent on dissemination and implementation pro-
grams, the application of dissemination science to psychological treatments is still a relatively
nascent field of study, and rigorous investigations of these leading dissemination and implemen-
Annu. Rev. Clin. Psychol. 2013.9. Downloaded from www.annualreviews.org

tation efforts are just now underway. As such, it is safe to say that the majority of the work needed
to clarify optimal methods for influencing broad mental health practices remains ahead of us.
by Cape Breton University on 03/16/13. For personal use only.

Indeed, at this early stage of activity, the state of dissemination and implementation science
in clinical psychology may be only slightly further along than was intervention science in the
1970s—largely correlational, naturalistic, or quasi-experimental in nature, and lacking systematic
controlled evaluations. Most existing controlled evaluations have only compared dissemination
efforts to no dissemination efforts at all (e.g., treatment as usual), which only provides information
about the utility of a broad dissemination package, rather than specific elements that may be most
associated with effectiveness or elements that may be unnecessary or even counterproductive.
Moreover, many early dissemination efforts have yielded mixed and/or disappointing findings,
including poor treatment adherence and sustainability. Importantly, as noted elsewhere (Schoen-
wald et al. 2012), despite a proliferation of scholarly commentaries on dissemination theories
and large program rollouts, broadly speaking, systematic investigations of dissemination models
and strategies have yet to occur on a large scale. Descriptive and correlational studies provide
important preliminary support for dissemination and implementation practices, but rigorous con-
trolled evaluations will be needed to provide the most compelling evidence of best practices in
dissemination efforts.
It can be tempting to conjecture how Hans Eysenck, were he alive today, would characterize
our current state of affairs. Based on his early conclusions about the effectiveness of psychotherapy
in the 1950s, it is quite possible that he would be skeptical of the utility of dissemination efforts.
Importantly, however, it seems instructive to take a page from our field’s earlier dialogue on the
effectiveness of psychotherapy—which progressed from Eysenck’s assertion that psychotherapy
may be ineffective to Paul’s (1967) more accurate and nuanced recognition that our real pursuit is to
identify what specific treatments are effective for which specific clients under what circumstances.
Indeed, it is increasingly apparent that the question is not, are dissemination and implementation
efforts effective? but rather, what specific dissemination and implementation components and
methods are effective in promoting evidence-based practices among which specific therapists for
which specific clients in which practice settings? Despite a great plethora of scholarly discussions
about optimal models of dissemination and implementation, only a small handful of controlled
evaluations, most with relatively small samples, have begun to address this more productive and
nuanced latter question (e.g., Beidas et al. 2012, Lochman et al. 2009, Sholomskas et al. 2005).
But early efforts do reveal some consistent findings. First, for lasting and quality implementation
in practice settings, didactic trainings alone are insufficient. Competency components, which
include ongoing consultation or supervision with experts, are essential for trainees to acquire the

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necessary proficiencies to administer treatments with skill and fidelity (Beidas et al. 2012, Crits-
Christoph et al. 1998, McHugh & Barlow 2012, Sholomskas et al. 2005). These competency
components often have trainees consult with treatment experts while applying the disseminated
techniques in their actual caseloads (Daleiden et al. 2006, Gleacher et al. 2011).
Second, the matter of sustainability, which is often implied but rarely pursued actively (Lyon
et al. 2011), cannot be ignored. Sustainability presents multiple challenges to the lasting impact
of even the most initially successful of dissemination efforts. Even seemingly simple and straight-
forward procedures have presented challenges to lasting implementation across all health care
disciplines. For example, each year two million Americans acquire an infection while at a hos-
pital and 90,000 die from this infection (Gawande 2007). Despite widespread efforts to promote
sustained adherence to hand washing procedures among hospital clinicians—procedures that can
substantially halt the spread of many of these hospital-acquired infections—clinician compliance
with hand washing procedures in hospitals remains at a dismal 33% to 50% (Gawande 2007). Com-
mon reasons offered for not engaging in systematic hand washing among noncompliant hospital
Annu. Rev. Clin. Psychol. 2013.9. Downloaded from www.annualreviews.org

staff include inconvenience, insufficient time, skin irritation, noxious odors of cleansers, and even
concerns that cleansers reduce fertility. Of course, the quality delivery of an indicated psychological
by Cape Breton University on 03/16/13. For personal use only.

treatment protocol is far more involved and complex than simply washing one’s hands, underscor-
ing the tremendous and unique challenge for our field’s efforts toward sustained implementation.
In addition to targeting individual trainee factors (Gallo & Barlow 2012), efforts to promote
sustainability must also target organizational factors (see Beidas & Kendall 2010). The targeting
of organizational factors is far less common across the majority of current dissemination and
implementation efforts. Low levels of agency support, the absence of internal program champions,
and fluctuating or insufficient agency resources interfere with organizational sustainability (Glisson
et al. 2008). Workforce instability presents another challenge. Community agencies, particularly
overburdened, poorly funded clinics, exhibit high staff turnover (Glisson et al. 2008). Given the
relatively lengthy nature of meaningful dissemination and implementation efforts, by the time
training is complete, a participating trainee may no longer work at the agency. Despite great
resources invested in training this individual, the knowledge and skills do not transfer to the next
individual holding the position. “Train-the-trainers” approaches, which focus on the training of
local supervisors who presumably have greater job stability than individual clinicians, provide
some protection against treatment fidelity drift across time.
Finally, for these reasons, quality large-scale dissemination and implementation efforts are
enormously costly. Some of the more successful programs have collectively cost hundreds of
millions of dollars and still have not actualized the large and lasting impacts aspired to at the
program’s outset. As such, rigorous evaluations at the patient, therapist, trainer, and organiza-
tional level, which themselves are costly, have not always been at the forefront of dissemination
and implementation agendas. Most commonly, research on dissemination programs has been re-
stricted to investigations of the feasibility of implementation and changes in provider attitudes and
knowledge, which may or may not correlate with changes in provider skill, and ultimately, patient
outcomes. As McHugh & Barlow (2010) note, the majority of leading dissemination efforts have
not included assessments related to patient outcomes, the number of patients receiving services, or
clinician outcomes (e.g., clinician attrition, percent of clinicians who achieve competence, clinical
skill level at pre- and posttreatment).
Controlled comparisons in which key dissemination elements are systematically manipulated
(e.g., heterogeneous stakeholder involvement, agency driven versus trainer driven, intensive versus
spaced training, in-person versus web-based training, individual versus group supervision, tape
feedback) will also be essential in order to optimize efforts. In the absence of such important

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evaluations, we may be ignoring that large components of our leading dissemination efforts are as
misguided as were large components of our early models of psychotherapy.
Concerns have been articulated elsewhere ( J.S. Comer & D.H. Barlow, manuscript submitted)
about putting all of our eggs into the dissemination and implementation basket in order to address
our field’s sizable problems regarding psychological treatment availability and quality in practice
settings. Importantly, low base-rate disorders and complex treatments present serious obstacles to
dissemination and implementation efforts. The time and expenses associated with quality training
and sustained implementation preclude large-scale dissemination efforts for the treatment of a
number of very serious mental health concerns that impose tremendous personal consequences
but affect only a relatively small proportion of patients seeking care (e.g., chronic tic disorders,
paraphilias, schizophrenia, selective mutism, Tourette’s disorder, trichotillomania). Moreover,
dissemination science across a range of disciplines shows that innovations that are too complex
do not get routinely incorporated into everyday practice (Rogers 2003), as innovation adopters
show preference for user-friendly and “plug-and-play” methods. Within the context of broad
Annu. Rev. Clin. Psychol. 2013.9. Downloaded from www.annualreviews.org

dissemination and implementation, there appears to be little role for treatment methods that
cannot be watered down for delivery in overburdened clinics by minimally trained professionals.
by Cape Breton University on 03/16/13. For personal use only.

Given the diversity of backgrounds represented across the mental health workforce (Ellis et al.
2009), some well-supported psychological treatments may prove too complex for inadequately or
insufficiently trained clinicians to implement.
In the event that broad dissemination and implementation efforts actualize their enormous
potential, we will have a high-quality workforce of generalist clinicians who are well equipped to
skillfully address the majority of presenting mental health problems with relatively uncomplicated
methods. The promotion of such a competent generalist mental health workforce will be increas-
ingly essential in the years to come, as the Affordable Care Act envisions an increased role for the
colocation of mental health care within integrated primary care settings. But a highly competent
generalist workforce alone will not ensure effective services for individuals with low base-rate con-
ditions or individuals requiring mental health care for conditions so uncommon that they are not
worth the considerable investment required for meaningful dissemination and implementation.
Thus the authors of the current review have identified a vital need for available specialty care in
the delivery of psychological treatments, transacting with the generalist workforce to collectively
ensure the greatest quality and timely delivery of appropriate treatments to patients in need ( J.S.
Comer & D.H. Barlow, manuscript submitted).
Given the limits of broad dissemination and implementation to local mental health work-
forces as well as the obstacles that traditionally interfere with the accessibility of expert spe-
cialty care (e.g., geographic workforce disparities), many believe technological innovations may
be central to this effort (Kazdin & Blasé 2011). Of course, technology-assisted delivery of psy-
chological treatments still merits considerable empirical scrutiny. But in the event of continued
support for technology-assisted treatments, specialty behavioral telehealth—in which expert spe-
cialty services are offered in real-time through the use of live videoconferencing either directly to
clients in their homes or in other private settings with Internet access—may offer a transforma-
tive option for patients suffering with low base-rate conditions or conditions for which complex
treatments show strongest support ( J.S. Comer & D.H. Barlow, manuscript submitted). How-
ever, before a specialty behavioral telehealth delivery model can be systematically incorporated
into mental health care, a number of logistic and professional issues will need to be resolved,
including licensure and liability matters governing the practice of telehealth, credentialing stan-
dards, and reimbursement and appropriate Current Procedural Terminology coding for telehealth
procedures.

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FINAL REMARKS
This update of evidence-based psychological treatments is best considered an interim report. In the
current state of science and practice we have clear accomplishments we can point to, but we have
much to be humble about. The barriers to greater availability of psychological treatments reviewed
above represent challenges in the near to the intermediate term that must be overcome. Central
to this mission will be identifying more clearly mechanisms of action in these treatments that will
presumably allow the development of more efficient and effective interventions. As these goals are
achieved and the public and policymakers alike become more aware of these developments, demand
and availability should continue to increase, and we will hopefully be closer to our collective goal
of relieving human suffering and enhancing human functioning.

DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
Annu. Rev. Clin. Psychol. 2013.9. Downloaded from www.annualreviews.org

might be perceived as affecting the objectivity of this review

by Cape Breton University on 03/16/13. For personal use only.

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