Empirically Supported

Treatments (ESTs) in Perspective:

Implications for Counseling Psychology Training
Charles A. Waehler
The University of Akron

Cynthia R. Kalodner
West Virginia University

Bruce E. Wampold
University of WisconsinMadison

James W. Lichtenberg
University of Kansas
There is a strong movement toward employing only evidence-based treatments or empirically validated treatments (EVTs) in delivering psychological services. This movement
is affecting professional practice, research, and training now and will continue to be
influential far into the future. Efficacious treatments attempt to respond successfully to
three prominent realms challenging psychologys professional integrity: practicing psychologists applications, scientific certainty, and marketplace demands. In addition,
training efficacy and adherence to ethical principles must be considered regarding
adopting EVTs. Although the successful blending of these domains holds forth great
potential for enriching training and practice, consolidating these areas may obscure elements essential to each pursuit. This article reviews both the merits and concerns the
EVT movement holds forth for the counseling psychology profession. Recommendations
are offered for integrating EVT knowledge into coursework and practica training.

Empirically validated treatments (EVTs) or empirically supported treatments (ESTs) refer to specified interventions designated as having demonstrated efficacy for individuals with specific psychological disorders
(Chambless & Hollon, 1998; Kendall, 1998). Although the terms used may
vary (EVT, EST, evidence based),1 the body of work in this domain appears at
first review to be relatively benign. However, the concept of EVTs sparks a
variety of reactions from psychologists, ranging from enthusiasm and
endorsement at one end to annoyance and concern at the other. Significantly,
informed opinions rarely espouse a moderate view so that discussion of
EVTs among psychologists parallels the provocative topics of politics or religion (Kendall, 1998). Given this environment, it would be tempting to avoid
THE COUNSELING
Waehler
et al. / ESTS IN
PSYCHOLOGIST
PERSPECTIVE / September 2000
Correspondence concerning this article and requests for reprints should be addressed to Charles
A. Waehler, The University of Akron, Akron, OH 44325-4301; e-mail: cwaehler@uakron.edu.
THE COUNSELING PSYCHOLOGIST, Vol. 28 No. 5, September 2000 657-671
2000 by the Division of Counseling Psychology.

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acknowledging EVTs potential impact on our profession as well as the

implications for training. To do so, however, would be irresponsible.
The movement surrounding EVTs is affecting professional practice and
research now and will continue to be highly influential far into the future.
Therefore, student training must take notice and respond from an informed
position. The significant literature base accumulated during the past several
years surrounding EVTs evidences the attention psychology is giving this
issue. Special sections of key journals in psychology (e.g., Journal of Consulting and Clinical Psychology, Psychotherapy Research) have been
devoted to this topic. To date, however, there has been scant attention to EVTs
in the counseling psychology literature. One notable exception has been an
American Psychological Association (APA) Division 17 Special Task
Group, which has developed a set of principles for establishing empirical
support for interventions in counseling psychology that have been adopted by
the executive board (Waehler & Wampold, 1999; Wampold, 1998). This
group developed principles for recognizing treatments, interventions, and
procedures as empirically supported. Nevertheless, little specific information exists regarding doctoral training implications compelled by the EVT
movement.
This article discusses activities within the EVT movement, giving special
attention to the challenges to training students engendered by these developments. Because attention to the EVT activity has become ensconced in the
Guidelines and Principles for the Accreditation of Programs in Professional
Psychology (APA, 2000), cognizance of these issues is now essential knowledge for training programs.

A BRIEF BACKGROUND OF THE EVT MOVEMENT

There are a number of forces propelling the EVT movement. Certainly, a
professional imperative within psychology to identify therapeutic interventions based on scientific findings undergirds the effort. To this end, clinical
psychology has been responsible for developing criteria and protocols for
establishing EVTs; they have published several lists and reports about EVTs
that help to identify best-practice treatments for clients. Other forcesnotably, managed health care, biological psychiatry, and other scientific interestshave shaped the activity as well.
The end of the 20th century witnessed a general emphasis in the health
care community to evaluate and reduce service cost, and forces attempting to
manage the price and maximize the value of all facets of health care have a
significant investment in substantiating treatment benefits in mental health
services. One solution within medical settings has been to institute diagnostic-

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related groups (DRGs), which provide a fixed treatment and payment plan by
diagnosis. The movement to expand DRGs beyond medical ailments into
mental health conditions has taken hold, and the influence has been present
for several years.
Biological psychiatry, a second force driving EVTs, has put pressure on
psychologists to justify empirically the efficacy of psychosocial intervention
strategies (Goldfried & Wolfe, 1996). This force has influenced the developers of the EVT criteria to base guidelines on the Food and Drug Administration (FDA) guidelines for approval of new drugs (e.g., manualization, diagnostic specificity, two studies). In this way, speaking their language may
help psychology ward off the superior treatment claims sometimes espoused
by biological psychiatry (Shapiro, 1996). However, such a strategy also puts
parameters on psychologists that may be better suited to physicians. Nathan
(1998) has described psychiatrists reactions to the American Psychiatric
Associations (APA) practice guidelines (e.g., for schizophrenia, major
depressive disorder, bipolar disorder, substance abuse disorders, and nicotine
dependence) as more positive than negative (p. 295) and notes that psychiatrists may be more accustomed to the notion of practice guidelines based on
their common use in physical medicine.
A third force driving the adoption of EVTs comes from psychologys own
scientific community and their attempts to answer Pauls (1967) query:
What treatment, by whom, is most effective for this individual with that specific problem under which set of circumstances? (p. 111). Having previously resolved Eysencks (1952) question of whether therapy works at all,
therapy researchers have moved from demonstrating the efficacy of generic
treatments to what might be referred to as specific prescriptive treatments
(see Sperry, Brill, Howard, & Grissom, 1996). In this regard, Sperry et al.
noted that as a result of ongoing research on empirically derived treatments,
several prescriptive treatments currently exist for well-defined diagnostic
entities such as depression for which specific treatment guidelines have been
issued (American Psychiatric Association, 1993) (p. 50).
With these three significant forcesmanaged health care, biological psychiatry, and scientific interestsproviding impetus to substantiate the
empirical validity of treatment approaches, Division 12 of APA established
the Task Force on the Promotion and Dissemination of Psychological Procedures. This group has produced two major contributions into this area in Volumes 48 and 49 (see also Volume 51) of The Clinical Psychologist (1995,
1996). These two articles outline the criteria the task force has specified to
designate treatments as empirically validated. The criteria have been revised
several times; the most recent appear in our appendix.
In their first publication, the task force listed 25 treatments that satisfied
these criteria (Division 12 Task Force on Promotion and Dissemination of

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Psychological Procedures, 1995). The response to this report was substantial.

Both supporting and dissenting material were presented and discussed at professional meetings and published in journals. The groups second entry in
The Clinical Psychologist (Chambless et al., 1998) was not published under
the task forces name but instead was published in the names of the committee members, because their report does not constitute nor is it intended to be
viewed as a clinical guideline, standard, or official policy statement of either
the Division of Clinical Psychology or of the American Psychological Association (p. 15). The report stated its intention to add to the preliminary list on
an annual basis and had increased its list of EVTs to 47. Perhaps responding
to some of the criticism from the first report, this article included such caveats
as: (a) This list is intended to facilitate education by identifying treatments
with a scientific basis (p. 5); (b) that a treatment is not on our list in no way
means that it has been shown to be ineffective (p. 5); (c) this list is particularly
incomplete where childrens problems and prevention programs are concerned (p. 5); (d) this list does not substitute for educators and practitioners
own decisions about what is the most appropriate treatment for a given client
(p. 5); (e) applications of manualized treatments to practice require flexibility
and adaptation to the requirements to each case and setting (p. 6); (f) we encourage readers to use our list as a starting point but to make their own judgments (p. 6), and; (g) keep in mind that validation is an ongoing process (p. 6).
Chambless et al. (1998) elucidated the distinction between efficacy and
effectiveness, a difference also included in the Template for Developing
Guidelines (American Psychological Association Task Force, 1995). Efficacy concerns the evaluation of the benefit of treatment for individuals in
well-controlled treatment outcome studies. Effectiveness refers to the use of
these treatments in the real world. This distinction is well worth examination
in both research and training of students in counseling psychology.
Expanding upon the intention to make treatments available to clinicians, the
Division 12 Task Force reports are available on the Web (http://www.apa.
org/divisions/div12/est). The January 1998 list included an additional 34
EVTs and began the practice of providing opportunities for training in many
of the specific treatments included.
Serving as an indicator of the importance of empirically supported interventions, training in EVTs has become formalized in the APA Standards for
Accreditation (1996). These standards, essential to most programs substantiation and claims for credibility, include the guidelines that
all students can acquire and demonstrate substantial understanding of and
competence in implementing intervention strategies (including training in
empirically supported procedures). . . . The program requires that its students
receive adequate and appropriate practicum experiences . . . in settings that . . .

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provide a wide range of training and educational experiences through applications of empirically supported intervention procedures. (pp. 6-7)

Supporting these APA standards but going beyond them, the Division 12
Task Force has recommended for APA site visitors for accreditation of doctoral programs to make training in empirically-validated treatments a high
priority issue (p. 7). Later, in the task forces report, the authors become
more emphatic by recommending that APA-site visit teams make training in
empirically-validated treatments a criterion for APA accreditation (p. 7). Their
rationale was that once graduate programs understand that the provision of
training in empirically-validated treatments is one criterion for accreditation,
programs would be more likely to look for supervisors with specific skills in
these treatments (p. 7). These recommendations have been supported by
others (e.g., Crits-Christoph, 1996; Persons, 1995; Wilson, 1995).
There are many consequences of the EVT movement for counseling psychology training programs. They include both potential benefits and advantages as well as drawbacks and threats.
Support for the EVT work includes the ability to bring closer relationships
between theory, research, and practice; disseminate knowledge about strategies that work; improve the care of clients; influence policy makers; foster
better training; encourage research on therapy; and promote discussion.
There is an ethical imperative to provide the best treatment for clients, which
means training students in these treatments.
However, there are many arguments against ESTs. Elliott (1998) divided
the arguments into two major categories, those against the EVT lists themselves and those against the criteria used to designate treatments as validated.
Arguments that suggest that the dissemination of the EVT list is premature
include the idea that effectiveness data are inadequate for the claims made,
the EVT lists appear to reflect an arbitrary political process, and the EVT lists
may inhibit clinical innovation. Regarding Division 12s EVT criteria, they
are described as too lenient, providing distraction from more important
research findings, relying on flawed randomized clinical trial designs, stifling therapy research, assuming diagnostic specificity, dehumanizing clients based on DSM diagnosis, and relying on adherence to treatment manuals
which can hinder effectiveness by turning therapists into technicians.
Garfields (1998) cautions regarding the EST movement resonate with
our own.
I have no quarrel with attempts to indicate therapies that have received empirical support and, in fact, have supported such attempts. What I have been critical
of was what I perceived as an attempt to certify and mandate the use of such
therapies prematurely, to link accreditation of graduate training and internships to such designated therapies, also to link every therapy to a specific

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psychiatric diagnosis, and by emphasizing the name or form of psychotherapy,

essentially to minimize the importance of patient variability and therapist skill.
(p. 121)

IMPLICATIONS SPECIFIC
TO COUNSELING PSYCHOLOGY TRAINING
We believe that it is necessary for counseling psychology training programs to include aspects of the EST curriculum into course work and practica
training. There are ethical issues inherent in applying ESTs as opposed to
doing your own thing as a therapist. Although it is likely that training programs already address ESTs to some extent, an explicit focus on ESTs may be
necessary to ensure that students are exposed to this topic and the kinds of
treatments included on the EST lists and that programs meet accreditation
requirements. At the same time, counseling psychology training programs
need to be vigilant about protecting issues that traditionally have been foci
within counseling psychology, including respect for issues of diversity and a
de-emphasis on diagnostic labeling and attention to career counseling,
psychoeducation, developmental concerns, and prevention programs.
Diversity concerns and diagnostic specificity. EVTs tend to obscure individual differences, a counseling psychology hallmark. Both client and therapist individual differences are usually ignored as greater attention is paid to
procedures. As Chambless et al. (1996) have noted in their review of treatment outcome studies, Not one used ethnicity as a variable of interest . . .
Strictly speaking, then, the efficacy of EVTs has not been established with
ethnic minority populations (p. 7).
There are many client variables that are important to consider when applying any intervention, including ethnicity, gender, social class, sexual orientation, attitudes and values, preferences for treatment type, willingness to
receive treatment, and purity of disorder or problem. Currently, the EVT criteria do not specify validity beyond promoting a particular treatment for a
specific syndrome or diagnostic label. Significantly, formal diagnosis (e.g., a
DSM-IV diagnosis) provides only one way to classify clientsa medically
based model of diagnosing disorders. This could undermine counseling
psychologys traditional focus on hygiological and developmental understandings of peoples problems and adaptive potential. At a minimum, initial
evaluations and outcome assessment should take into account general life
functioning, perspective, and costs and/or benefits; the sensitive appreciation
of individual differences; and the recognition of people as complex, holistic
entities. Unfortunately, as Davison and Lazarus (1995) suggest, beginning

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therapists may incorrectly assume that prepackaged interventions can be

used with any patient having a particular DSM diagnosis, and
when a therapist follows a treatment manualdesigned primarily for use in controlled outcome studieshe or she may overlook important personality factors . . .
It is important to guard against anything that undermines the central role of
assessment and case formulation. (p. 110)

In addition, client freedom to choose among efficacious programs is consistent with the values of counseling psychology and should not be abridged
without persuasive evidence that a particular treatment is demonstrably superior. Manualized treatment and EVTs have also been criticized as impractical
because they focus unrealistically on clients who fit precisely and distinctly
into a discrete DSM diagnostic classification. Unfortunately, another outcome of conforming to the medical model is that the EVT movement has
shown little willingness to examine prevention programs.
Focus on manuals versus generic training. Demands created by training in
specific EVTs may force counseling psychology to diminish or abandon its
traditional focus on generic training. As Wilson (1996) pointed out, future
generalists will have to become specialists for a number of disorders
(p. 242), but is this really the same as being a generalist? The facilitation of
the therapeutic relationship, which makes up a major component of many
training and supervision experiences, receives little attention within EVT
considerations. Overarching the training issues is a presumption that
research will lead to disorder-specific treatment guidelines and cookbook
interventions that can be implemented by individuals trained minimally in
general psychotherapy skills.
Manuals, endemic to the EVT process, have both positive and negative
potential. To be sure, there is real merit in teaching students step by step how
to conduct a particular intervention, and the use of treatment manuals may
facilitate training efficacy (Moras, 1993). Using manuals may not be so
different from the old school approach of using training scales (e.g., see
Truax & Carkhuff, 1967) to shape students to be empathic, genuine, and open.
The scales were and/or are, in a sense, a manual or guidebook for how to
counsel (nondirectively). Chambless (1996) commented, I find that students
learn treatment approaches much more quickly from their systematic depiction in manuals than through supervision alone (p. 231). Wilson (1996)
suggested,
Treatment manuals make psychological therapy, whatever its particular form,
more disseminable. They make it easier for therapists to learn specific treat-

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ment strategies and to acquire skill in using them. As a result . . . they are also
likely to broaden therapists repertoire of treatment skills and encourage
greater technical eclecticism than has previously been the case. They not only
facilitate the training of therapists, but make it easier for supervisors to monitor
their trainees expertise. (p. 296)

At the same time, even when manuals are used for training, programs must
not lose sight of the fact that competence, not adherence to a treatment manual, is what is related to outcome (Havik & VandenBos, 1996). Indeed, several people have reported that adherence to manuals may actually result in
decrements in therapist-demonstrated skill, so that manuals alone do not produce more effective treatments (Luborsky, 1993; Wilson, 1996). Supervisors
must consider that training according to manualized treatment does not preclude training in common factors such as the therapeutic relationship, the creation of hope, explanations, perceptual and cognitive change, homework
assignments, and the opportunity for emotional release (Garfield, 1998).
Training programs need to find a balance between training based on manuals
and general therapy skills that optimize their students development.
Program resources. Training in EVTs has the potential to place additional
demands on faculty and clinic resources as well as expanding training program curricula to the breaking point. Possessing a number of faculty who
have the knowledge and skill required for competency in the use of specific
ESTs represents one challenge. Although EVT lists on the Web
(http://www.apa.org/divisions/div12/est) suggest opportunities for training
in many of the specific treatments, human and monetary resources nevertheless will be needed. Calhoun, Moras, Pilkonis, and Rehm (1998) provide several suggestions for the improvement of continuing education (CE) offerings,
including providing extended formats for exposure to ESTs and assessment
of competence to perform new techniques. Aside from the need for those who
teach ESTs to be competent in these ESTs, there is an added push for CE from
the health care system because managed care companies specify targeted
outcomes using brief interventions.
Even if faculty are competent to train students in specific EVTs, supporting labs and practicum settings need to provide students with opportunities to
acquire skill with a particular treatment protocol. Consequently, training programs will need to evaluate placement options in light of the expected training in EVTs, but surely practicum and internship placements will vary
greatly in their commitment to ESTs (Crits-Christoph, Frank, Chambless,
Brody, & Karp, 1995). Training in narrow treatments specific to particular
disorders may lead students to spread their training among a cluster of different placements to receive a smattering of training experiences rather than an

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in-depth immersion with a particular agency and supervisor. In addition,

undertaking training in specific treatments may increase pressure to expand
what faculty and students recognize as an already-long training program
curricula.
Scientific issues of EVTs. Any discussion considering the merits of the
EVT movement questions whether the criteria established for evaluating
treatments may rest on a highly suspect scientific foundation. Several important articles (e.g., Borkovec & Castonguay, 1998; Wampold, 1997; Wilson,
1995, 1996) document scientific shortcomings within the fundamental EVT
assumptions. The important question of How do we know when a treatment
is effective? has yet to be fully answered (Garfield, 1996; Goldfried &
Wolfe, 1996; McFall, 1995; Wampold et al., 1997; Wilson, 1995, 1996). In
general, with regard to the science underlying EVTs, continuous examination must be paid to methodological issues (e.g., defining treatments, designing research, measuring outcome), problems discriminating between psychological treatments (e.g., common and specific confounds, difficulties in
disproving uniform efficacy, hazards in standardizing treatments), and establishment of the quality of empirical evidence (e.g., equal efficaciousness of
treatments and accounting for variance factors, such as therapist or error,
other than the differences among treatments). Also, the insistence on using
manualized treatment raises the issue of whether the psychotherapy studied
in research is less and less similar to that which takes place in practice
(Beutler, 1995, p. 489).
Meta-analyses can and do serve as a cornerstone of evidence-based practice, and counseling psychology approaches that make use of these analyses
should have a sound footing. At the same time, counseling psychology methods that remain unsupported by the kinds of evidence preferred by those who
control the budget of health care systems may be questioned or marginalized.
Although interventions unsubstantiated by empirical studies will undoubtedly continue to be offered, when intervention strategies compete, adherents
who have followed the EVT scientific strategy and derived an empirical base
of support for their interventions are likely to be the winners. In this regard,
although outcome measures that reflect goal attainment as well as (or in many
instances, instead of) measures of psychopathology may be in keeping with
counseling psychology traditions, they may be less amenable to EVT standards. Similarly, the EVT movement has shifted the major focus of research
away from the important process variables, which are a major part of counseling psychologys research interest, to treatment factors that produce little
variation in outcome (Garfield, 1996).
Specific to how treatment manuals may negatively affect science, Garfield
(1996) mentions six considerations that deserve serious attention:

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inability to assess the effects of therapist variables, diminished ability to study

the therapy process, focus on treatment fidelity rather than on competence,
increased expense for research, overresearching of older codified therapy procedures, and promotion of schoolism in psychotherapy. (p. 220)

EVT RECOMMENDATIONS
In light of the progress made in the EVT arena and because the APA
accreditation standards make it clear that students are required to receive
training about EVTs, we believe that it is necessary for counseling psychology training programs to integrate EVT curriculum into course work and
practica training. Although it is likely that most training programs already do
this, an explicit focus on EVTs may be necessary to ensure that students are
aware of the challenges in this area, at least minimally exposed to this topic,
and possibly trained in specific treatments included on the EVT lists.
The scientific issues embedded in studying outcome research may fit best
into research course work. Students can be educated about methodological
issues inherent in establishing scientific criteria for efficacy. Attention in
these courses can focus on internal and external validity concerns relevant to
the efficacy-effectiveness distinction. Dissertations, theses, and research
projects provide the opportunity to enhance the evidence-based knowledge
and expand it with attention to factors such as individual differences, work
with minority populations, and work with counseling psychology topic areas
such as vocational adjustment and developmental life changes.
The practical issues engendered by ESTs can be explored with students in
counseling theory and individual differences classes as well as practicum
training settings and courses. Calhoun et al. (1998) provide a model for training in ESTs that includes providing a conceptual understanding of the theory
of psychopathology and therapeutic change underlying the therapy
approach, learning specific skills defined as an EST, acquiring general therapy skills relevant to the relationship between the therapist and the client, and
learning how to provide ongoing assessment of the effectiveness of the intervention. The conceptual aspects of theories of wellness and therapeutic
change may be appropriate for counseling theories and multicultural classes.
Learning the specific EST skills along with refining general therapy skills
and learning how to provide ongoing assessment of the effectiveness of the
intervention are aspects of both practicum and internship training. Case studies, sensitive to clients individual differences, can highlight the use of specialized ESTs.
Calhoun et al.s (1998) guidelines directed toward training interns in
ESTs are also relevant to training predoctoral students, and we suggest that

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using preexisting videotapes to illustrate central EST components may be an

efficient method of exposing students to ESTs. Calhoun et al. suggest that the
use of videotapes may be most helpful early in training and again after students have had some experience providing the EST. Calhoun et al. also suggest the use of audio- or videotapes of therapy sessions for supervision,
thereby allowing supervisors to assess the implementation of an EST via
hearing and watching the students work with clients. Furthermore, because
adherence to the EST manual may be viewed as essential to the implementation of the treatment, using measures to assess the degree to which a student is
implementing the procedure as specified in the manual may be helpful.
Calhoun et al. also suggest designing and using materials that illustrate errors
made by therapists when implementing the EST. Their final suggestion, and
one to which we would subscribe, is that ongoing evaluation of the clients
response to an EST is necessary. Published studies include the names of measures used in the research and may be useful for a point of comparison for client change over time.
Havik and VandenBos (1996) summarized numerous observations
regarding the EVT movement, and they stated that
the field of psychology should be justifiably proud of the empirical research
currently being done on the process and outcome of psychotherapy, but it is
immature to limit training, practice, or reimbursement based on our current
fragmentary data-base of outcome findings. (p. 266)

CONCLUSIONS
Current trends reveal that the behavioral health care community is
responding to pressure for prescriptive, evidence-based practice by developing guidelines and standards for practice. Training programs may find it useful to distinguish between guidelines and standards: Guidelines are judgments for which there still are alternative perspectives; standards refer to
health care judgments for which there is virtually unanimous endorsement by
practitioners so that their implementation should be considered mandatory
(Eddy, 1990). As Baker (1998) noted, Practice guidelines serve an important function in clinical decision making by summarizing the best thinking of
subject matter experts who draw on research, clinical experience, and available standards of care (p. 149).
Counseling psychology programs that want their training to stay contemporary must keep alert to the guidelines and standards being established as
part of the EVT movement. The issues and processes involved in establishing
guidelines and standards can be highly educational and have the potential to

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benefit the entire psychological community. The EVT movement, with its
potential to bring together the science and the practice of our profession, may
rescue psychosocial interventions from the expanding influence of biological
psychiatry (Crits-Christoph, 1996). The reality of (and perhaps the necessity
for) managed health care means that counseling psychologists have to substantiate their efforts and be more effective in doing so. Training programs
that are not cognizant of these developments may find themselves and their
students marginalized in the larger field of psychology.
At the same time, endorsing all that is related to evidence-based treatment
without criticism is a mistake. In addition to the limits on the science underlying the identification of EVTs, the EVT movement has the potential to run
roughshod over counseling psychology traditions that value learning strong,
general therapy skills; attending to diversity issues and de-emphasizing diagnostic labeling; and promoting career counseling, psychoeducation, prevention programs, and developmental concerns. Counseling psychology needs
to both react to and actively shape the future that EVTs will undoubtedly have
in the profession. Counseling psychology programs can and should move to
the forefront of pioneering new and broader methods for validating a wide
array of psychological interventions that are not necessarily linked to particular psychopathology (e.g., career counseling, developmentally based treatments, critical incident stress reduction). Counseling psychology programs
can be on the forefront of extending research to account for more complex
client issues, including ethnicity, gender, social class, and sexual orientation.
To paraphrase the explanation for the Principles for Establishing Empirically
Support for Interventions in Counseling Psychology (Waehler & Wampold,
1999): Rather than science dictating practice, our field advances best when
science informs practice. Practitioners, scientists and trainers are an interwoven system. Practitioners, informed by research, trained by scientists and/or
educators, and reflective and continually learning through experience deliver
optimal interventions. Although practice guidelines are not yet ideal, they
have the potential to enhance both the effectiveness and the accountability of
interventions (Nathan, 1998, p. 298) and training.

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APPENDIX
Summary of Criteria for
Empirically Supported Psychological Therapies
1. Comparison with a no-treatment control group, alternative treatment group, or

placebo:
(a) in a randomized control trial, controlled single-case experiment, or equivalent
time-samples design and
(b) in which the EST is statistically superior to no treatment, placebo, or alternative
treatments or in which the EST is equivalent to a treatment already established
in efficacy, and power is sufficient to detect moderate differences.
2. These studies must have been conducted with:
(a) a treatment manual or its logical equivalent;
(b) a population, treated for specified problems, for which inclusion criteria have
been delineated in a reliable, valid manner;
(c) reliable and valid outcome assessment measures, at minimum tapping the
problems targeted for change; and
(d) appropriate data analysis.
3. For a designation of efficacious, the superiority of the EST must have been shown

in at least two independent research settings (sample size of 3 or more at each site
in the case of single case experiments). If there is conflicting evidence, the preponderance of the well-controlled data must support the ESTs efficacy.
4. For a designation of possibly efficacious, one study (sample size of 3 or more at
each site in the case of single-case experiments) suffices in the absence of conflicting evidence.
5. For a designation of efficaciousness and specific, the EST must have been shown
to be statistically significantly superior to pill or psychological placebo or to an
alternative bona fide treatment in at least two independent research settings. If
there is conflicting evidence, the preponderance of the well-controlled data must
support the ESTs efficacy and specificity.
SOURCE: Chambless and Hollon (1998, p. 18); Copyright 1998 by the American Psychological Association.
NOTE: EST = empirically supported treatments.

NOTE
1. The abbreviations EVT and EST will be used interchangeably throughout this article. The
older literature typically used EVT, whereas the newer literature has used EST more frequently.

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American Psychological Association. (2000). Guidelines and principles for accreditation of
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