The field of mental health treatment has reached a point of maturity such that most major behavioral and psychological problems now have empirically supported interventions available for application. These treatment packages have been derived from conceptual models of psychopathology that draw on basic experimental and clinical research. Available treatment packages, usually made available through treatment manuals developed and tested for particular disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSMā5; American Psychiatric Association, 2013), typically include multiple specific interventions. Yet, it is not always clear which components are essential and which are potentially less critical to good outcomes. Moreover, it might not be clear which components target which mechanisms of psychopathology. Accordingly, there might be insufficient guidance for clinicians when it comes to choices in treatment delivery; for example, when time constraints require use of the most essential components of an existing protocol, or when the presentation of a certain condition is more complicated than, or deviates from, descriptions and illustrations in treatment manuals. Further, it is conceivable that incorporating less effective treatment elements may actually hinder individual progress toward achieving wellness. Addressing these and other clinical conundrums can be challenging without clear and concise guidance that is based on the latest empirical research.
Accordingly, we have assembled this book to help the practicing clinician to more easily identify mechanisms that best explain observed psychopathology and then apply the appropriate empirically supported processes of change. Such an approach allows the clinician to practice as an evidenceābased practitioner even when they may need to deviate from disorderābased treatment manuals. This approach also raises the question of whether traditional psychiatric diagnosis (i.e., based on the DSMā5) is necessaryāa growing controversy in the mental health field. That is, if one conceptualizes psychopathology at the level of the individual mechanisms and processes, and then applies empirically supported techniques to reverse such mechanisms, what advantage is there to using diagnostic labels such as those in the DSM? It is our opinion that empirically supported practice begs a critical discussion of (a) mechanisms of psychopathology, (b) mechanisms of psychological change, and (c) a means for conceptualizing presenting behavioral and psychological problems and developing treatment plans that rely on valid perspectives unmoored from the current nosology.
This book was developed at an interesting time in the evidenceābased practice movement. It has been just about 20 years since the standards for determining what counts as an empirically supported treatment were developed (Chambless & Hollon, 1998). These criteria stipulated that a minimum of two randomized controlled trials (RCTs) be conducted by two different research teams, and show efficacy for a treatment, compared to a placebo intervention, in order for the protocol to be declared empirically supported. The full set of guidelines was considered pathābreaking at the time, as this was the first time any set of standards was articulated to guide practitioners in making treatment decisions. At the time these standards were developed, RCTs were comparably rare, with few studies comparing to attentionāplacebo control conditions.
Now, close to 20 years later, RCTs are conducted with far greater frequency. Online registries have been developed where investigators can register their trials a priori, with primary and secondary variables of interests declared. Many journals require that RCTs submitted for publication be registered in order to be considered. The virtue of these registries is that it allows other investigators to evaluate the full corpus of available research, including those that might be null findings that never made it to publication, in order to have a complete account of the efficacy of a treatment protocol. Given that the criteria for empirically supported treatments were silent on the matter of unpublished or null findings, a protocol could be declared empirically supported if it met the two RCT criteria, even if there were numerous failed prior trials. This problem has been addressed in the newly crafted criteria for empirically supported treatments (ESTs; Tolin, McKay et al., 2015; Tolin, Forman, et al., 2015). There was an incremental movement already underway to deal with this as evidenced by the ubiquity of metaāanalyses for specific treatment protocols, and the advent of the Cochrane reviews, which surveys in comprehensive detail the effects of specific treatment programs. As a result, we are now at the point where many treatments are fairly well understood with respect to their benefits and limitations and the components that are essential ingredients. Understanding what treatment elements are essential ingredients is the essence of evidenceābased practice, whereby direct service clinicians can select components of treatment that are deemed scientifically supported for specific problems faced by their clients.
The aims of this volume are therefore threefold. The first is to shed light on both the empirically supported and the unsupported components of conceptual models of psychopathology. Second, the volume aims to identify empirically supported components of existing psychological interventions and the rationales for how multicomponent interventions are sequenced. Thus, this text provides clinicians with an understanding of the sequential nature of interventions, and the criteria for moving from one intervention to the next, particularly for seemingly disparate treatment procedures that form multicomponent treatment packages. The third aim is to illustrate specific ways of identifying mechanisms of psychopathology that might attenuate treatment outcome with established protocols, and help the clinician use empirically supported methods to address these obstacles.
All chapters in the book draw on available research evidence to make clear the connection between science and practice; and these chapters are organized into five sections. The first section offers an overview, and outlines the aims and scope of the text, as well as a brief history of the empirically supported practice movement. The second section addresses the three aims of the book as they relate to conditions for which there is extensive support for mechanisms of psychopathology and empirically supported psychological treatment procedures and processes of change. Given the unique complexities and extensive research base, two chapters cover treatments for psychopathology emerging from traumatic events. This is an important aspect of the book given the various controversies around the possible risk for dropout with evidenceābased therapy for trauma (Imel et al., 2013). The third section covers areas of psychopathology and treatment for which there is emerging empirical support. The fourth section covers domains of psychopathology for which there is only preliminaryāor perhaps the potential forāevidenceābased approaches to psychopathology and treatment. The fifth and final section focuses on mechanisms of psychopathology and change across the age span.
To further orient the reader, each chapter follows a general format in which the nature of the psychopathology is first discussed. The focus is on components of relevant conceptual models, including an appraisal of their scientific support, rather than a review of major etiological theories. Next, each chapter turns to a discussion of empirically supported treatment components, including the sequencing of multicomponent interventions and the factors that can interfere with implementing these procedures. Finally, each chapter includes a discussion of how mechanisms of the psychopathology itself might interfere with treatment outcome, and how clinicians might adapt therapy to address these mechanisms and optimize treatment effectiveness. It is our hope that this edited text provides the field with a handbook for understanding the nature and treatment of psychopathology at the level of psychological mechanisms, with the broader aim of helping the field evolve from a focus on multicomponent treatment manuals for āmental disordersā to a more conceptually oriented processābased approach.
