Evidence-based” is a miracle term used in the field of mental health. It opens and closes doors, makes some people rich and others poor. Officially, it’s intended to promote quality of health services and safety of patients. And it works to some extent as it’s meant to. But it’s also used in a very flawed form as crypto marketing of books and training programs.
In his article (and the enclosed video) I’ll look at the term “evidence-based” in relation to Acceptance and Commitment Therapy and in relation to psychological treatments more generally. It is the first of a new series of articles, in which I answer a number of questions that I’m frequently asked during my workshops and lectures.
What is Acceptance & Commitment Therapy (ACT)?
The shortest answer is: ACT is a therapy specifically designed for targeting experiential avoidance. And experiential avoidance is one of the major contributors to psychopathology.
Experiential avoidance is not the only one. Other well-known contributors are, for example, repetitive negative thinking and self-focused attention. You can find a short overview of transdiagnostic processes in my article.
Although Experiential Avoidance accounts for a significant amount of mental health problems, its role in maintaining psychopathology can’t be evaluated on a general basis. It varies from person to person, from diagnosis to diagnosis, and depends on various circumstances.
Is ACT an “alternative therapy”?
Well, for me these two words exclude each other. Either something is a therapy, which means: it has scientific foundations; or something is an alternative to a therapy, which means: it lacks scientific foundations.
ACT is without any doubt a therapy – or a main-stream therapy if you prefer – with solid scientific foundations.
Is ACT an evidence-based treatment?
This is actually a three-fold question. So, let’s look at the three types of evidence.
1) Scientific foundations
Firstly, when we talk about evidence-based treatments, we have to look at the empirical status of their theoretical underpinnings. For that purpose Bruce Wampold proposed the term “bona fide therapies”, which means therapies that:
- are therapeutically intended,
- have a clear rationale and
- are guided by a coherent theoretical structure
- based on empirical research.
“Therapeutically intended” means here that it’s not enough to get better as a result of something to call it a therapy. A depressed person may for example become less depressed from attending dancing lessons, but they can’t be called “therapy” because they are not intended to have such an effect.
ACT meets all that criteria. It has a solid empirical basis rooted directly in experimental psychology and in empirical behavioral science. It also has a clear model of psychopathology – with practical implications for clinicians. So, we can conclude that ACT is a bona fide therapy.
2) Clinical outcomes
The second type of evidence for any treatment is evidence for its clinical effectiveness – provided by outcome studies. In practice, the term “evidence-based treatments” is usually used in a very reduced sense, and refers only to clinical outcome studies. That’s a great paradox. In fact, the majority of outcome studies have poor quality, and this is the weakest part of psychotherapy research.
A recent umbrella-review found out that only 7% of psychotherapeutic meta-analyses met methodological criteria necessary for providing evidence for their conclusions. (Dragioti, E. et al., 2017) If we tested medical drugs in the same way, no single pill would be allowed into the market. (That is just my digression).
There’s no such thing as evidence-based treatments in general. They are like Aspirin, may work for some problems, but not necessarily for other. So, we must always look at outcome data for a specific diagnosis, specific problem or for a precisely defined population.
There are currently about 450 randomized controlled trials on ACT, and you have to look into those studies to check out effectiveness for whatever you’re interested in or whatever is relevant for you.
My advice here is: one solid study is worth more than a 100 of poorly designed trials. So, when you read articles, look for some important quality markers, like:
A) Study power
– which depends on the number of participants. Underpowered trials, trials with too few participants, are common and are a real plague in our field. Such trials seem to provide us with some answers, but these answers lack validity.
B) Control group
Good studies use active comparison groups, not wait lists. Never compare something to nothing. It usually proves that something is better than nothing, but it’s not a comparison. Just ignore studies that compare those who received a treatment to those who have been placed on a wait list. Why?
Imagine that you have a health problem and suddenly get an invitation to a study on a new, promising treatment or medicine. You enthusiastically say “yes,”, but… a couple of days later you learn that you haven’t been chosen for the treatment, for now. You land on a waiting list. How would you feel?
After being assigned to a waiting list, many people feel worse than they did even before being invited to the study. Depressed people are pessimists. They believe in bad luck. And voila – here is the confirmation. They didn’t get through.
This is how inactive comparison groups are built. Researchers compare result of being a chosen one to result of being disappointed. What do they expect to find out?
Another problem with a wait list is that it just demobilizes people from trying to find alternative solutions to their problems. When you are refused treatment, you have to deal with problems on your own. It might be divorcing when you’re married or dating if you’re single. It might be changes in your lifestyle or quitting a frustrating job. It might be anything, but any initiative is better than passivity. When people are placed on the wait list, they tend to wait. They were promised a solution – in the future. It weakens their motivation to find a solution here and now, on their own. It reinforces passivity. Thus, waiting for psychotherapy may actually make them deteriorate.
So, when people in the active arm of a study make it better than the waiting list, it does not necessarily mean that the treatment worked. It may mean that it was the waiting list that worked – just in the negative direction.
C) Is it a non-inferiority or a superiority design?
Non-inferiority trials investigate whether the treatment is not worse than competitors. But not being worse is not the same as being better. I work in a big hospital. In order to implement any new treatment, we need something more than just the conclusion that it’s not worse than what we already have. It has to be superior in some aspects: if not in the outcome than at least in cost efficiency or in lower drop-out rate. So, always check for superiority.
D) Follow up
Human beings are a social species, and any positive attention and social interaction makes us feel better. So does any contact with a therapist. Especially when we lack other positive relationships in our lives.
We can easily expect that study participants will report improvement right after the treatment. Especially, when the treatment was delivered in a group format, and many trials use that format. Belonging to a group is our basic social need, thus it’s a strong reinforcer.
But the reported improvement may have nothing to do with the treatment. It may be a natural side-effect of meaningful and positive social interaction. Therefore, the more time passes after the treatment, the stronger credibility of the results. As a golden rule, don’t trust results obtained less than 6 months after the completion of therapy.
3) Standards and quality of delivery
The third kind of evidence, after theory and outcomes, is evidence of the implementation and delivery standards. Psychotherapy is not like pharmacotherapy. Here lies the biggest difference between the two: Psychotherapy can’t be manufactured under strictly controlled conditions in one factory (or at one university) and then physically distributed by anyone who can sell it. The quality of therapy always depends on who delivers it. In other words: psychotherapy is always re-made during each therapy session.
psychotherapy is always re-made during each therapy session
So, we can of course be guided by whether the treatment is considered as an evidence-based or not. But we must always be sure that what is being delivered to the client is actually that particular treatment, not only by name, but also by the content and quality.
That’s why we need supervision and certification of therapists.
Unfortunately, ACT does not meet this last criterion of evidence-based treatments. It does not have any formally approved training curriculum or standards and there’s no certification of ACT therapists.
The only certification process is peer-reviewing of ACT trainers, and I’m one of those guys. But peer-reviewed trainers represent various fields of expertise: some of us works clinically, while others work with organizations or in educational settings. And what is most important: we can train and supervise, but we can’t certify ACT therapists.
I think that this is the biggest obstacle in implementation and dissemination of ACT, especially in health care systems with high patient security. And I think that this is the reason why EMDR or mentalization based therapy are present in all Norwegian clinics, while ACT is almost absent. They don’t have a better support in evidence, but they have better training and implementation system. And of course, good marketing.
That’s all for today. If you have any questions you want me to address in my future articles (and videos), just mail them to me.
You can also pose your questions on our Facebook group for mental health professionals.
And if you’re interested in my upcoming trainings, visit regularily my website.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.