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În toamna lui 2014, Jurnalul de Psihoterapii Bazate pe Dovezi (Journal of Evidence-Based


Psychotherapies), succesor al Jurnalului de Psihoterapii Cognitiv-Comportamentale (Journal of
Cognitive and Behavioral Psychotherapies), afiliat Institutului Internațional pentru Studiul Avansat al
Psihoterapiei și Sănătate Mintală, condus de Daniel David la Cluj găzduia o dezbatere întrucâtva
surprinzătoare despre calitatea metodologică a studiilor de psihoterapie.

Menită a fi o dezbatere despre punctele tari și cele slabe ale cercetării în psihoterapie, schimbul de opinii
între cei cinci autori nord-americani (o raritate remarcabilă pentru publicistica științifică românească) s-a
transformat mai degrabă într-un cor pe o singură voce. După trecerea exhaustivă în revistă de către
James Coyne și Robin Kok a multiplelor probleme semnificative care separă cercetarea în psihoterapie
de alte tipuri de cercetare psihologică (conflicte evidente de interes, meta-analize deficitare și
părtinitoare, putere statistică extrem de scăzută a studiilor individuale, rata de rezultate
confirmatorii implauzibil de ridicată), ceilalți trei autori care răspund acestui articol au recunoscut
poziția ingrată în care se găseau, aceea de a nu putea decât să le dea dreptate lui Coyne și Kok, deși unii
dintre ei fuseseră chiar peer-revieweri la jurnale care publicau studii de psihoterapie.

Deși autorii propun o serie de reforme urgent necesare pentru îmbunătățirea credibilității cercetării în
psihoterapie (criticile lor fiind remarcate ca de mult știute de ceilalți autori), discuția a rămas, mult mai
mult decât în restul ariilor afectate de criza replicabilității mai grav (psihologia socială, cognitivă) fără
niciun răspuns relevant din partea marilor jurnale sau a cercetătorilor importanți din domeniu,
societățile de admirație reciprocă în care se face cercetare în psihoterapie menționate de Coyne și
Kok continuând să existe și astăzi fără probleme.
Journal of Evidence-Based Psychotherapies is the successor of the Journal of Cognitive and Behavioral Psychotherapies
(2001 •2013) and is published biannually (in March and September} in one volume per year by the International Institute for the
Advanced Studies ofPsychotherapy and Applied Mental Health. The journal is devoted to the advancement ofthe clinical theory
and practice of evidence-based psychotherapies (EBP) (e.g., evidence-based psychological assessments, evidence-based
psychological treatments). The journal publishes original papers dealing with EBP and psychology, psychiatry, the medical and
mental specialties, and allied areas of science. Submissions include (1) articles referring to clinical and experimental studies,
discussions of theory, and systematic reviews for inclusion in Article Section, (2) articles referring to clinical
discussions/developments for inclusion in the Clinical Forum Section, and (3) commentaries, letters to the editor, reviews
and abstracts ofbooks, tapes, and films, salient fmdings in EBP, and other information relevant to the journal's goal for inclusion
in the Development and Resources Section. Finally, the journal seeks to publish special issues devoted to topics of particular
interest, suggestions for which are welcomed by the Editor.
Indexed in: (1) Abstracted: Thomson ISI Web of Science/SSC!; SCOPUS; PsycINFO; and International Bibliography of
Social Science; (2) Full text: EBSCO andProQuest;
FOUNDING EDITOR:
Daniel David, Ph.D., Babe§-Bolyai University, Cluj-Napoca, Romania

EDITOR:
Ioana-Alina Cristea, Ph.D., Babe§-Bolyai University, Cluj-Napoca, Romania (2014-)

ASSOCIATE EDITORS:
Oana David, Ph.D., Babe§-Bolyai University, Cluj-Napoca, Romania
Madalina Sucala, Ph.D., Icahn School of Medicine at Mount Sinai, New York, USA

PAST EDITORS:
Daniel David, Ph.D., Babe~-Bolyai University, Cluj-Napoca, Romania (2001-2008)
Aurora Szentagotai Tatar, Ph.D., Babe~-Bolyai University, Clu}Napoca, Romania (2009-2013)
ADVISORY BOARD Donald Meicbenbaum, Ph.D., Guy Montgomery, Ph.D.,
Waterloo University, Canada Mount Sinai School ofMedicine, USA
David Barlow, Ph.D., Michael Nash, Ph.D., Cristina Pojoga, M.D.,
Boston University, USA Tennessee University, USA Adult Clinical Hospital, Romania
Aaron Beck, Ph.D., Pietro Pietrini, M.D., Ph.D., Simona Popa, Ph.D.,
Pennsylvania University, USA University ofPisa, Italy Oradea University, Romania
Pim Cuijpers, Ph.D. Tullio Scrimalli, M.D., Agnieszka Popiel, M.D.,
VU University, The Netherlands University of Catania Medical Medical University of Warsaw, Poland
Frank Dattilio, Ph.D., School, Italy Jan Prasko, M.D., Ph.D.,
University ofPennsylvania School of Jeffrey Young, Ph.D., 3rd Medical Faculty, Charles
Medicine and Harvard Medical Columbia University, USA University, Czech Republic
School, USA Adrian Rosan, Ph.D.,
Raymond DiGiuseppe, Ph.D., ACTING EDITORIAL BOARD Babe§-Bolyai University, Romania
St. Joh.n University, USA Dan Octavian Rusu, Ph.D.,
Thomas Dowd, Ph.D., Anca Dobrean, Ph.D., Babe§-Bolyai University, Romania
Kent State University, USA Babq-Bolyai University, Romania Mibaela Stinculete, M.D.,
Windy Dryden, Ph.D., Dan Lucian Dumitra,cu, M.D., Ph.D., Adult Clinical Hospital, Romania
London Universi UK luliu Hatieganu University ofMedicine Mehmet Z. Sungur, M.D., Ph.D.,
bert Ellis Ph.D. and Pharmacy, Romania Medical School of
Albert Ellis Institute, USA Claudio Gentili, M.D., Ph.D Marmara University, Turkey
Michael Eysenck, Ph.D., University ofPisa, Italy Jezdimir Zdravkovic, Ph.D.,
London University, UK Irina Holdevici, Ph.D., University ofNis, Serbia
Arthur Freeman, Ph.D., Titu Maiorescu University, Romania
Governors State University, USA Viorel Lupu, M.D., Ph.D., statistical Consultant
David Haaga, Ph.D., luliu Hatieganu University of Medicine Silviu Matu, Ph.D.,
American University, USA and Pharmacy, Romania Babe§-Bolyai University, Romania
Rod Holland, Ph.D., James McMahon, Ph.D.,
Northwick Park Hospital, London, UK Albert Ellis Institute, USA Scientific Secretary
Phillip Kendal, Ph.D., Simona Stefan, Ph.D., Cristina Costescu
Temple University, USA Babe§-Bolyai University, Romania Babef-Bolyai University, Romania
Irving Kirsch, Ph.D., Aurora Szentagotai Tatar, Ph.D.,
Plymouth University, UK Babe§-Bolyai University, Romania Journal's Website Administrator
Elisabeth Loftus, Ph.D., Bogdan Voinescu, Ph.D., Rlzvan Antonescu,
University of California- Irvine, USA Babe§-Bolyai University, Romania Cluj-Napoca, Romania
Scott Lllienfeld, Ph.D.,
Emory University, USA CONSULTING EDITORS Technical Editor
Steven Jay Lynn, Ph.D., Daniel Paul
SUNY at Binghamton, USA Richard Brown, Ph.D., Cluj-Napoca, Romania
Richard McNally, Ph.D., Institute ofNeurology, London, UK
Harvard University, USA Laszl6 Tringer, Ph.D.,
Semmelweis University, Hungary
JOURNAL OF EVIDENCE-BASED PSYCHOTHERAPIES
VOLUME 14 September 2014 NUMBER2

CONTENTS
ARTICLES SECTION
Invited article
Salvaging psychotherapy research: A manifesto 105
JAMES C. COYNE & ROBIN N. KOK

Invited Comment on "Salvaging psychotherapy research: A manifesto"


Improving publication standards for psychotherapy outcome studies 125
BRUCE A. THYER

Invited Comment on "Salvaging psychotherapy research: A manifesto"


The future of empirically supported treatments: A comment on 129
Coyne and Kok
E. DAVID KLONSK Y

Invited Comment on "Salvaging psyclwtherapy research: A manifesto"


Reply to "Salvaging psychotherapy research: A manifesto", by 133
James C. Coyne and Robin N. Kok
EILEEN GAMBRILL

Predictors of quality of life during chemotherapy for breast cancer. 13 7


Investigating the role of multidimensional symptoms and dysfunctional
beliefs
MA.DA.LINA SUCALA, CRISTINA PETRISOK PATRICfU ACHIMAS-CADARIU,
DANlEL DAVID

The development and evaluation of a flexible training course 149


"Understanding and developing compassion"
ANITA LAIDLAW, JENNIFER HUNTER, TONY TURVEY, MATT STILLMAN,
ROB WARREN, GOZDE OZAKINCI

Efficacy of the Rational Positive Parenting program for child 159


externalizing behavior: Can an emotion-regulation Enhanced Cognitive-
Behavioral Parent program be more effective than a standard one?
OANA ALEXANDRA DAVID, DANIEL DAYID, ANCA DOBREAN

Psychometric properties of the Turkish version of the Acceptance and 179


Action Questionnaire-II (AAQ-Il)
BAHAR MEUNIER, SINEM ATMACA, EL<;IN AYRANCI, BURCU PINAR
GDKDEMIR, TUGBA UY AR, GULBAHAR BASTUG

Differences between empathic responses in children with autism 197


spectrum disorder and typically developing children
IULIA BUTEAN, CRISTINA COSTESCU, ANCA DOBREAN

Definition of efficiency indices for three-category diagnostic tests 211


TERESA RIVAS & FRANCISCO FELIX CABALLERO
Mindfulness-Based Cognitive-Behavior Therapy (MCBT) versus Virtual 229
Reality (VR) Enhanced CBT, versus treatment as usual for chronic back
pain. A clinical trial
RALUCA IGNA, SIMONA STEFAN. IOAN ONAC, JOANA ONAC,
RODJCA-ANA UNGUR, AURORA SZENTAGOTAI TAT AR

The relationship between emotion regulation, dysfunctional beliefs 249


about sleep and sleep quality - An exploratory study
CRISTINA SANDRU & BOGDAN l VOINESCU

Evidence-based research: The importance for the present and future 259
of evidence-based practice
DEMETRIS KA TSIKIS

The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health
(HAS of PAMH) is a research Institute of the Babes-Bolyai University (BBU), located in Cluj-
Napoc~ Romania. Babes-Bolyai University is one of the oldest, most prestigious, and influential
academic settings in Romania and in the Eastern-Central Europe (http://www.ubbclui.ro). It has
been almost four centuries since the beginnings of this university of Cluj-Napoca. The first project
to set up a higher education institution in Cluj-Napoca was recorded in 1565, and in 1581 it wa'> set
up an academic college, organized and run by Jesuits. Since then Babes-Bolyai University has
become a modern institution which acquired a remarkable fame by its long-time achievements at
national and international level. The Institute will invite as affiliates/partners prestigious
organizations involved in the development of psychotherapy and applied mental health
interventions. JIAS of PAMH aims to promote advanced study and scholarship in applied mental
health by research ..

The Faculty of IIAS of PAMH will have strategic and consultative responsibilities. It is composed
of prestigious professionals in the area of Psychotherapy and Applied Mental Health Interventions:

Dr. David Barlow Boston University. USA Dr. Phillip Kendal, Temple University, USA
Dr. Aaron Beck, Pennsylvania University, USA Dr. Irving Kirsch, Plymouth University, UK
Dr. Michael Broder. Albert Ellis Institute. llSA Dr. Elisabeth Loftus, University of California-Irvine, USA
Dr Pim Cuijpers, VU University Amsterdam. The Dr. Scott Lilienfeld, Emory University, USA
Netherlands Dr. Steven Jay Lynn, SUNY at Binghamton, USA
Dr. Frank Dattilio, Harvard Medical School, USA Dr. Richard McNally, Harvard University, USA
Dr. Raymond DiGiuseppe, St John's University, USA Dr. Donald Meichenbaum, Waterloo University, Canada
Dr. Thomas Dowd, Kent State University, USA Dr. Emmett Velten+, Albert Ellis Institute, USA
Dr. Windy Dryden, London University, UK Dr. Ann Vernon, Albert Ellis Institute, USA
Dr. Albert Ellis +, Albert Ellis Institute, USA Dr. Jeffrey Young, Columbia University, USA
Dr. Michael Eysenck, London University, UK
Dr. Michael First, Columbia University, USA
Dr. Arthur Freeman, Governors State University, USA
Dr. David Haaga, American University, USA
Dr. Steven Hayes, University of Nevada, USA

Specific information and more detailed information about HAS of PAMH may be obtained by
visiting our website at: http://www.psychotherapy.ro or by emailing us to
internationalinstitute@psychology.ro
Articles Section

Journal of Evidence-Based Psychotherapies,


Vol. 14, No. 2, September 2014, 105-124.

Invited article

SALVAGING PSYCHOTHERAPY RESEARCH:


A MANIFESTO
James C. COYNE*1,2 & Robin N. KOK3,4
1
Department of Health Psychology, University of Groningen, University Medical
Center, Groningen, the Netherlands
2
Institute for Health, Health Care Policy and Aging Research, Rutgers,
The State University of New Jersey, USA
3
Department of Clinical Psychology and the EMGO institute for Health and Care
Research, Faculty of Psychology and Education,
VU University Amsterdam, The Netherlands
4
Centre for Mental Health Research, The Australian National University,
Canberra, Australia

Abstract
Recognition of the unreliability of findings in the biomedical literature, and
especially pharmaceutical trials has led to a number of reforms. These
include reporting preregistration of protocols for clinical trials and meta-
analysis, reporting standards and making data available to others for all
clinical trials, as well as recognition of the influence of conflicts of interest.
These improvements are only partially and inconsistently reflected in the
literature evaluating psychotherapies. The psychotherapy literature is
currently of too poor quality to provide a reliable guide to clinicians,
consumers, and policymakers. The literature is dominated by underpowered
trials with high risk of bias producing positive effects at a statistically
improbable rate. Meta-analyses that are poorly conducted with undisclosed
conflicts of interest compound these problems. A number of reforms are
proposed. These include accelerating adoption of those already occurring in
the pharmaceutical literature. Additionally, psychotherapy research should
parallel the orderly sequence of treatment development seen in the
pharmaceutical literature. Phase III trials providing the effect sizes of
treatments should not be conducted until the acceptability of treatment and
the feasibility of accruing sufficient numbers of patients are established.
The role of investigator allegiance as a potential and potent source of
conflict of interest needs to be recognized. Yet, enforcement of existing
standards could counter many of the deficiencies of the current literature,

*
Correspondence concerning this article should be addressed to:
E-mail: jcoynester@gmail.com

Salvaging Psychotherapy Research: A Manifesto 105


Articles Section

but such enforcement may only come with pressures emanating from
outside the field of psychotherapy.

Keywords: CONSORT, reporting standards, confirmatory bias, investigator


allegiance, meta-analysis, conflict of interest.

In landmark papers that were enlightening to some and infuriating to


others, John Ioannidis postulated that most positive findings in biomedical
journals are false (Ioannidis, 2005) and that most ‘breakthrough’ discoveries are
either exaggerated or fail to replicate (Ioannidis, 2008). In support, Ben Goldacre
(2012) has raised important issues about the integrity and credibility of the
literature concerning the efficacy of pharmaceuticals, including selective
publication of positive trial data. He documented that:
“Drugs are tested by the people who manufacture them, in poorly designed
trials, on hopelessly small numbers of weird, unrepresentative patients, and
analysed using techniques which are flawed by design, in such a way that they
exaggerate the benefits of treatments. Unsurprisingly, these trials tend to
produce results that favour the manufacturer. When trials throw up results that
companies don't like, they are perfectly entitled to hide them from doctors and
patients, so we only ever see a distorted picture of any drug's true effects.”
(Goldacre, 2012, p. x)
These revelations have added to widespread skepticism about claims of
the efficacy of pharmaceutical treatment as being based on results of poorly
designed studies, synthesized in meta-analyses that can only be as reliable as the
studies they integrate and that often introduce additional biases. For example,
entering results of unpublished studies that were reported to the US Food and
Drug Administration (FDA) into meta-analyses with published studies have led to
substantially lowered estimates of the efficacy of antidepressants (e.g., Turner,
Matthews, Linardatos, Tell, & Rosenthal, 2008).
Considerable efforts at reform are underway, involving;
1. Preregistration of clinical trials so that it is more difficult to hide negative
trials or alter analytic plans after results are known (Zarin, Tse, Williams,
Califf, & Ide, 2011);
2. Reporting standards that ensure more transparent and detailed papers so
that results of trials can be independently validated (CONSORT; Schulz,
Altman, & Moher, 2010).
3. Reporting standards (PRISMA; Liberati et al., 2009) and pre-registration
of plans for meta-analyses and systematic reviews (PROSPERO; Booth et
al., 2011);
4. Making trial data available for independent reanalysis (Peat et al., 2014).
The literature concerning the efficacy of psychotherapy is, in some
respects, modelled after the literature concerning the evaluation of
pharmaceuticals in randomized controlled trials (RCTs). However, psychotherapy
literature often lags in adopting reforms such as recognition of risk of bias,

106 James C. Coyne & Robin N. Kok


Articles Section

reporting standards, and preregistration of trials. For instance, in comparison with


biomedical journals, CONSORT was adopted later and less consistently by
psychological journals. The Association for Psychological Science has yet to
adopt CONSORT. An example of lapses in reporting can be found in its journal
Psychological Science, where a null clinical trial is presented as positive, with no
clear labeling as a clinical trial (Kok et al., 2013). Investigator allegiance (Thase,
2006) and conflicts of interest are still given little attention in evaluating results of
psychotherapy studies as compared to pharmacological trials. However, as a
conflict of interest, investigator allegiance poses the same risk of bias that is more
easily and readily recognized in psychopharmacological studies (Khurana,
Henderson, Walter, & Martin, 2012; Perlis et al., 2005; Shimazawa & Ikeda,
2014).
Although preregistration of psychotherapy trials is now encouraged –
indeed required by some journals – enforcement is lax, with some high profile
trials (Morrison et al., 2014) exposed as registered after initiation of collection of
data (Coyne & van Linschoten, 2014). Key features of pre-registered design and
analyses are simply ignored in the subsequent publication of results (Milette,
Roseman, & Thombs, 2011). Results of some trials, which could potentially alter
public perceptions of the efficacy of particular therapies, are left unpublished after
being registered and completed (Klingberg et al., 2010) and linger in the file
drawer. Unfortunately, preregistration of trials is inconsistent, so the full extent of
this phenomenon cannot be determined as we have no knowledge of trials that
were both unregistered and subsequently left unpublished. Ignoring or altering
details of a trial’s registration after trial completion negates the purpose of
registration, but is given little attention in the process of peer reviewing reports of
results for publication.
In this paper, we argue that the psychotherapy literature needs to at least
catch up to the pharmaceutical literature in terms of transparency, accountability
and reliability of findings. Of course, much remains to be done to ensure the
quality and transparency of drug studies and to get all of the data into public view.
But psychotherapy researchers would do well to adopt and enforce some of the
positive steps that are now seen in the pharmaceutical literature.
Furthermore, psychotherapy research would do well to adhere more to the
orderly, progressive treatment development seen in pharmaceutical research: from
proof of concept (Phase I) to demonstration of feasibility and acceptability (Phase
II) to evaluation in randomized trials (Phase III). Clear identification of phases
would allow distinguishing between what particular studies can, and possibly
even more important, cannot tell us. Moreover, a systematic weeding out of
interventions that are unacceptable to patients or unfeasible trials in Phases 1 and
2 would prevent many ill-conceived trials being interpreted as providing estimates
of efficacy, when they are crippled by problems in recruitment and low statistical
power.

Salvaging Psychotherapy Research: A Manifesto 107


Articles Section

As it now stands, the psychotherapy literature does not provide a


dependable guide to policy makers, clinicians, and consumers attempting to
assess the relative costs and benefits of choosing a particular therapy over others.
If such stakeholders uncritically depend upon the psychotherapy literature to
evaluate the evidence-supported status of treatments, they will be confused or
misled.

The dire state of psychotherapy research

In the broader field of science, many RCTs are underpowered, yet


consistently obtain positive results by redefining the primary outcomes after
results are known (Chan, Hróbjartsson, Haahr, Gøtzsche, & Altman, 2004; Pinto
et al., 2013). A psychotherapy trial with 30 or fewer patients in the smallest cell
has less than a 50% probability of detecting a moderate size, significant effect,
even if it is present (Coyne, Thombs, & Hagedoorn, 2010). Typical
psychotherapy RCTs are small, methodologically flawed studies conducted by
investigators with strong allegiances to one of the treatments being evaluated
(Munder, Brütsch, Leonhart, Gerger, & Barth, 2013). Moreover, a lack of
enforcement of trial preregistration allows for consistently positive results by
redefining the primary outcomes after results are known, effectively cherry-
picking the most positiveoutcomes from a battery of outcome measures.
Examination of the studies mustered for treatments being evidence
supported by APA Division 12 (http://www.div12.org/empirically-supported-
treatments/) indicates that many studies were of low methodological quality and
too underpowered to be reliably counted as evidence of efficacy, yet were
included without comment about these problems. Taking an overview, it is
striking to see the extent to which the literature continues to depend on small,
methodologically flawed RCTs conducted by investigators with strong
allegiances to one of the treatments being evaluated. Yet, which treatment is
preferred by investigators is a better predictor of the outcome of the trial than the
specific treatment being evaluated (Luborsky et al., 2006).
Many positive findings in psychotherapy research are created by spinning
outcomes, involving confirmatory bias, flexible rules of design and recruitment,
data analysis, selective outcome reporting and significance chasing (Simmons,
Nelson, & Simonsohn, 2011), as demonstrated in psychotherapy research on
depression (Flint, Cuijpers, Horder, Koole, & Munafò, 2014). Many studies
considered positive, including those that become highly cited, are basically null
trials for which results for the primary outcome are ignored, and post-hoc analysis
of secondary outcomes and subgroup analyses are emphasized (Bach & Hayes,
2002; Dimidjian et al., 2006; Morrison et al., 2014). In a recent re-analysis of
individual patient data trials, no fewer than 35% of re-analyses led to conclusions
that differed from the findings of the original paper (Ebrahim et al., 2014).

108 James C. Coyne & Robin N. Kok


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Confirmatory bias and the spinning of weak and null findings generally
start in abstracts (Yavchitz et al., 2012). Although CONSORT has specific
recommendations for what should be reported in abstracts (Hopewell et al., 2008),
these standards are largely ignored in reports of its psychotherapy interventions.
A recent review of studies of therapy for couples dealing with cancer found
important discrepancies between the positive spin in abstracts and the actual
results in the paper (Coyne, 2013; Cristea, Kafescioglu, & Coyne, 2013). It is
likely this pattern is much more common, given the lack of attention of editors
and reviewers to either CONSORT for abstracts or discrepancies between
abstracts and results sections. Indeed, there seems to be a strong link between
significant study results, subsequent publication bias and deviations from study
protocol (Dwan, Gamble, Williamson, & Kirkham, 2013).
The bulk of psychotherapy RCTs involve comparisons between a single
active treatment and an inactive control group such as wait list, no treatment, or
“routine care”. The latter is typically left undefined but often lacks exposure to
any treatment of adequate quality and intensity (Hesser, Weise, Rief, &
Andersson, 2011; Posternak & Miller, 2001). In many instances, there may be
little difference between routine care and no treatment at all. At best, these studies
with inactive control groups can tell us whether a treatment is better than doing
nothing at all, or better than the possible nocebo effect of patients expecting
treatment because they have enrolled in a trial but not getting it (Furukawa et al.,
2014). In sum, the design of a clinical trial and its comparison groups have a
substantial impact on effect sizes (Mohr et al., 2009) and this effect should not be
ignored, particularly as a source of heterogeneity in any synthesis of the literature.

Meta-silliness?

Hans Eysenck reacted to the first meta-analysis of the effects of


psychotherapy (Smith & Glass, 1977) with a dismissal of it as meta-silliness
(Eysenck, 1978). Regardless, Smith and Glass’ application of meta-analysis
showed the potential power of integrating data from multiple independent trials
into summary statistics. The trials that were available at that time were quite
limited in quality, and their integration in a single meta-analysis was crude by
contemporary standards. Nonetheless, the concept of using meta-analysis to
integrate and interpret data from multiple clinical trials caught on beyond
psychology.
However, psychotherapy researchers have generally lagged behind
clinical epidemiology and biomedical meta-analyses in terms of adopting
standards for conducting and reporting meta-analyses, as well as methodological
and statistical innovations. Meta-analyses of psychotherapy, even in top-tier
journals, often lack reproducible literature search strategies (e.g., Wolitzky-
Taylor, Horowitz, Powers, & Telch, 2008), do not qualify conclusions by grade of
evidence, ignore clinical and statistical heterogeneity, address investigator

Salvaging Psychotherapy Research: A Manifesto 109


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allegiance inadequately or not at all (Dragioti, Dimoliatis, & Evangelou, 2014),


downplay the domination of the analyses by small trials with statistically
improbable rates of positive findings (Rücker, Carpenter, & Schwarzer, 2011) and
ignore the extent to which positive effect sizes occur mainly in comparisons
between active and inactive treatments.
Meta-analyses of psychotherapies are strongly biased toward concluding
that treatments work, especially when conducted by those who have undeclared
conflicts of interest and investigator allegiances. This includes developers and
promoters of treatments that stand to gain financially or otherwise from their
branding as “evidence-supported” (e.g., Hayes, Luoma, Bond, Masuda, & Lillis,
2006; Johnson, Hunsley, Greenberg, & Schindler, 2006; Nowak & Heinrichs,
2008; Sanders, Kirby, Tellegen, & Day, 2014), as well as meta-analyses
organized by professional organizations (Hart et al., 2012) intent on
demonstrating the availability of evidence supported treatments for dissemination
and reimbursement (Coyne, 2012).
Overall, meta-analyses too heavily depend on underpowered, flawed
studies conducted by investigators with strong allegiances to a particular
treatment or to finding that psychotherapy is in general efficacious. When
controls are introduced for risk of bias or investigator allegiance, effects greatly
diminish or even disappear (Cristea, Kok, & Cuijpers, in press; Munder et al.,
2013; Staines & Cleland, 2007).
Conflicts of interest associated with authors having substantial financial
benefits at stake are rarely disclosed in the studies that are reviewed or the meta-
analyses themselves. Moreover, claims from these flawed meta-analyses are often
backed up by invoking Fail-safe N (Orwin, 1983), or number of negative trials
that would have to be published to bring the reported effect size to zero. Although
there are a number of serious statistical, conceptual and practical issues with this
statistic (Becker, 2005; Heene, 2010), this sometimes staggeringly high number is
touted as evidence for the robustness of the effect size, presenting the results to
unwitting readers as definitive ‘evidence’ and discouraging them from looking
further. Fail-safe N is often conveniently used even if more sensitive and accurate
techniques have been widely available for more than 15 years (e.g., Duval &
Tweedie, 2000; Egger, Smith, Schneider, & Minder, 1997). Moreover, if
publication bias is not reported, we should not simply assume it is not there – it
often is, but it is not reported either erroneously or deliberately (Onishi &
Furukawa, 2014). However, both journals and authors are to blame for the
publication bias (Malički & Marušić, 2014) and although some solutions have
been proposed (Smulders, 2013), these have not met with wide acceptance.

The scam of continuing education credit

Requirements that therapists obtain continuing education credit are


intended to protect consumers from outdated, ineffective treatments and to

110 James C. Coyne & Robin N. Kok


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disseminate up-to-date, evidence-based treatment into the community. But there is


inadequate oversight of the scientific quality of exactly what is offered and by
whom. Continued education credit is offered for treatments that have
unestablished efficacy or for which efficacy is established only in a narrow range
of clinical problems and populations. The American Psychological Association
(APA) suppresses discussion of the problem by prohibiting groups of members
publicly protesting the quality of what is being offered. As a result, APA
continues to allow education credits for bogus and unproven treatments
like thought field therapy and somatic experiencing.
Providing opportunities for continuing education credit is lucrative for
both accrediting bodies and sponsors. In the competitive world of workshops and
trainings, entertainment value trumps evidence. Training in delivery
of manualized evidence-supported treatments has little appeal when alternative
trainings emphasize patient testimonials and dramatic displays of sudden
therapeutic gain in carefully edited videotapes, often with actors rather than actual
patients. Branding treatments as evidence supported is used to advertise
workshops and trainings in which the particular crowd-pleasing interventions that
are presented are not evidence supported.
For instance, clinicians attending Acceptance and Commitment (ACT)
workshops may see videotapes where the presenter cries with patients. These
clinicians should ask themselves: “Entertaining, moving perhaps, but is this an
evidence supported technique?”. Although claims are made for the superiority of
clinical superiority of ACT over other therapies (Levin & Hayes, 2009), a recent
meta-analysis reveals that despite its widespread acceptance, the evidence base
for ACT is at best weak when compared to established treatments (Öst, 2014).
More generally, it is commonplace for psychotherapies with modest support from
evidence to be overenthusiastically advocated for conditions even though there is
no evidence for their efficacy for that particular condition. What would be
disallowed as “off label applications” for pharmaceuticals is routinely accepted in
psychotherapy workshops and when under scrutiny, ‘evidence-based’ often turns
out to mean ‘evidence-assumed’. Yet the therapists sign off on the attendance list
for continuing education credit, go home and the accrediting body gets its pay.
We know we can do better

Psychotherapy research has achieved considerable sophistication in


design, analyses, and comprehensive statistical strategies to compensate for
missing data such as multiple imputation and moderator analyses to elucidate
mechanisms of change. Yet, psychotherapy research lags behind the rigors of
pharmaceutical research and clinical epidemiology.
Psychotherapy research already has recommendations and requirements
for trial preregistration, a comprehensive checklist for structured reporting of
protocols of clinical trials (SPIRIT; Chan et al., 2013), including specification of

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primary outcomes; completion of CONSORT checklists to ensure basic details of


trials are reported; preregistration of meta-analyses and systematic reviews at sites
like PROSPERO, as well as completion of the PRISMA checklist for adequacy of
reporting of meta-analyses and systematic reviews (Liberati et al., 2009).
Recently, a strong call for promoting replications in psychological science was
issued (Koole & Lakens, 2012), but there is little echoing in the psychotherapy
literature.
Declarations of conflicts of interest are rare and exposure of authors who
routinely failed to disclose conflicts of interest is even rarer. At best, in the
unusual cases where someone is found out, the original paper may receive a
small, unnoticed erratum buried deep on the journal’s website.
Departures from preregistered protocols in published reports of RCTs are
common, and there is little checking of discrepancies in abstracts from results that
were actually obtained, or promised in preregistration by authors. There
is inconsistent and incomplete adherence to these requirements. There is little
likelihood that noncompliant authors will be held accountable and a strong
incentive to report positive findings in order for a study to be published in a
prestigious journal such as the APA’s Journal of Consulting and Clinical
Psychology (JCCP). Examining the abstracts of papers published in JCCP gives
the impression that trials are almost always positive, even when seriously
underpowered. A recent review of publication bias in JCCP even declared that
psychotherapy research was only marginally affected by selective reporting of
positive outcomes (Niemeyer, Musch, & Pietrowsky, 2013); despite recent
evidence of excess significance in psychotherapy research (Flint et al., 2014).
Psychotherapy research is conducted and evaluated within a mutual
admiration society in which members are careful not to disparage others’ results
or to embrace standards that they themselves might want relaxed when it comes to
evaluation of their own research. There are rivalries between tribes like
psychodynamic therapy and cognitive behavior therapy (Leichsenring & Rabung,
2011) that preclude acceptance of common methodological and statistical
standards once debate becomes heated (Coyne, Bhar, Pignotti, Tovote, & Beck,
2011). However, within the tribes, there is muted criticism and strenuous efforts
to create the appearance that tribe members only ‘do what works’ (Ioannidis,
2012).

Fewer, better randomized controlled trials


One striking contrast between the psychotherapy literature and the
literature concerning the evaluation of pharmaceuticals is the utter dearth of
psychotherapy studies explicitly labeled as Phase II studies in the predominance
of underpowered, under-resourced Phase III trials. In the development of
pharmaceutical research, a distinct Phase II trial is necessary, in which basic data
are collected in terms of the acceptability and tolerability of a treatment, including

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dosage required to increase acceptability and decrease negative side effects. At


this point, the drug is not assumed to have any therapeutic effect whatsoever.
Parameters set in Phase II trials are used to guide the design of Phase III trials so
that these later studies can be assured of accruing appropriate numbers of patients
and retaining them for follow-up. In psychotherapy literature, in contrast, there is
frequently a direct move from an interesting concept or variation on an existing
treatment to an underpowered efficacy trial that is nonetheless claimed to generate
large effect sizes. These trials are often under-resourced and when viewing odd,
small numbers of patients in each cell (e.g., why 14 patients rather than 17?), this
undoubtedly reflects a convenience sample and an inability to reach a larger
sample size with available resources and within an acceptable timeframe (for an
example, see Seppälä et al., 2014).
Without preregistration, there is no indication of why the investigators
stopped when they did, but such small sample sizes would hardly be justified by
any formal power analysis. We believe that this phenomenon reflects
investigators simply charging ahead and continuing accrual until resources are
exhausted, or worse, a monitoring of incoming data reveals a positive effect and
so recruitment is stopped, informed by the results that have been achieved.
Formal stopping rules and rules for interim analyses (SPIRIT item 21b, Chan et
al., 2013, p. 4) are rarely described in psychotherapy research protocols.
Preregistration may take time to be enforced as a requirement for publication, but
editors and reviewers can certainly be stopped from accepting small
underpowered trials and thereby stop entering spurious effect sizes into the
literature. The negative correlation between effect size and sample size and its
commensurate overabundance of p-values only just crossing the border of
statistical significance cannot be ignored (Kühberger, Fritz, & Scherndl, 2014).
Small trials may be used to generate information about basic parameters
in the design of larger trials, but should not be used to generate effect sizes.
Indeed, the accepted practice of investigators disguising what are more
appropriately Phase II trials as Phase III trials generating statistically improbable
effect sizes leads to gross overestimates of the efficacy of particular treatments
and discouragement of more adequately resourced and powered trials.

Keeping up pressures for reform from without

Journals and their editors have often resisted changes such as adoption of
CONSORT, structured abstracts, and preregistration of trials. The
Communications and Publications Board of the American Psychological
Association made APA one of the last major holdout publishers to endorse
CONSORT and initially provided an escape clause, stating that CONSORT only
applied to articles explicitly labeled as a randomized trial (Coyne, Cook, Palmer,
& Rusiewicz, 2004), even though implementation of CONSORT has resulted in a
measurable improvement in trial reporting elsewhere (Pandis, Shamseer, Kokich,

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Fleming, & Moher, 2014; Plint et al., 2006). The board also blocked a push by the
Editor of Health Psychology for structured abstracts (Hopewell et al., 2008) that
reliably report details needed to evaluate what had actually been done in trials and
the results were obtained. In both instances, the committee was most concerned
about the implications for the major outlet for clinical trials among its journals,
the Journal of Consulting and Clinical Psychology (2013 impact factor: 5.2).
Although generally not an outlet for psychotherapy trials, the journals of
the Association for Psychological Science (APS) show signs of even being worse
offenders in terms of ignoring standards and commitment to confirmatory bias.
For instance, it takes a reader a great deal of probing to discover that a high-
profile paper (Kok et al., 2013) was actually a randomized trial and it needs even
further detective work to discover that it was actually a null trial, despite its
positive abstract. There is no indication that a CONSORT checklist was ever filed
for the study. And despite this, results of the Psychological Science article are
cited to promote workshops (Mentorcoach, 2014) even though the published
article explicitly denies any conflict of interest for the authors (Kok et al., 2013, p.
1131).
There will undoubtedly be a struggle between APS and APA clinical
journals for top position in the hierarchy, by publishing only papers that are
attention grabbing, even if flawed, while leaving to other journals that are
considered less prestigious the publishing of negative and null trials and failed
replications. Standards for pre-registering and reporting clinical trials are likely to
continue to be sacrificed in the struggle.
If there is to be reform, pressures must come from outside the field of
psychotherapy, from professionals without vested interests in promoting
particular treatments or the treatments offered by members of professional
organizations. Pressures must also come from skeptical external review by
consumers and policymakers equipped to understand the games that
psychotherapy researchers play in creating the appearance that all treatments
work, but the dodo bird is dead.
We need to raise stakeholders’ levels of skepticism, disseminate critical
appraisal skills widely and provide for their application in evaluating exaggerated
claims and methodological flaws in articles published in prestigious, high impact
journals. Bad science in the evaluation of psychotherapy must be recognized as
the current norm, not an anomaly. Unfortunately, much psychotherapy research is
not just bad science – as this is easily spotted by the trained eye – but cargo-cult
science: bad science posturing as legitimate science while hiding its shortcomings
and inflating its positive results.

We could get far by enforcing rules that we already have

We need to continually expose journals’ failures to enforce accepted


standards about preregistration, disclosure of conflicts of interest, and

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discrepancies between published clinical trials and their preregistration. This is


especially the case for meta-analyses, as modern meta-analytical software has
made it trivial to produce meta-analyses. With carefully chosen selection criteria,
these meta-analyses can cherry-pick primary data to support a certain viewpoint
(Egger & Smith, 1998) while at the same time obfuscating the methodological
deficiencies of the primary studies. As the primary articles sink into oblivion, all
that remains is the inflated effect size reported in the meta-analysis, cleared from
all its methodological flaws.
There are too many blatant examples of investigators failing to deliver
what they promised in the preregistration, registering after trials have started to
accrue patients or openly changing trial protocols after recruitment, and reviewers
apparently not ever checking if authors deliver on the primary outcomes and
analyses promised in trial registration.

Implementing reform
Editors should:
• Require an explicit statement of whether the trial has been registered and
where. SPIRIT for trial protocols should be disseminated and enforced.
Trials without prior registration should be rejected outright;
• Insist that reviewers consult trial registration, including modifications
made during recruitment, and comment on any deviation; especially with
regards to sample size and outcome measures. Deviations from protocol
should be explicitly mentioned in the manuscript;
• Explicitly label registration and alterations dated after patient accrual has
started.
CONSORT for abstracts and outcome papers should be disseminated and
enforced. A lot of hype and misrepresentation in the media starts with authors’
own spin in the abstract. Editors should insist that main analyses for the
preregistered primary outcome be presented in the abstract and highlighted in any
interpretation of results to prevent minor, chance significant findings on
secondary outcomes from being hyped.
No more should underpowered exploratory / pilot / feasibility studies be
passed off as full-fledged RCTs when they achieve positive results. An orderly
sequence of treatment development should occur before conducting what are
essentially Phase III randomized trials. Researchers should be well aware of the
possibilities and limitations of feasibility and pilot trials (Arain, Campbell,
Cooper, & Lancaster, 2010; Leon, Davis, & Kraemer, 2011).
Here, as elsewhere in reforming psychotherapy research, there is
something to be learned from drug trials – both in what to do, and what not to do.
A process of intervention development ought to include establishing the
feasibility (or proof-of-concept) and basic parameters of clinical trials to proceed

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as Phase III randomized trials, but cannot be expected to substitute for Phase III
trials or to provide effect sizes for the purposes of demonstrating efficacy or
comparison to other treatments.
Use of wait list, no treatment, and ill-defined routine care as control
groups should be discouraged. No-treatment conditions are unethical if there are
well-established treatments and should be rejected outright by any Institutional
Review Board or Ethics Committee principally and by journals in the case of a
non-reviewed trial. Disconcertingly, these studies still appear to be published
(e.g., Jensen & Ramasamy, 2009).
For clinical conditions for which there are well-established treatments,
head-to-head comparisons should be conducted, as well as including control
groups that might elucidate mechanisms of action. A practical example of the
latter would be structured, supportive therapy that controls for attention and
positive expectation. These trials should be conducted in a properly powered non-
inferiority design with of necessity a large number of participants (D’Agostino,
Massaro, & Sullivan, 2003; Nutt, Allgulander, Lecrubier, Peters, & Wittchen,
2008), of course with the appropriate CONSORT-extension for non-inferiority
designs followed (Piaggio, Elbourne, Altman, Pocock, & Evans, 2006).
Preferably, analyses of outcomes should be conducted blinded by an independent
statistician.
There is little to be gained by a further accumulation of small,
underpowered studies in which the efficacy of the preferred treatment is assured
beforehand by comparing it to a lamed control group that lacks any conceivable
element of affective care. The winner is always a foregone conclusion in these
trials. There are enough pharmaceutical trials where the new drug is compared to
a sub-therapeutic dose of the competing drug – we see easily through this trick in
drug trials, why not in psychotherapy?
Evaluations of treatment effects should take into account prior
probabilities suggested by the larger literature concerning comparisons between
two active, credible treatments – not just previous trials with inflated effect sizes
from the same researchers. The well-studied treatment of depression literature
suggests some parameters: effect sizes associated with a treatment are greatly
reduced when comparisons are restricted to credible, active treatments; with better
quality studies; and when controls are introduced for investigator allegiance (Flint
et al., 2014).
It is unlikely that initial claims about a breakthrough new treatment
exceeding the efficacy of existing treatments will be sustained in larger studies
conducted by investigators independent of developers and promoters. However,
these initial claims are often eagerly accepted by high-impact journals and serve
as a basis for statistically powering subsequent trials and replications. After all,
trials are powered based on an expected effect size. As such, an initially hyped
treatment with a high effect size will lead later researchers to underpower their
studies as they expect to find an effect size roughly equivalent to the initial study.

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Such errors in powering can cascade through generations of underpowered trials


and label a new treatment as ‘promising’ for decades where just a few well-
powered rigorous trials would spell the end for this ‘promising’ new treatment.
Additionally, it could be argued that to conduct a number of these underpowered,
small-scale and inconclusive trials is not only a waste of resources but also
unethical to the trial participants, whose time, efforts and inconveniences
contributed to the trial are ultimately futile. These underpowered studies can have
negative effects on clinical services and social policy (Coyne & Kwakkenbos,
2013) that can be costly from a societal perspective.
Disclosure of conflicts of interest should be enforced and nondisclosure
identified in correction statements and further penalized. Apart from reporting of
conflicts of interest, reviewers and meta-analysts should consider investigator
allegiance when assessing risk of bias (Coyne, 2013a) and should themselves
proactively and voluntarily declare any conflicts of interest, financial or otherwise
(Viswanathan et al., 2014 propose some useful questions for this issue).
Developers of treatments and persons with significant financial gain from a
treatment being declared “evidence-supported” should be discouraged from
conducting meta-analyses of their own treatments (e.g., Sanders et al., 2014).
Trials should be conducted with sample sizes adequate to detect at least
moderate effects based on realistic – not hyped – prior effect sizes. When large
positive findings from underpowered studies are published, readers should
scrutinize the literature for similarly underpowered trials that achieve similarly
positive effects and be wary of any claims made.
Meta-analyses of psychotherapy should incorporate techniques to detect
significance chasing in primary studies (Kühberger et al., 2014), such as p-
hacking detection techniques (Simonsohn, Nelson, & Simmons, 2014) and tests of
excess significance (Ioannidis & Trikalinos, 2007; Ioannidis, 2013) to evaluate
the likelihood that patterns of significant findings exceeds likely probability.
Publication bias (Duval & Tweedie, 2000; Egger et al., 1997; Sterne & Egger,
2001), significant heterogeneity (Ioannidis, Patsopoulos, & Evangelou, 2007;
Thompson & Sharp, 1999) and small-study effects in meta-analyses (Harbord,
Egger, & Sterne, 2006) should also be explored and, when present, adequately
addressed or controlled for.
Adverse events and harms should routinely be reported (Vaughan,
Goldstein, Alikakos, Cohen, & Serby, 2014), including estimates of lost
opportunity costs such as failure to obtain more effective treatment.
We need to shift the culture of doing and reporting psychotherapy
research. We need to shift from praising exaggerated claims about treatment and
faux evidence generated to promote opportunities for therapists and their
professional organizations. Instead, it is much more praiseworthy to
provide robust, sustainable, reproducible, generalizable (even if more modest)
claims and to call out hype and hokum in ways that preserve the credibility of
psychotherapy.

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The alternative is to continue protecting psychotherapy research from


stringent criticism and enforcement of standards for conducting and reporting
research. We can simply allow the branding of psychotherapies as “evidence
supported” to fall into appropriate disrepute. We have the tools and the
knowledge, now we need the consensus, cooperation and persistence.

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Journal of Evidence-Based Psychotherapies,


Vol. 14, No. 2, September 2014, 125-128.

Invited Comment on
“Salvaging psychotherapy research: A manifesto”

IMPROVING PUBLICATION STANDARDS FOR


PSYCHOTHERAPY OUTCOME STUDIES
Bruce A. THYER*
College of Social Work, Florida State University, USA

Keywords: psychotherapy research, publication standards,


evidence-based practice

The manifesto on salvaging psychotherapy research has much to


commend it and I compliment Coyne and Kok for their unflinching criticism and
proposed stringent solutions. Almost all the methodological, peer review and
publication shortcomings they mention are legitimate concerns. In responding let
me state that I am a part of the problem. For the past 25 years I have served as the
Editor of a peer-reviewed journal titled Research on Social Work Practice
(RSWP), produced by Sage Publications. I founded RSWP to serve as an outlet
primarily for outcome studies on psychosocial interventions used by
social workers and attempted to model it after the prestigious Journal of
Consulting and Clinical Psychology, with which I was very familiar. Clinical
social workers are the largest provider of mental health services in the United
States, surpassing the combined numbers of psychologists and psychiatrists
(Hamp, Stamm, Christidis & Nigrinis, 2014). RSWP has been a success. For
two of the past three years it has had the highest impact factor of all social
work journals tabulated by the Journal Citation Reports, and it is received
by over 8000 subscribers. Over 150,000 articles are downloaded from the
journal’s website each year. Yet RSWP regularly publishes the type of
underpowered and methodologically weak outcome studies Coyne and Kok
fulminate against! RSWP has the most rigorous submission requirements of all
social work research journals, having adopted the APA’s Journal Article
Reporting Standards some years ago, shortly after they
*
Correspondence concerning this article should be addressed to:
E-mail: Bthyer@fsu.edu

Improving Publication Standards for Psychoterapy Outcome Studies 125


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first appeared. The journal has already published an article describing the
importance of registering randomized clinical trials in an appropriate registry
(Harrison & Mayo-Wilson, 2014), and years ago we began using
structured abstracts containing the subheadings of Purpose, Method,
Results, and Discussion. Here are some additional specific editorial policies of
RSWP which I have been planning for some time and will take effect in 2015,
steps which will move the field of psychotherapy research forward along the
lines suggested by Coyne & Kok.

The journal will clearly state that the authors of RCTs should have pre-
registered their study and provide a citation as to where this description can be
located. RCT submissions must be accompanied by a completed CONSORT
Checklist. Articles reporting the results of a quasi-experimental outcome study
must follow the standards found in the Transparent Reporting of
Evaluation Studies using Nonrandomized Designs (TREND) checklist.
Analogous to CONSORT, the TREND checklist will greatly facilitate the timely
peer-review of submissions and their transparency upon publication (see
http://www.cdc.gov/trendstatement/). All nomothetic outcome reports must
have a participant flow chart, depicting attrition at each stage of the study.
All reports of statistically significant differences or changes much be
accompanied by an appropriate effect size, and the meaning of this ES must
be discussed. Causal inferences, if any, should be made conservatively and
not go beyond the limits imposed by the presented methods and data. The
authors of outcome studies evaluating nonpharmacological interventions
(e.g., psychotherapies and other psychosocial treatments) are urged to
familiarize themselves with relevant guidelines useful for reporting such studies.
Grant et al. (2013) will be a recommended resource for authors to consult, as is
Boutron, Ravaud and Moher (2012).

Also effective for RSWP in 2015, articles claiming to be a Systematic


Review must adhere to the guidelines for preparing systematic reviews developed
by the Cochrane Collaboration (Higgins & Green, 2009) or the
Campbell Collaboration (2014). In addition, the authors of systematic reviews
and meta-analyses must follow the guidelines found in the PRISMA Statement
(Preferred Reporting Items for Systematic Reviews and Meta-analyses), found
at: http://www.prisma-statement.org/, and include a copy of a completed
PRISMA Checklist with the submitted manuscript. If the article does not
follow these standards, the paper should be subtitled as A Narrative Review, or A
Review, and the specific term Systematic Review should be avoided. Authors
submitting a systematic review for review and publication will strongly
encouraged to have pre-registered the review protocol in a suitable registry,
such as PROSPERO (www.crd.york.ac.uk/PROSPERO). The article by
Stewart, Moher and Shekelle (2012) will be referenced to authors for guidance
regarding the rationale for, and process, of pre-registering systematic review
protocols, and submissions should include a statement giving the reference to
any registry in which the protocol is

126 Bruce A. Thyer


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published. The EQUATOR Network (Enhancing the QUAlity and Transparency


of Health Research) will be a recommended resource for authors preparing
studies for submission to RSWP which deal with the general topic of health care,
including psychotherapy (see http://www.equator-network.org/).

There are risks in adopting such stringent guidelines. Submissions may


drop precipitously as authors opt for less demanding journal outlets. However, the
more forward-thinking members of the profession will likely applaud the
promulgation of such standards, and the journal may begin attracting the highest
quality studies, which all too often social work authors submit to non-social work
journals. A recent bibliography I am preparing has found that there are over 630
published randomized experiments authored by social workers, many of which
involve evaluating psychotherapy (Thyer & Massie, 2014). The earliest of these
appeared in 1949 and most of these have appeared in non-social work journals.

Adherence to the peer-review process itself can militate against rejecting


low-quality and under-powered psychotherapy studies. I always share my decision
letter to authors with the reviewers, along with all the reviewers’ comments. If
reviewers recommend acceptance, and I consistently rejected poorer-quality
works against the reviewers’ recommendations, soon I would have no reviewers!
Journals can only publish what they receive in the form of submissions, and like
other entities, the first rule is that of survival! Underpowered and poor-quality is
in the eye of the beholder and the peer-review process is flawed. A treatment
which is very strong can be appropriately evaluated with an RCT involving
relatively small numbers of participants. It is only comparatively weak and
ineffectual treatments that need very large Ns so that inferential statistics can be
used to detect reliable (but clinically meaningless differences). Psychotherapy
evaluation research is an evolving and imperfect process. The many laudable
initiatives outlined by Coyne and Kok and slowly being adopted in the higher
quality research journals (Thyer, 2014) are a positive sign that additional progress
is being made.

REFERENCES

Boutron, I., Ravaud, P. & Moher, D. (2012). Randomized clinical trials of


nonpharmacological treatments. New York: CRC Press.

Campbell Collaboration. (2014). Campbell Collaboration systematic review:


Policies and guidelines. The Campbell Collaboration. Available from
www.campbellcollaboration.org

Grant, S., Montgomery, P., Hopewell, S., Macdonald, G., Hoher, D. & Mayo-
Wilson, E. (2013). Developing a reporting guideline for social and psychological
intervention trials. Research on Social Work Practice, 23, 595-602.

Improving Publication Standards for Psychoterapy Outcome Studies 127


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Hamp, A., Stamm, K., Christidis, P. & Nigrinis, A. (2014, September).


What proportion of the nation’s behavioral health providers are psychologists?
Monitor on Psychology, p. 18.

Higgins J. P. T., & Green, S. (2009). Cochrane handbook for systematic


reviews of interventions, Version 5.0.2. The Cochrane Collaboration. Available
from www.cochrane-handbook.org.

Harrison, B. A. & Mayo-Wilson, E. (2014). Trial registration: Understanding


and preventing bias in social work research. Research on Social Work Practice,
24, 372-376.

Stewart, L., Moher, D. & Shekelle, P. (2012). Why prospective registration


of systematic reviews makes sense. Systematic Reviews, 1:7.
doi:10.1186/2046-4053-1-7

Thyer, B. A. (2014). Evolving reporting guidelines for social work research.


Nordic Social Work Research, 4(1), 1-4. DOI:10.1080/2156857X.2014.916887

Thyer, B. A. & Massie, K. (2014). A bibliography of randomized controlled


experiments in social work (1949 – 2013): Solvitur Ambulando. Unpublished
manuscript.

128 Bruce A. Thyer


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Journal of Evidence-Based Psychotherapies,


Vol. 14, No. 2, September 2014, 129-132.

Invited Comment on
“Salvaging psychotherapy research: A manifesto”

THE FUTURE OF EMPIRICALLY SUPPORTED


TREATMENTS: A COMMENT ON COYNE AND KOK
E. David KLONSKY *
Department of Psychology, University of British Columbia, Canada

Keywords: psychotherapy outcome research, empirically supported


treatments, society of clinical psychology.

Coyne and Kok (this issue) argue that the state of psychotherapy research
is dire. They further argue that substantial improvements in methodological
standards and practices are necessary for psychotherapy research to meet even
minimum scientific standards. I can share a particular perspective on this issue.
From 2007-2012 I served as Editor of the Society of Clinical Psychology’s
(Division 12, APA) list of empirically supported treatments
(PsychologicalTreatments.org). This position put me in regular contact with the
latest research on psychological treatments of all varieties. And my response to
Coyne and Kok is easy to summarize: I agree.
My unqualified agreement with Coyne and Kok may seem surprising
given the extensive time and energy I devoted to maintaining the Division 12 list
of empirically supported treatments. After all, the website utilized the ‘Chambless
criteria’ – a set of specific, objective, and well-known criteria for determining the
efficacy of treatments (Chambless & Hollon, 1998) – and the website lists dozens
and dozens of treatments that meet these criteria. In brief, to meet the highest
standard of “well-established” (termed “Strong” on PsychologicalTreatments.org)
a treatment must be supported by at least two independently conducted well-
designed studies or by a large series of single case design experiments.
Characteristics of a well-designed study include use of a treatment manual, a
well-characterized sample, and random assignment to treatment and control

*
Correspondence concerning this article should be addressed to:
E-mail: Bthyer@fsu.edu

The Future of Empirically Supported Treatments: A Comment on Coyne and Kok 129
Articles Section

conditions. To meet the standard of “probably efficacious” (termed “Modest” on


the website) a treatment must be supported by at least one well-designed study or
a small series of single case design experiments.
These criteria have substantially impacted the field. Published versions
and updates of these criteria have been cited more than 4,000 times according to
Google Scholar (e.g., Chambless & Hollon, 1998; Chambless & Ollendick, 2001;
Chambless, Sanderson, Shoham, et al., 1996). Arguably, the Division 12 criteria
helped bring about the field’s recent emphasis on evidence-based practice (APA,
2006; Kazdin, 2008; Norcross, Beutler, & Levant, 2005). The criteria were
ground-breaking, and moved the field forward like few other innovations.
However, it is also true that the landscape of treatment outcome research
was very different when the criteria were developed. Two decades ago, when
outcome studies were rare, it was indeed plausible to construe two studies
supporting a given treatment as representing strong evidence. Fast forward to
2014: there are now thousands of randomized controlled trials, and tremendous
advances in methodological sophistication (many of which are emphasized by
Coyne and Kok). It is time to thank the original Division 12 criteria for all they
have done for the field (and they have done a lot), and move on to more
methodologically sound, scientifically valid approaches to generating and
quantifying psychotherapy outcome research. The field would do well to heed the
recommendations of Coyne and Kok.
Unfortunately, culture change is slow. Psychotherapy studies have been
conducted a certain way for two decades and it will be difficult to effect the kind
of sea change envisioned by Coyne and Kok. Therefore, I would like to use the
rest of this commentary to list initial steps that I believe can facilitate the most
change in the shortest amount of time.

Step 1. Division 12 should publish new criteria. I noted earlier the


substantial influence and citation count of the original Division 12 criteria. In my
experience as Editor of the Division 12 treatments list, many psychologists
seemed to reify the criteria, as if they were synonymous with the concept of
‘empirically supported treatment’. Of course there are numerous perspectives and
debates regarding how to quantify empirical evidence for psychological
treatments (e.g., Borkovec & Costonguay, 1998). In fact, David Tolin, current
President of Division 12, is spearheading a committee charged to substantially
update the Division’s perspective on how psychotherapy research evidence is
conceptualized and quantified (full disclosure: I am a member of this committee).
Given the influence of the original Division 12 criteria on scholarship and
outcome research, it is likely that a strong update to the criteria published by
Division 12 would get the field’s attention, and help fast-track the kinds of
changes advocated by Coyne and Kok.

130 E. David Klonsky


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Step 2. Increase sample sizes. Perhaps no single limitation affects the


validity and generalizability of psychotherapy outcome research as much as small
sample size. As Coyne and Kok note, small sample sizes are the rule rather than
the exception in psychotherapy research, and this limitation result in countless
false positives that render the literature difficult to interpret. Unlike some other
critical recommendations by Coyne and Kok, increasing sample size is a very
specific, concrete step that can happen quickly if psychotherapy researchers
decide doing so is a priority. An increase in standards for sample size can be
encouraged easily if journals update their criteria for what is considered
publishable, and simply refuse to publish underpowered outcome trials.

Step 3. Emphasize effect-sizes rather than statistical significance. The


original Division 12 criteria rely on statistically significant results to determine if
a given treatment is more efficacious than a placebo. However, the better question
in any domain of healthcare is not whether a treatment is better than nothing, but
how much better. A statistically significant improvement does not at all imply that
a patient has been cured or experienced a meaningful improvement in symptoms
or quality of life. A focus on effect-sizes, including measures of clinically
significant change (e.g., for examples see Jacobson et al., 1999; also see Laupacis,
Sackett, & Roberts, 1988), would: a) help the field move away from the
categorical, ‘box-score’ approach utilized by the original Division 12 criteria, b)
encourage more precise and sophisticated comparisons of the relative efficacy of
various treatments, and c) facilitate meta-analyses of therapy outcome studies.
Like Step 2, this step would be relatively easy if prioritized. The data necessary to
calculate effect-sizes and indices of clinical significance are already collected in
typical treatment outcome studies.
In conclusion, there is little question that the field of psychotherapy
outcome research needs a major overhaul, and would benefit substantially by
taking the recommendations of Coyne and Kok. Coyne and Kok provide a
thoughtful and important vision. We must be equally thoughtful in determining
how to make this vision a reality.

REFERENCES

APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based


practice in psychology. American Psychologist, 61(4), 271-285.
Borkovec, T.D. & Costonguay, L.G. (1998). What is the scientific meaning of empirically
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Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies.
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interventions: controversies and evidence. Annual Review of Psychology, 52, 685-
716.
Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett-Johnson, S., Pope, K. S., Crits-

The Future of Empirically Supported Treatments: A Comment on Coyne and Kok 131
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Christoph, P., . . . McCurry, S. (1996). An update on empirically validated therapies. The


Clinical Psychologist, 49, 5-18.
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American Psychological Association.

132 E. David Klonsky


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Journal of Evidence-Based Psychotherapies,


Vol. 14, No. 2, September 2014, 133-135.

Invited Comment on
“Salvaging psychotherapy research: A manifesto”

REPLY TO
“SALVAGING PSYCHOTERAPY RESEARCH:
A MANIFESTO”
BY JAMES C. COYNE AND ROBIN N.KOK
Eileen GAMBRILL*
School of Social Welfare, University of California at Berkeley, USA

Coyne and Kok describe many of the shortcomings of research design


and reporting. Many have been described for decades yet continue, revealing the
degree of avoidable ignorance in this area encouraged by pursuit of status and
money and related cognitive biases. Such shortcomings are vital to highlight (and
avoid if possible) given the hoped-for guidance of practice and policy decisions
by empirical research: if the research is flawed, drawing on this may do more
harm than good; policy makers, clinicians and clients all may be misled. As the
authors note, many publications are characterized by inflated claims of
effectiveness and hiding of harms. These are classic propaganda/marketing
strategies (Gambrill, 2012). Reforms such as trial registration that arose because
of dubious practices in research concerning pharmaceuticals (e.g., hiding negative
results), are, as the authors note, important for all research.

Ioannidis (2005) has led a growing critique of research in the bio-medical


area which has encouraged a critique in areas such as psychology including
efforts to replicate prior research, often with disappointing results. This thrust has
been encouraged by the rigorous guidelines for conduct of systematic reviews
described by the Cochrane and Campbell Collaborations, the former initiated in
1992. Conducting research that cannot answer questions posed is a waste of
money which hopefully will be discouraged by enterprises such as the Meta-
Research Innovation Center (METRICS) recently established at Stanford to
strengthen the quality of scientific evidence and combat research waste. Original

*
Correspondence concerning this article should be addressed to:
E-mail: gambrill@berkeley.edu

Reply to “Salvaging Psychotherapy Research: A Manifesto” by J.C. Coyne & R.N. Kok 133
Articles Section

publications describing the philosophy and process of evidence-informed


practice call for the integration of data from well-designed research concerning
clinical questions and client circumstances and characteristics, including their
preferences and values, drawing on clinical expertise (Straus, Richardson,
Glasziou, & Haynes, 2010). This process is a way to handle the inevitable
uncertainty in making decisions in an informed, ethical manner. Bogus claims
based on flawed research impede such efforts.

Improving the quality of research concerning psychotherapy will require


attention to professional education venues awarding degrees as well as continuing
education programs (e. g., Baker, McFall, & Shoham, 2008; McFall, 1991). It will
require attention to how problems are framed as well as to methodological quality
(Gambrill, 2014). Problem framing receives no attention in quality filters such as
CONSORT. A psychiatric framing of life’s travails dominates psychology,
psychiatry, and social work (e. g., Kirk, Gomory, & Cohen, 2013). Alternative
well-argued views (e. g., social learning theory) are often ignored in descriptions
of randomized controlled trials (e. g., Gambrill & Reiman, 2012). Fortunately,
many sources are now available for critically appraising and/or designing research
including user-friendly websites such as Testing Treatments, Interactive (TTi) and
books such as How to read a paper (Greenhalgh, 2010) and Randomized
controlled trials (Jadad & Enkin, 2007). The greater attention to involvement of
clients in the conduct, appraisal and use of research is also an important
development.

Is it wise to use the term “well established” in view of the history of


science and medicine that shows that most claims we thought were “well-
established,” were wrong? Why not clearly describe the evidentiary status of an
intervention (e. g., this intervention has been tested in three well-designed and
…. ). “Salvaging psychotherapy research” will require attending to the role of
nonspecific factors as well as specific interventions (see the work of Bruce
Wampold and his colleagues). Placebo effects must be considered. It will require
asking: “Is this intervention bona fide?” (e. g., Benish, Imel, & Wampold, 2008).

The increasing call to integrate research evidence into practice and policy
contexts highlights the importance of conducting high-quality research that
accurately describes the evidentiary status of interventions. It highlights the
importance of taking a close look at how problems are framed. Are they framed as
individual problems when indeed environmental stress is predominant? Coyne
and Kok contribute to this important endeavor.

134 Eileen Gambrill


Articles Section

REFERENCES

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Benish, S. G., Imel, Z., & Wambold, B. E. (2008). The relative efficacy of bona
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Reply to “Salvaging Psychotherapy Research: A Manifesto” by J.C. Coyne & R.N. Kok 135

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