Towards a Consensus in the Evaluation of the Evidence of Psychological Treatments

Introduction

In the last decades, there has been a remarkable advance in the development of psychological interventions for a wide range of mental disorders in children, adolescents, and adults as a complement or an alternative to pharmacological treatments. Since the publication of the first lists of evidence-based psychological treatments for the different mental disorders, several professional and scientific institutions (such as the American Psychological Association [APA], the Cochrane Collaboration, and the National Institute for Health and Care Excellence [NICE]) have been involved in recommending and spreading those treatments that are based on the scientific knowledge (evidence-based treatments, EBTs).

These organizations have stablished some criteria to assess and grade the quality of the available evidence that have enabled the possibility that health managers (from both public and private health systems) provide and recommend only those treatments that are empirically supported. In this line, the mentioned criteria have been used by university teachers as a guide to train psychiatry and psychology students and those from other disciplines related with mental health in selecting the most accurate therapy for each case according to their proven efficacy. In addition, they are also useful for patients and their relatives because they can know the best alternatives for the treatment of their mental health issues.

However, the publication of EBTs lists is somehow controversial since, among other problems, the hypothesis that the active element in psychological treatments is the technique used is against the approaches that defend that the efficacy of the therapy might be explained by common factors related to the therapeutic relationship. In this sense, there are plenty of studies that indicate that a positive therapeutic alliance is related with a clinical improvement of the patients. Therefore, some authors (Goldfried & Davila, 2005) claim that there is a synergy in a patient’s change process between the therapeutic relationship and the specific treatment used, since a good therapeutic relationship increases the adherence of the patient to the therapy and, at the same time, the successful implementation of the therapy could improve the quality of the mentioned relationship.

Despite the advantages that assessing the scientific evidence of psychological treatments might involve, there is not a consensus between the organizations about how to develop this process. That is why their recommendations may be different from each other, which transgress their supposed scientific-professional nature. With the objective of demonstrating that the existence of different assessment systems could lead to differences in the reported evidence of psychological treatments, recent studies (Gálvez-Lara et al., 2018; Moriana et al., 2017) have revised the recommendations of several prestigious international organizations for the treatment of mental disorders in children, adolescents, and adults. The results of these studies showed that, for both adults and children, the level of agreement among the different institutions analyzed was low for most mental disorders, with numerous discrepancies appearing among the recommendations made by the different organizations.

It is concerning and paradoxical there is not a complete agreement among the organizations that inform about the scientific evidence of psychological treatments. They do not only differ in the grade of evidence, but also about the treatments of choice. This picture might generate some doubts about what is the best treatment for a particular disorder in professional (clinicians and health managers) and non-professional (patients and their relatives) users. Likewise, the lack of an international and unified assessment system could suggest the need of agreement about the meaning of scientific evidence. Therefore, due to the impact that psychological treatments have on the mental health of the population, an international consensus should be promoted through the creation of working groups and conferences that include representatives of various organizations to establish common criteria to assess and grade the quality of the evidence of the different psychological interventions.

Within the different systems used to assess the evidence, the GRADE system (Balshem et al., 2011) seems to be the most internationally supported one. Recently, Division 12 of the APA has raised the use of a method to evaluate the evidence of psychological treatments based on GRADE (Tolin et al., 2015). This new system presents a high methodological rigor, since it proposes to consider all the systematic reviews and meta-analyses available in the literature that meet a minimum methodological quality and clinical relevance, and that are bias-free. After confirming the quality of the systematic review, this system aims to assess the quality of the evidence of the different results presented in the review using the GRADE system. Finally, according to the quality of the evidence obtained by the different reviews examined through GRADE, it classifies EBTs into a hierarchical system with four levels of recommendation (very strong recommendation, strong recommendation, weak recommendation, and insufficient evidence). Even though this institution started the process of updating its treatment lists using this new system in 2015, only the status of two therapies have been updated so far.

Further, the scientific community should establish strategies to improve the methodological aspects of randomized controlled trials (RCTs) in psychology and to determine the requirements they should meet to be included in systematic reviews and meta-analyses. Although RCTs are considered the gold standard of science, this type of experimental designs shows important limitations due to their application to human behavior (Moriana & Gálvez-Lara, 2020). Therefore, several strategies should be taken into account in order to improve RCTs’ quality in particular and the research about psychological treatments in general: 1) previous registration of the RCT protocol in platforms that ensure some minimal quality requirements (such as clinialtrials.gov or protocols.io); 2) promoting the development and use of standardized designs (e.g., CONSORT, SPIRIT); 3) providing RCT data through open repositories (e.g., www.osf.io); 4) facilitating the collaboration between the different organizations and research centers in order to increase the statistical power of the study and the size of the sample; 5) empowering the role of external institutions in the supervision of the development and quality of the RCT; 6) developing protocols to improve the treatment adherence and the attendance to the follow-up assessments; 7) studying the elements involved in the therapeutic relationship that might be associated with the therapeutic alliance, clinical expertise, empathy, charisma or abilities of the therapist; 8) evaluating simple units of analysis that determine why an specific component from a psychological treatment is effective; 9) incorporating assessment measures beyond classic DSM/ICD symptoms and criteria, such as RDOC, psychophysiological measures, quality of life measures or subjective distress measures; 10) promoting any kind of resources of assessment that allow knowing the reliability and validity of the instruments used (that is proving empirical evidence not only for the treatment but also for the assessment); 11) determining a flexible limit between the manualized treatment and the individualization of that treatment; 12) avoiding waiting-lists groups and use “be-friendly” groups as an alternative in which the professional assumes a friendly and listening role during a similar time than in the experimental group; 13) and, lastly, ensuring that patients are asked for, informed of, and involved in everything that is related with the research and the treatments used, since they can have a direct effect on their health.

The use of different assessment criteria and systems in the classification of the evidence and the limitations that RCTs present in the context of human behavior are not the only issues that the EBTs approach face. Indeed, it is known that the progress in this field have had little impact on the clinical practice of the different professionals. In the light of the above, and with the aim of reducing the gap between research and practice, the scientific community should improve the strategies of dissemination of research results and promote bidirectional communication between researchers and applied professionals (Dozois, 2013). Moreover, it should facilitate the information, understanding, and education of citizens, users, and health managers. Recently, some promising alternatives have been developed, such as the adoption of “quality publication practices” (Waters et al., 2020), that would involve that researchers, clinicians, journals, health institutions, and scientific-professional organizations had to work together in pursuit of an increase in the quality of publications about psychological treatments. In addition, it would be advisable establishing open and practice-oriented research networks, with the objective that researchers and clinicians could communicate in a bidirectional manner to be able to develop applicable research in clinical practice (Fernández-Álvarez et al., 2020; Gaines et al., 2021).

In short, due to the high prevalence of mental disorders, with the aim of improving the mental health of the population, researchers, organizations that report the evidence of interventions, and applied professionals should optimize their communication, coordination, and their systems of choice of treatments.