Empirically supported treatments (ESTs) are interventions that have been found to be efficacious for one or more psychological conditions, like major depression, panic disorder, or obsessive-compulsive disorder, within a given population. Prior to the 1990s, there were no specific guidelines for either practitioners or mental health consumers regarding which treatments to select for which conditions among children, adolescents, and adults. As a consequence, the psychotherapy field was plagued by serious problems with quality control.

This state of affairs changed in 1993 when a task force appointed by the Society for Clinical Psychology (Division 12) within the American Psychological Association (APA) developed a set of criteria for (and provisional list of) what were then termed "empirically validated treatments," later termed ESTs. According to the current task force guidelines (Chambless & Hollon, 1998), ESTs are therapies that have demonstrated (a) superiority to a placebo (dummy treatment) in two or more methodologically rigorous controlled studies, (b) equivalence to a well-established treatment in several rigorous and independent controlled studies, or (c) efficacy in a large series of single-case controlled designs (i.e., within subjects designs that systematically compare the effects of a treatment with those of a control condition). Moreover, the treatments utilized in these studies must be performed according to treatment manuals that specify a reasonably clear "recipe" for how to conduct the intervention.

There is general (Kendall, 1998)-although by no means universal (e.g., Westen, Novotny, & Thompson-Brenner, 2004)-agreement among psychotherapy researchers that the movement toward ESTs is a necessary first step toward providing practitioners with guidelines for good psychotherapy practice.

In 1998, the Society of Clinical Child and Adolescent Psychology (Division 53 of the APA) initiated a targeted review of evidence-based psychosocial treatments for young people with a range of mental health problems and diagnostic profiles. Treatment recommendations, which were based on the EST criteria outlined above and compiled by experts in each of their respective sub-specialties of developmental psychopathology, were published in a special issue of the Journal of Clinical Child and Adolescent Psychology (JCCAP). In 2008, JCCAP published a second special issue drawing on a "Ten Year Update" of research evidence; the treatment recommendations provided in this website are based on this latest review.

ESTs: Misconceptions and Misunderstandings

The push to develop lists of ESTs has been immensely controversial (Arkowitz & Lilienfeld, 2006) and has been met with fierce resistance in some quarters. Although several of the criticisms of ESTs may have merit (see "ESTs: Future Directions"), several others appear to reflect a general misunderstanding of EST criteria. Below are some of the most widespread misconceptions regarding ESTs (see Chambless & Ollendick, 2001; Weisz, Weersing, & Hengeller, 2005, for further discussions of these and other misconceptions).

1. Randomized controlled trials (RCTs), on which the EST list is based, are fallible and no more informative than other sources of evidence. This claim is problematic on two fronts. First, the EST list does not require treatments to be tested using RCTs; as noted above, a series of rigorous single-case designs can also suffice. Second, the assertion that RCTs are no more valuable than other sources of evidence is misinformed; RCTs currently represent the "gold standard" of evidence in that they control for a host of sources of error, such as placebo effects, spontaneous remission, regression to the mean, and demand characteristics.
2. The EST list is biased against psychodynamic therapies. To some degree this accusation is true, although this is generally due to the fact that most psychodynamic therapies (i.e., those based largely on the theories of Sigmund Freud and his followers) have been inadequately researched and therefore have yet to accumulate a sufficient research base.
3. The EST list is unfair because some treatments that have yet to be studied may turn out to be efficacious. It is indeed true that one must distinguish unvalidated treatments (i.e., those that have yet to be adequately researched) from invalidated treatments (i.e., those that have been researched and shown not to work). The EST list should not be construed as implying that unvalidated treatments might not later become empirically supported with sufficient research; it implies only that such treatments have yet to prove their efficacy. Nevertheless, it is crucial to recall that the burden of proof falls on proponents of treatments to show that they work, not on critics to show that they do not work. Hence, the argument that it is unfair to exclude unvalidated treatments from the EST list violates one of the most crucial standards of science, namely, that one should not accept claims without adequate evidence.
4. The EST list is unnecessary because research shows that all psychotherapies work equally well. In criticizing the EST list, some researchers have invoked the "Dodo Bird verdict," named after the Dodo Bird in "Alice and Wonderland," who famously said (following a race) that "Everybody has won and all must have prizes." Accordingly, it has been claimed that all therapies work equally well and, therefore, the EST list is based on the erroneous premise that some therapies work better for certain disorders than do others. Recent research has clearly demonstrated, however, that this characterization is false. Numerous studies have shown that behavioral and cognitive-behavioral treatments are more effective than other treatments for childhood disorders.
5. Some of the studies on which the EST list is based are flawed. Although this contention is almost certainly true, it should be remembered that virtually all research studies are flawed in certain respects. The goal of the EST list, like that of all advances in science, is to reduce uncertainty. Without this list, there would be little or no explicit guidance to clinicians regarding which treatments should be administered for whom and with which conditions. Imperfect but informative scientific evidence is almost always better than no evidence at all.
6. ESTs are not generalizable to the real world. Some critics have charged that research on "efficacy" (i.e., how well treatments perform in carefully controlled settings) do not generalize to research on "effectiveness" (i.e., how well they perform in real-world situations). In part, the rationale behind this criticism is based on the fact that EST efficacy studies often exclude severely disordered patients or patients with "comorbid" (co-occurring) conditions. Although there is some truth to this criticism, many recent efficacy studies have begun to examine patients with problems that more closely reflect the complexities of those found in real-world settings. These studies have typically found that treatments with high efficacy also display high effectiveness.
7. Because ESTs are manualized, they necessarily constrain clinical creativity. This criticism is largely based on an inaccurate caricature of manualized therapies. Treatment manuals are not meant to be rigidly adhered to in every clinical situation nor do they, for example, prescribe fixed responses to patients' behaviors in therapy. Instead, most manuals provide flexible guidelines for how to proceed at different stages of treatment. Moreover, increasing numbers of treatment manuals afford therapists considerable leeway to respond flexibly to differing patient trajectories within treatment.
8. The EST list is fixed and cannot change in response to new evidence. This criticism could not be further from the truth. Researchers are constantly evaluating and comparing the effects of various treatments for a variety of child and adolescent mental health problems. Thus, the EST list is always a work in progress, subject to continual updating as new data become available. Indeed, as noted above, this website was explicitly created to provide revised treatment recommendations for children and adolescents based on a 10 year research update.

ESTs: Future Directions

Thus, although many of the concerns with the American Psychological Association's approach to defining, identifying, and cataloguing ESTs are based on fundamental misunderstandings, there are alternative and complementary approaches that appear to have merit for connecting the research on children's mental health treatments to clinical practice. For example, some researchers have noted that many ESTs appear to differ only in their superficial features, and that a number of seemingly different treatments may work for the same underlying reasons. They have argued that a list of "empirically supported principles of change," such as the exposure to feared stimuli in many effective treatments for anxiety disorders or the restoration of hope in many effective treatments for depression, may ultimately be more fruitful than a list of ESTs (Rosen & Davison, 2003). There is considerable merit to this suggestion, although it will need to await stronger consensus among clinical scientists regarding the underlying mechanisms of change that cut across many therapies.

Similarly, other researchers have argued that the specific clinical techniques that comprise most ESTs appear to draw from a relatively limited number of procedures, and that there is merit to mapping the relationship between specific clinical procedures (e.g., cognitive restructuring, relaxation training) and client or contextual features (e.g., clinical problem, age, gender, setting) (Chorpita & Daleiden, 2009). This paradigm is seen as one that potentially complements a "list" approach, offering detail about the specific procedures that commonly characterize the numerous ESTs often applicable to a given area and pointing out what most ESTs do and do not have in common with one another.

Several research groups have begun to consider the question of how to define evidence for real-world systems, with some systems developing an expanded number of "levels of evidence" (Chorpita et al., 2002), and with some researchers emphasizing the importance of repeated measurement of client outcomes as a primary source of evidence (Bickman, 2008; Daleiden & Chorpita, 2005; Lambert, 2005).

Finally, the EST list is intended to inform practitioners and mental health consumers about effective treatments, but it does not warn them about potentially harmful treatments (Chorpita et al., 2002; Lilienfeld, 2007). For example, recent evidence suggests that that such widely used treatments as crisis debriefing for individuals exposed to trauma and "Scared Straight" programs for adolescents with conduct problems may make some clients worse. It may therefore be equally important to construct a list of potentially harmful treatments (PHTs), as consumers of psychotherapy need to be well informed about interventions that may harm as well as those that help.

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Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.

Chorpita, B. F., & Daleiden, E. L. (2009). Mapping evidence-based treatments for children and adolescents: Application of the distillation and matching model to 615 treatments from 322 randomized trials. Journal of Consulting and Clinical Psychology, 77, 566-579.

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Rosen, G. M., & Davison, G. C. (2003). Psychology should identify empirically supported principles of change (ESPs) and not credential trademarked therapies or other treatment packages. Behavior Modification, 27, 300-312.

Weisz, J. R., Weersing, V. R., & Henggeler, H. T. (2005). Jousting with straw men: Comment on Westen, Novotny, and Thompson-Brenner (2004). Psychological Bulletin, 131, 418-426.

Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631-663.