The Limitations of Empirically-Supported Treatments

Empirically-supported treatments (ESTs)—manualized protocols developed in clinical research settings and then proven effective in randomized controlled trials—have epitomized the gold standard of mental health practice for decades and therapists and patients have benefited greatly from these scientific advances. But people generally do not fit neatly within the clearly defined diagnostic categories on which ESTs are based and tested. Moreover, psychiatric comorbidity is the norm rather than the exception (Kessler et al., 2005), and this is a challenge among therapists who must be increasingly creative when assessing and treating patient problems (Rizvi & Hardne, 2013). As Rochelle Frank, PhD, and Joan Davidson, PhD—authors of The Transdiagnostic Roadmap for Case Formulation and Treatment Planning—attest, symptom clusters across disorders often are not mutually exclusive, and individuals frequently present with co-occuring conditions that pose significant challenges when trying to develop optimal treatment plans. Someone seeking treatment for depression may also present with anxiety, panic attacks, and a history of childhood trauma, and may resort to self-harm as a means of regulating overwhelming emotions. In that case, identifying which diagnostic hypotheses to consider and which factors might be driving the individual’s presenting problems can be—and often is—quite daunting. To make matters more complicated, therapists have had limited guidance in choosing among a continually expanding disorder-specific treatment protocols at their disposal. 

The idea that using ESTs alone to meet the needs of patients presenting with clusters of symptoms across diagnoses is not new (Addis et al., 1999; Barlow et al., 1999; Chambless & Ollendick, 2001). Similarly, critiques of randomized controlled trials, too, highlight their shortcomings and emphasize the need to augment evidence-based practice with approaches based on other sources.

Attempts to overcome the acknowledged limits of EST protocols are also not new. In 1998, Kendall and colleagues encouraged therapists to incorporate flexibility and creativity when conceptualizing patient problems and implementing treatment protocols, in order to avoid robotically choosing and implementing interventions. For example, Kendall and Beidas (2007) proposed the idea of flexibility within fidelity as a guiding principle for implementing cognitive behavioral therapy with children. But even when ESTs are tailored to specific patient needs, manual-based protocols target singular disorders and do not allow for inclusion of other interventions that are effective in treating those same problems.

The importance of incorporating flexibility when implementing ESTs in clinical practice settings is clear (Beidas et al., 2010; Beidas & Kendall, 2010), though therapists must use caution to prevent decreased treatment effectiveness as a result of departing from standardized procedures (Koerner et al., 2007). When it comes to implementing treatments, there is a fine line between flexibility and infidelity. While there are some recommendations available for remaining both flexibility and maximum efficacy, there are few guideposts to help therapists navigate this still largely uncharted territory.

Next time we’ll take this discussion one step further, looking at some of the current models for case conceptualization that have attempted to compensate for the limits of ESTs alone.


Addis, M. E., Wade, W. A., & Hatgis, C. (1999). Barriers to dissemination of evidence-based practices: Addressing practitioners’ concerns about manual-basedpsychotherapies.Clinical Psychology: Science and Practice, 6, 430–441.

Barlow, D. H., Levitt, J. T., & Bufka, L. F. (1999). The dissemination of empirically supported treatments. Behaviour Research and Therapy, 37, 147–162.

Beidas, R. S., Benjamin, C. L., Puleo, C. M., et al. (2010). Flexible applications of the Coping Cat program for anxious youth. Cognitive and Behavioral Practice, 17, 142–153.

Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence-based practice. Clinical Psychology: Science and Practice, 17, 1–30.

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

Kessler, R. C., Chiu, W. T., Demler, O., et al. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617–627.

Koerner, K., Dimeff, L. A., & Swenson, C. R. (2007). Adopt or adapt: Fidelity matters. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice. New York: Guilford.

Rizvi, S. L., & Harned, M. S. (2013). Increasing treatment efficiency and effectiveness: Rethinking approaches to assessing and treating comorbid disorders. Clinical Psychology: Science and Practice, 20, 285–290.

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