An even broader objection has to do with the fact that the research literature is unrepresentative of the kinds of problems most people bring to therapy. Most clients seek psychotherapy not because of distinct DSM-IV disorders, but because of less clearly defined problems in everyday living—relationship conflicts, multiple problems that fit no diagnostic category, and situational stresses that trigger strong emotional reactions. In accenting DSM problems, the lists of treatments slant the practice of psychotherapy away from what most people seek therapy for and toward a "medical" model, disconnected from the realities of the practice of psychotherapy, say the critics.

The mental health profession owes much to researchers who've established its empirical track record. No doubt, the willingness of insurance companies to reimburse for the sometimes hard-to-define services that psychotherapists provide has more to do with studies on DSM disorders than an interest in clients' personal growth or relational harmony. Nevertheless, a vocal dissident group in the research community has questioned whether the scientific foundation of the field can still be defended, even while questioning the bona fides of current "research-supported" approaches. They've called for a shift away from a narrow focus on contrasting treatments to a highlighting of distinctive features of successful therapy that cut across different approaches.

The critiques of lists of research-supported therapies have led to a parallel movement to build an alternative catalogue of the aspects of psychotherapy that are evidence-based, not disorder by disorder, but in terms of well-established trends across studies. These efforts move away from a narrow focus on contrasting treatments to ask what aspects of psychotherapy have been empirically demonstrated to make a difference. The core notion behind this initiative is that therapists should be trained in and practice these core skills, rather than specific, evidence-based therapy models. Following from this perspective, the American Psychological Association's Division of Psychotherapy, under the leadership of John Norcross, is in the process of reevaluating the evidence of such treatment-bridging factors summarized in the 2002 book Psychotherapy Relation-ships That Work. His task force is concerned with determining the factors that make the biggest difference in therapy outcome—variables such as the client's stage of change and the therapist's empathy and positive regard, and relationship variables such as the quality of the client–therapist alliance and goal consensus.

Others have come to believe the best way to bring a stronger empirical orientation into the psychotherapy field is by instituting a systematic way for clients to provide ongoing feedback to clinicians about their perceived progress. This point of view stresses the use of research methodology in ongoing therapy on a session-by-session basis, so as to track change—or the lack of it. Systems for providing such feedback have been developed by psychologists Michael Lambert, Kenneth Howard, William Pinsof, Scott Miller, Barry Duncan, Leonard Bickman, and others. Miller and Duncan utilize a short scale, asking the client how he or she is doing and feels about the therapy, which they regularly review with the client as therapy progresses. Lambert's measure, the OQ-44, is completed by clients before each session and computer scored, generating regular feedback letting therapists know how a case is progressing in comparison to results with similar clients at a similar stage in the treatment process. Lambert has already shown that feedback to therapists about cases that are going worse than expected can have a considerable positive effect on therapy outcome.

Cautions

So what does all this say about what the ordinary clinician, not trained in the close analysis of clinical research, needs to know? For most client problems, psychotherapy, as a broad activity, is well established as being effective. Therapy studies suggest that differences in treatment are far less important than therapist, client, and relationship factors. For some problems widely acknowledged as difficult to treat, however, such as panic disorder, obsessive-compulsive disorder, borderline personality disorder, adolescent substance use and delinquency, bipolar disorder, and schizophrenia, the jury is no longer out: certain research-supported therapies have clearly shown themselves to achieve superior outcomes. For example: panic disorder responds well to treatments such as David Barlow and Michelle Craske's cognitive-behavioral based Panic Control Treatment; obsessive-compulsive disorder to Edna Foa's Exposure and Ritual Prevention Treatment; borderline personality disorder to Marsha Linehan's Dialectical Behavior Therapy; and adolescent substance abuse to such family treatments as Howard Liddle's Multidimensional Family Therapy, Jose Szapocznik's Brief Strategic Family Therapy, and James Alexander's Functional Family Therapy. These are problems that clinicians widely regard as difficult to treat, and the limited outcome data we have suggest that other forms of treatment that aren't designed to deal with the special aspects of these problems yield poor outcomes and high rates of recidivism. Until proven otherwise, the research-supported treatments should be regarded as treatments of choice for these problems.

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