What is Evidence-Based Therapy?

A Definition
Evidence-Based Therapy (EBT), more broadly referred to as evidence-based
practice (EBP), is any therapy that has shown to be effective in peer-reviewed
scientific experiments. According to the Association for Behavioral and Cognitive
Therapies, evidence-based practice is characterized by an:

“[a]dherence to psychological approaches and techniques that are based on

scientific evidence”.

The American Psychiatric Association and the American Psychological

Association both consider EBT/EBP to be:

“‘best practice’ and one of the ‘preferred’ approaches for the treatment of
psychological symptoms”.

In relevant literature, evidence-based medicine has also been defined as the:

“conscientious, explicit, and judicious use of current best evidence in making

decisions about the care of individual patients” (Sackett et al., 1996).

Recently, this definition has expanded to include “consideration of patients’

preferences, actions, clinical state, and circumstances” (Cook et al., 2017). This
expansion of the definition is particularly important in the context of
psychotherapy where the effectiveness of the treatment is in large part determined
by the patient’s investment and belief in the efficacy of the treatment.

To sum up these discussions, we can think of Evidence-Based Therapy or practice

as referring to psychotherapy practices that have research that been proven
effective rather than based solely on theory.

The Goals and Benefits of Evidence-Based Therapy

Two of the main goals behind evidence-based practice are:

1. increased quality of treatment, and

2. increased accountability.

Meeting these goals will make it more likely that patients will only pay for and
undergo treatments that have shown to be effective (Spring, 2007). Research has
shown that Evidence-Based Therapy is indeed cost-effective (Emmelkamp et al.,
2014), likely due to the decrease in time spent receiving treatment compared to
those undergoing treatment plans which may or may not be effective.
In fact, some commentators have even argued that, along with the push for
Evidence-Based Therapy, subscribers to EBT should also promote therapy that has
shown to be cost-effective as well as clinically effective (Castelnuovo et al., 2016).

These commentators have also stressed that caution must be taken to ensure that
this does not result in treatment plans that are only cheap because they are
ineffective (or of unknown effectiveness) in other words, there should be an
emphasis on EBT being both clinically effective and cost-effective, not just one of
the two.

Some recent literature has also argued that the therapist has more of an impact on
treatment effectiveness than the therapy practices deployed, leading one paper to
declare that “the time is overdue for the psychotherapy field as a whole to research
and develop the idea of evidence-based therapists” rather than simply focusing on
Evidence-Based Therapy (Blow & Karam, 2017).

Proponents argue that since certain therapists are more effective for certain clients
than other therapists (Kraus et al., 2016), therapists should then be held
accountable for their effectiveness just like treatment plans are.

If adopted, this approach would likely involve tracking a therapist’s success rate
and ensuring that they continue to provide proof of their effectiveness, just as one
would assess the effectiveness of a certain treatment plan. This idea is still in its
infancy, but it may prove to be a popular one in the coming years.

Examples of Interventions Used in Evidence-Based

Therapy
There are dozens, if not hundreds, of scenarios in which one or more therapies
have been shown to effectively treat psychological symptoms.

Listing them all would make for an extremely long read; instead, consider these
examples and continue looking for more in the areas that interest you.

1. Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) has been shown to be effective in

the treatment of anxiety disorders, depression, addiction, and certain physical
health issues (A-Tjak et al., 2015).
A recent meta-analysis of 39 randomized controlled trials (RCT, often called the
“gold standard” of determining clinical effectiveness) found that ACT was more
effective than either placebo or what the researchers called “treatment as usual,” or
the standard treatment for such issues; however, ACT was not found to outperform
cognitive behavioral therapy.

2. Cognitive Behavioral Therapy

Cognitive Behavioral Therapy, or CBT, is perhaps the most well-known and

widely accepted form of treatment for many psychological issues.

In recent years, several independent meta-analyses have found solid evidence for
the effectiveness of CBT in treating anxiety (Carpenter et al., 2018), depression (in
all treatment delivery formats; Cuijpers, Noma, Karyotaki, Cipriani, & Furukawa,
2019), psychosis (Hazell, Hayward, Cavanagh, & Strauss, 2016), Body
Dysmorphic Disorder (BDD; Harrison, de la Cruz, Enander, Radua, & Mataix-
Cols, 2016), and eating disorders (Linardon, Wade, de la Piedad Garcia, &
Brennan, 2017), among other psychological issues.

Due to its wide-reaching effectiveness, CBT is a commonly used treatment for a

variety of ailments.

Although CBT is a big commitment, requiring a large investment of both time and
resources (not to mention effort and energy on behalf of both therapist and patient),
it has been so effective for so many disorders, which has led some researchers to
explore the possibilities in making CBT more accessible.

One such effort examined the feasibility of internet-delivered cognitive behavior

therapy (IBCT), which found that ICBT can be effective in treating children and
adolescents with anxiety and depressive symptoms (Vigerland et al., 2016). CBT is
an effective, evidence-based treatment plan for a wide range of disorders, so
making it accessible as possible should be a priority. ICBT is a crucial first step
towards that goal.

3. Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) is also an evidence-based treatment, as it

has been shown to be effective for relieving the symptoms and improving
outcomes for patients with both borderline personality disorder (BPD) and
substance abuse (Linehan et al., 1999) as well as for patients with trichotillomania
(Keuthen et al., 2011).
As a side note, DBT may benefit more than just patients with BPD; there is also
evidence that DBT may be an effective treatment for other psychological issues,
including patients struggling with intellectual disabilities, but more research is
needed to determine its effectiveness (McNair et al., 2017).

4. Mindfulness-Based Cognitive Therapy

Mindfulness-Based Cognitive Therapy (MBCT) has been found to be effective

in reducing relapse rates of Major Depressive Disorder (MDD) (Lilja et al., 2016).

As noted earlier, CBT research has proven it as effective for the treatment of both
MDD and generalized anxiety disorder (GAD), along with several other disorders
(Gratzer & Goldbloom, 2016); however, the addition of mindfulness to cognitive
therapy may boost its effectiveness in some situations.

Evidence-based psychotherapies have been shown to be efficacious and cost-effective for a wide
range of psychiatric conditions. Psychiatric disorders are prevalent worldwide and associated with
high rates of disease burden, as well as elevated rates of co-occurrence with medical disorders,
which has led to an increased focus on the need for evidence-based psychotherapies. This chapter
focuses on the current state of evidence-based psychotherapy. The strengths and challenges of
evidence-based psychotherapy are discussed, as well as misperceptions regarding the approach that
may discourage and limit its use. In addition, we review various factors associated with the optimal
implementation and application of evidence-based psychotherapies. Lastly, suggestions are provided
on ways to advance the evidence-based psychotherapy movement to become truly integrated into
practice.

Background
Psychiatric disorders are prevalent worldwide [1] and are associated with high rates of
disease burden, including elevated rates of morbidity and mortality [2, 3]. In addition, there is
a high rate of co-occurrence between psychiatric and medical disorders [4, 5]. When
psychiatric disorders co-occur with medical problems, not only are the medical symptoms
more problematic, but the treatment of the medical condition is often more complicated [6].
For example, there is often lowered levels of treatment adherence and higher levels of
healthcare service utilization, with its associated costs [4]. Therefore, increasing attention has
been paid to the need for evidence-based pharmacological and psychotherapeutic
interventions for a range of psychiatric disorders [7, 8].
This chapter focuses on the current state of evidence-based psychotherapy. These
psychotherapies are efficacious, beneficial, and cost-effective for myriad psychiatric
disorders [9, 10]. Moreover, people prefer psychotherapy to pharmacological treatments [11].
Unfortunately, despite the sizable evidence base, there is a significant gap between the
availability of effective psychotherapies and the delivery of such interventions in the
community [12].
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History of Evidence-Based Practice

The roots of evidence-based medicine go back centuries [13]. Yet evidence-based practice
(EBP; i.e., evidence-based treatment) did not became a “hot topic” in medicine until the
1990s, as attention began to be paid to the value of using evidence-based medicine to support
decision-making in practice, educational, and policy contexts. This laid the groundwork for
the adoption of EBP in medicine, as well as other healthcare professions.
The term “evidence-based” was first used by Eddy in 1987 in his workshops on designing
clinical practice guidelines in medicine. In the 1990s, the phrase began to be used in relation
to a clinical decision-making approach informed by published findings [13–15]. The term
was first formally defined by Sackett, often viewed as the father of this movement, and his
colleagues in 1996. They stated, evidence-based medicine is the “conscientious, explicit, and
judicious use of current best evidence in making decisions about the care of individual
patients” [16]. They noted that it requires the integration of the practitioner’s clinical
expertise with the best available data gleaned from systematic investigations [16]. Over time,
the concept has expanded and now includes consideration of patients’ preferences, actions,
clinical state, and circumstances [17]. The key steps of EBP in medicine include formulating
the clinical question based on the presenting problem, critically evaluating the pertinent
literature with regard to its validity and usefulness for a given patient, implementing the
research findings in clinical practice, and evaluating the outcomes [18].
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EBP and Psychotherapy

The American Psychological Association developed a policy on the EBP of psychotherapy
[19] that follows the definition put forth by Sackett et al. [16] and the Institute of Medicine
[20]. This policy emphasizes integrating the best-available research with clinical expertise in
the context of the patient’s culture, individual characteristics, and personal preferences. The
best research evidence refers to data from meta-analyses, randomized controlled trials,
effectiveness studies, and process studies, as well as information obtained from single-case
reports, systematic case studies, qualitative and ethnographic research, and clinical
observation. The applicability of evidence to specific cases must be considered, which ties to
the emphasis placed on integrating clinical expertise and specific clinical information vis-à-
vis the patient with the pertinent research evidence to make clinical decisions, implement
treatment plans, foster a therapeutic alliance, and achieve positive outcomes. This policy
makes clear that the effectiveness of any psychotherapy is influenced by the unique
characteristics of each patient, such as developmental history and life stage, personal
problems, strengths, personality structure, functional status, readiness to change or engage in
psychotherapy, degree of social support, and family and sociocultural factors. The policy also
highlights consideration of the patient’s environment when choosing an evidence-based
psychotherapy modality and notes the role of healthcare disparities and specific stressors
(e.g., unemployment, major life events).
One key goal of EBP psychotherapy is to maximize patient choice about options. Since the
outset of EBP generally and the psychotherapy movement specifically, patients’ preferences
are prioritized, which affords them active choices. Clinical decisions associated with
evidence-based psychotherapies optimally are made collaboratively with the patient, based on
the best available evidence, with attention to costs, benefits, available resources, and options
[21, 22]. Such decision-making involves ongoing monitoring and adjustment.
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Strengths of Evidence-Based Psychotherapy

There are advantages of evidence-based psychotherapies for practitioners, clinical teams, and
patients [18]. It has been argued that for practice to be ethical it is imperative that it is guided
by the relevant data [23]. By incorporating research into clinical practice, providers use
research-driven evidence rather than rely solely on personal opinion. Using empirical
evidence reduces opinion-based bias of recalling only “successes”. When practiced
appropriately, EBP can complement clinical expertise when making judgments. Incorporating
research inevitably promotes the development of guidelines, databases, and other clinical
tools that can help clinicians make critical treatment decisions, particularly in community-
based settings [24]. Evidence-based psychotherapy encompasses both scientific and local
evidence, such as diagnostic patient information, situational information including cost and
time constraints, and the provider’s judgment and experience to achieve the best outcome
[25].
Applying evidence-based principles ensures that providers use the best existing evidence as a
starting framework, while simultaneously affording them flexibility to individualize
treatment. More specifically, evidence-based practice ensures that providers critically assess
the data available and apply it to individual patient circumstances. When the evidence is
appraised and fully understood, providers can decide if and how to incorporate it into
practice. In addition, using evidence-based psychotherapies helps providers determine
treatment plans, including in situations in which there are limited data or experience [26]. In
fact, in patients with multiple medical and psychiatric comorbidities, using evidence-based
treatments offers providers a starting point to develop complex treatment plans [27].
One misperception of evidence-based psychotherapy use is that in order to be useful, the
evidence must be from a randomized controlled trial, which is typically challenging for many
fields but particularly for psychotherapies. In fact, the evidence supporting the wide variety
of psychotherapies available can include numerous methodologies as long as the evidence is
assessed and applied appropriately in clinical decision-making [25]. Ideally, practitioners
who actively employ EBPs save time, money, and resources by avoiding treatments with
little or questionable effectiveness for their patients.
Training professionals to utilize EBPs enhances people’s knowledge, skills, and attitudes and
clinical acumen [28, 29], especially when accompanied by a focus on reflection [30]. In
addition, training in the use of myriad evidence-based psychotherapies ensures that providers
are familiar with the state-of-the-field and have depth and diversity in their clinical practice.
Training in an EBP, coupled with an active and ongoing learning process, is required for
professionals to facilitate patient change and other positive outcomes [28, 31].
Ultimately, the goal of EBP is the promotion and implementation of psychotherapies that are
safe, consistent, and cost-effective [32]. As a result, evidence-based psychotherapies are
associated with higher quality and more accountability [29], as well as the enhancement of
the health and well-being of the public [19]. Because providers adhere less to evidence-based
methods over time, quality of care diminishes with increasing years of experience. In
addition, providers with more experience may be less up to date with current knowledge,
guidelines, or standards of care, and, as a result, their patients may have poorer treatment
outcomes [33].
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Challenges of Evidence-Based Psychotherapy

Despite the many strengths of using evidence-based psychotherapy, there are challenges that
must be considered [30, 34]. First, concerns have been raised about the generalizability of the
findings, given that the conditions and characteristics of randomized controlled treatment
outcome research versus those of real-world clinical practice differ significantly [34]. For
example, research samples often under-represent minority populations or patients with
comorbid conditions [35] and, as a result, evidence-based psychotherapies often are not
effective for individuals with complex multimorbidities or from sociodemographic groups for
which the intervention has yet to be tested [30]. In addition, many psychotherapy trials for
depression and anxiety recruit participants with limited psychosocial stressors given their
confounding nature. However, in actual practice, most patients face these stressors and it is
unclear how well the purported evidence-based psychotherapies will treat these individuals
[34]. Evidence-based psychotherapy is also challenging to apply to individuals given that the
evidence is based on a composite of multiple subjects, with limited attention to the impact of
individual factors and influences on the patient’s health.
Second, there are a number of marked differences between the processes of commonly
practiced psychotherapies and EBP. For example, EBP tends to focus on ameliorating
symptoms or disorders, whereas many people seek out psychotherapy to cope more
effectively with life’s challenges and have a greater sense of meaning in their lives. In
addition, psychotherapies typically prioritize empowerment and supporting people in
achieving their own treatment goals, whereas evidence-based approaches risk not attending to
patients as agents of change or self-healers. As another example, diverse forms of
psychotherapy guided by myriad theoretical perspectives or a combination of such models are
practiced. The majority of evidence-based psychotherapies are cognitive–behavioral, whereas
many practitioners employ existential–humanistic, interpersonal, psychodynamic, systemic,
and/or integrative models [9]. While there appears to be a divide between evidence-based
research and practice and clinical application, evidence-based psychotherapies synthesize
new knowledge when providers test evidence-based guidelines and adapt them to cohort
specific circumstances.
Third, reliance on scientific research is problematic, as for many practices the level of
evidence required to be considered “evidence-based” is lacking or unattainable. There are no
agreed-upon criteria for determining if a psychotherapy is evidence-based or empirically
supported and what is statistically significant and suggestive of empirical support may not be
clinically relevant [12, 30, 34]. In addition, often times the randomized controlled trials
compare an active intervention with a wait-list control or attention control condition that does
not exist in the community. Until efficacy and effectiveness studies include treatment
conditions that resemble practice in the real world, it is challenging to draw conclusions from
the existing data that can meaningfully affect clinical practice [36]. Similarly, there are
limited data regarding the mechanisms of change in an intervention that produce effective
outcomes [37].
Professionals must have timely access to information for optimal implementation. This is
challenging in that there are often lags between conduction of research and publication, and
then from publication to adoption into practice or policy. As with any research modality,
evidence-based psychotherapies are subject to biases, such as sponsorship of research,
methodologies used, subjects chosen, and publications, which may impact on the credibility
of the particular treatment.
Fourth, overemphasis on using evidence-based psychotherapies could erroneously ignore
other clinical tools, most notably professionals’ own clinical experience. Similarly, when
evidence-based psychotherapies are applied too rigidly, there is risk of diminishing their
value, particularly if applied to patients for whom effectiveness will be limited, causing the
psychotherapy (and policy) to be called into question. Such over-reliance on rules may result
in psychotherapeutic practice that is management driven, rather than patient-centered [30].
Finally, from the practitioner’s standpoint, dedicated use of evidence-based psychotherapies
could impose burden in terms of continuing education and training. Clinicians using
evidence-based psychotherapies must maintain up-to-date knowledge of the latest evidence
supporting current or new methods, which, of course, takes a considerable amount of time.
Providers must have adequate training to identify and implement the most appropriate
psychotherapy for a patient [38]. Other components, such as database and journal access, in
addition to training, can be costly and challenging to locate for more remote clinicians.
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Misperceptions of Evidence-Based Psychotherapy

Resistance to using evidence-based psychotherapies results from clinicians and patients, often
due to misunderstandings or misperceptions of the role of evidence-based psychotherapies
[23]. Exposure to caricatured versions of evidence-based psychotherapies causes
oversimplification of treatments that could easily discourage clinicians from utilizing them
[39]. There is a misperception that evidence-based psychotherapies are merely “cookbook”
practice instructions that force clinical professionals to replace their judgment with
“manualized” procedures. In reality, most guidelines, including those of the American
Psychological Association [19], strongly recommend incorporation of clinical expertise and
judgment into applicable practice of evidence-based psychotherapies. Evidence-based
psychotherapies are more appropriately considered as a “map” of potential routes, with the
practitioner determining which treatment path to take based on the unique history and
presentation of the patient. Even empirically supported psychotherapies do not generally
recommend predetermined responses to patients’ behaviors or rigid adherence to protocols
[40]. Inflexibility in treatment protocols can lead to undesirable treatment outcomes [41]. As
a result, Kendall et al. [42] advocate for a model that embodies “flexibility within fidelity” in
which practitioners follow basic treatment guidelines of an evidence-based psychotherapies
without rigid adherence. Such fidelity should relate to core components, rather than specific
techniques, given that it is fidelity to core components during treatment that ensures good
outcomes [43].
It is often assumed that using an evidence-based psychotherapy means that patients’ values
and preferences are ignored in order to pursue a prescribed, rigid treatment plan. This plan is
often viewed as a costing-cutting measure rather than a first-line modality. However,
appropriate use of evidence-based psychotherapy incorporates clinical expertise, which, by
definition, requires incorporating patient values, preferences, and individual circumstances as
integral parts of decision-making. Incorporating evidence-based psychotherapy and clinical
expertise creates the most effective means of treatment resulting in cost savings.
Many clinicians hold a misperceived idea that the psychotherapy provided could never meet
EBP criteria or standards, because data are insufficient or flawed. While all research has
limitations, the key to evidence-based psychotherapies is to use the best available evidence
and differentiate between limitations and “fatal” flaws. Treatments without sufficient
evidence may be used with caution and careful monitoring and in accord with clinical
expertise and patient preference.
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Implementation and Application of Evidence-Based Psychotherapy

In this section, attention is paid to various factors association with the optimal
implementation of evidence-based psychotherapies. The factors addressed include
relationships, fidelity, flexibility context, and providers.

Relationships
While much attention has been paid to the value of evidence-based psychotherapies, there is
considerable evidence that the therapeutic relationship makes substantial and consistent
contributions to psychotherapy outcomes independent of the type of treatment [44–46]. The
relationship acts in concert with treatment methods, patient characteristics, and practitioner
qualities in determining effectiveness. In fact, the therapeutic relationship accounts for why
patients improve, or fail to improve, at least as much as the particular treatment method. In
addition, adapting or tailoring the therapeutic relationship to specific patient characteristics,
including diagnoses, further enhances the effectiveness of treatment [44]. As a result, any
discussion of evidence-based psychotherapies must include attention to evidence-based
relationships.
Demonstrably effective elements of the relationship include forming a positive therapeutic
alliance in individual, youth and family psychotherapy; cohesion among patients in a group
therapy setting; empathy; and eliciting patient feedback [44]. Elements that are probably
effective include goal consensus, collaboration, and positive regard and support [44]. There is
insufficient, yet promising, research on the elements of congruence or genuineness, repairing
alliance ruptures, and managing countertransference. Ineffective elements of the therapeutic
relationship can curtail progress or contribute to negative outcomes [44]. Ineffective elements
include inappropriate or ill-timed confrontations, negative processes, or making assumptions
about the patient. Therapist centricity, or providing treatment that revolves around the
psychotherapist’s goals or agenda, is also ineffective and impedes progress. Similarly, rigidly
adhering to a uniform procrustean bed of psychotherapy for all patients ineffectively binds
the individual to ineffective treatment [44].
Efforts to promulgate evidence-based psychotherapy must include a focus on the therapeutic
relationship. There are several recommendations to ensure the therapeutic relationship makes
evidence-based psychotherapy as effective as possible. First, a comprehensive understanding
of effective (and ineffective) psychotherapy must consider how the therapeutic relationship
acts in concert with other determinants and their optimal combinations. Practice and
treatment guidelines should explicitly address therapy behaviors and qualities that promote a
facilitative therapeutic relationship. Psychotherapists must prioritize understanding their
patients, recognizing them as agents of change within sessions, supporting them as self-
healers, and intentionally shaping their interventions based on being attuned to the patients’
experiences of psychotherapy. This involves viewing psychotherapy as a process of change
through structured curiosity and deep engagement in pattern identification and narrative
reconstruction. Psychotherapists must be caring, understanding, and accepting, which allows
patients to internalize positive messages and enter the change process of developing self-
awareness [47]. In addition, they must recognize that professional structures create credibility
and clarity, but cast suspicion on care within the relationship. Psychotherapists who forge
productive relationships with their patients appreciate that psychotherapy progresses as a
collaborative effort with discussion of differences between both parties. They also recognize
that patients’ agency with regard to decision-making and the therapeutic process increases the
likelihood that responsive interventions are employed that fit their needs and that result in
positive outcomes.

Fidelity
In addition to attention to the therapeutic relationship, evidence-based psychotherapies that
yield good outcomes are those that are practiced with a high level of fidelity such that the
core components of the psychotherapy are implemented [43]. The core components refer to
the basic elements of the evidence-based psychotherapy that are required for applicability and
validity of the intervention [48]. Core components are often defined by the evidence-based
psychotherapy developers or in policy guidelines and help describe population
characteristics, content of the psychotherapy, context or setting of the intervention, and
sequence of the treatment. For example, population characteristics could include adult
women with post-traumatic stress disorder; the content is described as 5 lessons on 5 themes
of emotion regulation; the context is in a clinic group therapy room on a weekly basis; and
the sequence is described as first, emotional identification, then promotion of positive
emotions.
Fidelity to an evidence-based psychotherapy is important because when elements of the
treatment are changed, the practice is no longer the same as the researched practice. In other
words, psychotherapists are no longer implementing an EBP when it no longer resembles the
practice in the evidence. Consistency, achieved through fidelity, allows for stronger
statements about the efficacy of a practice. Evidence-based psychotherapies implemented
with fidelity are more likely to achieve the desired outcomes (as described in the evidence).
Many tools for maintaining fidelity are available and include toolkits and training manuals,
ongoing training and supervision, and fidelity monitoring and fidelity scales.
Fidelity adherence when using evidence-based psychotherapies faces some challenges.
Unfortunately, other than in efficacy research, it is not generally feasible to closely monitor
fidelity in real-world implementation. Rigid application of fidelity reduces the usability of a
particular psychotherapy. For example, labeling a treatment as only for depression without
anxiety eliminates application to many patients with depression. Maintaining fidelity often
requires time and resources for training and ongoing monitoring. In fact, programs with high
staff turnover requiring repeated trainings of new-hires, leadership or government
requirements, and extensive training for the psychotherapy can influence fidelity over time,
particularly for larger-scale implementation of evidence-based psychotherapies [49]. Some
evidence-based psychotherapies are simply more challenging to implement with fidelity than
others. Fidelity requires conscientious application of the principles of the evidence-based
psychotherapy to practice, which is subject to problems in translation or competence,
particularly in the context of dissemination efforts.

Flexibility
While fidelity is a crucial component of successful evidence-based psychotherapy practice,
implementation with flexibility is also necessary. Flexibility refers to areas where the
application of the psychotherapy differs from the specific EBP, such as deviations from
manual-based protocol or individualized applications based on patient characteristics.
Flexible implementation should still retain core components of the evidence-based
psychotherapy. Flexibility may be desirable in a number of different situations. For example,
therapists may use flexibility to build rapport, select treatment modality, or alter the pacing of
the intervention in order to assist a patient who has difficulty learning multiple skills rapidly
or integrating particular aspects of the treatment. Flexibility also may be warranted in
working with people’s reactions to current life stressors, such as a death in the family or other
traumatic events, as these often fall outside of the evidence-based protocol. Moreover,
flexibility may be necessary in situations in which individuals present with comorbid
conditions, as these must be taken into account in treatment selection and implementation.
For example, patients struggling with obsessive thoughts in addition to post-traumatic stress
disorder will likely need an alternative therapy prior to starting evidence-based trauma
exposure treatment. Modality changes may also be needed for unique patient situations, such
as telephone or internet sessions if the patient travels frequently. In addition, some patients
prefer the use of technology (e.g., smartphones and other mobile devices) for the receipt of
psychological treatments and this may require flexible modification of an EBP traditionally
administered in the more usual office setting [8]. Finally, many patients benefit from booster
sessions or skills refreshers that are not necessarily built into evidence-based protocols and
therapists must be open to accommodating such needs.
Incorporating flexibility into an evidence-based psychotherapy treatment is not without
challenges. Flexibility can be difficult to include in research on evidence-based
psychotherapy as the variation from the protocol becomes challenging to monitor and
introduces confounding factors. Overuse of flexibility reduces fidelity, which as discussed
earlier, is critical to maintaining an effective evidence-based psychotherapy. The challenge
psychotherapists face is walking the fine line between flexible implementation of an
evidence-based psychotherapy and the maintenance of the core components of the
intervention. It is for this reason therefore that evidence-based psychotherapies are
increasingly being developed that provide guidance with regard to both flexibility and
fidelity. For example, the Skills Training in Affective and Interpersonal Regulation–Narrative
Therapy (STAIR-NT) protocol includes a wide range of sessions per topic, allows for
nonprotocol sessions to address individual patient crises, and encourages optional booster
sessions [50].

Context
Effective implementation must also take context into account. In terms of context, evidence-
based psychotherapies are implemented across a multitude of settings, including private
practices, Veterans Health Administration facilities, counseling centers, medical centers, and
educational systems to name a few. While some evidence-based psychotherapies are designed
for specific contexts, others are formulated for implementation across multiple contexts. As
with other components of evidence-based psychotherapies, the context of development
should be considered when selecting a treatment.
Although the intent is generally to implement evidence-based psychotherapies across
multiple settings, therapists should consider the extent of applicability to their patient
population. For example, the Veterans Health Administration (VHA) often uses guidelines
for various disorders and postdeployment health, and evidence-based psychotherapies are
often a major cornerstone of treatment. Indeed, the VHA has been a leader in training staff in
the delivery of evidence-based interventions and in disseminating and implementing these
psychotherapies [51]. Data from program evaluations reveal that such training has resulted in
positive outcomes for psychotherapies, such as greater clinical competence and self-efficacy
[51]. In addition, patient outcomes have been encouraging in response to these evidence-
based psychotherapies as well, in terms of both symptom reduction and improvements in
quality of life. The large-scale dissemination efforts in this context suggest that it is feasible
to overcome the science to practice based gap that has existed historically vis-à-vis evidence-
based psychotherapy practice and that efforts to bridge this gap can yield positive outcomes
[51].
Unfortunately, this has led to concern that treatment at the VA is based on modules and
algorithms with limited flexibility or individualized care and may not be suited to all settings.
For example, medical settings face challenges with the stepped care or algorithm-based care
rather than treatment tailored to the individual needs of the patient. In the medical context,
motivational interviewing is an effective modality for addressing behavioral health issues,
such as substance use disorders, obesity, chronic pain, and diabetes, and is a valuable
evidence-based psychotherapeutic intervention for depression that is flexible in its delivery
and easily integrated into primary care settings [52, 53].
The education system is a very different type of site that provides evidence-based
psychotherapies to people diagnosed with autism spectrum disorders, depression, and
anxiety. In addition, the education system provides suicide prevention screening for all
students. Those in educational settings face numerous challenges to the implementation of
EBP, including the cost of manuals for evidence-based interventions, selection of a specific
EBP intervention, provider reluctance to use EPB, and stigma regarding the interventions
from students, parents, and teachers [54].
Although evidence-based psychotherapies are typically thought of as primarily oriented
toward cognitive-based therapies (CBT), there are evidence-based psychotherapies associated
with a multitude of therapeutic orientations. When selecting evidence-based psychotherapies,
it is important to consider the therapeutic orientation in terms of what is most applicable to
the patient and what is most authentic to the provider. Examples of first- and second-wave
CBTs include applied behavioral analysis, behavioral therapy for various disorders,
behavioral parenting training, CBT for various disorders (depression, anxiety, psychosis,
etc.), cognitive processing therapy, exposure therapy and prolonged exposure therapy,
lifestyle modification, and behavior couples and family therapy. Third-wave CBT is a
modality that is sensitive to context and functions of psychological phenomena and focuses
on metacognition, cognitive fusion, emotions, acceptance, mindfulness, dialectics,
spirituality, and the therapeutic relationship. Examples of third-wave CBT include behavioral
activation, schema therapy, acceptance and commitment therapy, cognitive behavioral
analysis system of psychotherapy, dialectical behavior therapy, metacognitive therapy,
mindfulness-based cognitive therapy, and mindfulness-based stress reduction. Other
orientations of evidence-based psychotherapies include interpersonal, emotion focused,
systemic (e.g., functional family therapy, multisystemic therapy), psychodynamic, and
integrative models including the STAIR-NT, parent–child interaction therapy, trauma-based
CBT, and integrative behavioral couples therapy. As may be evident from these listings, there
are evidence-based therapies for young people [55], adults, older adults, and couples and
families [12, 55–57].
Most evidence-based psychotherapies are designed for single-diagnosis conditions, while the
reality is that many patients have multiple comorbid conditions that all require treatment [58].
Fortunately, some evidence-based psychotherapies are specifically designed for comorbid
conditions or have research available for comorbid conditions. For example, the Seeking
Safety protocol addresses post-traumatic stress disorder and comorbid substance use disorder
[59]. Adolescent Coping with Depression [60] treats young people with both depression and
conduct disorder. Motivational interviewing, CBT, and/or family/caregiver interventions can
address comorbid substance use disorders and mood and/or schizophrenia spectrum
disorders. Recently there has been movement toward a transdiagnostic approach for
addressing comorbid disorders effectively with evidence-based psychotherapies.

Provider
A crucial component of evidence-based psychotherapy is the provider. Many evidence-based
psychotherapies imply that psychologists are the primary providers. However, given the
multitude of contexts and settings using evidence-based psychotherapies, there is an equally
wide variety of providers, including physicians, nurses, social workers, professional
counselors, and graduate students. Therapist variables must be considered, including
individual attributes such as training, clinical experience, theoretical orientation, and therapist
attitudes towards EBP .
An essential part of most evidence-based psychotherapies is training, including both initial
training and ongoing training and supervision. Complex interventions may require additional
provider training and skill. Therapist knowledge improves and attitudinal change occurs
following training, and the method for training (particularly ongoing) influences ease of
implementation, accessibility, and desirability. Organizational variables and culture influence
training and consequent therapist uptake and adoption of evidence-based psychotherapy
Training can occur during a specific period or be part of life-long learning, and typically
includes didactics, manual review, practice, and supervised experience, often in groups and
with review of actual case materials, as well as training to become a trainer. The training
method is an important vehicle and active learning, an interactive process that uses action and
reflection has been an effective teaching strategy .
Clinical experience is an additional important provider variable and the therapists in EBP will
vary with some being more skilled. Research settings often rely on trainees in various
disciplines and specialties; however, therapists in clinical trials are selected for their expertise
and may be removed from the study if they cannot deliver the treatment skillfully ]. In
clinical settings, there often is a combination of providers with different specialties and levels
of training that can create challenges, as there are no clear replicable procedures for how to
tailor EBP to an individual patient, and different providers may not reliably select a similar
individualized plan when presented the same case .
Provider theoretical orientation and attitudes towards EBP are key factors. Provider training
and level of professional development should be considered as those who trained using
evidence-based assessment protocols are more likely utilize these methods. Moreover,
therapists who have an allegiance to other treatments may bias the outcomes and also have
issues with adherence to the treatment (fidelity concerns as above). In addition, provider
attitudes are influential in the willingness to adopt and implement EBP and educational
attainment is positively associated with endorsement of EBP and attitudes toward its adoption