The chapters in this book offer a glimpse of what effective therapies look like, but we are just at the beginning of fully realizing what science-based therapy will become. As described in Chapter 1, the Society of Clinical Psychology (SCP; Division 12 [D12] of the American Psychological Association) provided the first major comprehensive framework for identifying efficacious psychological treatments. Within this framework – sometimes referred to as the “Chambless criteria” – the highest designation that an empirically supported treatment (EST) can be given is to be officially characterized as well-established (Reference Chambless and HollonChambless & Hollon, 1998; Reference Chambless and OllendickChambless & Ollendick, 2001) and informally described as having strong research support (www.psychologicaltreatments.org). Table 22.1 provides a summary of the psychological treatments for adults that have achieved this highest level of support (for a similar table about treatments for youth, see Reference Hupp, Hupp, Stea and HuppHupp & Hupp, 2023).

As can be gleaned from the table, the majority of ESTs fall within the behavioral and cognitive traditions. Moreover, the blended approach of cognitive-behavioral therapy (CBT) – and its many variants – has frequently been identified as being well established. These time-limited behavioral and cognitive therapies have been particularly well suited to being investigated by using randomized controlled trials (RCTs), which many consider to be the “gold standard” for determining treatment efficacy.

However, it’s important to recognize that the emphasis on RCTs has been criticized for not being applicable to “real-world” settings (Reference BeutlerBeutler, 1998; Reference Goldfried and WolfeGoldfried & Wolfe, 1996, Reference Goldfried and Wolfe1998; Reference Gonzales and ChambersGonzales & Chambers, 2002; Reference NorcrossNorcross, 1999; Reference SeligmanSeligman, 1996), and it has been correctly noted that many patients seeking psychological treatment will deviate from the RCT sample in some important ways (Reference Fensterheim and RawFensterheim & Raw, 1996; Reference Westen, Novotny and Thompson-BrennerWesten et al., 2004b). Whereas RCTs commonly exclude patients for “comorbid” psychiatric conditions (Reference Westen and MorrisonWesten & Morrison, 2001), clinic patients frequently meet criteria for multiple disorders, making it difficult to isolate a single disorder (Reference Goldfried and Eubanks-CarterGoldfried & Eubanks-Carter, 2004; Reference WachtelWachtel, 2010; Reference Westen, Novotny and Thompson-BrennerWesten et al., 2004a). The operationalizing of psychotherapeutic procedures in the form of manualized treatments allowed for greater consistency across therapists, created some minimal standards of practice, and allowed practitioners and patients alike to more clearly understand what was to be done. This process, however, raised eyebrows among many (e.g., Reference FonagyFonagy, 1999; Reference LevantLevant, 2004; Reference NorcrossNorcross, 1999), with some suggesting that these manuals overestimate the degree of homogeneity among patients with a particular diagnosis, forcing a “one-size-fits-all” approach (Reference WachtelWachtel, 2010). Others criticized treatment manuals as a “straightjacket for a talented therapist” (Reference Goldfried and Eubanks-CarterGoldfried & Eubanks-Carter, 2004, p. 670). Aware of these criticisms, some researchers have worked toward including participants with comorbidities, offering treatment manuals that allow for greater flexibility, and prioritizing investigations in real-world settings.

As described in Chapter 1, the updated Division 12 EST guidelines – sometimes referred to as the “Tolin criteria” (Reference Tolin, McKay, Forman, Klonsky and ThombsTolin, McKay, et al., 2015) set out to encourage greater emphasis on research in real-word settings. Other priorities of these newer criteria also include a demonstration of meaningful outcome improvement, lasting treatment gains, and other contextual factors such as the identification of active ingredients. Since the publication of these new EST criteria, the evidence base for several psychological treatments has been formally evaluated according to these standards. Psychological treatments that have been evaluated in coordination with the SCP include exposure and response prevention for obsessive-compulsive disorder (Reference Tolin, McKay, Forman, Klonsky and ThombsTolin, Melnyk, et al., 2015), CBT for insomnia disorder (Reference Boness, Hershenberg and KayeBoness et al., 2020), CBT for substance use disorder (Reference Boness, Votaw and SchwebelBoness et al., 2023), contingency management for drug use (Reference Pfund, Ginley and BonessPfund et al., 2022), and CBT for gambling harm (Reference Pfund, Ginley and KimPfund et al., 2023). Additional evaluations for psychological treatments are currently in progress. Table 22.2 provides a summary of the results of these reviews, and a current list of completed and in-progress evaluations is maintained by the SCP’s Committee on Science and Practice. Treatments evaluated with the “Tolin criteria” are also located on the SCP’s website.

As shown in the table, the treatments evaluated with the Tolin criteria to date have received a strong recommendation – but not a very strong recommendation. Moreover, very few treatments have been evaluated at all. Thus, the need for rigorous research persists, and the door is open for many more reviews. Our call to action is this: Consider conducting a treatment evaluation using these criteria and submitting that evaluation to Division 12 for consideration as an EST. To do so, a good first step would be to read the brief manual: The Society of Clinical Psychology’s Manual for the Evaluation of Psychological Treatments Using the Tolin Criteria (Reference Boness, Hershenberg and GrassoBoness et al., 2021), available for free on the SCP website (https://div12.org/psychological-treatments/). The manual describes the next steps, including how to submit a letter of intent to the SCP’s Committee on Science and Practice.

Of course, evaluating the empirical support for a treatment with the Tolin criteria is no small undertaking. To aid in the process, there have been attempts to manualize the application of the criteria and offer tools for simplifying the process (Reference Boness, Hershenberg and GrassoBoness et al., 2021). Although there are required elements of evaluating a treatment with the Division 12 Criteria, there is no one “right” way, and specific practices may vary across evaluation teams (e.g., the decision to statistically combine effect sizes or not, which review quality tool to use). The lack of a single “right” way to conduct these evaluations can be a challenge for some teams, particularly in cases where the team lacks sufficient expertise to deviate from the manual.

In our opinion, adequately evaluating the evidence for a particular psychological treatment requires a diverse team with both content and methodological experience. It is valuable to have a team member with expertise in a given treatment for the particular disorder in question (e.g., CBT for insomnia disorder) as well as a team member with expertise in systematic review methodology, including meta-analyses. In ideal circumstances, it can also be helpful to have a team member with expertise in additional or adjacent treatments for the same disorder (e.g., brief behavioral treatment for insomnia disorder), particularly if that person has less allegiance to the treatment being evaluated compared to other team members. Teams might even seek out a member who is critical of the treatment under evaluation as they can bring a healthy level of skepticism to the process.

One of the greatest resources to engage when undertaking a systematic review of any type is a librarian, particularly one with subject matter expertise. Librarians can help formulate comprehensive search strategies and conduct literature searches to ensure all relevant reviews are captured for the evaluation. In some cases, they may also be able to help guide other steps in the evaluation, including the selection of software for screening reviews and extracting data as well as the selection of standardized instruments for evaluating review quality. We strongly advise consulting a librarian early and often in the evaluation process, and even formally including them as a team member. Whether a librarian is included or not, staying organized throughout the evaluation process is critical for transparent reporting and rigorous treatment evaluation.

A final word of advice when conducting these evaluations is to take the consideration of contextual factors seriously. Contextual factors include considering features such as how the current treatment’s effect size compares to other well established treatments; whether the current treatment offers an advantage in cost, efficiency, or practicality; evidence that the treatment is effective across diverse individuals, patient populations, and settings; whether the treatment has been studied by a wide array of researchers without strong allegiance to the treatment; and evidence linking the treatment to the purported mechanism of change. These are critical to consider in treatment evaluations because they have the potential to influence the overall treatment rating (i.e., weak, strong, very strong) and can provide insight into what additional work might be needed to strengthen the evidence base for the treatment.

Although evaluating treatments with the Tolin criteria may seem like a massive undertaking, with the right team and robust systems for staying organized, these evaluations are feasible to complete. Evaluation teams are not required to pursue publication of their evaluations, but we strongly encourage them to for the sake of dissemination. As more evaluations are completed, the criteria can also be updated and refined to ensure that the evidence base for psychological treatments is being evaluated with rigor, further supporting the dissemination of effective treatments and the improvement of mental health care for all people.