CURRENT DIRECTIONS IN PSYCHOLOGICAL S CIENCE
Empirically Supported
Complexity
Rethinking Evidence-Based Practice in Psychotherapy
Drew Westen1,2 and Rebekah Bradley2
1
Department of Psychology, Emory University, and 2Department of Psychiatry and Behavioral Sciences, Emory University
ABSTRACT—Over the last 10 years, evidence-based practice
in psychology has become synonymous with a particular
operationalization of it aimed at developing a list of em-
pirically supported therapies. Although much has been
learned since the emergence of the empirically supported
therapies movement, its restrictive definition of evidence
(excluding, for example, basic science as a source of evi-
dence to be used by clinicians) is problematic, and the as-
sumptions inherent in its nearly exclusive focus on brief,
focal treatments for specific disorders are themselves not
generally supported by the available data. Recent meta-
analytic data support a more nuanced view of treatment
efficacy than one that makes dichotomous judgments of
empirically supported or unsupported, suggesting the need
for a more refined concept of evidence-based practice in
psychology.
KEYWORDS—evidence based practice; empirically support-
ed therapy; multidimensional meta-analysis; psychothera-
py; treatment research; exclusion criteria; generalizability;
dissemination
The last several years have seen a worldwide movement toward
evidence-based practice in medicine (Sackett, Straus, Ri-
chardson, Rosenberg, & Haynes, 2000). It is difficult to imagine
how anyone could object to such a movement (or what an alter-
native might be). What is too seldom appreciated, however, is
that evidence-based practice is a construct (i.e., an idea, ab-
straction, or theoretical entity) and thus must be operationalized
(i.e., turned into some concrete form that comes to define it). The
way it is operationalized is not incidental to whether its net
effects turn out to be positive, negative, or mixed.
Address correspondence to Drew Westen, Departments of Psychology
and Psychiatry, Emory University, 532 Kilgo Circle, Atlanta, GA
30322; e-mail: dwesten@emory.edu.
266 Copyright r 2005 American Psychological Society
Over the last 10 years, evidence-based practice has become
synonymous in psychology with a particular operationalization
of it, the empirically supported therapies movement (defined by
an attempt to develop a list of empirically supported treatments
for specific disorders; Chambless & Ollendick, 2000). Psycho-
therapy research (and hence the effort to base psychotherapy on
evidence) actually existed long before this movement. In 1977,
Smith and Glass demonstrated meta-analytically (by combining
data across hundreds of studies) that ‘‘generic’’ psychotherapy
yields a very large effect (in the average study, patients who had
received psychotherapy fell in the 85th percentile of patients in
the control condition on measures of mental health). Subsequent
research has corroborated these findings (Wampold, 2001),
documenting that most psychotherapies ‘‘work’’ for most pa-
tients. In this sense, the practice of generic psychotherapy has
been evidence based at least since 1977.
What distinguishes the empirically supported therapies
movement from prior efforts to place psychotherapy on terra
firma are two interrelated features. First, to counter psychiatric
practice guidelines that tended to understate the effects of
psychological treatments, the empirically supported therapies
movement adopted a U.S. Food and Drug Administration (FDA)
model in which treatments are classified as either supported (and
hence to be used) or unsupported (and hence not to be used).
Evidence was thus limited, in this model, primarily to data ob-
tained in randomized controlled trials, which compare outcomes
between groups of patients who have been randomly assigned to
either active or control treatments.
Second, the empirically supported therapies movement fo-
cused on brief, focal treatments for specific disorders (e.g., major
depressive disorder) as defined by the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV; American Psychiatric
Association, 1994). Although researchers converged on the
study of brief treatments (rather than the longer-term treatments
that are the norm in clinical practice) for many reasons, brevity is
advantageous from a researcher’s perspective because of a
simple fact of experimental method as applied to psychotherapy:
Volume 14—Number 5
 Drew Westen and Rebekah Bradley
The longer the treatment, the more within-group variability; the
more variability, the less one can draw precise causal conclu-
sions. Testing treatments of brief and fixed duration for patients
who meet diagnostic criteria for a specific disorder thus allows
researchers to minimize within-group variability in both patient
characteristics and treatment delivered. The typical empirically
supported therapy for children and adolescents as well as adults
lasts 8 to 10 weeks; we know of only one that exceeds 4 months’
duration.1
The empirically supported therapies movement has been as-
sociated with impressive advances in the treatment of several
disorders, such as panic disorder, obsessive-compulsive disor-
der, and posttraumatic stress disorder (PTSD). Yet a new body of
evidence suggests that dichotomous, either–or judgments of
empirically supported versus unsupported may seriously mis-
represent the state of the science of psychotherapy (Westen &
Morrison, 2001; Westen, Novotny, & Thompson-Brenner, 2004,
2005).
A RESTRICTED VIEW OF EVIDENCE
Elsewhere we have described a number of problems with ope-
rationalizing evidence-based practice as a list of approved
(proven) treatments. Here we note three.
First, empirically supported therapies research arose as a
psychotherapeutic analog to drug trials and thus is implicitly
predicated on a pharmaceutical model: Researchers in the
laboratory create new psychological ‘‘compounds,’’ compare
them to placebos, and then ‘‘disseminate’’ them to clinicians.
The problem is that no one knows whether the psychological
compounds researchers have assembled, based on the same
kinds of intuitive hunches that Meehl (1954) warned against, are
superior to the home-brewed compounds assembled by clini-
cians in the community, particularly those who get the best re-
sults.
Unlike medications, which require years of research and de-
velopment in the laboratory, many therapeutic interventions
(e.g., cognitive therapy) emerge from practice, not the laboratory.
As psychotherapy researchers, we would do well to use clinical
practice as a natural laboratory for identifying promising treat-
ment approaches, which we could then compare to laboratory-
derived interventions—rather than testing the one or two treat-
1
Whether these characteristics are inherent in the methodology of empirically
supported therapies is a matter of some debate, but they are, empirically, char-
acteristic of nearly all empirically supported therapies. The only such therapies
not characterized by these features have obtained some of the most impressive
results in the literature, but they are multifaceted treatment packages whose
elements have never been dismantled, and hence whose active ingredients (and
efficacy relative to the multifaceted, often integrative or eclectic treatments
widely practiced in the community) are unknown. New treatments are also on the
horizon for addressing some of the limitations of single-disorder manuals for
mood, anxiety, and eating disorders, which is a very promising development.
However, to our knowledge, these treatments are maintaining the 20-session
upper limit characteristic of the empirically supported therapies literature,
which seems contrary to their goals of addressing broader targets than treatments
of similar length aimed at single disorders.
Volume 14—Number 5
ments researchers imagine a priori are best, finding that
they outperform interventions intended to be inert (which they
inevitably will, if they are as effective as the generic psycho-
therapies studied by Smith & Glass, 1977), and declaring them
the treatment or treatments of choice. From a strictly statistical
perspective, it seems very unlikely that the one or two treatments
per disorder that researchers bet their money on at the outset
would consistently outperform the interventions obtained by,
say, the 20% of experienced, full-time, doctoral-level clinicians
in the community who get the best results with their patients.
It might thus be worth taking the time to identify and study the
practices of such clinicians. Wampold (personal communica-
tion, December, 2004) has recently found, in fact, that 60% of
therapists in an outpatient HMO sample actually obtain results
comparable to the results obtained in relevant randomized
controlled trials.
Second, researchers have routinely compared their treatments
to no treatment (control groups of patients on waiting lists for
treatment); treatments provided by underskilled, underpaid,
bachelors-level counselors with enormous caseloads; and other
intent-to-fail conditions (e.g., pseudotreatments designed spe-
cifically as control groups to prove the superiority of the inves-
tigator’s preferred treatment and that have no theoretical
rationale or are delivered by graduate students who know they
are administering treatment that is not supposed to work). Un-
fortunately, such control conditions do not control for any of the
most important confounds that threaten causal inference—
namely, the factors common to most therapies (i.e., talking with a
presumed expert who offers hope, support, empathy, a coherent
theoretical rationale, advice, etc.) that we know produce large
effects. We know of no published study in the last decade pur-
ported to demonstrate specific efficacy of a treatment that has
ruled out the most parsimonious rival hypothesis: that something
intended to be effective works better than something intended
to be ineffective.2
Third, science is about examining all the evidence, not just the
results from particular designs. Experimental designs are the
best method we have for assessing causal relations, and for this
reason randomized controlled trials are of particular importance
in evidence-based practice. However, the tradeoff of external to
internal validity in randomized controlled trials—that is, the
emphasis on really ‘‘tight,’’ well-controlled designs as opposed to
generalizability to the real world—tends to be very high, ren-
dering imperative the use of multiple forms of evidence. Para-
doxically, by exhorting clinicians to apply treatment manuals
usually developed 10 to 20 years earlier (the time it takes for one
or two National Institute of Mental Health-funded replications),
the empirically supported therapies movement has minimized
the importance of basic science in evidence-based practice.
Surely, developments over the last decade in the understanding
2
A study by Marsha Linehan on dialectical behavior therapy will, to our
knowledge, be the first.
267
 Evidence-Based Practice in Psychotherapy
of the neural mechanisms of learning, personality diatheses (i.e.,
underlying vulnerabilities) for psychiatric disorders, comor-
bidity (co-occurrence of multiple disorders), implicit (uncon-
scious) processes, attitude formation and maintenance, emotion,
developmental psychopathology, and other psychological pro-
cesses should be considered by clinicians delivering evidence-
based interventions, whether or not these developments have yet
been assimilated by applied researchers into particular treat-
ment manuals.
BRIEF TREATMENTS FOR DISCRETE DISORDERS
The empirically supported therapies movement is predicated on
the assumption that most patients either have, or can be treated
as if they have, one primary syndrome, for which a single
treatment package can be designed. Without this assumption,
researchers would need to test dozens of manuals to address all
the possible interactions among disorders for even a handful of
common disorders (e.g., the interaction of major depression and
panic disorder, of major depression and substance abuse, or of
major depression and both panic and substance abuse). This
assumption is not inherent in the use of randomized controlled
trials; indeed, it is precisely what distinguishes randomized
controlled trials in the empirically supported therapies era from
randomized controlled trials in the past, which often used mixed
patient samples.
In retrospect, the effort to create a list of empirically supported
therapies without first empirically addressing the question of
what brings most patients in for treatment (i.e., conducting a
needs assessment) was a serious error. Many patients in clinical
practice do not meet the thresholds imposed by DSM-IV for
‘‘having’’ a specific disorder (e.g., a patient may frequently binge
and purge but not twice a week every week for 3 months, hence
receiving the diagnosis of eating disorder not otherwise specified
instead of bulimia nervosa). After 20 years of research, we know
little about the generalizability of research on disorders such as
major depressive disorder, generalized anxiety disorder, or
PTSD for the vast numbers of patients who present with de-
pression, high trait anxiety, or a history of childhood trauma,
respectively.
Further, patients who present with a single syndrome are the
exception rather than the rule in both clinical practice and re-
search settings. Indeed, the correlation between self-report
measures of anxiety and depression tends to be large in both
normal and clinical samples, raising questions about focusing
primary attention on discrete syndromes. Studies consistently
find that most clinical syndromes occur together with other
syndromes or with personality pathology and that the presence of
co-occurring conditions, like the presence of significant per-
sonality pathology, often (but not always) augurs poorly for
therapy outcome in brief clinical trials. Advocates of empirically
supported therapies usually suggest that the way to handle such
co-occurring symptoms or syndromes in practice is to apply
268
manuals sequentially, beginning with the most distressing or
debilitating disorder first and then working one’s way through
manuals for the other disorders. That this is the most effective
way to address the complex, multifaceted concerns that bring
most patients into treatment is, however, an untested assump-
tion. This assumption is likely to be problematic when seemingly
distinct syndromes reflect common underlying causes or when
the presence of multiple syndromes has emergent properties not
reducible to each alone.
In fact, shared diatheses (i.e., two putatively distinct disorders
having related causes) and emergent properties appear to be
more the norm than the coincidental occurrence of unrelated
syndromes, for which a sequential-manuals approach might be
appropriate. Paradoxically, the movement to codify a list of
empirically supported therapies for specific disorders emerged
at precisely the same time (and often in the same laboratories) as
basic-science research demonstrating that vulnerabilities based
in personality and temperament account for much of the reason
patients tend to come in with multiple mood, anxiety, or other
disorders (e.g., substance use disorders, eating disorders; Brown,
Chorpita, & Barlow, 1998; Krueger, 2002). Research using
statistical methods like structural equation modeling and other
multivariate techniques consistently finds that personality
variables such as negative affectivity (the tendency to experi-
ence unpleasant feelings) underlie an internalizing spectrum of
pathology—that is, a spectrum of symptoms and syndromes
reflecting problems with anxiety and depression. From this point
of view, treatment researchers might do well to develop inter-
ventions for personality diatheses (e.g., negative affectivity,
impulsivity, maladaptive ways of trying to regulate emotions, and
repetitive interpersonal patterns and views of the self and rela-
tionships that underlie many of these patterns) and spend less
time developing treatments to address the residual variance
accounted for by specific symptom clusters. More likely, treat-
ment research should focus on both the person and the specific
symptoms with which the person presents.
The growing recognition of the role of personality in psycho-
pathology suggests substantial limits to the brief, focal treat-
ments that have been the near-exclusive focus of empirically
supported therapies research (see Westen, Gabbard, & Blagov,
in press). The primary treatments tested in randomized con-
trolled trials to date were never intended to bring about per-
sonality change. The interpersonal therapy manual for
depression, for example, is explicit in its focus on current rather
than recurrent interpersonal patterns. The cognitive-behavioral
therapy manual for depression focuses the first 5 to 6 sessions on
psychoeducation and behavioral activation, leaving little time to
explore anything but explicit or readily accessible automatic
thoughts that help maintain the present episode.
Equally problematic is the assumption, implicit in the modest
treatment lengths characteristic of empirically supported ther-
apies, that psychopathology is relatively mutable over brief in-
tervals. This assumption appears to be valid for some disorders,
Volume 14—Number 5
 Drew Westen and Rebekah Bradley
notably anxiety syndromes characterized by an association
between an identifiable stimulus or small set of stimuli and a
conditioned emotional response. For most disorders, however,
studies of both naturalistic and treatment samples find that re-
lapse and residual impairment are the rule rather than the ex-
ception. The natural course of major depression, for example, is
one of repeated reoccurrences with residual symptoms often
persisting between major depressive episodes.
EMPIRICALLY UNDERQUALIFIED CONCLUSIONS
We turn now to the findings of studies widely viewed as vali-
dating empirically supported therapies. To what extent a treat-
ment can be considered empirically supported depends on what
one considers a positive outcome. In fact, a treatment can look
like it is empirically supported using one set of criteria and
empirically unsupported using another. Over the last several
years, we have used meta-analysis to summarize findings about
both treatment outcome and generalizability of results to eve-
ryday practice across studies of empirically supported therapies
for a number of disorders. In these investigations, we have de-
scribed the state of the art using multiple metrics that provide
distinct, often nonoverlapping indicators of empirical support in
what we have called a multidimensional meta-analysis. The goal
is to provide a more nuanced view of treatment efficacy than a
simple thumbs up or thumbs down.
The first and most familiar metric, effect size, describes the
magnitude of the effect the average patient can expect to receive,
usually relative to a control group (i.e., how much benefit does
the average patient get from this treatment?). A treatment could,
however, obtain a moderate effect size by producing a very large
effect for a small subset of patients (or a moderate but incomplete
reduction in symptoms for many). Thus, two other useful metrics
are percent recovered and percent improved. In calculating im-
provement and recovery rates, however, the devil is in the de-
nominator: percent improved or recovered out of what number?
A liberal estimate limits the denominator to patients who com-
pleted the treatment (completer analyses). A more conservative
estimate uses the number of patients who actually began treat-
ment (intent-to-treat analyses), on the logic that patients who
drop out should be factored into the results. Neither metric is
more definitive than the other; each provides incremental in-
formation—that is, information that the other does not provide.
Complicating matters further, a treatment could lead to sub-
stantial improvement in most patients but nevertheless leave
them highly symptomatic. Thus, another important index is re-
sidual post-treatment symptomatology. Also important is sus-
tained efficacy over time, particularly in disorders characterized
by frequent recurrence. And a final set of variables quantifies
generalizability. If researchers screen substantially to maximize
the homogeneity of samples (e.g., eliminating patients with
certain troublesome forms of comorbidity), they need to qualify
the population to whom their results are intended to generalize.
Volume 14—Number 5
100
% Improved of completed treatment
90
% Improved of entered treatment
80
70
60
50
40
30
20
10
0
OCD Panic GAD PTSD Depression
Fig. 1. Percent of patients improved of those who entered or completed
psychotherapy for five disorders: obsessive-compulsive disorder (OCD),
panic disorder, generalized anxiety disorder (GAD), posttraumatic stress
disorder (PTSD), and depression. The data come from randomized con-
trolled trials for each disorder summarized meta-analytically (i.e. across
studies). Across disorders, around half of those who completed these
treatments tended to improve; less than half of patients who entered
treatment (including those who, for whatever reasons, did not choose to
complete treatment) typically improved. (Comparable data were not
available for bulimia nervosa, hence their absence here, although recovery
rates for bulimia tend to resemble improvement rates for other disorders.)
To index generalizability, one can describe the common inclu-
sion/exclusion criteria used in studies of a given disorder, the
number of exclusion criteria used to weed out patients whose
complexities may complicate treatment, and the percent of
patients excluded of those screened.
Thus far we have completed multidimensional meta-analyses
on six widely studied disorders: major depressive disorder, panic
disorder, generalized anxiety disorder, obsessive-compulsive
disorder, bulimia nervosa, and PTSD (Bradley, Greene, Russ,
Dutra, & Westen, 2005; Eddy, Dutra, Bradley, & Westen, 2004;
Thompson-Brenner, Glass, & Westen, 2003; Westen & Morrison,
2001). Across disorders, treatment-versus-control effect sizes
tend to be moderate to large (generally within the 95% confi-
dence interval identified by Smith & Glass, 1977), providing a
compelling portrait of the efficacy of these treatments.
Data on percent of patients improved and recovered paint a
more variable picture. Figure 1 describes improvement rates in
randomized controlled trials for patients receiving active treat-
ments widely described as empirically supported for a number of
disorders. On average, roughly half of patients who complete
treatments in such trials improve. Recovery is harder to come by,
with both completer and intent-to-treat analyses showing re-
covery rates in the 30s or low 40s for most disorders.
The good news is that these response rates are generally
substantially higher than for patients in the control conditions.
However, we suspect most patients would be chagrined to learn
that what is widely described in the research literature as the
treatment of choice for their disorder gives them a 1 in 3 chance
of recovery, and that in the last 20 years of psychotherapy re-
search virtually no one has considered doubling or tripling the
‘‘dose’’ of these therapies. Nor has anyone compared the im-
provement and recovery rates obtained in randomized trials of
269
 Evidence-Based Practice in Psychotherapy
100
90
80
70
60
50
40
30
20
10
0
Panic Depression Bulimia
Fig. 2. Percent of psychotherapy patients treated for panic, depression, or
bulimia who remained improved at 12- to 24-month follow-up. The data
come from randomized controlled trials for each disorder summarized
meta-analytically (i.e. across studies), where follow-up data were available.
brief therapies to results obtained by experienced clinicians,
some percent of whom, either by chance, trial and error (i.e.,
operant conditioning), or creativity, experimentation, and ex-
perience, are likely to have happened upon something more
effective.
Data on residual post-treatment symptomatology tell a similar
story of a glass both half empty and half full. Treatments for
bulimia nervosa have produced some of the most impressive
recovery rates of the disorders we have studied meta-analyti-
cally: Roughly 40% of patients who enter treatment and 50%
who complete it no longer binge and purge at the end of treat-
ment. However, the average rates of bingeing in patients in
randomized controlled trials, including both those patients who
have stopped completely and the remainder of patients treated
with empirically supported therapies, is once to twice a week,
and the average rate of purging is twice to three times a week—
just short of the threshold for being diagnosed with the disorder.
(In this case, as in the other disorders we have studied, the
numbers are not substantially different for specific treatments
widely believed to be the treatment of choice than for other
treatments intended to work.) These data provide two very im-
portant take-home messages, neither of which is ‘‘more true’’
than the other. The first is that the average patient experiences a
dramatic reduction in binge and purge episodes after treatment
(many of these patients begin treatment bingeing and purging
daily). The second is that the average patient is not restored to
health in 18 to 20 weeks.
For most disorders, the data on sustained efficacy are more
troubling. Researchers generally have not followed patients
suffering from chronic or recurrent disorders beyond 6 to 9
months, and when they have, the results have often been so-
bering. Figure 2 shows the meta-analytic data on the percentage
of patients in active treatments in randomized controlled trials
showing sustained improvement or recovery at 12 to 24 months.
270
The data for panic disorder are very impressive. The data for
depression, for which researchers have made broad claims about
efficacy, are poor. The most recently published, high-quality
randomized controlled trial for major depression yielded similar
findings: Only one in four patients treated with cognitive be-
havioral therapy recovered and remained recovered 2 years later
(Hollon et al., 2005).
With respect to generalizability, the vast majority of patients
who appear for an initial interview (let alone of those who call
and are screened out on the phone) are excluded from most
studies for most disorders, raising questions about the extent to
which these treatments can be generalized to patients in the
community. The universal exclusion of patients who are thinking
about suicide from treatment studies of major depression is a
troubling example (in both psychotherapy and medication tri-
als), given that the alternative is to send these patients off for
therapies that are empirically untested.
CONCLUSIONS
The empirically supported therapies movement provided one
approach to operationalizing evidence-based practice—an ap-
proach that made considerable sense in light of the context in
1995. At that time, prominent psychiatric treatment guidelines,
often influenced by the pharmaceutical industry, were placing
psychotherapy on the back burner. However, it has become clear
over time that this operationalization of evidence-based practice
is limited by the evidence it includes and excludes; by the as-
sumptions inherent in focusing on brief treatments for discrete
syndromes, many of which are themselves empirically prob-
lematic; and by the assumption that treatments can be readily
classified as either supported or unsupported, which seems
untenable in light of meta-analytic data from randomized con-
trolled trials. If the goal is to identify best practice, researchers
should consider all available data (e.g., basic research on psy-
chopathology), not just data using one research design; they
should identify promising treatment strategies empirically
rather than testing only those treatments preferred a priori by
researchers that can be readily tested in brief versions; they
should impose only those exclusion criteria in randomized
controlled trials that a sensible clinician would impose in every-
day practice (e.g., psychosis or severe brain damage in treating
depression) to maximize generalizability; and they should rou-
tinely compare laboratory-derived treatments to empirically
identified best practice in the community rather than to waitlist
controls and intent-to-fail conditions (e.g., treatments for buli-
mia nervosa in which the therapist is forbidden from discussing
the symptom). The burden of proof for a new treatment should be
that its outcomes compare favorably to the outcomes obtained by
experienced clinicians, not that it survives a test of the null
hypothesis (i.e., that it works better than nothing, or better than
something intended to fail), given the consistent finding over
30 years that most psychotherapies for most patients produce a
Volume 14—Number 5
 Drew Westen and Rebekah Bradley
large effect relative to controls. Indeed, researchers would likely
find experienced clinicians much more receptive to dissemi-
nation of their treatments if they could demonstrate that these
treatments outperform what experienced clinicians currently do.
We should repeat that we are not arguing against the impor-
tance of randomized controlled trials. No other method is as
definitive in demonstrating causation. We are arguing, rather,
that the utility of such trials is being unnecessarily compromised
by systematic biases in both the range and duration of inter-
ventions being tested and the targets of intervention (single,
categorically defined disorders, which defy everything we know
about psychopathology).
We can summarize our argument in a single equation: EBP >
EST (i.e., evidence-based practice [EBP] is more than a list of
empirically supported therapies [ESTs] for discrete disorders).
The empirically supported therapies movement has helped
foster a more empirical attitude toward psychotherapy that was
long overdue in clinical psychology. However, as an operation-
alization of evidence-based practice, its definition of evidence
eliminates too much of the available science; its focus on brief
treatments for discrete disorders reflects a set of assumptions
that are not themselves empirically supported; and its tendency
to foster dichotomous, ‘‘either–or’’ thinking about empirical
support is neither scientifically useful nor justified by the
available evidence.
Recommended Reading
Barlow, D. (2002). Anxiety and its disorders (2nd ed.). New York:
Guilford Press.
Borkovec, T.D., & Castonguay, L.G. (1998). What is the scientific
meaning of empirically supported therapy? Journal of Consulting
and Clinical Psychology, 66, 136–142.
Westen, D., & Morrison, K. (2001). (See References)
Westen, D., Novotny, C., & Thompson-Brenner, H. (2004). (See Refer-
ences)
Acknowledgments—Preparation of this article was supported
in part by NIMH Grants MH62377 and MH62378.
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