Evidence-Based Psychological Treatments for Adults: A Selective Review

Central Thesis and Objectives

This paper presents a selective review of empirically supported psychological treatments (ESPT) for addressing psychological disorders in adults. The authors argue that although psychological treatments have demonstrated their efficacy, effectiveness, and efficiency in managing mental disorders, there is a notable lack of updates in Spanish regarding which interventions have empirical support. The central objective is to synthesize and disseminate available scientific knowledge using the ICD-11 classification system from the World Health Organization, enabling psychology professionals to make informed decisions when implementing empirically grounded psychotherapeutic procedures.

Theoretical Framework and Contextualization

The ESPT movement originated with Eysenck's pioneering work in 1952 on the effects of psychotherapy. An important milestone is Luborsky et al.'s (1975) research, which proposed the "Dodo bird verdict," where all psychotherapies showed similar positive effects. Evidence-based medicine emerged in Canada during the 1980s, publishing its manifesto in 1992. The American Psychological Association (APA) assumed a central role when its Division 12 published the "Task Force on Promotion and Dissemination of Psychological Procedures" report in 1995, promoting evidence-based treatments. In 1998, explicit criteria were established to identify "empirically validated treatments." Subsequently, in 2005, the APA promoted "evidence-based psychological practice," conceptualized as the integration of best available research with clinical expertise in the context of client characteristics, culture, and preferences.

The paper's theoretical framework emphasizes that psychology is the science of the subject and behavior, operating within a narrow epistemological band connecting neurobiological substrate with sociocultural context, without falling into biological, brain-centric, or socio-cultural reductionism. The authors argue that psychological disorders are not fixed or natural mental illnesses, but rather interactive entities representing responses to "life problems" (adversities, conflicts, traumas, losses, etc.). The material cause of disorders is better understood in terms of reasons rather than causes. The authors use Karl Menninger's metaphor of a fish hooked to an anchor to illustrate how unusual behaviors represent efforts to free oneself from suffering.

The importance of rigorous criteria to evaluate intervention nature and available scientific support is emphasized. Spain's National Health System (SNS), through its Clinical Practice Guidelines (GPC), proposes evidence levels (from 1++ to 4) and recommendation grades (A, B, C, D) that serve as an organizing framework. These criteria are based on study quality: meta-analyses and systematic reviews of randomized controlled trials (RCT) at the highest levels, expert opinion at the lowest.

Argumentative Development

The paper develops a central argument about the necessity of distinguishing between "evidence" (a term the authors consider a poor translation of the English "evidence") and "scientific proof" or "empirical support." They note that evidence is not synonymous exclusively with RCTs or meta-analyses, but should include both "evidence-based practice" and "practice-based evidence," incorporating multiple factors such as professional experience, clinical judgment, phronesis, and prudence.

The authors emphasize the importance of both specific factors (technical treatment methods) and common factors (therapeutic relationship, therapist competencies) in obtaining empirical evidence about treatment efficacy. They note that no procedure works solely through its active component, but rather within a therapeutic process that enables it. The review groups treatments into three categories: specific techniques (exposure, contingency management), treatment programs (STEPPS, Unified Protocol), and general intervention models (cognitive-behavioral therapy).

The argument traverses multiple diagnostic categories following ICD-11: psychotic disorders, bipolar disorders, depressive disorders, anxiety disorders, obsessive-compulsive disorder, stress-related disorders, dissociative disorders, somatic symptom disorders, feeding and eating disorders, substance use disorders, addictive behavior disorders, personality disorders, impulse control disorders, perinatal mental disorders, and suicidal behavior. For each category, the review presents treatments with the greatest empirical support and their evidence level according to SNS criteria.

Key findings include: in psychotic disorders, cognitive-behavioral therapy (CBT), family interventions, and early intervention have level 1+ and grade A; in bipolar disorders, CBT, psychoeducation, and family-centered therapy show levels 1+; in depression, Beck's CBT, behavioral activation, interpersonal therapy, and mindfulness-based cognitive therapy have levels 1++ and 1+; in anxiety disorders, CBT is considered the treatment of choice with level 1++ and grade A; in OCD, exposure with response prevention has level 1++ and grade A; in post-traumatic stress disorder, prolonged exposure, cognitive processing therapy, and EMDR have levels 1++ and 1+ with grade A.

An important point in the development is acknowledgment that many fields require further research. For example, in dissociative disorders, empirical support is limited; in personality disorders, although Borderline Personality Disorder dominates research, at least four highly effective treatments exist (dialectical behavior therapy, mentalization-based therapy, schema therapy, transference-focused psychotherapy).

Implications

The work's implications are multidimensional:

For Clinical Practice: The review enables psychology professionals to have rigorous, up-to-date information for informed decision-making. This improves the quality of psychological care provided to society and reduces the research-practice gap.

For the Profession and Science: The article fulfills the mandate of the Spanish Psychologist Code of Ethics, which establishes the obligation for continuous professional competency updates and use of only sufficiently contrasted procedures within current scientific knowledge. It promotes psychology's projection as science to society and facilitates informed decision-making.

For Health Systems: ESPT availability has consequences for quality improvement, cost-effectiveness, cost-utility, accessibility, and resource management in mental health systems. It enables governments and health systems to understand psychotherapy's utility in mental health.

For Theoretical Integration: The authors argue for genuine integration of psychotherapy within a personalized, collaborative, and process-based approach, beyond specific schools and brands of psychotherapy. They propose complementing the topographic approach (symptoms) with approaches centered on processes maintaining the problem.

Critical Reflection on Methodology: The article suggests it is necessary to modify established criteria for determining "evidence levels" and "recommendation grades," as these were developed in medicine and do not always adjust well to psychology. It advocates for a more open and dynamic understanding of evidence beyond positivist criteria.

Importance and Contribution

This work's contribution to the psychology field is significant across multiple dimensions:

Knowledge Update: Provides the first systematic, up-to-date review in Spanish of ESPT for adults, synthesizing scientific knowledge generated in recent years. This information was not previously available in Spanish-speaking contexts in integrated form.

Research-Practice Bridge: Reduces the gap between scientific research and clinical practice, enabling international study findings to reach professionals in Spanish-speaking contexts.

Methodological Rigor: Uses explicit, internationally recognized criteria (evidence levels and recommendation grades from Spain's SNS) to evaluate treatment empirical support, providing a systematic and objective basis for decision-making.

Defense of Psychotherapy: Demonstrates that psychological treatments have broad empirical support for an extensive range of mental disorders in diverse contexts. Provides evidence that "psychotherapy appears to be the treatment of choice for addressing a large part of mental disorders."

Promotion of Evidence-Based Practice: Emphasizes the ethical and professional responsibility of psychologists to implement empirically grounded psychotherapeutic procedures, meeting quality and professional standards.

Recognition of Limitations and Future Needs: The work identifies fields where research is limited (dissociative disorders, certain impulse control disorders) and calls for collaborative, transversal research to improve understanding and addressing of psychological disorders.

Theoretical Repositioning: Contributes to theoretical repositioning within psychology by questioning the prevailing biomedical model and promoting a more dynamic, contextual, holistic, and interactive understanding of psychological disorders.

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