Current systems for listing empirically supported therapies (ESTs) provide recognition to treatment packages, many of them proprietary and trademarked, without regard to the principles of change believed to account for their effectiveness. Our position is that any authoritative body representing the science and profession of psychology should work solely toward the identification of empirically supported principles of change (ESPs). As challenging as it is to take this approach, a system that lists ESPs will keep a focus on issues central to the science and practice of psychology while also insulating the profession from undue entrepreneurial influences.

Systematic desensitization, demonstrated in both clinical and experimental studies to reduce avoidance behavior, entails the contiguous pairing of aversive imaginal stimuli with anxiety-competing relaxation. If, as is widely assumed, the efficacy of the procedure derives from a genuine counterconditioning process, a disruption of the pairing between graded aversive stimuli and relaxation should render the technique ineffective in modifying avoidance behavior. This hypothesis was strongly confirmed: significant reduction in avoidance behavior was observed only in densensitization Ss, with none occurring either in yoked Ss for whom relaxation was paired with irrelevant stimuli or in yoked Ss who were gradually exposed to the imaginal aversive stimuli without relaxation. Other theoretical issues were raised, especially the problem of transfer from imaginal to actual stimulus situations.Recent years have witnessed increasing application of the systematic desensitization procedure, as developed by Wolpe (1958), to the modification of a wide range of neurotic disorders. In this therapeutic method the client is deeply relaxed and then instructed to imagine scenes from a hierarchy of anxietyprovoking stimuli. Initially he is asked to imagine the weakest item in the list and, if relaxation is unimpaired, is gradually presented incremental degrees of aversive stimuli until eventually he is completely desensitized to the most upsetting scene in the anxiety hierarchy.In numerous publications, both Wolpe (e.g., 19S2, 1958) and other clinical workers (e.g.,

No abstract

Several issues concerning stepped care are discussed: the constraints of using Diagnostic and Statistical Manual of Mental Disorders diagnoses in randomized clinical trials (RCTs), the importance of basic and process research, the unintended negative effects of exaggerated claims of effectiveness and efficiency, the limits of RCTs in evaluating improvement and deterioration, the self-correcting nature of stepped care, the link between stepped care and empirically supported treatments, clinical judgment in clinical work, the concept of the least restrictive alternative, the costs of using low-intensity but ineffective psychosocial treatments, and the costs of both ineffective and effective psychotropic drug therapy. An analysis of stepped care can lead to an appreciation that the dialectic operating between science and practice affords an opportunity to synthesize the seemingly irreconcilable standards and needs of researchers and clinicians.