Efficacy combined with specified ingredients: a new direction for empirically supported addiction treatment

Abstract

Aims: With the increased need for sanctioning behavioral addiction treatments to guide key stakeholders, focus has shifted to developing and applying criteria for establishing empirically supported treatments (EST). Among the many criteria offered, demonstration of incremental efficacy over a placebo or comparison in at least two independent randomized clinical trials (RCTs) has been the gold standard. While necessary, the present EST criteria are not sufficient. The present work: (i) argues for empirically supported specificity in behavioral addiction treatment, (ii) explores the limitations of empirical support for EST efficacy without evidence of specificity and (iii) discusses implications and recommendations for ultimately raising the bar for status as an EST.

Methods: The authors review relevant literature on ESTs, evidence-based practice and clinical trial design in the addictions and related disciplines.

Results: We clarify that the additional bar of specificity does not denote uniqueness in causal processes and we argue that specificity should not be inferred only via the nature of the experimental contrast. Rather, a treatment has specificity if its active ingredients are identified and validated empirically as predictors of subsequent treatment-related outcomes. Within this new definition, there are implications for clinical research and other key stakeholders.

Conclusions: A heightened centrality of empirically supported addiction treatment ingredients moving forward will advance clinical knowledge and evaluation methodology at a far greater pace.

© 2012 The Authors, Addiction © 2012 Society for the Study of Addiction.

Figures

Figure One

Causal paths tested and validated in the traditional RCT paradigm Notes. In a traditional RCT paradigm if path from Treatment A vs. B is significant then paths a (treatment to ingredients) and c (direct effect of treatment on outcome) are demonstrated; the b path from treatment ingredients to outcome is untested.