This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments (notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies.

Objective-The Diagnostic and Statistical Manual of Mental Disorders (DSM) is designed primarily as a clinical tool. Yet high rates of diagnostic "crossover" among the anorexia nervosa subtypes and bulimia nervosa may reflect problems with the validity of the current diagnostic schema, thereby limiting its clinical utility. This study was designed to examine diagnostic crossover longitudinally in anorexia nervosa and bulimia nervosa to inform the validity of the DSM-IV-TR eating disorders classification system.Method-A total of 216 women with a diagnosis of anorexia nervosa or bulimia nervosa were followed for 7 years; weekly eating disorder symptom data collected using the Eating Disorder Longitudinal Interval Follow-Up Examination allowed for diagnoses to be made throughout the follow-up period.Results-Over 7 years, the majority of women with anorexia nervosa experienced diagnostic crossover: more than half crossed between the restricting and binge eating/purging anorexia nervosa subtypes over time; one-third crossed over to bulimia nervosa but were likely to relapse into anorexia nervosa. Women with bulimia nervosa were unlikely to cross over to anorexia nervosa.Conclusions-These findings support the longitudinal distinction of anorexia nervosa and bulimia nervosa but do not support the anorexia nervosa subtyping schema.With the preparation for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders under way, the validity of the DSM-IV-TR classification system for eating disorders has been called into question (1). In the current diagnostic system, anorexia nervosa and bulimia nervosa are recognized as full syndrome eating disorders with specific criteria sets. DSM is designed to serve primarily as a clinical tool, providing "clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders" (DSM-IV-TR, p. xxxvii). Yet the high rates of diagnostic "crossover," such as movement from anorexia nervosa to bulimia nervosa, may reflect problems with the validity of the current diagnostic schema for eating disorders, thereby limiting its utility.

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the interrelationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, bs 5 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies.However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.Resumen: Objetivo: La alianza terap eutica entre paciente y terapeuta ha demostrado ser una relaci on con resultados psicoterap euticos favorables en el tratamiento de los trastornos de la conducta alimentaria (TCA). Sin embargo, quedan preguntas acerca de la inter-relaci on entre alianza temprana, mejoría temprana de síntomas y resultados del tratamiento. Hicimos un meta-an alisis de la relaci on entre estos constructos y los posibles moderadores de estas relaciones en los tratamientos psicosociales para TCA. M etodo: Veinti un estudios reunieron los criterios de inclusi on y aportaron suficientes datos suplementarios. Resultados: los resultados revelaron un efecto de la talla pequeño a moderado, b 5 0.13 a 0.22 (p < .05), encontrando que la mejoría temprana de los síntomas estuvo relacionada con la subsecuente calidad de la alianza y las calificaciones de la alianza tambi en estuvieron relacionadas con la subsecuente reducci on de los síntomas. La relaci on entre alianza temprana y resultados de tratamiento fue parcialmente explicada por la temprana mejoría de los síntomas. Con relaci on a los moderadores, la alianza temprana mostr o d ebiles asociaciones con el resultado en terapias con un fuerte componente conductual relativo a terapias no conductuales. Sin embargo, la alianza mostr o m as fuerte relaci on con los resultados para pacientes m as j ovenes (versus mayores), por encima y sobre la varianza compartida con la temprana mejoría de síntomas. Discusi on: En resumen, la reducci on temprana de los síntomas refuerza la alianza terap eutica y los resultados del tratamiento en TCA, pero la alianza temprana puede reque...

The data provide accumulating evidence for the validity of three personality subtypes in patients with eating disorders.