The role of theory in bridging interdisciplinary research with evidence-based...Patrick Connolly
The role of theory in shaping and translating research into practice is neglected in the field of psychology at present. Internationally, there has been a growing call for development of an integrative theoretical framework within which research results can be understood as well as applied. A recent article in Nature Human Behaviour (Muthukrishna & Henrich, 2019), has proposed that the replication crisis currently facing the psychological sciences is the result of the lack of development of such integrative theoretical frameworks. Those authors propose that researchers should confine the questions that they ask, and the analyses that they do, to the predictions made within a particular theoretical framework. This is an important suggestion, because without a coherent theory, research results can only ever be applied to practical questions as a heuristic (or problem-solving strategy). It is suggested here that this state of affairs is the reason for the most common critical challenge made of research for evidence-based practice, which is the problem of knowing which intervention to apply, in which way, to which person, at what time, by which professional, and so on. Only a coherent theoretical framework can address these problems in applying research to practice. Finally, following Tretter and Loeffler-Statska (2018), it is proposed that systems theory (including information theory) is the best candidate for a integrative clinical theory framework that not only has potential of successfully bridging different disciplines, but also integrating the key assumptions and propositions of most dominant theories of psychology today.
Counselling Psychology QuarterlyVol. 24, No. 1, March 2011, .docxvoversbyobersby
Counselling Psychology Quarterly
Vol. 24, No. 1, March 2011, 43–53
How special are the specialties? Workplace settings in counseling
and clinical psychology in the United States
Greg J. Neimeyer
a*, Jennifer M. Taylor
a
, Douglas M. Wear
b
and
Aysenur Buyukgoze-Kavas
c
a
Department of Psychology, University of Florida, P.O. Box 112250, Gainesville, FL
32611, USA;
b
Psychology and Community Counseling Clinic, Antioch University Seattle,
Seattle, WA 98121, USA;
c
Department of Educational Sciences, Division of Psychological
Counseling and Guidance, Middle East Technical University, Ankara, Turkey
(Received 1 February 2010; final version received 18 February 2011)
How special are the specialties? Although clinical and counseling psychol-
ogy each have distinctive origins, past research suggests their potential
convergence across time. In a survey of 5666 clinical and counseling
psychologists, the similarities and differences between their workplace
settings were examined during early-, mid-, and late-career phases to
explore the distinctiveness of the two specialties. Overall, clinical and
counseling psychologists reported markedly similar workplace settings.
However, some significant differences remained; a greater proportion of
counseling psychologists reported working in counseling centers, while a
greater proportion of clinical psychologists reported working in medical
settings. In addition, during late-career, substantially more counseling and
clinical psychologists worked in independent practice contexts than in
community mental health centers, medical settings, academia, or university
counseling centers. Findings are discussed in relation to the ongoing
distinctiveness of the two specialties and the implications of this for training
and service in the field of professional psychology.
Keywords: clinical psychology; counseling psychology; workplace settings
Introduction
Recognized as distinct specialties by the American Psychological Association,
clinical and counseling psychology each have distinct histories, intersecting appli-
cations, and longstanding concerns regarding their continuing, or diminishing,
differences. This article explores these issues and examines the contemporary
similarities and differences between these two specialties as reflected in their
workplace settings. Workplace settings are examined at early, mid, and late career
in order to determine whether differences vary by cohort in a way that might reflect
either on their enduring or diminishing differences over time.
Enduring or diminishing differences?
Historically, the specialties of clinical and counseling psychology have developed
from different origins and formed distinctly different trajectories as a result
*Corresponding author. Email: [email protected]
ISSN 0951–5070 print/ISSN 1469–3674 online
� 2011 Taylor & Francis
DOI: 10.1080/09515070.2011.558343
http://www.informaworld.com
(Munley, Duncan, McDonnell, & Sauer, 2004). Clinical psych.
Rationale and Standards of Evidence in Evidence-Based Practice.docxmakdul
Rationale and Standards of Evidence in Evidence-Based Practice
OLIVER C. MUDFORD, ROB MCNEILL, LISA WALTON
AND KATRINA J. PHILLIPS
What is the purpose of collecting evidence to inform clinical practice in psychology concerning the effects of psychological or other interventions? To quote Paul’s (1967) article that has been cited 330 times before November 4, 2008, it is to determine the answer to the question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?” (p. 111). Another answer is pitched at a systemic level, rather than concerning individuals. That is, research evidence can inform health-care professionals and consumers about psychological and behavioral interventions that are more effective than pharmacological treatments, and to improve the overall quality and cost-effectiveness of psychological health service provision (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). The most general answer is that research evidence can be used to improve outcomes for clients, service providers, and society in general. The debate about what counts as evidence of effectiveness in answering this question has attracted considerable controversy (Goodheart, Kazdin, & Sternberg, 2006; Norcross, Beutler, & Levant, 2005). At one end of a spectrum, evidence from research on psychological treatments can be emphasized. Research-oriented psychologists have promoted the importance of scientific evidence in the concept of empirically supported treatment. Empirically supported treatments (ESTs) are those that have been sufficiently subjected to scientific research and have been shown to produce beneficial effects in wellcontrolled studies (i.e., efficacious), in more natural clinical environments (i.e., effective), and are the most cost-effective (i.e., efficient) (Chambless & Hollon, 1998). The effective and efficient criteria of Chambless and Hollon (1998) have been amalgamated under the term “clinical utility” (APA Presidential Task Force on Evidence-Based Practice, 2006; Barlow, Levitt, & Bufka, 1999). At the other end of the spectrum are psychologists who value clinical expertise as the source of evidence more highly, and they can rate subjective impressions and skills acquired in practice as providing personal evidence for guiding treatment (Hunsberger, 2007). Kazdin (2008) has asserted that the schism between clinical researchers and practitioners on the issue of evidence is deepening. Part of the problem, which suggests at least part of the solution, is that research had concentrated on empirical evidence of treatment efficacy, but more needs c01 20 April 2012; 12:43:29 3 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID= ...
The role of theory in bridging interdisciplinary research with evidence-based...Patrick Connolly
The role of theory in shaping and translating research into practice is neglected in the field of psychology at present. Internationally, there has been a growing call for development of an integrative theoretical framework within which research results can be understood as well as applied. A recent article in Nature Human Behaviour (Muthukrishna & Henrich, 2019), has proposed that the replication crisis currently facing the psychological sciences is the result of the lack of development of such integrative theoretical frameworks. Those authors propose that researchers should confine the questions that they ask, and the analyses that they do, to the predictions made within a particular theoretical framework. This is an important suggestion, because without a coherent theory, research results can only ever be applied to practical questions as a heuristic (or problem-solving strategy). It is suggested here that this state of affairs is the reason for the most common critical challenge made of research for evidence-based practice, which is the problem of knowing which intervention to apply, in which way, to which person, at what time, by which professional, and so on. Only a coherent theoretical framework can address these problems in applying research to practice. Finally, following Tretter and Loeffler-Statska (2018), it is proposed that systems theory (including information theory) is the best candidate for a integrative clinical theory framework that not only has potential of successfully bridging different disciplines, but also integrating the key assumptions and propositions of most dominant theories of psychology today.
Counselling Psychology QuarterlyVol. 24, No. 1, March 2011, .docxvoversbyobersby
Counselling Psychology Quarterly
Vol. 24, No. 1, March 2011, 43–53
How special are the specialties? Workplace settings in counseling
and clinical psychology in the United States
Greg J. Neimeyer
a*, Jennifer M. Taylor
a
, Douglas M. Wear
b
and
Aysenur Buyukgoze-Kavas
c
a
Department of Psychology, University of Florida, P.O. Box 112250, Gainesville, FL
32611, USA;
b
Psychology and Community Counseling Clinic, Antioch University Seattle,
Seattle, WA 98121, USA;
c
Department of Educational Sciences, Division of Psychological
Counseling and Guidance, Middle East Technical University, Ankara, Turkey
(Received 1 February 2010; final version received 18 February 2011)
How special are the specialties? Although clinical and counseling psychol-
ogy each have distinctive origins, past research suggests their potential
convergence across time. In a survey of 5666 clinical and counseling
psychologists, the similarities and differences between their workplace
settings were examined during early-, mid-, and late-career phases to
explore the distinctiveness of the two specialties. Overall, clinical and
counseling psychologists reported markedly similar workplace settings.
However, some significant differences remained; a greater proportion of
counseling psychologists reported working in counseling centers, while a
greater proportion of clinical psychologists reported working in medical
settings. In addition, during late-career, substantially more counseling and
clinical psychologists worked in independent practice contexts than in
community mental health centers, medical settings, academia, or university
counseling centers. Findings are discussed in relation to the ongoing
distinctiveness of the two specialties and the implications of this for training
and service in the field of professional psychology.
Keywords: clinical psychology; counseling psychology; workplace settings
Introduction
Recognized as distinct specialties by the American Psychological Association,
clinical and counseling psychology each have distinct histories, intersecting appli-
cations, and longstanding concerns regarding their continuing, or diminishing,
differences. This article explores these issues and examines the contemporary
similarities and differences between these two specialties as reflected in their
workplace settings. Workplace settings are examined at early, mid, and late career
in order to determine whether differences vary by cohort in a way that might reflect
either on their enduring or diminishing differences over time.
Enduring or diminishing differences?
Historically, the specialties of clinical and counseling psychology have developed
from different origins and formed distinctly different trajectories as a result
*Corresponding author. Email: [email protected]
ISSN 0951–5070 print/ISSN 1469–3674 online
� 2011 Taylor & Francis
DOI: 10.1080/09515070.2011.558343
http://www.informaworld.com
(Munley, Duncan, McDonnell, & Sauer, 2004). Clinical psych.
Rationale and Standards of Evidence in Evidence-Based Practice.docxmakdul
Rationale and Standards of Evidence in Evidence-Based Practice
OLIVER C. MUDFORD, ROB MCNEILL, LISA WALTON
AND KATRINA J. PHILLIPS
What is the purpose of collecting evidence to inform clinical practice in psychology concerning the effects of psychological or other interventions? To quote Paul’s (1967) article that has been cited 330 times before November 4, 2008, it is to determine the answer to the question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?” (p. 111). Another answer is pitched at a systemic level, rather than concerning individuals. That is, research evidence can inform health-care professionals and consumers about psychological and behavioral interventions that are more effective than pharmacological treatments, and to improve the overall quality and cost-effectiveness of psychological health service provision (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). The most general answer is that research evidence can be used to improve outcomes for clients, service providers, and society in general. The debate about what counts as evidence of effectiveness in answering this question has attracted considerable controversy (Goodheart, Kazdin, & Sternberg, 2006; Norcross, Beutler, & Levant, 2005). At one end of a spectrum, evidence from research on psychological treatments can be emphasized. Research-oriented psychologists have promoted the importance of scientific evidence in the concept of empirically supported treatment. Empirically supported treatments (ESTs) are those that have been sufficiently subjected to scientific research and have been shown to produce beneficial effects in wellcontrolled studies (i.e., efficacious), in more natural clinical environments (i.e., effective), and are the most cost-effective (i.e., efficient) (Chambless & Hollon, 1998). The effective and efficient criteria of Chambless and Hollon (1998) have been amalgamated under the term “clinical utility” (APA Presidential Task Force on Evidence-Based Practice, 2006; Barlow, Levitt, & Bufka, 1999). At the other end of the spectrum are psychologists who value clinical expertise as the source of evidence more highly, and they can rate subjective impressions and skills acquired in practice as providing personal evidence for guiding treatment (Hunsberger, 2007). Kazdin (2008) has asserted that the schism between clinical researchers and practitioners on the issue of evidence is deepening. Part of the problem, which suggests at least part of the solution, is that research had concentrated on empirical evidence of treatment efficacy, but more needs c01 20 April 2012; 12:43:29 3 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID= ...
C O N C E P T A N A L Y S I SClinical reasoning concept a.docxclairbycraft
C O N C E P T A N A L Y S I S
Clinical reasoning: concept analysis
Barbara Simmons
Accepted for publication 4 December 2009
Correspondence to B. Simmons:
e-mail: [email protected]
Barbara Simmons PhD RN
Clinical Assistant Professor
Department of Biobehavioral Health Science,
University of Illinois at Chicago, USA
S I M M O N S B . ( 2 0 1 0 )S I M M O N S B . ( 2 0 1 0 ) Clinical reasoning: concept analysis. Journal of Advanced
Nursing 66(5), 1151–1158.
doi: 10.1111/j.1365-2648.2010.05262.x
Abstract
Title. Clinical reasoning: concept analysis.
Aim. This paper is a report of a concept analysis of clinical reasoning in nursing.
Background. Clinical reasoning is an ambiguous term that is often used synony-
mously with decision-making and clinical judgment. Clinical reasoning has not been
clearly defined in the literature. Healthcare settings are increasingly filled with
uncertainty, risk and complexity due to increased patient acuity, multiple
comorbidities, and enhanced use of technology, all of which require clinical reasoning.
Data sources. Literature for this concept analysis was retrieved from several data-
bases, including CINAHL, PubMed, PsycINFO, ERIC and OvidMEDLINE, for the
years 1980 to 2008.
Review methods. Rodgers’s evolutionary method of concept analysis was used be-
cause of its applicability to concepts that are still evolving.
Results. Multiple terms have been used synonymously to describe the thinking skills
that nurses use. Research in the past 20 years has elucidated differences among these
terms and identified the cognitive processes that precede judgment and decision-
making. Our concept analysis defines one of these terms, ‘clinical reasoning,’ as a
complex process that uses cognition, metacognition, and discipline-specific
knowledge to gather and analyse patient information, evaluate its significance, and
weigh alternative actions.
Conclusion. This concept analysis provides a middle-range descriptive theory of
clinical reasoning in nursing that helps clarify meaning and gives direction for future
research. Appropriate instruments to operationalize the concept need to be developed.
Research is needed to identify additional variables that have an impact on clinical
reasoning and what are the consequences of clinical reasoning in specific situations.
Keywords: clinical reasoning, concept analysis, decision-making, diagnostic
reasoning, clinical judgment, nursing, problem-solving
Introduction
Clinical reasoning guides nurses in assessing, assimilating,
retrieving, and/or discarding components of information that
affect patient care. It is considered a characteristic that
separates professional nurses from ancillary healthcare
providers. Worldwide, nurses are increasingly more autono-
mous, responsible, and accountable for patient care.
� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 1151
J A N JOURNAL OF ADVANCED NURSING
Shortened hospital stays, patient .
1
Annotated Bibliography: Topic (Chosen from the list provided)
[Name]
South University Online
[Template instructions: Replace the information in red with your work-then delete this line]
2
Annotated Bibliography: Topic (Chosen from the list provided)
[APA formatted reference for source (list in alphabetical order) using a hanging indent]
[Underneath the reference, give a summary of the article then an analysis:
Summary of article: 1-2 paragraphs that describe the following information in your own words
in paragraph format (not bullet points).
• Why the article was written?
• What are the major points of the article?
• If the article was a study, describe:
o The methods used in the research: Include the participants, how the research question(s)
was tested or measured (e.g. survey, interview, formal testing…)
o The results of the study: What did the researchers find out?
o The conclusions: What did the researchers conclude from the study? What were the
limitations of the research?
NOTE: The article doesn’t need to be cited in the body of the annotated bibliography
because it is referenced in the beginning of the review. For any other sources used
(e.g. the text) you would cite as you normally do and list them in the reference section.
[Analysis of the article: 1-2 paragraphs describing the following: Whether or not the
points made by the author are logical and supported by evidence and whether the author
demonstrates any bias in presenting the arguments. Were other arguments or possibilities
considered? Are the author’s conclusions supported? Do they fit with your understanding
of the topic and your textbook's description (cite the textbook and any other sources you
use for analyzing your article – include any additional sources you cite as part of your
analysis in your reference list)? Why or why not (provide support for your opinion)?]
3
Example of formatting:
Boonstra, A., & Broekhuis, M. (2010). Barriers to the acceptance of electronic medical records by
physicians from systematic review to taxonomy and interventions. BMC Health Services
Research, 10(1), 231-248. doi:10.1186/1472-6963-10-231
Authors conducted a systematic review of research papers between 1998 and 2009 that
examined physician perceptions of barriers to implementation of electronic medical
records. An examination of 1671 articles….
DeVore, S. D., & Figlioli, K. (2010). Lessons Premier hospitals learned about implementing electronic
health records. Health Affairs, 29(4), 664-667. doi:10.1377/hlthaff.2010.0250
Premier healthcare alliance is a network of 2300 non-profit hospitals and 63,000
outpatient facilities in the United States, This paper summarized lessons learned from
reviewing implementation practices within their system….
4
References
List any references you cited in your analyses of your chosen sources. DO NOT list the references ...
Integrative and Biopsychosocial Approaches in Contemporary Clinica.docxnormanibarber20063
Integrative and Biopsychosocial Approaches in Contemporary Clinical Psychology
Chapter Objective
· To highlight and outline how contemporary clinical psychology integrates the major theoretical models using a biopsychosocial approach.
Chapter Outline
· The Call to Integration
· Biopsychosocial Integration
· Synthesizing Biological, Psychological, and Social Factors in Contemporary Integration
· Highlight of a Contemporary Clinical Psychologist: Stephanie Pinder-Amaker, PhD
· Application of the Biopsychosocial Perspective to Contemporary Clinical Psychology Problems
· Conclusion
Having now reviewed the four major theoretical and historical models in psychology in Chapter 5, this chapter illustrates how integration is achieved in the actual science and practice of clinical psychology. In addition to psychological perspectives per se, a full integration of human functioning demands a synthesis of psychological factors with both biological and social elements. This combination of biological, psychological, and social factors comprises an example of contemporary integration in the form of the biopsychosocial perspective. This chapter describes the evolution of individual psychological perspectives into a more comprehensive biopsychosocial synthesis, perhaps first touched upon 2,500 years ago by the Greeks.
The Call to Integration
While there are over 400 different types of approaches to psychotherapy and other professional services offered by clinical psychologists (Karasu, 1986), the major schools of thought reviewed and illustrated in Chapter 5 have emerged during the past century as the primary perspectives in clinical psychology. As mentioned, these include the psychodynamic, cognitive-behavioral, humanistic, and family systems approaches. Prior to the 1980s, most psychologists tended to adhere to one of these theoretical approaches in their research, psychotherapy, assessment, and consultation. Numerous institutes, centers, and professional journals were (and still are) devoted to the advancement, research, and practice of individual perspectives (e.g., Behavior Therapy and International Journal of Psychoanalysis). Professionals typically affiliate themselves with one perspective and the professional journals and organizations represented by that perspective (e.g., Association for Behavioral and Cognitive Therapies), and have little interaction or experience with the other perspectives or organizations. Opinions are often dogmatic and other perspectives and organizations viewed with skepticism or even disdain. Surprisingly, psychologists with research and science training sometimes choose not to use their objective and critical thinking skills when discussing the merits and limitations of theoretical frameworks different from their own. Choice of theoretical orientation is typically a by-product of graduate and postgraduate training, the personality of the professional, and the general worldview held of human nature. Even geographical regions.
Running head RESEARCH PROPOSAL ON COUPLES COUNSELING RESEA.docxtoltonkendal
Running head: RESEARCH PROPOSAL ON COUPLES COUNSELING
RESEARCH PROPOSAL ON COUPLES COUNSELING 5
Research Proposal on Couples Counseling
Social Work Practice Research I (SOCW - 6301 - 3)
Introduction
This research proposal is about undertaking research to find the best therapy method for couples between individual, group, and couples therapy. The proposal will detail the findings of past researchers and will occasionally focus on the therapy methods in the context of a couple that is experiencing conflict mainly based on the rejection of their same-sex marriage by their respective families. It will also detail the methodologies used by other researchers in investigating the therapy methods. The study will reveal the most recommended therapy method and the variations of the method.
Research Problem and Question
Many couples quarrel because their respective families reject their union or relationship or marriage. Most of the affected couples are those whose respective families are deeply divided on the basis of religion, race/ethnicity and socio-economic status. However, some families just oppose relationships because they threaten their traditions, which are mostly rooted on religion. Some families oppose gay or lesbian relationships or marriages. Even when a family member reveals that he or she may attracted to a member of the opposite sex, the other family members may rise up against that family member. It may make teenagers and young adults hide about their sexual orientation. The stigmatization may be too unbearable for the affected individuals, who may choose to go into seclusion and engage in suicidal actions. There are couples like Kathleen and Lisa who courageously seek the help of therapists. Upon setting a stage for positive development, couples can ease the tension in the mind. They can open up to people and feel ready to solve problems together. The question that comes in mind in light of these facts is: What it the true impact of sexual orientation-based rejection by family members on a relationship? How can a social worker help couples overcome sexual orientation-based rejection by family members on a relationship? The research question of the study is: which between individual, group, and couples therapy is the best therapy method for couples?
Literature Review on Individual, Group, and Couples Therapy
The therapeutic alliance concept is mainly associated with individual psychotherapy, particularly in literature. Yet, the concept is increasingly used together within the marital and family therapy domains. According to Pinsof and Catherall (1986), “a systemic perspective is brought to bear on the concept within individual psychotherapy. A new, integrative definition of the alliance is presented that conceptualizes individual, couple and family therapy as occurring within the same systemic framework”. The authors examined family, couple and individual therapy and used some methodologies and deve ...
Expanding the Lens of EBP: A Common Factors in AgreementScott Miller
The authors explore the limitations of the traditional view of evidence-based practice with its emphasis on specific methods and diagnosis. An alternative is proposed based on the common factors.
INSTRUCITONSThe purpose of this assignment is to draft and submi.docxLeilaniPoolsy
INSTRUCITONS
The purpose of this assignment is to draft and submit a comprehensive and complete rough draft of your Nursing Theory Comparison paper in APA format. Your rough draft should include all of the research paper elements of a final draft, which are listed below. This will give you an opportunity for feedback from your instructor before you submit your final draft during week 7.
Based on the reading assignment (
McEwen
& Wills,
Theoretical Basis for Nursing,
Unit II: Nursing Theories, chapters 6–9), select a grand nursing theory.
·
After studying and analyzing the approved theory, write about this theory, including an overview of the theory and
specific examples of how it could be applied in your own clinical setting.
Based on the reading assignment (
McEwen
& Wills,
Theoretical Basis for Nursing,
Unit II: Nursing Theories, chapters 10 and 11), select a middle-range theory.
·
After studying and analyzing the approved theory, write about this theory, including an overview of the theory and
specific examples of how it could be applied in your own clinical setting.
The following should be included:
1.
An introduction, including an overview of both selected nursing theories
2.
Background of the theories
3.
Philosophical underpinnings of the theories
4.
Major assumptions, concepts, and relationships
5.
Clinical applications/usefulness/value to extending nursing science testability
6.
Comparison of the use of both theories in nursing practice
7.
Specific examples of how both theories could be applied in your specific clinical setting
8.
Parsimony
9.
Conclusion/summary
10.
References: Use the course text and a minimum of three additional sources, listed in APA format
The paper should be 8–10 pages long and based on instructor-approved theories. It should be typed in Times New Roman with 12-point font, and double-spaced with 1" margins. APA format must be used, including a properly formatted cover page, in-text citations, and a reference list. The proper use of headings in APA format is also required.
CHAPTER 6: Overview of Grand Nursing Theories
Evelyn M. Wills
Janet Turner works as a nurse on a postsurgical, cardiovascular floor. Because she desires a broader view of nursing knowledge and wants to become a clinical specialist or family nurse practitioner, she recently began an online RN to BSN degree program that would prepare her to enter a master’s degree program in nursing. The requirements for a course entitled “Scholarly Foundations of Nursing Practice” led Janet to become familiar with some of the many nursing theories. From her readings, she learned about a number of ways to classify theories: grand theory, conceptual model, middle range theory, practice theory, borrowed theory, interactive–integrative model, totality paradigm, and simultaneous action paradigm. She came to the conclusion that there is no cohesion among authors of nursing theory and even wondered what relation theory had to what she was doi.
Thinking Like a Nurse A Research-Based Model of Clinical JuGrazynaBroyles24
Thinking Like a Nurse: A Research-Based
Model of Clinical Judgment in Nursing
Christine A. Tanner, PhD, RN
ABsTRACT
This article reviews the growing body of research on
clinical judgment in nursing and presents an alternative
model of clinical judgment based on these studies. Based
on a review of nearly 200 studies, five conclusions can
be drawn: (1) Clinical judgments are more influenced by
what nurses bring to the situation than the objective data
about the situation at hand; (2) Sound clinical judgment
rests to some degree on knowing the patient and his or
her typical pattern of responses, as well as an engagement
with the patient and his or her concerns; (3) Clinical judg-
ments are influenced by the context in which the situation
occurs and the culture of the nursing care unit; (4) Nurses
use a variety of reasoning patterns alone or in combina-
tion; and (5) Reflection on practice is often triggered by a
breakdown in clinical judgment and is critical for the de-
velopment of clinical knowledge and improvement in clini-
cal reasoning. A model based on these general conclusions
emphasizes the role of nurses’ background, the context of
the situation, and nurses’ relationship with their patients
as central to what nurses notice and how they interpret
findings, respond, and reflect on their response.
C
linical judgment is viewed as an essential skill
for virtually every health professional. Florence
Nightingale (1860/1992) firmly established that
observations and their interpretation were the hallmarks
of trained nursing practice. In recent years, clinical judg-
ment in nursing has become synonymous with the widely
adopted nursing process model of practice. In this model,
clinical judgment is viewed as a problem-solving activity,
beginning with assessment and nursing diagnosis, pro-
ceeding with planning and implementing nursing inter-
ventions directed toward the resolution of the diagnosed
problems, and culminating in the evaluation of the effec-
tiveness of the interventions. While this model may be
useful in teaching beginning nursing students one type
of systematic problem solving, studies have shown that
it fails to adequately describe the processes of nursing
judgment used by either beginning or experienced nurses
(Fonteyn, 1991; Tanner, 1998). In addition, because this
model fails to account for the complexity of clinical judg-
ment and the many factors that influence it, complete reli-
ance on this single model to guide instruction may do a
significant disservice to nursing students. The purposes of
this article are to broadly review the growing body of re-
search on clinical judgment in nursing, summarizing the
conclusions that can be drawn from this literature, and
to present an alternative model of clinical judgment that
captures much of the published descriptive research and
that may be a useful framework for instruction.
DefiNiTioN of TeRMs
In the nursing literature, the terms “clinica ...
Model of TreatmentEducation and its EvaluationProblem.docxhelzerpatrina
Model of Treatment/Education and its Evaluation
Problem(s)
Will Power +
Common Factors +
Any Specific Factor (any treatment model EBP or other) +
Feedback Informed Treatment + Deliberate Practice =
Effective Outcome
SPECIAL ARTICLE
How important are the common factors in
psychotherapy? An update
BRUCE E. WAMPOLD
Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA; Modum Bad Psychiatric Center, Vikersund, Norway
The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting
them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-
analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differ-
ences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and compe-
tence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.
Key words: Common factors, contextual model, psychotherapy, alliance, empathy, expectations, cultural adaptation, therapist differences,
specific ingredients
(World Psychiatry 2015;14:270–277)
The so-called common factors have a long history in psy-
chiatry, originating with a seminal article by S. Rosenzweig
in 1936 (1) and popularized by J. Frank in the various
editions of his book Persuasion and Healing (2-4). During
this period, the common factors have been both embraced
and dismissed, creating some tension (5-9). The purpose of
this paper is not to review or discuss the debate, but to pro-
vide an update, summarizing the evidence related to these
factors.
To understand the evidence for the common factors, it is
important to keep in mind that these factors are more than a
set of therapeutic elements that are common to all or most
psychotherapies. They collectively shape a theoretical mod-
el about the mechanisms of change in psychotherapy.
A particular common factor model, called the contextual
model, has been recently proposed (8,10). Although there
are other common factor models (e.g., 4,11), based on differ-
ent theoretical propositions, the predictions made about the
importance of various common factors are similar and the
choice of the model does not affect conclusions about the
impact of these factors. The contextual model is presented
below, followed by a review of the evidence for the common
factors imbedded in the model.
THE CONTEXTUAL MODEL
The contextual model posits that there are three path-
ways through which psychotherapy produces benefits. That
is, psychotherapy does not have a unitary influence on
patients, but rather works through various mechanisms.
The mechanisms underlying the three pathways entail
evolved characteristics of humans as the ultimate social spe-
cies; as such.
Model of TreatmentEducation and its EvaluationProblem.docxroushhsiu
Model of Treatment/Education and its Evaluation
Problem(s)
Will Power +
Common Factors +
Any Specific Factor (any treatment model EBP or other) +
Feedback Informed Treatment + Deliberate Practice =
Effective Outcome
SPECIAL ARTICLE
How important are the common factors in
psychotherapy? An update
BRUCE E. WAMPOLD
Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA; Modum Bad Psychiatric Center, Vikersund, Norway
The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting
them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-
analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differ-
ences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and compe-
tence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.
Key words: Common factors, contextual model, psychotherapy, alliance, empathy, expectations, cultural adaptation, therapist differences,
specific ingredients
(World Psychiatry 2015;14:270–277)
The so-called common factors have a long history in psy-
chiatry, originating with a seminal article by S. Rosenzweig
in 1936 (1) and popularized by J. Frank in the various
editions of his book Persuasion and Healing (2-4). During
this period, the common factors have been both embraced
and dismissed, creating some tension (5-9). The purpose of
this paper is not to review or discuss the debate, but to pro-
vide an update, summarizing the evidence related to these
factors.
To understand the evidence for the common factors, it is
important to keep in mind that these factors are more than a
set of therapeutic elements that are common to all or most
psychotherapies. They collectively shape a theoretical mod-
el about the mechanisms of change in psychotherapy.
A particular common factor model, called the contextual
model, has been recently proposed (8,10). Although there
are other common factor models (e.g., 4,11), based on differ-
ent theoretical propositions, the predictions made about the
importance of various common factors are similar and the
choice of the model does not affect conclusions about the
impact of these factors. The contextual model is presented
below, followed by a review of the evidence for the common
factors imbedded in the model.
THE CONTEXTUAL MODEL
The contextual model posits that there are three path-
ways through which psychotherapy produces benefits. That
is, psychotherapy does not have a unitary influence on
patients, but rather works through various mechanisms.
The mechanisms underlying the three pathways entail
evolved characteristics of humans as the ultimate social spe-
cies; as such.
Addiction Research and TheoryAugust 2008; 16(4) 305–307.docxnettletondevon
Addiction Research and Theory
August 2008; 16(4): 305–307
Editorial
The Hierarchy of Needs and care planning in addiction
services: What Maslow can tell us about addressing
competing priorities?
D. BEST
1
, E. DAY
1
, T. McCARTHY
2
, I. DARLINGTON
3
,
& K. PINCHBECK
1
1
Department of Psychiatry, University of Birmingham, Birmingham, B15 2QZ UK,
2
National Treatment Agency, Hercules House, London, UK, and
3
Homeless Link, London, UK
(Received 17 December 2007; accepted 18 December 2007)
‘‘It is quite true that man lives by bread alone – when there is no bread. But what happens
to man’s desire when there is plenty of bread and when his belly is chronically filled? At once
other (and ‘higher’) needs emerge and these, rather than physiological hungers, dominate
the organism. And when these in turn are satisfied, again new (and still ‘higher’) needs
emerge and so on. This is what we mean by saying that the basic human needs are organised
into a hierarchy of relative prepotency.’’ (Maslow 1943, p. 375)
The recent publication of a series of documents providing guidance for practice in the
drug misuse treatment field in the UK (Orange Guidelines, Department of Health, 2007)
has raised questions as to the exact role of the ‘drug worker’. Guidance from the National
Treatment Agency highlights the central role of key working and case management within
drug treatment, and NICE guidelines about psychosocial treatments for drug user
emphasises the effectiveness of brief and targeted interventions over broader and more
humanistic psychological approaches. This will feel like a dramatic change in direction for
many staff working in the field, and will not sit easily with many of them. However, such a
strategy is part of a series of moves to standardise the quality of drug treatment services in the
UK, and support for this broad strategy comes from a well established source.
Abraham Maslow proposed his theory of a ‘Hierarchy of Needs’ in a paper entitled
A Theory of Human Motivation in 1943, and this is presented graphically below. Although
later in his career, Maslow focussed increasingly on higher-order needs and the relationship
Correspondence: Professor David Best, Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric
Hospital, Birmingham, B15 2QZ, UK. E-mail: [email protected]
ISSN 1606-6359 print/ISSN 1476-7392 online � 2008 Informa UK Ltd.
DOI: 10.1080/16066350701875185
between self-actualisation and transcendence, from an addictions treatment perspective we
should turn our attention to the base of the pyramid (Figure 1).
What is frequently described as a model of motivation, and utilised in workplace theories
of staff functioning and drive, has considerable ramifications for the treatment of individuals
with complex and multi-axial problems. The presenting needs of drug users accessing adult
treatment services are frequently bewildering in their complexity, often involving multiple
su.
EBSCO Publishing Citation Format APA (American Psychologica.docxtidwellveronique
EBSCO Publishing Citation Format: APA (American Psychological Assoc.):
NOTE: Review the instructions at http://support.ebsco.com.library.capella.edu/help/?int=ehost&lang=&feature_id=APA and make any
necessary corrections before using. Pay special attention to personal names, capitalization, and dates. Always consult your library
resources for the exact formatting and punctuation guidelines.
References
Brossart, D. F., Meythaler, J. M., Parker, R. I., McNamara, J., & Elliott, T. R. (2008). Advanced regression methods for single-
case designs: Studying propranolol in the treatment for agitation associated with traumatic brain injury. Rehabilitation
Psychology, 53(3), 357–369. https://doi-org.library.capella.edu/10.1037/a0012973
<!--Additional Information:
Persistent link to this record (Permalink): http://library.capella.edu/login?url=http://search.ebscohost.com
/login.aspx?direct=true&db=pdh&AN=2008-11210-010&site=ehost-live&scope=site
End of citation-->
Advanced Regression Methods for Single-Case Designs: Studying Propranolol in the Treatment for Agitation
Associated With Traumatic Brain Injury
By: Daniel F. Brossart
Department of Educational Psychology, Texas A&M University;
Jay M. Meythaler
Department of Physical Medicine and Rehabilitation, Wayne State University;
Rehabilitation Institute of Michigan, Detroit, Michigan
Richard I. Parker
Department of Educational Psychology, Texas A&M University
James McNamara
Department of Educational Psychology, Texas A&M University
Timothy R. Elliott
Department of Educational Psychology, Texas A&M University
Acknowledgement: This study was funded in part by National Institute of Disability Research and Rehabilitation
Grant H 133G000072 awarded to Jay M. Meythaler. Appreciation is expressed to Michael E. Dunn for sharing
information and opinions about the history of single-case designs in rehabilitation psychology research. Graphs of
participant data not presented in this article are available upon request from Daniel F. Brossart.
In a thoughtful commentary, Aeschleman (1991) observed a decreasing interest in single-case research (SCR)
designs in the rehabilitation psychology literature: Between 1985 and 1989, Aeschleman found only 6 out of 402
empirical papers published in Rehabilitation Psychology, Archives of Physical Medicine and Rehabilitation, and
Rehabilitation Counseling Bulletin used a single-subject design (<1.5% of the total; Aeschleman, 1991, p. 43). A brief
examination of the past 15 years of Rehabilitation Psychology reveals one article that offered an innovative way to
analyze single-case data (Callahan & Barisa, 2005) and another that was a true single-case study (Pijnenborg,
Withaar, Evans, van den Bosch, & Brouwer, 2007).
We disagree with Aeschleman's bleak conclusion that SCR designs “… have not made a methodological impact on
research in reh.
Attaining Expertise
You are training individuals you supervise on how to attain expertise in your field.
Write
a 1,050- to 1,200-word paper on the processes involved with attaining expertise, using your assigned readings in Anderson. Explain how these processes apply to attaining expertise in your current field or in the field you plan to enter. Focus on the cognitive processes that are involved in mastering knowledge and skills.
Include
a title page and references list consistent with APA guidelines.
Click
the Assignment Files tab to submit your assignment.
.
attachment Chloe” is a example of the whole packet. Please follow t.docxcelenarouzie
attachment “Chloe” is a example of the whole packet. Please follow the format and write in professional PR tone. So for each paragraph, you should refer to what’s write in the example. The packet includes a pitch letter, a news release (which i already wrote), a feature release, a fact sheet, a executive biography and a media alert. I have already wrote the news release part. I also put in the attachment.
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C O N C E P T A N A L Y S I SClinical reasoning concept a.docxclairbycraft
C O N C E P T A N A L Y S I S
Clinical reasoning: concept analysis
Barbara Simmons
Accepted for publication 4 December 2009
Correspondence to B. Simmons:
e-mail: [email protected]
Barbara Simmons PhD RN
Clinical Assistant Professor
Department of Biobehavioral Health Science,
University of Illinois at Chicago, USA
S I M M O N S B . ( 2 0 1 0 )S I M M O N S B . ( 2 0 1 0 ) Clinical reasoning: concept analysis. Journal of Advanced
Nursing 66(5), 1151–1158.
doi: 10.1111/j.1365-2648.2010.05262.x
Abstract
Title. Clinical reasoning: concept analysis.
Aim. This paper is a report of a concept analysis of clinical reasoning in nursing.
Background. Clinical reasoning is an ambiguous term that is often used synony-
mously with decision-making and clinical judgment. Clinical reasoning has not been
clearly defined in the literature. Healthcare settings are increasingly filled with
uncertainty, risk and complexity due to increased patient acuity, multiple
comorbidities, and enhanced use of technology, all of which require clinical reasoning.
Data sources. Literature for this concept analysis was retrieved from several data-
bases, including CINAHL, PubMed, PsycINFO, ERIC and OvidMEDLINE, for the
years 1980 to 2008.
Review methods. Rodgers’s evolutionary method of concept analysis was used be-
cause of its applicability to concepts that are still evolving.
Results. Multiple terms have been used synonymously to describe the thinking skills
that nurses use. Research in the past 20 years has elucidated differences among these
terms and identified the cognitive processes that precede judgment and decision-
making. Our concept analysis defines one of these terms, ‘clinical reasoning,’ as a
complex process that uses cognition, metacognition, and discipline-specific
knowledge to gather and analyse patient information, evaluate its significance, and
weigh alternative actions.
Conclusion. This concept analysis provides a middle-range descriptive theory of
clinical reasoning in nursing that helps clarify meaning and gives direction for future
research. Appropriate instruments to operationalize the concept need to be developed.
Research is needed to identify additional variables that have an impact on clinical
reasoning and what are the consequences of clinical reasoning in specific situations.
Keywords: clinical reasoning, concept analysis, decision-making, diagnostic
reasoning, clinical judgment, nursing, problem-solving
Introduction
Clinical reasoning guides nurses in assessing, assimilating,
retrieving, and/or discarding components of information that
affect patient care. It is considered a characteristic that
separates professional nurses from ancillary healthcare
providers. Worldwide, nurses are increasingly more autono-
mous, responsible, and accountable for patient care.
� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 1151
J A N JOURNAL OF ADVANCED NURSING
Shortened hospital stays, patient .
1
Annotated Bibliography: Topic (Chosen from the list provided)
[Name]
South University Online
[Template instructions: Replace the information in red with your work-then delete this line]
2
Annotated Bibliography: Topic (Chosen from the list provided)
[APA formatted reference for source (list in alphabetical order) using a hanging indent]
[Underneath the reference, give a summary of the article then an analysis:
Summary of article: 1-2 paragraphs that describe the following information in your own words
in paragraph format (not bullet points).
• Why the article was written?
• What are the major points of the article?
• If the article was a study, describe:
o The methods used in the research: Include the participants, how the research question(s)
was tested or measured (e.g. survey, interview, formal testing…)
o The results of the study: What did the researchers find out?
o The conclusions: What did the researchers conclude from the study? What were the
limitations of the research?
NOTE: The article doesn’t need to be cited in the body of the annotated bibliography
because it is referenced in the beginning of the review. For any other sources used
(e.g. the text) you would cite as you normally do and list them in the reference section.
[Analysis of the article: 1-2 paragraphs describing the following: Whether or not the
points made by the author are logical and supported by evidence and whether the author
demonstrates any bias in presenting the arguments. Were other arguments or possibilities
considered? Are the author’s conclusions supported? Do they fit with your understanding
of the topic and your textbook's description (cite the textbook and any other sources you
use for analyzing your article – include any additional sources you cite as part of your
analysis in your reference list)? Why or why not (provide support for your opinion)?]
3
Example of formatting:
Boonstra, A., & Broekhuis, M. (2010). Barriers to the acceptance of electronic medical records by
physicians from systematic review to taxonomy and interventions. BMC Health Services
Research, 10(1), 231-248. doi:10.1186/1472-6963-10-231
Authors conducted a systematic review of research papers between 1998 and 2009 that
examined physician perceptions of barriers to implementation of electronic medical
records. An examination of 1671 articles….
DeVore, S. D., & Figlioli, K. (2010). Lessons Premier hospitals learned about implementing electronic
health records. Health Affairs, 29(4), 664-667. doi:10.1377/hlthaff.2010.0250
Premier healthcare alliance is a network of 2300 non-profit hospitals and 63,000
outpatient facilities in the United States, This paper summarized lessons learned from
reviewing implementation practices within their system….
4
References
List any references you cited in your analyses of your chosen sources. DO NOT list the references ...
Integrative and Biopsychosocial Approaches in Contemporary Clinica.docxnormanibarber20063
Integrative and Biopsychosocial Approaches in Contemporary Clinical Psychology
Chapter Objective
· To highlight and outline how contemporary clinical psychology integrates the major theoretical models using a biopsychosocial approach.
Chapter Outline
· The Call to Integration
· Biopsychosocial Integration
· Synthesizing Biological, Psychological, and Social Factors in Contemporary Integration
· Highlight of a Contemporary Clinical Psychologist: Stephanie Pinder-Amaker, PhD
· Application of the Biopsychosocial Perspective to Contemporary Clinical Psychology Problems
· Conclusion
Having now reviewed the four major theoretical and historical models in psychology in Chapter 5, this chapter illustrates how integration is achieved in the actual science and practice of clinical psychology. In addition to psychological perspectives per se, a full integration of human functioning demands a synthesis of psychological factors with both biological and social elements. This combination of biological, psychological, and social factors comprises an example of contemporary integration in the form of the biopsychosocial perspective. This chapter describes the evolution of individual psychological perspectives into a more comprehensive biopsychosocial synthesis, perhaps first touched upon 2,500 years ago by the Greeks.
The Call to Integration
While there are over 400 different types of approaches to psychotherapy and other professional services offered by clinical psychologists (Karasu, 1986), the major schools of thought reviewed and illustrated in Chapter 5 have emerged during the past century as the primary perspectives in clinical psychology. As mentioned, these include the psychodynamic, cognitive-behavioral, humanistic, and family systems approaches. Prior to the 1980s, most psychologists tended to adhere to one of these theoretical approaches in their research, psychotherapy, assessment, and consultation. Numerous institutes, centers, and professional journals were (and still are) devoted to the advancement, research, and practice of individual perspectives (e.g., Behavior Therapy and International Journal of Psychoanalysis). Professionals typically affiliate themselves with one perspective and the professional journals and organizations represented by that perspective (e.g., Association for Behavioral and Cognitive Therapies), and have little interaction or experience with the other perspectives or organizations. Opinions are often dogmatic and other perspectives and organizations viewed with skepticism or even disdain. Surprisingly, psychologists with research and science training sometimes choose not to use their objective and critical thinking skills when discussing the merits and limitations of theoretical frameworks different from their own. Choice of theoretical orientation is typically a by-product of graduate and postgraduate training, the personality of the professional, and the general worldview held of human nature. Even geographical regions.
Running head RESEARCH PROPOSAL ON COUPLES COUNSELING RESEA.docxtoltonkendal
Running head: RESEARCH PROPOSAL ON COUPLES COUNSELING
RESEARCH PROPOSAL ON COUPLES COUNSELING 5
Research Proposal on Couples Counseling
Social Work Practice Research I (SOCW - 6301 - 3)
Introduction
This research proposal is about undertaking research to find the best therapy method for couples between individual, group, and couples therapy. The proposal will detail the findings of past researchers and will occasionally focus on the therapy methods in the context of a couple that is experiencing conflict mainly based on the rejection of their same-sex marriage by their respective families. It will also detail the methodologies used by other researchers in investigating the therapy methods. The study will reveal the most recommended therapy method and the variations of the method.
Research Problem and Question
Many couples quarrel because their respective families reject their union or relationship or marriage. Most of the affected couples are those whose respective families are deeply divided on the basis of religion, race/ethnicity and socio-economic status. However, some families just oppose relationships because they threaten their traditions, which are mostly rooted on religion. Some families oppose gay or lesbian relationships or marriages. Even when a family member reveals that he or she may attracted to a member of the opposite sex, the other family members may rise up against that family member. It may make teenagers and young adults hide about their sexual orientation. The stigmatization may be too unbearable for the affected individuals, who may choose to go into seclusion and engage in suicidal actions. There are couples like Kathleen and Lisa who courageously seek the help of therapists. Upon setting a stage for positive development, couples can ease the tension in the mind. They can open up to people and feel ready to solve problems together. The question that comes in mind in light of these facts is: What it the true impact of sexual orientation-based rejection by family members on a relationship? How can a social worker help couples overcome sexual orientation-based rejection by family members on a relationship? The research question of the study is: which between individual, group, and couples therapy is the best therapy method for couples?
Literature Review on Individual, Group, and Couples Therapy
The therapeutic alliance concept is mainly associated with individual psychotherapy, particularly in literature. Yet, the concept is increasingly used together within the marital and family therapy domains. According to Pinsof and Catherall (1986), “a systemic perspective is brought to bear on the concept within individual psychotherapy. A new, integrative definition of the alliance is presented that conceptualizes individual, couple and family therapy as occurring within the same systemic framework”. The authors examined family, couple and individual therapy and used some methodologies and deve ...
Expanding the Lens of EBP: A Common Factors in AgreementScott Miller
The authors explore the limitations of the traditional view of evidence-based practice with its emphasis on specific methods and diagnosis. An alternative is proposed based on the common factors.
INSTRUCITONSThe purpose of this assignment is to draft and submi.docxLeilaniPoolsy
INSTRUCITONS
The purpose of this assignment is to draft and submit a comprehensive and complete rough draft of your Nursing Theory Comparison paper in APA format. Your rough draft should include all of the research paper elements of a final draft, which are listed below. This will give you an opportunity for feedback from your instructor before you submit your final draft during week 7.
Based on the reading assignment (
McEwen
& Wills,
Theoretical Basis for Nursing,
Unit II: Nursing Theories, chapters 6–9), select a grand nursing theory.
·
After studying and analyzing the approved theory, write about this theory, including an overview of the theory and
specific examples of how it could be applied in your own clinical setting.
Based on the reading assignment (
McEwen
& Wills,
Theoretical Basis for Nursing,
Unit II: Nursing Theories, chapters 10 and 11), select a middle-range theory.
·
After studying and analyzing the approved theory, write about this theory, including an overview of the theory and
specific examples of how it could be applied in your own clinical setting.
The following should be included:
1.
An introduction, including an overview of both selected nursing theories
2.
Background of the theories
3.
Philosophical underpinnings of the theories
4.
Major assumptions, concepts, and relationships
5.
Clinical applications/usefulness/value to extending nursing science testability
6.
Comparison of the use of both theories in nursing practice
7.
Specific examples of how both theories could be applied in your specific clinical setting
8.
Parsimony
9.
Conclusion/summary
10.
References: Use the course text and a minimum of three additional sources, listed in APA format
The paper should be 8–10 pages long and based on instructor-approved theories. It should be typed in Times New Roman with 12-point font, and double-spaced with 1" margins. APA format must be used, including a properly formatted cover page, in-text citations, and a reference list. The proper use of headings in APA format is also required.
CHAPTER 6: Overview of Grand Nursing Theories
Evelyn M. Wills
Janet Turner works as a nurse on a postsurgical, cardiovascular floor. Because she desires a broader view of nursing knowledge and wants to become a clinical specialist or family nurse practitioner, she recently began an online RN to BSN degree program that would prepare her to enter a master’s degree program in nursing. The requirements for a course entitled “Scholarly Foundations of Nursing Practice” led Janet to become familiar with some of the many nursing theories. From her readings, she learned about a number of ways to classify theories: grand theory, conceptual model, middle range theory, practice theory, borrowed theory, interactive–integrative model, totality paradigm, and simultaneous action paradigm. She came to the conclusion that there is no cohesion among authors of nursing theory and even wondered what relation theory had to what she was doi.
Thinking Like a Nurse A Research-Based Model of Clinical JuGrazynaBroyles24
Thinking Like a Nurse: A Research-Based
Model of Clinical Judgment in Nursing
Christine A. Tanner, PhD, RN
ABsTRACT
This article reviews the growing body of research on
clinical judgment in nursing and presents an alternative
model of clinical judgment based on these studies. Based
on a review of nearly 200 studies, five conclusions can
be drawn: (1) Clinical judgments are more influenced by
what nurses bring to the situation than the objective data
about the situation at hand; (2) Sound clinical judgment
rests to some degree on knowing the patient and his or
her typical pattern of responses, as well as an engagement
with the patient and his or her concerns; (3) Clinical judg-
ments are influenced by the context in which the situation
occurs and the culture of the nursing care unit; (4) Nurses
use a variety of reasoning patterns alone or in combina-
tion; and (5) Reflection on practice is often triggered by a
breakdown in clinical judgment and is critical for the de-
velopment of clinical knowledge and improvement in clini-
cal reasoning. A model based on these general conclusions
emphasizes the role of nurses’ background, the context of
the situation, and nurses’ relationship with their patients
as central to what nurses notice and how they interpret
findings, respond, and reflect on their response.
C
linical judgment is viewed as an essential skill
for virtually every health professional. Florence
Nightingale (1860/1992) firmly established that
observations and their interpretation were the hallmarks
of trained nursing practice. In recent years, clinical judg-
ment in nursing has become synonymous with the widely
adopted nursing process model of practice. In this model,
clinical judgment is viewed as a problem-solving activity,
beginning with assessment and nursing diagnosis, pro-
ceeding with planning and implementing nursing inter-
ventions directed toward the resolution of the diagnosed
problems, and culminating in the evaluation of the effec-
tiveness of the interventions. While this model may be
useful in teaching beginning nursing students one type
of systematic problem solving, studies have shown that
it fails to adequately describe the processes of nursing
judgment used by either beginning or experienced nurses
(Fonteyn, 1991; Tanner, 1998). In addition, because this
model fails to account for the complexity of clinical judg-
ment and the many factors that influence it, complete reli-
ance on this single model to guide instruction may do a
significant disservice to nursing students. The purposes of
this article are to broadly review the growing body of re-
search on clinical judgment in nursing, summarizing the
conclusions that can be drawn from this literature, and
to present an alternative model of clinical judgment that
captures much of the published descriptive research and
that may be a useful framework for instruction.
DefiNiTioN of TeRMs
In the nursing literature, the terms “clinica ...
Model of TreatmentEducation and its EvaluationProblem.docxhelzerpatrina
Model of Treatment/Education and its Evaluation
Problem(s)
Will Power +
Common Factors +
Any Specific Factor (any treatment model EBP or other) +
Feedback Informed Treatment + Deliberate Practice =
Effective Outcome
SPECIAL ARTICLE
How important are the common factors in
psychotherapy? An update
BRUCE E. WAMPOLD
Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA; Modum Bad Psychiatric Center, Vikersund, Norway
The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting
them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-
analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differ-
ences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and compe-
tence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.
Key words: Common factors, contextual model, psychotherapy, alliance, empathy, expectations, cultural adaptation, therapist differences,
specific ingredients
(World Psychiatry 2015;14:270–277)
The so-called common factors have a long history in psy-
chiatry, originating with a seminal article by S. Rosenzweig
in 1936 (1) and popularized by J. Frank in the various
editions of his book Persuasion and Healing (2-4). During
this period, the common factors have been both embraced
and dismissed, creating some tension (5-9). The purpose of
this paper is not to review or discuss the debate, but to pro-
vide an update, summarizing the evidence related to these
factors.
To understand the evidence for the common factors, it is
important to keep in mind that these factors are more than a
set of therapeutic elements that are common to all or most
psychotherapies. They collectively shape a theoretical mod-
el about the mechanisms of change in psychotherapy.
A particular common factor model, called the contextual
model, has been recently proposed (8,10). Although there
are other common factor models (e.g., 4,11), based on differ-
ent theoretical propositions, the predictions made about the
importance of various common factors are similar and the
choice of the model does not affect conclusions about the
impact of these factors. The contextual model is presented
below, followed by a review of the evidence for the common
factors imbedded in the model.
THE CONTEXTUAL MODEL
The contextual model posits that there are three path-
ways through which psychotherapy produces benefits. That
is, psychotherapy does not have a unitary influence on
patients, but rather works through various mechanisms.
The mechanisms underlying the three pathways entail
evolved characteristics of humans as the ultimate social spe-
cies; as such.
Model of TreatmentEducation and its EvaluationProblem.docxroushhsiu
Model of Treatment/Education and its Evaluation
Problem(s)
Will Power +
Common Factors +
Any Specific Factor (any treatment model EBP or other) +
Feedback Informed Treatment + Deliberate Practice =
Effective Outcome
SPECIAL ARTICLE
How important are the common factors in
psychotherapy? An update
BRUCE E. WAMPOLD
Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA; Modum Bad Psychiatric Center, Vikersund, Norway
The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting
them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-
analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differ-
ences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and compe-
tence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.
Key words: Common factors, contextual model, psychotherapy, alliance, empathy, expectations, cultural adaptation, therapist differences,
specific ingredients
(World Psychiatry 2015;14:270–277)
The so-called common factors have a long history in psy-
chiatry, originating with a seminal article by S. Rosenzweig
in 1936 (1) and popularized by J. Frank in the various
editions of his book Persuasion and Healing (2-4). During
this period, the common factors have been both embraced
and dismissed, creating some tension (5-9). The purpose of
this paper is not to review or discuss the debate, but to pro-
vide an update, summarizing the evidence related to these
factors.
To understand the evidence for the common factors, it is
important to keep in mind that these factors are more than a
set of therapeutic elements that are common to all or most
psychotherapies. They collectively shape a theoretical mod-
el about the mechanisms of change in psychotherapy.
A particular common factor model, called the contextual
model, has been recently proposed (8,10). Although there
are other common factor models (e.g., 4,11), based on differ-
ent theoretical propositions, the predictions made about the
importance of various common factors are similar and the
choice of the model does not affect conclusions about the
impact of these factors. The contextual model is presented
below, followed by a review of the evidence for the common
factors imbedded in the model.
THE CONTEXTUAL MODEL
The contextual model posits that there are three path-
ways through which psychotherapy produces benefits. That
is, psychotherapy does not have a unitary influence on
patients, but rather works through various mechanisms.
The mechanisms underlying the three pathways entail
evolved characteristics of humans as the ultimate social spe-
cies; as such.
Addiction Research and TheoryAugust 2008; 16(4) 305–307.docxnettletondevon
Addiction Research and Theory
August 2008; 16(4): 305–307
Editorial
The Hierarchy of Needs and care planning in addiction
services: What Maslow can tell us about addressing
competing priorities?
D. BEST
1
, E. DAY
1
, T. McCARTHY
2
, I. DARLINGTON
3
,
& K. PINCHBECK
1
1
Department of Psychiatry, University of Birmingham, Birmingham, B15 2QZ UK,
2
National Treatment Agency, Hercules House, London, UK, and
3
Homeless Link, London, UK
(Received 17 December 2007; accepted 18 December 2007)
‘‘It is quite true that man lives by bread alone – when there is no bread. But what happens
to man’s desire when there is plenty of bread and when his belly is chronically filled? At once
other (and ‘higher’) needs emerge and these, rather than physiological hungers, dominate
the organism. And when these in turn are satisfied, again new (and still ‘higher’) needs
emerge and so on. This is what we mean by saying that the basic human needs are organised
into a hierarchy of relative prepotency.’’ (Maslow 1943, p. 375)
The recent publication of a series of documents providing guidance for practice in the
drug misuse treatment field in the UK (Orange Guidelines, Department of Health, 2007)
has raised questions as to the exact role of the ‘drug worker’. Guidance from the National
Treatment Agency highlights the central role of key working and case management within
drug treatment, and NICE guidelines about psychosocial treatments for drug user
emphasises the effectiveness of brief and targeted interventions over broader and more
humanistic psychological approaches. This will feel like a dramatic change in direction for
many staff working in the field, and will not sit easily with many of them. However, such a
strategy is part of a series of moves to standardise the quality of drug treatment services in the
UK, and support for this broad strategy comes from a well established source.
Abraham Maslow proposed his theory of a ‘Hierarchy of Needs’ in a paper entitled
A Theory of Human Motivation in 1943, and this is presented graphically below. Although
later in his career, Maslow focussed increasingly on higher-order needs and the relationship
Correspondence: Professor David Best, Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric
Hospital, Birmingham, B15 2QZ, UK. E-mail: [email protected]
ISSN 1606-6359 print/ISSN 1476-7392 online � 2008 Informa UK Ltd.
DOI: 10.1080/16066350701875185
between self-actualisation and transcendence, from an addictions treatment perspective we
should turn our attention to the base of the pyramid (Figure 1).
What is frequently described as a model of motivation, and utilised in workplace theories
of staff functioning and drive, has considerable ramifications for the treatment of individuals
with complex and multi-axial problems. The presenting needs of drug users accessing adult
treatment services are frequently bewildering in their complexity, often involving multiple
su.
EBSCO Publishing Citation Format APA (American Psychologica.docxtidwellveronique
EBSCO Publishing Citation Format: APA (American Psychological Assoc.):
NOTE: Review the instructions at http://support.ebsco.com.library.capella.edu/help/?int=ehost&lang=&feature_id=APA and make any
necessary corrections before using. Pay special attention to personal names, capitalization, and dates. Always consult your library
resources for the exact formatting and punctuation guidelines.
References
Brossart, D. F., Meythaler, J. M., Parker, R. I., McNamara, J., & Elliott, T. R. (2008). Advanced regression methods for single-
case designs: Studying propranolol in the treatment for agitation associated with traumatic brain injury. Rehabilitation
Psychology, 53(3), 357–369. https://doi-org.library.capella.edu/10.1037/a0012973
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Advanced Regression Methods for Single-Case Designs: Studying Propranolol in the Treatment for Agitation
Associated With Traumatic Brain Injury
By: Daniel F. Brossart
Department of Educational Psychology, Texas A&M University;
Jay M. Meythaler
Department of Physical Medicine and Rehabilitation, Wayne State University;
Rehabilitation Institute of Michigan, Detroit, Michigan
Richard I. Parker
Department of Educational Psychology, Texas A&M University
James McNamara
Department of Educational Psychology, Texas A&M University
Timothy R. Elliott
Department of Educational Psychology, Texas A&M University
Acknowledgement: This study was funded in part by National Institute of Disability Research and Rehabilitation
Grant H 133G000072 awarded to Jay M. Meythaler. Appreciation is expressed to Michael E. Dunn for sharing
information and opinions about the history of single-case designs in rehabilitation psychology research. Graphs of
participant data not presented in this article are available upon request from Daniel F. Brossart.
In a thoughtful commentary, Aeschleman (1991) observed a decreasing interest in single-case research (SCR)
designs in the rehabilitation psychology literature: Between 1985 and 1989, Aeschleman found only 6 out of 402
empirical papers published in Rehabilitation Psychology, Archives of Physical Medicine and Rehabilitation, and
Rehabilitation Counseling Bulletin used a single-subject design (<1.5% of the total; Aeschleman, 1991, p. 43). A brief
examination of the past 15 years of Rehabilitation Psychology reveals one article that offered an innovative way to
analyze single-case data (Callahan & Barisa, 2005) and another that was a true single-case study (Pijnenborg,
Withaar, Evans, van den Bosch, & Brouwer, 2007).
We disagree with Aeschleman's bleak conclusion that SCR designs “… have not made a methodological impact on
research in reh.
Similar to Available online at www.sciencedirect.comScienceDirectBe.docx (20)
Attaining Expertise
You are training individuals you supervise on how to attain expertise in your field.
Write
a 1,050- to 1,200-word paper on the processes involved with attaining expertise, using your assigned readings in Anderson. Explain how these processes apply to attaining expertise in your current field or in the field you plan to enter. Focus on the cognitive processes that are involved in mastering knowledge and skills.
Include
a title page and references list consistent with APA guidelines.
Click
the Assignment Files tab to submit your assignment.
.
attachment Chloe” is a example of the whole packet. Please follow t.docxcelenarouzie
attachment “Chloe” is a example of the whole packet. Please follow the format and write in professional PR tone. So for each paragraph, you should refer to what’s write in the example. The packet includes a pitch letter, a news release (which i already wrote), a feature release, a fact sheet, a executive biography and a media alert. I have already wrote the news release part. I also put in the attachment.
.
AttachmentFor this discussionUse Ericksons theoretic.docxcelenarouzie
Attachment
For this discussion:
Use Erickson's theoretical framework to explore adolescent attachment and its developmental impact.
Choose two issues related to adolescent attachment (for example, attachment relationships with parents and peers, or the nature of attachment system in adolescence) and describe possible implications for adult life.
Support your response with APA-formatted citations from scholarly sources, including both those provided in this unit and any additional evidence you may have researched.
.
Attachment and Emotional Development in InfancyThe purpose o.docxcelenarouzie
Attachment and Emotional Development in Infancy
The purpose of this discussion is to consider the stages of attachment from birth to one year, and emotional development and psychosocial crisis in infancy.
Briefly discuss attachment patterns and what you see as the most significant impact on the development of attachment.
Describe strategies that caretakers can implement to promote the child's ability to regulate emotions as he or she develops.
Remember to appropriately cite any resources, including the textbook, that you use to support your thinking in your initial post.
.
ATTACHEMENT from 7.1 and 7.2 Go back to the Powerpoint for thi.docxcelenarouzie
ATTACHEMENT from 7.1 and 7.2
Go back to the Powerpoint for this week and reread slides 12 and 13
Select at least 5 bullet points that you think are important because they affect the way justice is carried out in the State and or at the local level.
Write your entry explaining why you chose those 5 elements. Why are they important. What would you change?
.
Attached the dataset Kaggle has hosted a data science competitio.docxcelenarouzie
Attached the dataset
Kaggle has hosted a data science competition to predict category of crime in San Francisco based on 12 years (From 1934 to 1963) of crime reports from across all of San Francisco’s neighborhoods (time, location and other features are given).
I would like you to explore the dataset attached visually using Tableau and uncover hidden trends:
Are there specific clusters with higher crime rates?
Are there yearly/ Monthly/ Daily/ Hourly trends?
Is Crime distribution even across all geographical areas or different?
.
Attached you will find all of the questions.These are just like th.docxcelenarouzie
Attached you will find all of the questions.
These are just like the others I put up before. they need to be awnsered individually. Please use APA format with in text citations and references. My book is at least required as one of the references:
Harr, J. S., Hess, M. H., & Orthmann, C. H. (2012).
Constitutional law and the criminal justice system
(5th ed.). Belmont, CA: Wadsworth.
This assignment needs to be done by Friday by 11:00 P.M Eastern Time.
.
Attached the dataset Kaggle has hosted a data science compet.docxcelenarouzie
Attached the dataset
Kaggle has hosted a data science competition to predict category of crime in San Francisco based on 12 years (From 1934 to 1963) of crime reports from across all of San Francisco’s neighborhoods (time, location and other features are given).
I would like you to explore the dataset attached visually using Tableau and uncover hidden trends:
Are there specific clusters with higher crime rates?
Are there yearly/ Monthly/ Daily/ Hourly trends?
Is Crime distribution even across all geographical areas or different?
.
B. Answer Learning Exercises Matching words parts 1, 2, 3,.docxcelenarouzie
B. Answer Learning Exercises
* Matching words parts 1, 2, 3, and 4
* Definitions
*Matching Terms and Definitions 1, 2
C. Answer the following questions base in chapter 1:
1. Define Word root, mention 5 examples.
2. Define Suffixes, mention 5 examples.
3. Define Prefixes, mention 5 examples.
4. Some prefixes are confusing because they are similar in spelling, but opposite in meaning, those are call Contrasting Prefixes; mention 5 examples and their meaning.
.
B)What is Joe waiting for in order to forgive Missy May in The Gild.docxcelenarouzie
B)What is Joe waiting for in order to forgive Missy May in “The Gilded Six-Bits”? How does period of deliberation affect his forgiveness of her – does it make more of less sincere? What does this say about their relationship going into the future?
C) How is Dave in “The Man Who Was Almost A Man” not a man? Is there one central force preventing him from becoming a man? How does he go about overcoming this? Is it even possible for him to do so?
.
B)Blanche and Stella both view Stanley very differently – how do the.docxcelenarouzie
B)Blanche and Stella both view Stanley very differently – how do they see him and what does this view say about themselves? What causes Stella to continue to return to Stanley? Does she really trust him? Does she ultimately sacrifice her sister for him?
C) What is the difference between how Blanche presents herself and what she really is? Why does she choose to present herself so differently?
250 words each
.
b) What is the largest value that can be represented by 3 digits usi.docxcelenarouzie
b) What is the largest value that can be represented by 3 digits using radix-3?
c) Why do you think that binary logic is much more commonly used than ternary logic? Be brief.
The ASCII code for the letter E is 1000101, and the ASCII code for the letter e is 1100101. Given that the ASCII code for the letter M is 1001101, without looking at Table 2.7, what is the ASCII code for the letter m?
.
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B A S I C L O G I C M O D E L D E V E L O P M E N T Pr.docxcelenarouzie
B A S I C L O G I C M O D E L D E V E L O P M E N T
Produced by The W. K. Kellogg Foundation
53535353
Developing a Basic Logic
Model For Your Program
Drawing a picture of how your program will achieve results
hether you are a grantseeker developing a proposal for start-up funds or a
grantee with a program already in operation, developing a logic model can
strengthen your program. Logic models help identify the factors that will
impact your program and enable you to anticipate the data and resources
you will need to achieve success. As you engage in the process of creating your
program logic model, your organization will systematically address these important
program planning and evaluation issues:
• Cataloguing of the resources and actions you believe you will need to reach intended
results.
• Documentation of connections among your available resources, planned activities and
the results you expect to achieve.
• Description of the results you are aiming for in terms of specific, measurable, action-
oriented, realistic and timed outcomes.
The exercises in this chapter gather the raw material you need to draw a basic logic
model that illustrates how and why your program will work and what it will accomplish.
You can benefit from creating a logic model at any point in the life of any program.
The logic model development process helps people inside and outside your
organization understand and improve the purpose and process of your work.
Chapter 2 is organized into two sections—Program Implementation, and Program
Results. The best recipe for program success is to complete both exercises. (Full-size
masters of each exercise and the checklists are provided in the Forms Appendix at the
back of the guide for you to photocopy and use with stakeholder groups as you design
your program.)
Exercise 1: Program Results. In a series of three steps, you describe the results you
plan to achieve with your program.
Exercise 2: Program Resources and Activities by taking you through three steps
that connect the program’s resources to the actual activities you plan to do.
Chapter
2
W
B A S I C L O G I C M O D E L D E V E L O P M E N T
Produced by The W. K. Kellogg Foundation
54545454
The Mytown Example
Throughout Exercises 1 and 2 we’ll follow an example program to see how the logic
model steps can be applied. In our example, the folks in Mytown, USA are striving to
meet the needs of growing numbers of uninsured residents who are turning to Memorial
Hospital’s Emergency Room for care. Because that care is expensive and not the best
way to offer care, the community is working to create a free clinic. Throughout the
chapters, Mytown’s program information will be dropped into logic model templates for
Program Planning, Implementation, and Evaluation.
Novice Logic modelers may want to have copies of the Basic Logic Model Template in
front of them and follow along. Those read.
B H1. The first issue that jumped out to me is that the presiden.docxcelenarouzie
B H
1. The first issue that jumped out to me is that the president and two vice presidents were the ones to develop the program. Our lecture notes and the text tell us that safety is one topic where management and employees can usually come to an agreement. Everyone wants a safe work environment. We are also taught that consultation is the best way to approach health and safety at work. Again, this means involving more than three people at the company. For starters, I would recommend that the safety program be dismantled and reconstructed by a committee consisting of at least 50% employees, not just senior leadership. I would keep this committee as small as possible and not have it controlled by one person only. The committee should be formed of employees from all sections and representing all possible departments where health and safety are potential issues.
2. The first issue that jumped out to me is that the president and two vice presidents were the ones to develop the program. Our lecture notes and the text tell us that safety is one topic where management and employees can usually come to an agreement. Everyone wants a safe work environment. We are also taught that consultation is the best way to approach health and safety at work. Again, this means involving more than three people at the company. For starters, I would recommend that the safety program be dismantled and reconstructed by a committee consisting of at least 50% employees, not just senior leadership. I would keep this committee as small as possible and not have it controlled by one person only. The committee should be formed of employees from all sections and representing all possible departments where health and safety are potential issues.
N S
1. 1.Top of Form
There could be a number of problems with CMI's safety awareness plan. One major one is that they could not be promoting safety. That is the first step into getting the program to work...employee involvement. First the awareness program was developed by the president and the vice presidents. A safety awareness program can be more successful if employees are involved in the development, and remain involved as it is adjusted and refined. Rules should be in place, and employers must ensure that those rules are followed and enforced consistently. Incentives and competition could be another way to promote safety in the work place. Our text cites that having employees work in teams and have them determine the incentives will keep them involved and promote safety. Also, of course keeping employees up to date on all rules will also promote safety.
2. I think the supervisor's response to employee complaints about John Randall is not appropriate at all. Even thought it is difficult, home problems should not be brought into the work place. Especially if coworkers are complaining about someone's behavior. This does not promote safety at all. To say that Randall will get over it and to disclose that he has personal problems is.
b l u e p r i n t i CONSUMER PERCEPTIONSHQW DQPerception.docxcelenarouzie
b l u e p r i n t i CONSUMER PERCEPTIONS
HQW DQ
Perceptions Impact
Your Market?
By Nicole Olynk Widmar and
Melissa McKendree, Purdue University
I aintaining existing mar-
kets for pork products,
I cultivating new markets
for existing products and
creating new products for new markets
are some avenues that the U.S. pork
industry has sought, and continues to
explore, for growth. When it comes to
maintaining markets, there are several
relationships that must be considered.
End consumers, whether in restaurant
or supermarket settings, are increas-
ingly interested in social issues and the
production processes employed in food
production. Livestock products (meat
and dairy products) certainly seem
to get the majority of the spotlight in
regard to consumers' concern for pro-
duction processes.
Shoppers in supermarkets and din-
ers in restaurants have increased access
to information via the Internet, and are
in constant communication with one
another via social media and alterna-
tive news sources about perceptions
of animal agriculture. Even though
most U.S. consumers are not directly
in contact with livestock, concern for
the treatment of animals, including
those employed in food production,
is evident — and increasing. While
in the past consumers were mainly
concerned with factors like the fat or
nutritional content of pork, for exam-
ple, today's savvy shoppers are con-
sidering other factors, like the welfare
of livestock (pigs), safety of workers
employed on farms and potential envi-
ronmental impacts (externalities) of
livestock operations.
Large-scale changes in production
practices are taking place in livestock
24 April 15, 2014
production due to pressures from vari-
ous interested parties. Changes such
as the discontinued use of gestation
stalls, for example, are being sought
via traditional regulatory channels in
some states, but are also being pushed
via non-traditional market channels.
Consider the cumbersome process
of changing regulations, versus the
oftentimes faster (and perhaps easier)
channel of influencing key market
actors. It is no surprise that consum-
ers' concerns are increasingly voiced to
supermarkets and restaurants which,
in turn, take action to satisfy their
customers by placing pressure on sup-
ply-chain players. Changes sought via
"the market," rather than legislation or
regulation, are increasingly common,
and the use of market channels for
communicating throughout the supply
chain is unlikely to stop anytime soon.
www.nationalhogfarmer.com
Figure 1. Reported Recollection of Exposure to Media
Stories Regarding Pig Welfare, by Source
7 0 %
0 %
Television Internet
Media source
Printed Magazines
Newspaper
Books I have not seen
any media stories
regarding pig
welfare.
Melissa McKendree (left) and Nicole Olynk Widmar
A national-scale study completed
at Purdue University by Nicole Olynk
Widmar, Melissa McKendree, and
Candace Croney in 2013 was focused
on assessing consumers' perceptions of
various por.
B R O O K I N G SM E T R O P O L I TA N P O L I CY .docxcelenarouzie
B R O O K I N G S
M E T R O P O L I TA N
P O L I CY
P R O G RA M
6
I . I N T R O D U C T I O N
A
s the global economy has become more integrated and urbanized,
fueled in large part by technology, major cities and metropolitan
areas have become key engines of economic growth. The 123 largest
metro areas in the world generate nearly one third of global output
with only 13 percent of the world’s population.
In this urban-centered world, the classic notion of a
global city has been upended. This report introduces
a redefined map of global cities, drawing on a new
typology that demonstrates how metro areas vary in
the ways they attract and amass economic drivers
and contribute to global economic growth in distinct
ways. New concerns about economic stagnation—in
both developing and developed economies—add
urgency to mapping the role of the world’s cities and
the extent to which they are well-positioned to deliver
the next round of global growth.1
Instead of a ranking or indexed score, which many
prior cities indices and reports have capably deliv-
ered,2 this analysis differentiates the assets and
challenges faced by seven types of global cities.
This perspective reveals that all major cities are
indeed global; they participate as critical nodes in
an integrated marketplace and are shaped by global
currents. But cities also operate from much differ-
ent starting points and experience diverse economic
trajectories. Concerns about global growth, productiv-
ity, and wages are not monolithic, and so this typology
can inform the variety of paths cities take to address
these challenges. For metro leaders, this typology
can also ensure better application of peer com-
parisons, enable the identification of more relevant
global innovations to local challenges, and reinforce a
city-region’s relative role and performance to inform
economic strategies that ensure ongoing prosperity.
This report proceeds in four parts. In the following
section, Part II, we explore the three global forces of
urbanization, globalization, and technological change,
and how together they are demanding that city-
regions focus on five core factors—traded clusters,
innovation, talent, infrastructure connectivity, and
governance—to bolster their economic competitive-
ness. Building on these factors, Part III outlines the
data and methods deployed to create the metropoli-
tan typology. Part IV explores the collective economic
clout of the metro areas in our sample and introduces
the new typology of global cities. Finally, Part V
explores the future investments, policies, and strate-
gies required for each grouping of metro areas. Within
the typology framework, we explore the priorities for
action going forward, including the implications for
governance.
REDEFINING
GLOBAL CITIES
THE SEVEN TYPES
OF GLOBAL METRO
ECONOMIES
7
U R B A N I Z AT I O N
The world is becoming more urba.
B L O C K C H A I N & S U P P LY C H A I N SS U N I L.docxcelenarouzie
B L O C K C H A I N &
S U P P LY C H A I N S
S U N I L W A T T A L
T E M P L E U N I V E R S I T Y
• To understand the power of blockchain systems, and the things they can do, it is important to
distinguish between three things that are commonly muddled up, namely the bitcoin currency,
the specific blockchain that underpins it and the idea of blockchains in general.
• Economist, 2015
WHAT IS BLOCKCHAIN?
• A technology that permits transactions to be recorded
– Cryptographically chains blocks in order
– Allows resulting ledger accessed by different servers
– Information stored can never be deleted
• A digital distributed ledger that is stored and maintained on multiple systems belonging to multiple
entities sharing identical information (Deloitte)
• Bitcoin was the first demonstrable use
HISTORY OF BLOCKCHAIN
T YPES OF BLOCKCHAINS
• public or permissionless blockchains
– everyone who wants to engage in the network can openly see all transactions. The technology is
transparent, and all who want to engage in making transactions on the blockchain can do so.
• private or permissioned blockchains
– closed and accessible only to a selected few who have permission to engage in the blockchain.
BLOCKCHAIN FEATURES
• A blockchain lets us agree on the state of the system, even if we don’t all trust each other!
• We don’t want a single trusted arbiter of the state of the world.
• A blockchain is a hash chain with some other stuff added
– Validity conditions
– Way to resolve disagreements
• The spread of blockchains is bad for anyone in the “trust business”
WHAT IS BITCOIN
• A protocol that supports a decentralized, pseudo-anonymous, peer-to-peer digital currency
• A publicly disclosed linked ledger of transactions stored in a blockchain
• A reward driven system for achieving consensus (mining) based on “Proofs of Work” for
helping to secure the network
• A “scare token” economy with an eventual cap of about 21M bitcoins
10
OTHER USES OF BLOCKCHAIN
• Supply Chain
• Online advertising
• Smart Contracts
• Voting
BENEFITS OF BLOCKCHAIN
• Consistent
• Democratic
• Secure and accurate
• Segmented and private
• Permanent and tamper resistant
• Quickly updated
• Intelligent – smart contracts
BARRIERS TO BLOCKCHAIN
ADOPTION
• Hype
• Finding the right balance in regulation
• Cybersecurity
• Ease of use over shared databases
• Lack of understanding and knowledge
SUPPLY CHAIN CHALLENGES
• Margin Erosion
• Demand changes
• Ripple Effect
• Supply Chain Risk Management
• Lack of end to end visibility
• Obsolescence of Technology
APPLICATIONS IN SUPPLY CHAINS
• Traceability
• International Trade
• Continuity of Information
• Data Analytics
• Visibility
• Digital contracts and payments
• Check fraud and gaming
EX AMPLES OF BLOCKCHAIN IN
SUPPLY CHAINS
• 300 Cubits
– Blokcchain technology for the shipping industry
• BanQu
– Payment for small businesses
• Bext360
– Social sustainability.
Año 15, núm. 43 enero – abril de 2012. Análisis 97 Orien.docxcelenarouzie
Año 15, núm. 43 / enero – abril de 2012. Análisis 97
Orientalizing New Spain:
Perspectives on Asian Influence
in Colonial Mexico1
Edward R. Slack, Jr.2
Resumen
E ste artículo investiga la totalidad de la influencia de Asia sobre la Nueva España que resultó de la conquista de Manila en 1571 y la re-gularización del comercio Transpacífico -comúnmente conocido como
los galeones de Manila o las naos de China- entre las Filipinas y Acapulco.
En sus inicios, una oleada constante de inmigrantes asiáticos, mercancías y
nuevas técnicas de producción influyeron mesuradamente en la sociedad y
la economía colonial mediante un proceso que el autor denomina “Orientali-
zación”. No obstante, en ninguna manera “Orientalización” se debe equiparar
con el concepto de Edward Said de “Orientalismo” por la relación histórica,
única e intima de la Nueva España con Asia a principios de la edad Moderna.
Abstract
This article examines the totality of Asia’s influence on New Spain that resulted
from the conquest of Manila in 1571 and the regularization of transpacific tra-
de – more widely known as the Manila Galleons or naos de China – between the
Philippines and Acapulco. In its wake, a steady stream of Asian immigrants,
commodities, and manufacturing techniques measurably impacted colonial
society and economy through a process the author calls “Orientalization.”
However, “Orientalization” should in no way be equated with Edward Said’s
1. Artículo recibido el 28 de octubre de 2011 y dictaminado el 16 de noviembre de 2011.
2. Eastern Washington University.
98 México y la Cuenca del Pacífico. Año 15, núm. 43 / enero – abril de 2012
Edward R. Slack, Jr.
concept of “Orientalism” because of New Spain’s uniquely intimate historical
relationship with Asia in the early Modern era.
Introduction
Contrary to popular belief, the Philippines Islands were more a colony of New
Spain (Nueva España) than of “Old Spain” prior to the nineteenth century.
The Manila galleons, or naos de China (China ships), transported Asian pro-
ducts and peoples to Acapulco and other Mexican ports for approximately
250 years. Riding this ‘first wave’
of maritime contact between
the Americas and Asia were tra-
velers from China, Japan, the
Philippines, various kingdoms in
Southeast Asia and India known
collectively in New Spain as chinos
(Chinese) or indios chinos (Chine-
se Indians), as the word chino/a
became synonymous with the
Orient. The rather indiscrimi-
nate categorizing of everything
“Asian” under the Spanish noun
for the Ming/Qing empire, its
subjects and export items is easily
discovered in a variety of sources
from that age. To illustrate, the
eig hteenth centur y works of
Italian adventurer Gamelli Carreri and the criollo priest Joachin Antonio
de Basarás (who evangelized in Luzon) nonchalantly refer to the Philippine
Islands as “la China.”3 Additionally, words such as chinería (Chinese-esque,
European/Mexican imitation of Chines.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
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Model Attribute Check Company Auto PropertyCeline George
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Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Available online at www.sciencedirect.comScienceDirectBe.docx
1. Available online at www.sciencedirect.com
ScienceDirect
Behavior Therapy 44 (2013) 580–591
www.elsevier.com/locate/bt
The Importance of Theory in Cognitive Behavior Therapy:
A Perspective of Contextual Behavioral Science
James D. Herbert
Drexel University
Brandon A. Gaudiano
Butler Hospital/Alpert Medical School of Brown University
Evan M. Forman
Drexel University
For the past 30 years, generations of scholars of cognitive
behavior therapy (CBT) have expressed concern that clinical
practice has abandoned the close links with theory that
characterized the earliest days of the field. There is also a
widespread assumption that a greater working knowledge of
theory will lead to better clinical outcomes, although there is
currently very little hard evidence to support this claim. We
suggest that the rise of so-called “third generation”models of
CBT over the past decade, along with the dissemination of
statistical innovations among psychotherapy researchers, have
given new life to this old issue.We argue that theory likely does
matter to clinical outcomes, and we outline the future research
that would be needed to address this conjecture.
Keywords: theory; cognitive behavior therapy; acceptance and
commitment therapy; contextual behavioral science
3. complexity and richness of the underlying theory. A
robust theory, for example, can generate new
therapies or can draw on existing therapies that are
consistent with it" (p. 6). David and Montgomery
(2011) proposed a new framework for defining
evidence-based psychological practice that pri-
oritizes the level of empirical support of the theory
http://dx.doi.org/
http://dx.doi.org/
http://dx.doi.org/
mailto:[email protected]
581theory in cbt
supporting a treatment. Recommendations that
clinicians should develop better working knowledge
of the theories underlying CBTs often are presented
during discussions of how to maximize treatment
outcomes, prevent treatment failures, and ameliorate
treatment resistance in complex cases (Foa &
Emmelkamp, 1983;McKay, Abramowitz, & Taylor,
2010; Whisman, 2008). An interorganizational task
force led by the ABCT recently issued a report on
doctoral training in cognitive behavioral psychology
inwhich training in theory and even thephilosophyof
science underlying CBTs was emphasized (Klepac
et al., 2012).
The call for greater emphasis on theory within
CBT therefore spans the generations. In fact, if one
were tomask the author anddate, itwould be hard to
distinguish writings on this subject made by contem-
porary authors from thosewritten over 30 years ago.
There appears to exist a widespread assumption
among many clinicians and researchers alike that
4. better knowledge of theory will bear fruit in terms of
improved clinical outcomes across a number of con-
texts. Although this notion has considerable face
validity, there is a paucity of research that has directly
evaluated it.
Historically, the desire for empirically supported
treatments led to testing psychotherapies in controlled
clinical trials to determine their efficacy, a procedure
borrowed from other medical treatments. For
example, the seminal study known as the National
Institute ofMental Health's Treatment of Depression
Collaborative Research Program (Elkin et al., 1995)
randomized patients with major depression to cog-
nitive therapy, interpersonal psychotherapy, or anti-
depressant medication, and ushered in a new era of
evaluating psychotherapies in large-scale and meth-
odologically rigorous clinical trials. CBTs, given
their empirical basis, inherent structure, and time-
limited nature, were particularly well-suited for
testing in clinical trials. As a result, CBTs became
highly manualized in an effort to ensure treatment
fidelity, an important component of the internal
validity of such trials (Addis & Krasnow, 2000).
Originally CBTs were more principle-driven and
theory-dependent in the way that they were concep-
tualized and implemented (e.g.,Goldfried&Davison,
1994). With the growth of clinical trials during the
1970s and 80s, however, treatment manuals began
to focus more on how to implement specific CBT
techniques and strategies and less on interventions
derived from case conceptualization based on the
ideographic assessment of the patient guided by an
underlying theory. We are unaware of data directly
comparing the level of theoretical knowledge of early
practitioners of behavior therapy relative to modern
5. CBT clinicians. Nevertheless, even a casual compar-
ison of the field’s early books and journals targeting
clinicians relative to later works reveals a stark
contrast in the degree of emphasis on theory.
As the evidence base for CBTs expanded due to the
rapid accumulation of supportive efficacy research,
the problem of how best to implement and dissem-
inate the treatments emerged as a pressing problem
(Addis, 2006). Although novel psychotherapies
typically begin in complex and sophisticated forms
because they are created by experienced researchers
and clinicians, disseminating them to community
practitioners exerts pressure to simplify them as
much as possible. It is easier to train nonexpert
therapists to implement a set of standard techniques
than it is to train them to comprehend an underlying
theory. Once standard techniques are mastered,
clinicians well versed in theory can potentially
apply their knowledge to unique cases in order to
deduce tailored interventions.
The picture is complicated further because there is
no single CBT model, nor single theory underlying it.
CBT is a broad umbrella term that encompasses a
range of distinct therapy models (Herbert & Forman,
2011). These models share certain features, while also
havingdistinct characteristics. The theories underlying
these approaches likewise share certain commonalities
(e.g., traditional respondent and operant conditioning
principles), while also positing unique features.More-
over, key theoretical issues, such as the best way to
understand the role of cognitive processes in treat-
ment, are currently the subject of intense professional
debate (Hofmann, 2008; Longmore&Worrell, 2007;
Worrell & Longmore, 2008), and have undergone
6. considerable changes over the years (Beck, 2005).
We believe that two developments over the past
decade have added a new twist to the long-standing
question about the role of theory in guiding
psychotherapy. First, the question has been reinvigo-
rated by the rise of the so-called “third wave” (also
known as “third generation”) models of CBT. These
newer CBT approaches such as Mindfulness-Based
Cognitive Therapy (Segal, Williams, & Teasdale,
2002), Dialectical Behavior Therapy (Linehan, 1993),
and especially Acceptance and Commitment Therapy
(ACT; Hayes, Strosahl, & Wilson, 2011) eschew a
simplistic focus on specific techniques and strategies in
favor of increased attention to the putative principles
underlying behavior change, which are in turn linked
with basic psychological theories (Ablon, Levy, &
Katenstein, 2006; Hayes, 2004; Rosen & Davison,
2003). Second, psychotherapy treatment researchers
have increasingly focused on therapy processes using
component analysis studies (Borkovec & Sibrava,
2005; Lohr, DeMaio, & McGlynn, 2003) and the
identification of treatment-related mediators and
moderators (Kraemer, Wilson, Fairburn, & Agras,
582 herbert et al .
2002). These two developments have had synergistic
effects, further stimulating discussion of the role of
theory in CBTs. For example, calls by proponents
of third-generation approaches to focus on psycho-
therapy processes, rather thanmerely techniques, has
accelerated research on the mechanisms of action in
CBTs more generally. Simultaneously, more accessi-
ble and advanced statistical procedures have made it
7. easier for researchers to investigate mechanisms of
change, and have stimulated therapy innovators to
evaluate the proposed theories underlying their
approaches. Although the argument that under-
standing theory will improve clinical outcomes has
been a perennial theme in the field, innovations
associated with the development of third-generation
models of CBT, along with the development of new
statistical tools, have brought this issue back into the
forefront of discussion.
We should not lose sight of the fact that proponents
of the utility of theory are often themselves theoreti-
cians and may thus overestimate the importance of
theory. The extent to which improving clinicians'
theoretical knowledge does, in fact, result in improved
clinical outcomes is ultimately an empirical question.
The best approach to evaluating this supposition is
itself complicated and will require clarification of a
number of related issues. First and foremost, are there
compelling reasons to hypothesize that knowledge of
theory will, in fact, improve outcomes? Second, what
evidence, if any, currently supports the notion that
gaining a better theoretical understanding of a
psychotherapeutic approach enhances outcomes
over and above mere technical knowledge of the
approach? Third, even if theoretical knowledge is
found to accrue incremental benefits, does it pass a
cost-benefit test? Fourth, if such efforts can indeed be
demonstrated to be cost effective, how much theoret-
ical knowledge and training is needed to improve
outcomes? Fifth, which theory or theories should be
prioritized? Presumably, some theories have greater
breadth, depth, precision, explanatory power, and
incremental efficacy than others, making them more
useful guides. Sixth, to what degree is it necessary
8. simply to understand theory in abstract terms versus
being able to apply it to individual cases?And seventh,
and perhaps most fundamentally, what exactly do we
mean by the term “theory”? We will briefly explore
these and related questions regarding the role of
theory, using ACT in particular as a case in point.1
1We focus on ACT as the prototypical “third-generation”
model of CBT for two reasons. First, it has received the most
research attention to date of these various approaches. Second,
as
elaborated below, it is based on a well-developed theory, and it
strongly emphasizes the link between theory and technique. The
emphasis on ACT is not meant to imply that other approaches
are
not also theoretically grounded.
What Is “Theory”?
The word “theory” derives from the Greek theoria,
meaning looking at, viewing, beholding, or con-
templation (Oxford English Dictionary Online,
2012). This sense of perspective is reflected in its
modern use in the context of psychotherapy as a
set of basic concepts and principles, along with
statements that describe their interactions, which
can be used to describe, predict, and guide
intervention with respect to specific behavioral
and psychological phenomena. The concepts that
are the building blocks of theories can be general-
izations directly derived from sensory experience
(e.g., “reinforcement”), or abstractions of these
generalizations that are linguistically coherent with
other concepts, but are farther removed from
specific perceptual experiences (e.g., “recovery” or
“well-being”). Moreover, although some concepts
fit the classical Aristotelian definition of meeting
necessary and sufficient criteria, more commonly
psychological concepts have indistinct and over-
9. lapping boundaries, as described by prototype
theory (Rosch, 1983). Psychological theories can
range from the very general and abstract to the
more focused and applied. In fact, one can think
of theories along a continuum, linking basic
philosophical assumptions on the one hand with
specific assessment and intervention techniques on
the other.
For example, consider the theory underlying
Beck’s cognitive therapy (CT; Beck, 1979).2 At the
most abstract level are its philosophical roots which,
like most mainstream psychology, are grounded in a
philosophy of science known as elemental realism.
From this perspective, the world exists independent
of our senses, and comes predivided into units. The
purpose of science is to build increasingly more
accurate models that describe this world, that
effectively carve nature at its joints, and that describe
how these constituent pieces interact. In this sense,
statements about the world can be objectively true or
false in terms of how well they model underlying
reality. Following from these philosophical assump-
tions, CT theory posits various concepts such as
schemas, conditional assumptions, and automatic
thoughts, which are believed to interact with current
environmental conditions to result in emotions and
behavior. In turn, models of specific clinical phe-
nomena such as depression or panic disorder are
built from these more general concepts. Clinical
2 A detailed analysis of the theory underlying CT and how it is
similar to and different from ACT theory is beyond the scope of
this analysis. Interested readers are referred to Dozois and Beck
(2011), Forman and Herbert (2009), and Herbert and Forman
(2013).
10. 583theory in cbt
strategies and techniques, which may be derived
from the basic theoretical concepts, are guided by
these clinical models.
ACT is similarly undergirded by philosophical
assumptions. In fact, examining ACT’s philosophical
assumptions helps to bring into relief the assumptions
of CT described above, which are often overlooked or
taken for granted. In contrast to CT, ACT is based on
a pragmatic philosophy of science known as func-
tional contextualism (Hayes, 1993). This perspective
sidesteps ontological questions about the ultimate
nature of reality in favor of a pragmatic focus onwhat
works in a given context (Barnes-Holmes, 2000).
There is no assumption that the world comes
predivided into constituent parts. Rather, all classifi-
cations, concepts, and descriptions ofmechanisms are
viewed as social constructions and are evaluated with
respect to how well they work with respect to a
defined goal. A concept that is “true” (in the sense of
being useful) in one context may therefore not be
“true” in another. That is, the world is “textured” in
such away that some theorieswork better than others
with regard to a given goal. This philosophy forms the
basis of a behavioral theory of language and cognition
known as relational frame theory (Barnes-Holmes,
Barnes-Holmes, McHugh & Hayes, 2004; Hayes,
Barnes-Holmes, & Roche, 2001). RFT is a basic
theory that describes the powerful effects of
language on human psychology. Like many
basic scientific theories, RFT is not especially
accessible to nonexperts, and uses unfamiliar
terms (e.g., “arbitrarily applicable derived rela-
11. tional responding”) in the name of precision. In
order to make these basic concepts more useful to
practicing clinicians, a more accessible model was
developed, known variously as the “psychological
flexibility theory” or the “hexaflex model,” and a
separate body of research has examined this theory
(Levin, Hildebrandt, Lillis, & Hayes, 2012).
Psychological flexibility theory is composed of
what Hayes, Barnes-Holmes, andWilson (2012) call
“middle-level terms,” which are defined as “looser
functional abstractions” that serve to “orient prac-
titioners to some features of a domain in functional
contextual terms so as to produce better outcomes
and to facilitate knowledge development” (p. 7).
Intervention techniques and strategies, although
ultimately rooted in FC and RFT, can be conceptu-
alized from the perspective of this more accessible
“mid-level” model.
Proponents of ACT, more than any other
contemporary psychotherapy approach, have
stressed the interconnected nature of philosophy,
basic theory, applied clinical theory, and technique,
and have clearly articulated a vision of each of these
levels of analysis. This unified approach is known
as “contextual behavioral science” (CBS; Hayes,
Barnes-Holmes, & Wilson, 2012; Hayes, Levin,
Plumb, Villatte, & Pistorello, 2013; Ruiz, 2010).
Whether considering CT, ACT, or any other
variant of the CBT family, an appreciation of this
continuum of levels of analysis from philosophy to
theory to technique brings into focus several
considerations. First, the precision gained by more
basic theoretical levels of analysis sacrifices accessi-
bility, and vice versa. Even if a thorough under-
12. standing of basic theories underlying the major
models of CBT were deemed desirable, questions
immediately arise regarding how realistic it would be
to train front-line clinicians in such theories. Second,
although linked, concepts at one level of analysis do
not directly dictate those at another. One can adopt
the philosophical and theoretical perspectives asso-
ciated with ACT, for example, as a platform from
which to understand the techniques of CT. Likewise,
one can use the philosophy and theory associated
with CT to understand the clinical application of
ACT. Third, a point that is often unappreciated is
that one cannot avoid theory and philosophy. All
psychological applications are inevitably grounded
in some theory, which is in turn rooted in basic
philosophical assumptions. However, these theoret-
ical and philosophical assumptions often remain
implicit and unarticulated. When a cognitive thera-
pist guides her anxious patient to test irrational
thoughts against data in order to correct systematic
biases on the assumption that doing so will reduce
anxiety and lead to improved functioning, she is
making a host of theoretical assumptions, whether or
not she realizes she is doing so.A corollary is that true
theoretical eclecticism is impossible. One can borrow
concepts fromdifferent theories and combine them in
newways, but one has then created yet a new theory,
not an eclecticmix of the original ones. Similarly, one
can utilize one theory in some circumstances and
another at other times, but doing so requires a meta-
theory that guides, even if implicitly, the circum-
stances under which each theory is to be applied;
again, this is not true eclecticism. Thus, although
clinicians can choose not to examine the (implicit)
theories that underlie their work, they cannot truly
avoid theory altogether.
13. This analysis raises the question of what level of
theory is necessary or desirable for clinicians to
appreciate, as well as what specific theory or theories
should be prioritized. Calls for clinicians to have
stronger theoretical grounding have generally failed
to specify the kind of theory in question. In terms of
analytic levels, should clinicians routinely appreciate
the philosophical assumptions that underlie the
major forms of CBT? Should they become fluent in
basic theories such as RFT? What about more
584 herbert et al .
specific theories such as particular cognitive models
or psychological flexibility theory? And once the
level of analysis is clarified, which specific theoretical
approaches should be emphasized? There is no
reason to assume that all theories work equally
well as guides to effective clinical practice. These are
ultimately empirical questions. Testing them will
require recognition of the different possiblemeanings
of “theory,” and clear specification of the kind of
theoretical knowledge under consideration.
The question of the proper role of theory in
clinical practice shares similarities with the debate
regarding the relative effectiveness of standardized
interventions versus those based on a highly
individualized case conceptualization. There is
currently strong support, particularly within the
CBT community, for approaches that emphasize case
conceptualization (e.g., Kuyken, Padesky,&Dudley,
2009; Needleman, 1999; Norcross & Lambert,
2011; Persons, 2008). However, there are surpris-
14. ingly fewdata to support this position. In fact, there is
a paucity of research in this area, and what data do
exist are not especially favorable. Anumber of studies
raise questions about the inter-assessor reliability of
case conceptualizations (Caspar et al., 2000; Eells,
2001; Persons & Bertagnolli, 1999). The few trials
that have directly evaluated the relative utility of
individualized treatment have generally not been
supportive. For example, two early studies random-
ized patients to three conditions: a standardized
intervention, one based on an individualized case
conceptualization, and a third condition in which the
treatment was either yoked to another participant’s
case conceptualization (Schulte, Kuenzel, Pepping,
& Schulte-Bahrenberg, 1992) or was explicitly
mismatched to the assessment of the participant’s
specific problems (Nelson et al., 1989). In both cases,
there were no differences in outcomes between the
two individualized conditions, and in fact some
evidence of the superiority of the standard interven-
tion. It should be noted, however, that the case
conceptualizations used in these studies were quite
crude relative to modern standards, and were
certainly not well grounded in theory, and each
study had other methodological limitations. Never-
theless, these results underscore the importance of
empirical tests of the role of theory in practice. It is
not enough that the value of theoretically guided
practice is plausible; the burden of proof is on those
who propose that theoretical knowledge improves
practice to demonstrate that this is the case.
Why Theory Probably Matters: The Case
of ACT
Because of its relatively well-developed theoretical
15. basis and the emphasis placed by its proponents
on linking philosophy, theory, and technology
(i.e., application), ACT represents a useful context
for examining questions regarding the utility of a
working knowledge of theory to effective clinical
practice. There are at least three ways in which one
might practice ACT: (a) with familiarity of charac-
teristic techniques but minimal knowledge of under-
lying theory; (b) with a working knowledge of both
technique and psychological flexibility theory; or
(c) with knowledge of technique, psychological
flexibility theory, as well as more basic behavioral
theoretical concepts, including RFT. Let us imagine
three ACT therapists, each with these varying
levels of theoretical understanding, facing the same
challenging case. The first clinician appreciates a few
key ACT principles, such as the importance of
embracing rather than fighting distressing thoughts
and feelings, as well as many characteristic tech-
niques, including common metaphors and experien-
tial exercises. She applies these techniques in a
standard order, first highlighting the futility of efforts
to control distressing experiences, then presenting
psychological acceptance as an alternative, before
moving on to enhancing the ability to distance oneself
fromone’s experience, then on to values clarification,
and so on. This approach will likely work well for
many patients. In fact, the success of ACT self-help
interventions (e.g., Fledderus, Bohlmeijer, Pieterse,&
Schreurs, 2012; Hesser et al., 2012; Muto, Hayes, &
Jeffcoat, 2011) and clinical trials following structured
treatment protocols (Arch, Eifert, et al., 2012;
Forman et al., in press; Hernández-López, 2009;
Westin et al., 2011; Wetherell et al., 2011) speak to
the power of such an approach.
But imagine a patient with severe generalized
16. anxiety with panic attacks, comorbid depression,
marital problems, and a history of heart disease and
other problems, includingmultiple heart attacks. The
patient initially resonates with the idea that efforts to
control his distress have not worked, but despite the
first ACT therapist’s use of multiple standard
interventions, he is unable to let go of the struggle
with his disturbing thoughts and feelings. Moreover,
he objects to exercises promoting psychological
acceptance on the grounds that merely accepting
his catastrophic thoughts and his anxiety (and
especially panic) sensations may lead him to ignore
the impending signs of another heart attack,
precluding effective action. In fact, mindfulness
meditation exercises prescribed as homework have
precipitated panic attacks. He also finds the idea that
he should focus his efforts on changing his behavior
rather than his subjective distress to reflect the
therapist’s lack of appreciation of the depth of his
emotional pain. The first therapist continues to
invoke metaphors and to enact more experiential
585theory in cbt
exercises, in hopes of breaking through what has
now become an increasingly deadlocked clash in
perspectives.
The second ACT therapist, who has a strong
working knowledge of psychological flexibility
theory, is not tied to any particular sequence of
interventions, nor even to any particular techniques.
After further assessment, the therapist tentatively
concludes that the patient has become highly
17. attached to an identity as a helpless victim of his
medical and psychological problems. He implements
interventions designed to undermine the literal truth
of, and limitations associated with, this particular
identity, as well as personal narratives more gener-
ally. He also recognizes the very high level of the
patient’s “fusion” with his distressing thoughts and
feelings, and so begins defusion exercises slowly, in
limited contexts, before gradually expanding them to
include longer time periods, more settings, and more
psychological contexts. The therapist recognizes that
the patient has become so focused on his distress that
he has lost touch with any larger purposes in his life.
The therapist judiciously introduces values clarifica-
tion and goal-setting exercises, but is careful to avoid
doing so in a way that would come across as
dismissive of the patient’s distress. A functional
analysis reveals that the depression and marital
problems appear to be secondary to the isolation
resulting from the patient’s extreme anxiety, thereby
justifying focusing primarily on the latter, in antici-
pation that the depression will lift and marital issues
resolve as the anxiety improves. The patient begins
makingmore progress. However, the issue of his fear
of another heart attack continues to loom large, and
he continues to resist fully embracing the notion of
psychological acceptance for fear of dismissing signs
of an impending heart attack. This, in turn, keeps
him from pursuing various goal-directed activities
and limits his overall quality of life.
In addition to familiarity with standard ACT
techniques and psychological flexibility theory, the
third ACT therapist also has a thorough grounding
in basic behavioral theories, including RFT. She
understands that the patient’s unique history has
18. resulted in the word “heart attack,” feelings of
shortness of breath, and anxiety symptoms such as
tremulousness, sweaty palms, and racing thoughts,
all sharing functional properties. As a result of this
“stimulus equivalence,” common physiological
arousal has automatically come to elicit the same
emotional reaction that would occur from an actual
heart attack. This has resulted not only in the
patient’s attempts to suppress any signs of arousal,
but also in hypervigilance for the appearance of any
signs of arousal. Attempts to monitor and control
his symptoms (known as “experiential avoidance”
in ACT parlance) paradoxically—but predictably—
result in greater anxiety. The therapist understands
that learning is always additive, and that she cannot
erase the relationship between anxiety symptoms
and heart attack. But she can intervene to expand
the associations with the anxiety symptoms so that
they also evoke additional, less ominous, responses,
while she also works to weaken the control of all of
the patient’s subjective experience over his behav-
ior. This conceptualization leads her to introduce
the idea that “reality testing” distressing thoughts,
in this case thoughts about having a heart attack, is
in fact useful in a limited sense, provided the issue at
hand is truly a question of information. She helps
the patient carefully frame his questions, examine
which of these are truly about needed information,
and which function maladaptively to avoid anxiety
through unnecessary reassurance seeking. For the
former only, the therapist works with the patient to
obtain relevant data (e.g., by checking with his
cardiologist about the differences between symptoms
of anxiety and those of a heart attack). Once this is
accomplished, the stage is then set for experiential
acceptance interventions, including—when theoreti-
19. cally indicated—acceptance of the patient’s thoughts
that he is having a heart attack. There is no
assumption that the information will eliminate the
distressing thoughts or feelings. But one can now
move beyond ongoing “reality testing” to begin
experiencing them from amore detached perspective,
eventually even welcoming them openly and non-
defensively, thereby minimizing their negative effects.
Of course, it is possible that the first ACT therapist
with minimal theoretical grounding, or perhaps even
a good clinician working from a different CBT
framework, might make similar therapeutic moves
based on intuition and personal experience. Our
thesis, however, is that a well-developed theory
provides a more reliable guide for conceptualizing
and intervening with complex cases. This is not to
suggest that theory completely replaces judicious
clinical judgment. Applying theoretical concepts to
individual cases requires considerable clinical acu-
men. The question is not whether clinical judgment
and skill are important, but whether practice that is
theoretically guided will be more effective than
practice that is not.
Call for Research
As noted above, the larger CBT community has
recently increased attempts to link clinical interven-
tions to basic theories of behavior change and more
specific models of psychopathology. This includes
renewed interest in the study of these theories in their
own right. RFT, for example, has recently witnessed
strong growth as evidenced in the number of
20. 586 herbert et al .
manuscripts published. For example, one analysis
observed an exponential growth in publications
published on RFT from 1991 to 2008, totaling 62
empirical and 112 nonempirical manuscripts
(Dymond et al., 2010). This body of research has
sought to empirically and theoretically define RFT
concepts and to test predictions derived from
the theory (e.g., the effects of multiple-exemplar
training). There is little question that such theoretical
development is critical to better understanding the
origins of psychopathology and other forms of
human suffering, and to the continued development
of more effective assessment, prevention, and inter-
vention technologies. The only alternative is a
piecemeal collection of observations and surrepti-
tious discoveries, which then must be individually
evaluated for their utility in various contexts.
So whereas theory may be indispensible for
psychotherapy innovators and researchers, ques-
tions remain regarding the importance of theory to
practicing clinicians. Addressing these questions
will require a multipronged research program.
therapist surveys
One lesson learned from earlier efforts was that
attempting to disseminate CBTs to practicing clini-
cians will not work as a completely “top-down”
process (Addis, Wade, & Hatgis, 1999). Many
clinicians have been unwilling, for various reasons,
to alter their practices based on emerging research
findings supporting specific approaches (Baker,
McFall, & Shoham, 2008; Timbie, Fox, Van
Busum, & Schneider, 2012). For example, Freiheit,
21. Vye, Swan, and Cady (2004) surveyed practicing
psychologists and found that the majority were not
using exposure when treating anxiety disorders,
despite the widespread consensus that exposure is
crucial to effective treatment. We would expect a
similar response if research emerged that supported
theoretical knowledge in guiding treatment. Re-
search on training clinicians in evidence-based
practices suggests that a good values-intervention
fit is essential for the adoption of new practices
(Aarons, Sommerfeld, Hecht, Silovsky, & Chaffin,
2009). Thus, clinicians who already may be com-
fortable using CBT techniques but who still oper-
ate using largely opposing theoretical models
(e.g., psychodynamic) may not find replacing their
theory readily acceptable. Similarly, those whose
theoretical knowledge is implicit, and who believe
themselves to function atheoretically, may not
readily appreciate the value of acquiring theoretical
knowledge. Research suggests that clinicians tend
to rely largely on their personal experiences and
intuition when making clinical decisions (Gaudiano,
Brown, & Miller, 2011; Stewart & Chambless,
2007). Thus, it may be important to ensure that
therapists not only understand theory in the abstract,
but also can develop personal experiences that
demonstrate to them the utility of using theory to
inform their practice. In addition, there are a number
of emotional barriers to learning new practices,
including the increased effort required and the
temporary discomfort involved when trying an
unfamiliar approach (Varra,Hayes,Roget,&Fisher,
2008).
Thus, it will be important to begin with national
surveys of therapists and students to answer a
22. number of related questions:
1. How do therapists currently view the role of
theory in informing their practices? Therapists
tend to operate using tacit and idiosyncratic
theories to guide their decisions, but their
openness to learning and using specific theories
related to CBTs specifically is unknown.
2. How familiar are therapists already in various
theories underlying CBTs? Is it possible, for
example, that some therapists may be knowl-
edgeable about certain theories, but may not
regularly use them to inform their practice?
Similarly, the depth of understanding can
vary in ways that dramatically influence one’s
practices. To what extent do therapists adopt
simplified versions of therapies (help patients
to think more positively; help patients “get in
touch” with/vocalize their emotions), and
how does this play out in practice?
3. How can practicing clinicians best be taught
to apply CBT theories to specific cases to
improve their evidence-based practice? For
example, vignettes could be used to examine
therapists' ability to apply theory to treating
hypothetical clinical cases in an effort to
identify which areas require further training.
4. What are other practical barriers to learning
CBT theories, and how can those be
addressed? For example, timing and cost of
training are important barriers often cited by
clinicians that impede their ability to learn
new practices.
23. The latter point underscores the importance of
making theories as accessible as possible, if they are
going to be useful to clinicians. For example, the
original presentations of RFT (e.g., Hayes et al.,
2001) emphasized theoretical precision and, as a
result, were difficult for nonexperts to follow.
Recent strides have been made to make the theory
more accessible (e.g., Törneke, 2010), but even these
remain inappropriate for widespread dissemination
587theory in cbt
among practicing clinicians. Clearly, a great deal
more work is needed in this area.
evaluation of theories themselves
Theoretically guided practice assumes the validity
of the theory itself (where “validity” in this context
refers both to a theory’s internal consistency and
coherence as well as its scientific support). Research
is needed to evaluate the theories underlying
psychotherapies, and to guide their ongoing devel-
opment. This research can include studies of
hypotheses derived from specific theories, as well
as studies of competing hypotheses derived from
different theories. As discussed above, in the case
of CBS there is a rapidly developing literature
evaluating hypotheses derived from RFT. Levin
et al. (2012) conducted a meta-analysis of 66
laboratory-based component studies of the ACT’s
psychological flexibility model and found greater
effects for values, acceptance, present moment,
mindfulness, and values components relative to
24. comparison conditions.
In addition to empirical studies, conceptual
analyses are also needed to evaluate various aspects
of theories, including their internal consistency,
explanatory power, parsimony, and degree of
connection with actual intervention techniques. For
instance, Hofmann and Asmundson (2008) used
Gross’s (2001) theory of emotion regulation in an
attempt to explain the differences between charac-
teristic CT and ACT interventions. They suggested
that cognitive restructuring (characteristic of CT)
and psychological acceptance (characteristic ofACT)
could be considered as antecedent-focused versus
response-focused emotion regulation strategies, re-
spectively. However, as we have noted elsewhere
(Gaudiano, 2011; Herbert & Forman, 2013), this
analysis fails on both conceptual and empirical
grounds. Most centrally, the antecedent-response dis-
tinction does not map well onto the restructuring-
acceptance distinction. Cognitive restructuring often
takes place after the emotional response has been
activated, and in this sense would be a form of
response-focused emotion regulation. The ACT
strategies aimed at developing nonjudgmental
acceptance of distressing experience may lead over
time to a change in the way events themselves are
experienced and to decreased emotional arousal,
so in that sense would be considered an antecedent-
focused process. Thus, both CT and ACT interven-
tions operate both before and following emotional
activation. This example illustrates the important
role of critical analyses of theoretical concepts, in this
case with regard to the theory-technology link. Such
analyses can help clarify the best targets for fruitful
empirical research.
25. experimental trials
Ultimately, the best way to resolve questions
regarding the role of theory in clinical practice is
through controlled research. Practicing clinicians
could be randomized to one group in which training
and supervision is limited to technical and practical
aspects of the treatment versus a comparison
condition in which a substantial portion of the
training is devoted to building theoretical knowl-
edge. Patient outcomes would then be assessed and
compared across therapist groups. An aim of this
type of studywould be to determinewhether training
time is more productively spent on technique or
on theory. Variations on this basic design could be
envisioned, including comparisons of training in
different theories, parametric studies of varying
amounts of theoretical training, and comparisons
of different training modalities, among others.
Moreover, cost-benefit analyses could be included
in all of these studies.Of course, in order to draw firm
conclusions it will be important to attend to
methodological details, such as pre- and posttraining
tests of clinicians’ theoretical knowledge, highly
knowledgeable and competent trainers, etc., in the
design and execution of such studies.
An early prototype of this kind of research was
conducted by Strosahl, Hayes, Bergan, and Romano
(1998). In that study, practicing master’s-level
clinicians working in a community health mainte-
nance organization were assigned to receive training
in ACT theory and technique (n = 8) or no addi-
tional training (n = 10). At follow-up assessment,
patients of the therapists who underwent training
had significantly better outcomes on a number of
26. measures relative to patients of therapists who did
not receive the training. This study suffers from a
number ofmethodological weaknesses, including the
lack of random assignment of therapists to condi-
tions and the absence of control conditions to rule
out that receiving training in any CBT model would
have resulted in better outcomes. Nevertheless, it
represents an early version of the kind of study that
can examine the practical impact of training in theory
on clinical outcomes.
examination of
mediators/moderators
Researchers and clinicians are increasingly aware of
the limitations in knowledge gained from so-called
“horse race” trials in which two therapies are tested
against each other and differences in outcomes
alone are examined. First, many such trials have
failed to show clear differences in outcomes among
competing psychotherapies. Second, even when
differences are found, these trials fail to provide
clear evidence for which aspects of the treatments
588 herbert et al .
are responsible for those differences. It was over
50 years ago that Gordon Paul (1967) famously
asked, “What treatment, by whom, is most effective
for this individual with that specific problem, and
under which set of circumstances?” (p. 111). In
modern parlance, Paul is referring to questions
related to moderation and mediation of treatment
effects. Moderation refers to who is more likely to
respond to treatment or under what conditions a
27. treatment is likely to be effective. Mediation refers
to how a treatment works or the mechanisms
through which a treatment produces its response.
Historically, it has been difficult to examine
systematically these types of empirical questions.
Although procedures for exploring questions of
moderation and mediation in psychotherapy trials
were pioneered by Baron and Kenny (1986), many
improvements have been made over recent years. The
ease of use andpower of these techniques, especially in
smaller psychotherapy samples, have grown dramat-
ically (Kraemer, Kiernan, Essex, & Kupfer, 2008;
Kraemer et al., 2002; Preacher & Hayes, 2008).
A recent study of ACT versus traditional CBT for
mixed anxiety disorders provides an example of the
knowledge that canbe gained froman examination of
mediators andmoderators. Althoughboth treatments
improved symptoms similarly (Arch, Eifert, et al.,
2012), ACT produced somewhat greater improve-
ments in cognitive defusion, which mediated out-
comes in both treatments (Arch, Wolitzky-Taylor,
et al., 2012). Furthermore, in terms of moderation,
CBT produced better outcomes in those with greater
baseline anxiety sensitivity, whereas ACT produced
greater improvements in those with comorbid
depression (Wolitzky-Taylor, Arch, Rosenfield, &
Craske, 2012). Results such as these serve as tests
of the theories underlying psychotherapy programs,
and can lead to further developments of those
theories.
Conclusion
Scholars of psychotherapy, and of CBTs in particu-
lar, have repeatedly called over the past three decades
for renewed interest in theory, and there are signs
28. that the field is beginning to heed such calls. This
renewed appreciation of the role of theory is driven
by the confluence of a number of factors, including
the growth of third-generation models of CBT that
tend to emphasize linking technique to theory, and
the development of refined statistical methods to
study psychotherapy processes. Although the ideal
role of theoretical knowledge in clinical practice is
ultimately an empirical question, there are good
reasons to hypothesize that a working knowledge of
theory may lead to enhanced outcomes. Evaluating
these questions will require a multifaceted research
program, which will in turn depend on first
addressing a number of conceptual issues regarding
the nature of theories to be examined.
The importance of examining the role of theory in
clinical practice is underscored by recent initiatives to
disseminate CBTs widely to front-line practitioners.
Beginning in 2006 the U.K. governments have been
implementing the Improving Access to Psychological
Therapies program (Department of Health, 2011),
which has committed hundreds of millions of dollars
to training thousands of therapists to provide
CBT to over 600,000 people with disorders such as
depression and anxiety. In the U.S., the VA is
implementing a similar initiative to train clinicians
in CBT to improve access to effective treatment
among military veterans (Ruzek, Karlin, & Zeiss, in
press). Taking full advantage of these efforts will
require not only further theoretical developments,
but also a better understanding of the role of theory in
clinical practice.
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RECEIVED: November 12, 2012
ACCEPTED: March 1, 2013
Available online 13 March 2013
The Importance of Theory in Cognitive Behavior Therapy: A
Perspective of Contextual Behavioral ScienceWhat Is
“Theory”?Why Theory Probably Matters: The Case of ACTCall
for ResearchTherapist SurveysEvaluation of Theories
ThemselvesExperimental TrialsExamination of
Mediators/ModeratorsConclusionReferences
Paula Cortez
Identifying Data: Paula Cortez is a 43-year-old Catholic
Hispanic female residing in New York City, NY. Paula was born
in Colombia. When she was 17 years old, Paula left Colombia
and moved to New York where she met David, who later
became her husband. Paula and David have one son, Miguel, 20
years old. They divorced after 5 years of marriage. Paula has a
five-year-old daughter, Maria, from a different relationship.
Presenting Problem: Paula has multiple medical issues, and
there is concern about whether she will be able to continue to
41. care for her youngest child, Maria. Paula has been
overwhelmed, especially since she again stopped taking her
medication. Paula is also concerned about the wellness of
Maria.
Family Dynamics: Paula comes from a moderately well-to-do
family. Paula reports suffering physical and emotional abuse at
the hands of both her parents, eventually fleeing to New York to
get away from the abuse. Paula comes from an authoritarian
family where her role was to be “seen and not heard.” Paula
states that she did not feel valued by any of her family members
and reports never receiving the attention she needed. As a
teenager, she realized she felt “not good enough” in her family
system, which led to her leaving for New York and looking for
“someone to love me.” Her parents still reside in Colombia with
Paula’s two siblings.
Paula met David when she sought to purchase drugs. They
married when Paula was 18 years old. The couple divorced after
5 years of marriage. Paula raised Miguel, mostly by herself,
until he was 8 years old, at which time she was forced to
relinquish custody due to her medical condition. Paula
maintains a relationship with her son, Miguel, and her ex-
husband, David. Miguel takes part in caring for his half-sister,
Maria.
Paula does believe her job as a mother is to take care of Maria
but is finding that more and more challenging with her physical
illnesses.
Employment History: Paula worked for a clothing designer, but
she realized that her true passion was painting. She has a
collection of more than 100 drawings and paintings, many of
which track the course of her personal and emotional journey.
Paula held a fulltime job for a number of years before her health
prevented her from working. She is now unemployed and
receives Supplemental Security Disability Insurance (SSD) and
Medicaid. Miguel does his best to help his mom but only works
part time at a local supermarket delivering groceries.
Paula currently uses federal and state services. Paula
42. successfully applied for WIC, the federal Supplemental
Nutrition Program for Women, Infants, and Children. Given
Paula’s low income, health, and Medicaid status, Paula is able
to receive in-home childcare assistance through New York’s
public assistance program.
Social History: Paula is bilingual, fluent in both Spanish and
English. Although Paula identifies as Catholic, she does not
consider religion to be a big part of her life. Paula lives with
her daughter in an apartment in Queens, NY. Paula is socially
isolated as she has limited contact with her family in Colombia
and lacks a peer network of any kind in her neighborhood.
Five (5) years ago Paula met a man (Jesus) at a flower shop.
They spoke several times. He would visit her at her apartment
to have sex. Since they had an active sex life, Paula thought he
was a “stand-up guy” and really liked him. She believed he
would take care of her. Soon everything changed. Paula began
to suspect that he was using drugs, because he had started to
become controlling and demanding. He showed up at her
apartment at all times of the night demanding to be let in. He
called her relentlessly, and when she did not pick up the phone,
he left her mean and threatening messages. Paula was fearful for
her safety and thought her past behavior with drugs and sex
brought on bad relationships with men and that she did not
deserve better. After a couple of months, Paula realized she was
pregnant. Jesus stated he did not want anything to do with the
“kid” and stopped coming over, but he continued to contact and
threaten Paula by phone. Paula has no contact with Jesus at this
point in time due to a restraining order.
Mental Health History: Paula was diagnosed with bipolar
disorder. She experiences periods of mania lasting for a couple
of weeks then goes into a depressive state for months when not
properly medicated. Paula has a tendency toward paranoia.
Paula has a history of not complying with her psychiatric
medication treatment because she does not like the way it makes
her feel. She often discontinues it without telling her
psychiatrist. Paula has had multiple psychiatric hospitalizations
43. but has remained out of the hospital for the past 5 years. Paula
accepts her bipolar diagnosis but demonstrates limited insight
into the relationship between her symptoms and her medication.
Paula reports that when she was pregnant, she was fearful for
her safety due to the baby’s father’s anger about the pregnancy.
Jesus’ relentless phone calls and voicemails rattled Paula. She
believed she had nowhere to turn. At that time, she became
scared, slept poorly, and her paranoia increased significantly.
After completing a suicide assessment 5 years ago, it was noted
that Paula was decompensating quickly and was at risk of
harming herself and/or her baby. Paula was involuntarily
admitted to the psychiatric unit of the hospital. Paula remained
on the unit for 2 weeks.
Educational History: Paula completed high school in Colombia.
Paula had hoped to attend the Fashion Institute of Technology
(FIT) in New York City, but getting divorced, then raising
Miguel on her own interfered with her plans. Miguel attends
college full time in New York City.
Medical History: Paula was diagnosed as HIV positive 15 years
ago. Paula acquired AIDS three years later when she was
diagnosed with a severe brain infection and a Tcell count of less
than 200. Paula’s brain infection left her completely paralyzed
on the right side. She lost function in her right arm and hand as
well as the ability to walk. After a long stay in an acute care
hospital in New York City, Paula was transferred to a skilled
nursing facility (SNF) where she thought she would die. After
being in the skilled nursing facility for more than a year, Paula
regained the ability to walk, although she does so with a severe
limp. She also regained some function in her right arm. Her
right hand (her dominant hand) remains semi-paralyzed and
limp. Over the course of several years, Paula taught herself to
paint with her left hand and was able to return to her beloved
art.
Paula began treatment for her HIV/AIDS with highly active
antiretroviral therapy (HAART). Since she ran away from the
family home, married and divorced a drug user, then was in an
44. abusive relationship, Paula thought she deserved what she got in
life. She responded well to HAART and her HIV/AIDS was well
controlled. In addition to her HIV/AIDS disease, Paula is
diagnosed with Hepatitis C (Hep C). While this condition was
controlled, it has reached a point where Paula’s doctor is
recommending she begin a new treatment. Paula also has
significant circulatory problems, which cause her severe pain in
her lower extremities. She uses prescribed narcotic pain
medication to control her symptoms. Paula’s circulatory
problems have also led to chronic ulcers on her feet that will
not heal. Treatment for her foot ulcers demands frequent visits
to a wound care clinic. Paula’s pain paired with the foot ulcers
make it difficult for her to ambulate and leave her home. Paula
has a tendency not to comply with her medical treatment. She
often disregards instructions from her doctors and resorts to
holistic treatments like treating her ulcers with chamomile tea.
When she stops her treatment, she deteriorates quickly. Maria
was born HIV negative and received the appropriate HAART
treatment after birth. She spent a week in the neonatal intensive
care unit as she had to detox from the effects of the pain
medication Paula took throughout her pregnancy.
Legal History: Previously, Paula used the AIDS Law Project, a
not-for-profit organi nization that helps individuals with HIV
address legal issues, such as those related to the child’s father .
At that time, Paula filed a police report in response to Jesus'
escalating threats and successfully got a restraining order. Once
the order was served, the phone calls and visits stopped, and
Paula regained a temporary sense of control over her life. Paula
completed the appropriate permanency planning paperwork with
the assistance of the organization The Family Center. She
named Miguel as her daughter’s guardian should something
happen to her.
Alcohol and Drug Use History: Paula became an intravenous
drug user (IVDU), using cocaine and heroin, at age 17. David
was one of Paula’s “drug buddies” and suppliers. Paula
continued to use drugs in the United States for several years;
45. however, she stopped when she got pregnant with Miguel.
David continued to use drugs, which led to the failure of their
marriage.
Strengths: Paula has shown her resilience over the years. She
has artistic skills and has found a way to utilize them. Paula has
the foresight to seek social services to help her and her children
survive. Paula has no legal involvement. She has the ability to
bounce back from her many physical and health challenges to
continue to care for her child and maintain her household.
David Cortez: father, 46 years old
Paula Cortez: mother, 43 years old
Miguel Cortez: son, 20 years old
Jesus (unknown):
Maria’s father, 44 years old
Maria Cortez: daughter, 5 years old