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.
This document summarizes the theoretical framework, instruments, and design of a study evaluating the effectiveness and cost-effectiveness of long-term psychoanalytic treatment. The study uses a multiple cohort design to follow patients in four cohorts representing different phases of treatment: before treatment, one year into treatment, at the end of treatment, and two years post-treatment. Outcome measures assess symptomatic functioning and structural change, using both theory-based and a-theoretical instruments. The study aims to expand the evidence base for psychoanalytic treatment given difficulties with randomized controlled trials for long-term interventions.
Artigo (acupuntura) - Uma revisão sistemática sobre a expectativa ao tratamen...Renato Almeida
This systematic review identified 9 studies that assessed or manipulated patient expectancies regarding acupuncture treatment and related expectancies to health outcomes. The studies used heterogeneous methodologies, preventing meta-analysis. A descriptive review found that 5 studies reported statistically significant effects of expectancy on at least one outcome, with 3 also finding evidence suggestive of an interaction between expectancy and whether real or placebo acupuncture was received. While some trends were observed, conclusions are limited by the heterogeneity of study designs. Future research should further consider how best to assess or manipulate expectancies in this area.
Article in Division 29's journal, psychotherapy that reviews the research on routine outcome monitoring, arguing that current efforts are at risk for repeating the history of failed efforts to improve the outcome of psychotherapy.
This study examined the effect of complementary music therapy on postoperative patients' anxiety, pain, and noise satisfaction. Researchers recruited 41 postoperative patients from a hospital and assigned them to music therapy or control groups. Patients in the music therapy group listened to 30 minutes of non-lyrical music after analgesia, while controls received usual care. Patients completed questionnaires measuring anxiety, pain, and noise satisfaction at various times. Results showed music therapy increased pain and noise satisfaction but not anxiety. Researchers concluded music therapy may improve some postoperative outcomes but limitations included the small sample size. They recommended replicating the study with a larger, more diverse sample.
1. Researchers evaluate the effectiveness of therapies through methods like meta-analyses of existing studies to identify the most effective treatments for issues like depression. Common factors like the therapeutic relationship contribute to positive outcomes.
2. While therapies like CBT are supported as effective, researchers still do not fully understand why they work. Prevention strategies aim to reduce mental illness at the primary, secondary, and tertiary levels through skills training, early identification and treatment, and relapse prevention.
3. Evaluating therapeutic effectiveness and identifying common success factors helps improve treatments, while prevention research works to reduce mental illness occurrence and severity.
Order #163040071 why risk factors of cardiovascular diseases are mjack60216
This document outlines a research proposal to study why cardiovascular disease risk factors are more prevalent among Hispanics in Florida. The proposal includes an introduction discussing relevant background literature, hypothesized significance and importance of the study, a proposed methodology involving collecting data on Hispanics and a control group, and an expected timeline and budget. The proposal would analyze risk factors like high cholesterol, blood pressure, obesity, diabetes, and smoking among Hispanics and potential causes like a lack of risk awareness.
This document summarizes the theoretical framework, instruments, and design of a study evaluating the effectiveness and cost-effectiveness of long-term psychoanalytic treatment. The study uses a multiple cohort design to follow patients in four cohorts representing different phases of treatment: before treatment, one year into treatment, at the end of treatment, and two years post-treatment. Outcome measures assess symptomatic functioning and structural change, using both theory-based and a-theoretical instruments. The study aims to expand the evidence base for psychoanalytic treatment given difficulties with randomized controlled trials for long-term interventions.
Artigo (acupuntura) - Uma revisão sistemática sobre a expectativa ao tratamen...Renato Almeida
This systematic review identified 9 studies that assessed or manipulated patient expectancies regarding acupuncture treatment and related expectancies to health outcomes. The studies used heterogeneous methodologies, preventing meta-analysis. A descriptive review found that 5 studies reported statistically significant effects of expectancy on at least one outcome, with 3 also finding evidence suggestive of an interaction between expectancy and whether real or placebo acupuncture was received. While some trends were observed, conclusions are limited by the heterogeneity of study designs. Future research should further consider how best to assess or manipulate expectancies in this area.
Article in Division 29's journal, psychotherapy that reviews the research on routine outcome monitoring, arguing that current efforts are at risk for repeating the history of failed efforts to improve the outcome of psychotherapy.
This study examined the effect of complementary music therapy on postoperative patients' anxiety, pain, and noise satisfaction. Researchers recruited 41 postoperative patients from a hospital and assigned them to music therapy or control groups. Patients in the music therapy group listened to 30 minutes of non-lyrical music after analgesia, while controls received usual care. Patients completed questionnaires measuring anxiety, pain, and noise satisfaction at various times. Results showed music therapy increased pain and noise satisfaction but not anxiety. Researchers concluded music therapy may improve some postoperative outcomes but limitations included the small sample size. They recommended replicating the study with a larger, more diverse sample.
1. Researchers evaluate the effectiveness of therapies through methods like meta-analyses of existing studies to identify the most effective treatments for issues like depression. Common factors like the therapeutic relationship contribute to positive outcomes.
2. While therapies like CBT are supported as effective, researchers still do not fully understand why they work. Prevention strategies aim to reduce mental illness at the primary, secondary, and tertiary levels through skills training, early identification and treatment, and relapse prevention.
3. Evaluating therapeutic effectiveness and identifying common success factors helps improve treatments, while prevention research works to reduce mental illness occurrence and severity.
Order #163040071 why risk factors of cardiovascular diseases are mjack60216
This document outlines a research proposal to study why cardiovascular disease risk factors are more prevalent among Hispanics in Florida. The proposal includes an introduction discussing relevant background literature, hypothesized significance and importance of the study, a proposed methodology involving collecting data on Hispanics and a control group, and an expected timeline and budget. The proposal would analyze risk factors like high cholesterol, blood pressure, obesity, diabetes, and smoking among Hispanics and potential causes like a lack of risk awareness.
This document provides a critique of the article "Effects of Spirituality on Professionals at Risk of Developing Secondary Traumatic Stress Disorder". The critique examines several points, including the practical application of the research findings, the view of spirituality as a trait versus process, additional variables that could influence results, and whether resilience truly requires spiritual processes. In summarizing, the critique states that while the research on spirituality and resilience among therapists is intriguing, it does not have enough data to stand alone and further research is needed to better illustrate or falsify the hypothesis.
This document discusses key terms used to describe outcomes in antidepressant treatment research and clinical practice, specifically response, remission, recurrence, and recovery. It notes that while remission is now considered the optimal treatment goal, implying wellness, definitions of remission have varied inconsistently across studies. True wellness should be determined by a lack of symptoms, good functional status, and reduced pathophysiology. The document calls for clinical trials to better reflect the treatment goal of sustained wellness through longer durations, larger sample sizes, and assessment of functional outcomes.
This study examined whether psychotherapists' outcomes improve over time and with increased experience. The researchers analyzed data from over 6,500 patients seen by 170 psychotherapists over an average of 4.73 years. Using multilevel modeling, they found that while therapists' outcomes were generally comparable to clinical trials, there was a very small but statistically significant tendency for patient outcomes to diminish as therapists gained more experience in terms of both time and number of patients seen. However, therapists showed lower rates of early termination as their experience increased. The results suggest that while experience may not necessarily lead to better patient outcomes, it can reduce dropout rates.
Of Dodo birds and common factors: A scoping review of direct comparison trial...Will Dobud
Background: Adventure therapy (AT) is a term that includes therapies such as wilderness therapy and adventure-based counseling. With growing empirical support for AT, the diversity of studies make it difficult to attribute outcomes to specific treatment factors.
Objectives: Researchers explored whether AT, often perceived as an alternative therapy, works because of AT's unique components, or whether factors shared by all therapies were responsible.
Methods: A scoping review was undertaken utilizing a search of major databases, unpublished disser- tations, and a hand search for direct comparison trials matching AT with another therapeutic intervention.
Results: 881 publications were identified. 105 quantitative studies were included following a title and abstract review. Only 13 met the full inclusion criteria. Little to no differences were found to isolate specific therapeutic factors.
Conclusions: We discuss the implications of these results considering the movement toward evidence- based practice and recommend future research to eclipse our current understanding of AT.
Individual expertise versus domain expertise (2014)Scott Miller
This document discusses the effectiveness of evidence-based practices (EBPs) for veterans with mental illness. It states that EBPs have led to unprecedented improvements for some veterans, not achieved in decades of prior treatment. However, more work needs to be done to refine EBPs and promote their wider use in clinical settings. Veterans and others with mental illness deserve the most effective care available now and in the future.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
critique osteoarthritis and cartilagefinal4182016James Nichols
This document summarizes a research study that evaluated the efficacy of non-surgical treatment for pain and sensitization in patients with knee osteoarthritis. The study used a pre-defined ancillary analysis of a randomized controlled trial to compare outcomes between a treatment group receiving neuromuscular exercise, education, diet, insoles and pain medications (MEDIC-treatment) and a control group receiving usual care. Outcomes included measures of pain intensity, pain pattern, pain spreading, medication usage, and pain sensitization, which were assessed at baseline and 3-month follow up. The study found some improvements in pain outcomes in the MEDIC-treatment group compared to usual care, though limitations in generalizability and potential confounding factors
This thesis examines the impact of gender and age on the efficacy of electroconvulsive therapy (ECT) for treating major depressive disorder (MDD). The author conducted a chart review of 157 MDD patients who received ECT at Providence Care. Statistical analyses found no significant differences in response rates based on gender or age. Limitations in study design prevented definitive conclusions. Future research is needed to further understand how patient characteristics influence ECT outcomes.
Feedback informed treatment (fit) achieving(apa ip miller hubble seidel chow ...Scott Miller
1) The document discusses Feedback Informed Treatment (FIT), which uses routine monitoring of a client's progress and the therapeutic alliance to improve outcomes. Short scales like the Session Rating Scale and Outcome Rating Scale are used to gather feedback from clients.
2) Research shows that formal collection and discussion of client feedback doubles rates of reliable change, decreases dropout rates by 50%, and cuts deterioration rates by a third compared to treatment without feedback.
3) The feedback allows therapists to adjust their approach if a client is not progressing well or the alliance is weakening, in order to maximize the fit between client, therapist, and treatment for that individual.
The Therapeutic Alliance, Ruptures, and Session-by-Session FeedbackScott Miller
Chris Laraway's doctoral dissertation presents a thorough review of the literature on the link between the therapeutic alliance and outcome, and how session by session feedback can be used to repair ruptures in the therapeutic relationship.
This study investigated whether providing client feedback data to supervisors for use in supervision would influence supervision and counselor self-efficacy. Trainees were assigned to either a continuous feedback condition, where feedback was provided to supervisors, or a no-feedback condition. Results showed that trainees in both conditions improved client outcomes over the year, but those in the feedback condition improved more. However, ratings of supervisory alliance and satisfaction did not differ between conditions. The relationship between counselor self-efficacy and outcomes was stronger for those in the feedback condition, suggesting feedback may facilitate a more accurate assessment of skills.
This document proposes classifying happiness as a psychiatric disorder. It reviews literature showing happiness has affective, cognitive, and behavioral components, like positive mood and satisfaction. While its prevalence and causes are uncertain, some evidence suggests it is statistically abnormal and associated with cognitive abnormalities. The document argues happiness meets criteria for a psychiatric disease by forming a symptom cluster and potentially reflecting an underlying pathological process. It acknowledges classifying happiness as a disorder would be controversial but says the case merits consideration and future research.
If you are looking for Article critique on public health care, then you can check the complete presentation here or download from http://studentsassignmenthelp.co.uk/answers/article-critique-assignment-help/
This study examined factors that influence relapse in people with mental health disorders in Indonesia, specifically in West Sumatera Province. The study found that stress of caregivers was the strongest predictor of relapse, with caregivers experiencing high stress being over 8 times more likely to experience patient relapse than low-stress caregivers. The study also found that lack of home visits from healthcare workers was associated with a higher likelihood of relapse. Improving home visit programs and supporting caregivers to reduce their stress levels could help lower relapse rates. The study was a cross-sectional analysis of 313 caregivers in West Sumatera that examined how demographic characteristics, stigma, home visits and caregiver stress related to patient relapse.
Evidence-Based Treatments and Integrative PsychotherapyKevin Rushton
The document discusses reactions to the "Dodo bird verdict" which suggests that all major psychotherapies are equally effective. Researchers have tried to disprove this through efficacy research to identify superior therapies, while practitioners have embraced integration by combining different approaches. The document also examines criticisms of efficacy research methodology and the rise of psychotherapy integration among practitioners.
This document summarizes a research study that surveyed 837 mental health professionals to determine their views on various models of mental illness. It found that professionals' endorsement of models differed depending on the specific illness. For schizophrenia, they most endorsed a biological model followed by cognitive and behavioral aspects. For depression, a social model was most endorsed followed by cognitive and behavioral aspects, with biological being least endorsed. For antisocial personality disorder, professionals most endorsed social constructionist and nihilist models, suggesting lack of interest in viewing it as a mental illness. The implications of professionals' endorsed models are discussed, such as impacts on treatment approaches, responsibility attribution, stigma, and access to social benefits.
North & south counselling outcomes article march 2013Scott Miller
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms for those who already suffer from conditions like anxiety and depression.
How do psychotherapists experience the use of outcome questionnaires ors and ...Scott Miller
A Swedish study (with an English abstract) describing research on how psychotherapists experience the use of outcome and alliance measures in their clinical work. Findings are relevant to anyone considering implementing FIT.
This document provides a critique of the article "Effects of Spirituality on Professionals at Risk of Developing Secondary Traumatic Stress Disorder". The critique examines several points, including the practical application of the research findings, the view of spirituality as a trait versus process, additional variables that could influence results, and whether resilience truly requires spiritual processes. In summarizing, the critique states that while the research on spirituality and resilience among therapists is intriguing, it does not have enough data to stand alone and further research is needed to better illustrate or falsify the hypothesis.
This document discusses key terms used to describe outcomes in antidepressant treatment research and clinical practice, specifically response, remission, recurrence, and recovery. It notes that while remission is now considered the optimal treatment goal, implying wellness, definitions of remission have varied inconsistently across studies. True wellness should be determined by a lack of symptoms, good functional status, and reduced pathophysiology. The document calls for clinical trials to better reflect the treatment goal of sustained wellness through longer durations, larger sample sizes, and assessment of functional outcomes.
This study examined whether psychotherapists' outcomes improve over time and with increased experience. The researchers analyzed data from over 6,500 patients seen by 170 psychotherapists over an average of 4.73 years. Using multilevel modeling, they found that while therapists' outcomes were generally comparable to clinical trials, there was a very small but statistically significant tendency for patient outcomes to diminish as therapists gained more experience in terms of both time and number of patients seen. However, therapists showed lower rates of early termination as their experience increased. The results suggest that while experience may not necessarily lead to better patient outcomes, it can reduce dropout rates.
Of Dodo birds and common factors: A scoping review of direct comparison trial...Will Dobud
Background: Adventure therapy (AT) is a term that includes therapies such as wilderness therapy and adventure-based counseling. With growing empirical support for AT, the diversity of studies make it difficult to attribute outcomes to specific treatment factors.
Objectives: Researchers explored whether AT, often perceived as an alternative therapy, works because of AT's unique components, or whether factors shared by all therapies were responsible.
Methods: A scoping review was undertaken utilizing a search of major databases, unpublished disser- tations, and a hand search for direct comparison trials matching AT with another therapeutic intervention.
Results: 881 publications were identified. 105 quantitative studies were included following a title and abstract review. Only 13 met the full inclusion criteria. Little to no differences were found to isolate specific therapeutic factors.
Conclusions: We discuss the implications of these results considering the movement toward evidence- based practice and recommend future research to eclipse our current understanding of AT.
Individual expertise versus domain expertise (2014)Scott Miller
This document discusses the effectiveness of evidence-based practices (EBPs) for veterans with mental illness. It states that EBPs have led to unprecedented improvements for some veterans, not achieved in decades of prior treatment. However, more work needs to be done to refine EBPs and promote their wider use in clinical settings. Veterans and others with mental illness deserve the most effective care available now and in the future.
Although many of you may not be interested in the psychometric details of the ORS and SRS, it does bear importantly on whether there are seen as credible. Jeff Reese and I (Duncan & Reese, 2013) recently exchanged views with Halstead, Youn, and Armijo (2013), debating when a measure is too brief and when it is too long. Here is our paper. First regarding when a measure is too brief: There is no doubt that 45 items, 30 items, or even 19 items is psychometrically better than 4 items, and that the increased reliability and validity of longer measures likely result in better detection, prediction, and ultimate measurement of outcome. But how much better is the really the question. Are these differences clinically meaningful and do they offset the low compliance rates and resulting data integrity issues from missing data? These are the questions that require empirical investigation to determine how brief is too brief, although from my experience, the verdict has already been rendered. But when is a measure too long? The answer is simple: When clinicians won’t use it.
critique osteoarthritis and cartilagefinal4182016James Nichols
This document summarizes a research study that evaluated the efficacy of non-surgical treatment for pain and sensitization in patients with knee osteoarthritis. The study used a pre-defined ancillary analysis of a randomized controlled trial to compare outcomes between a treatment group receiving neuromuscular exercise, education, diet, insoles and pain medications (MEDIC-treatment) and a control group receiving usual care. Outcomes included measures of pain intensity, pain pattern, pain spreading, medication usage, and pain sensitization, which were assessed at baseline and 3-month follow up. The study found some improvements in pain outcomes in the MEDIC-treatment group compared to usual care, though limitations in generalizability and potential confounding factors
This thesis examines the impact of gender and age on the efficacy of electroconvulsive therapy (ECT) for treating major depressive disorder (MDD). The author conducted a chart review of 157 MDD patients who received ECT at Providence Care. Statistical analyses found no significant differences in response rates based on gender or age. Limitations in study design prevented definitive conclusions. Future research is needed to further understand how patient characteristics influence ECT outcomes.
Feedback informed treatment (fit) achieving(apa ip miller hubble seidel chow ...Scott Miller
1) The document discusses Feedback Informed Treatment (FIT), which uses routine monitoring of a client's progress and the therapeutic alliance to improve outcomes. Short scales like the Session Rating Scale and Outcome Rating Scale are used to gather feedback from clients.
2) Research shows that formal collection and discussion of client feedback doubles rates of reliable change, decreases dropout rates by 50%, and cuts deterioration rates by a third compared to treatment without feedback.
3) The feedback allows therapists to adjust their approach if a client is not progressing well or the alliance is weakening, in order to maximize the fit between client, therapist, and treatment for that individual.
The Therapeutic Alliance, Ruptures, and Session-by-Session FeedbackScott Miller
Chris Laraway's doctoral dissertation presents a thorough review of the literature on the link between the therapeutic alliance and outcome, and how session by session feedback can be used to repair ruptures in the therapeutic relationship.
This study investigated whether providing client feedback data to supervisors for use in supervision would influence supervision and counselor self-efficacy. Trainees were assigned to either a continuous feedback condition, where feedback was provided to supervisors, or a no-feedback condition. Results showed that trainees in both conditions improved client outcomes over the year, but those in the feedback condition improved more. However, ratings of supervisory alliance and satisfaction did not differ between conditions. The relationship between counselor self-efficacy and outcomes was stronger for those in the feedback condition, suggesting feedback may facilitate a more accurate assessment of skills.
This document proposes classifying happiness as a psychiatric disorder. It reviews literature showing happiness has affective, cognitive, and behavioral components, like positive mood and satisfaction. While its prevalence and causes are uncertain, some evidence suggests it is statistically abnormal and associated with cognitive abnormalities. The document argues happiness meets criteria for a psychiatric disease by forming a symptom cluster and potentially reflecting an underlying pathological process. It acknowledges classifying happiness as a disorder would be controversial but says the case merits consideration and future research.
If you are looking for Article critique on public health care, then you can check the complete presentation here or download from http://studentsassignmenthelp.co.uk/answers/article-critique-assignment-help/
This study examined factors that influence relapse in people with mental health disorders in Indonesia, specifically in West Sumatera Province. The study found that stress of caregivers was the strongest predictor of relapse, with caregivers experiencing high stress being over 8 times more likely to experience patient relapse than low-stress caregivers. The study also found that lack of home visits from healthcare workers was associated with a higher likelihood of relapse. Improving home visit programs and supporting caregivers to reduce their stress levels could help lower relapse rates. The study was a cross-sectional analysis of 313 caregivers in West Sumatera that examined how demographic characteristics, stigma, home visits and caregiver stress related to patient relapse.
Evidence-Based Treatments and Integrative PsychotherapyKevin Rushton
The document discusses reactions to the "Dodo bird verdict" which suggests that all major psychotherapies are equally effective. Researchers have tried to disprove this through efficacy research to identify superior therapies, while practitioners have embraced integration by combining different approaches. The document also examines criticisms of efficacy research methodology and the rise of psychotherapy integration among practitioners.
This document summarizes a research study that surveyed 837 mental health professionals to determine their views on various models of mental illness. It found that professionals' endorsement of models differed depending on the specific illness. For schizophrenia, they most endorsed a biological model followed by cognitive and behavioral aspects. For depression, a social model was most endorsed followed by cognitive and behavioral aspects, with biological being least endorsed. For antisocial personality disorder, professionals most endorsed social constructionist and nihilist models, suggesting lack of interest in viewing it as a mental illness. The implications of professionals' endorsed models are discussed, such as impacts on treatment approaches, responsibility attribution, stigma, and access to social benefits.
North & south counselling outcomes article march 2013Scott Miller
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms for those who already suffer from conditions like anxiety and depression.
How do psychotherapists experience the use of outcome questionnaires ors and ...Scott Miller
A Swedish study (with an English abstract) describing research on how psychotherapists experience the use of outcome and alliance measures in their clinical work. Findings are relevant to anyone considering implementing FIT.
Athena Software has partnered with the International Center for Clinical Excellence to integrate Dr. Scott Miller’s Feedback Informed Treatment (FIT) / Partners for Change Outcome Management System (PCOMS) into Penelope Case Management software. This allows clients to provide feedback on their wellbeing and session satisfaction through intuitive data input sliders, which is then contrasted against a large dataset to evaluate treatment effectiveness and presented in reports. Penelope Case Management Software is used by social services in 15 countries for case management, clinical notes, scheduling, and outcomes evaluation.
Implementing fit in institutions (danish with english abstract)Scott Miller
Article about implementing feedback-informed treatment in mental health agencies. Based on their experience of implementing the approach, the authors highlight the challenges and outline six specific steps for improving chances of success.
Is psychotherapy getting better (cole)Scott Miller
This article discusses the 30th anniversary of a psychotherapy magazine and reflects on efforts over the past 30 years to quantify and measure the effectiveness of psychotherapy. It describes how Hans Eysenck challenged the field in 1952 by claiming there was no proof psychotherapy worked. This sparked the modern quest to establish psychotherapy's scientific legitimacy through randomized controlled trials. While cognitive therapy pioneer Aaron Beck began testing his approach in the 1970s, randomized controlled trials did not become a driving force until 1993 when the APA established a task force to identify empirically supported treatments. The article suggests that establishing evidence-based therapies through randomized controlled trials has been important for accountability, third-party reimbursement, and determining the allocation of time and resources.
This document outlines a workshop on teaching chaste living. The workshop aims to teach participants about the Church's teachings on sexuality from creation stories in Genesis and how to identify the sacramental nature of physical intimacy. Participants will also review the US Bishops' document "Catechetical Formation in Chaste Living" which provides guidelines for developing curriculum on teaching chastity to youth.
This document summarizes and critiques common myths about antidepressant medications. It discusses how popular culture and marketing have promoted the idea that depression is solely a biological condition cured by medication, rather than a complex issue influenced by various life experiences. However, the document asserts that research does not actually support the view that antidepressants are dramatically more effective than placebo pills or psychotherapy. It claims antidepressants have been exaggerated as "miracle drugs" due more to profit-driven marketing than objective science.
The document discusses thought reform and totalitarianism in the context of the LDS Church's missionary training program. It summarizes Scott D. Miller's analysis comparing the eight themes of thought reform identified by Robert J. Lifton to techniques used in the Missionary Training Center (MTC). These include milieu control through rigid schedules and regulations on what missionaries can see, hear, read, etc. It also discusses mystical manipulation by provoking specific behaviors and emotions to validate LDS ideology. The document raises ethical questions about thought reform in the MTC and missionary environment.
When mental health practitioners use methods that are totally lacking in scientific support, particularly when the treatment has been demonstrated to be harmful and evidence-based alternatives are available, they should be liable for malpractice. Organizations like the American Psychological Association claim to support scientific standards but leave loopholes that allow psychologists to practice pseudoscientific nonsense. Several steps must be taken to close the gap between science and practice in mental healthcare, including malpractice reform, improved guidelines based on evidence, consumer education, and a commitment to scientific practice by professional organizations.
The document discusses the interplay between a therapist's personal characteristics and qualities (therapist variables) and a client's theory of change. It argues that the most effective therapy occurs when the therapist is aware of how their variables may influence the therapeutic alliance and adapts their approach to align with the client's theory of change. Case studies are presented to illustrate therapists monitoring client feedback to improve outcomes. Effective therapists recognize when their approach does not match a client's needs and make adjustments to better facilitate the client's process of change.
The document outlines a presentation given by Nancy L. Morgan on the 7 qualities most desired in a therapist according to client feedback. It discusses common mistakes made by therapists including talking too much and not listening enough. The results of surveys given to clients at different facilities identified the top 7 qualities as: compassion, empathy, listening skills, accessibility, respect, competence and being receptive. The presentation emphasizes developing therapeutic alliance and understanding client needs to provide the greatest gift of helping them.
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= ...
This annotated bibliography summarizes 5 research studies related to counseling and psychotherapy. The studies examined: 1) how COVID-19 has impacted counseling professionals and clients and areas for future research, 2) the need to adapt psychotherapy approaches to different cultural contexts, 3) the benefits and limitations of thematic analysis as a research method in counseling, 4) challenges to providing psychotherapy to vulnerable older adults and training needs, 5) how counseling approaches can effectively treat depression when evaluated based on different types of evidence. The annotation provides a brief overview of each study's purpose, findings, strengths, and weaknesses.
717JRRDJRRD Volume 49, Number 5, 2012Pages 717–728Coup.docxsleeperharwell
717
JRRDJRRD Volume 49, Number 5, 2012Pages 717–728
Couple/family therapy for posttraumatic stress disorder: Review to
facilitate interpretation of VA/DOD Clinical Practice Guideline
Candice M. Monson, PhD;1–2* Alexandra Macdonald, PhD;3 Amy Brown-Bowers1
1Ryerson University, Toronto, Ontario, Canada; 2Department of Veterans Affairs (VA) National Center for PTSD,
Women’s Health Sciences Division, Boston, MA; 3VA National Center for PTSD, Behavioral Science Division, and
Boston University School of Medicine, Boston, MA
Abstract—A well-documented association exists among Vet-
erans’ posttraumatic stress disorder (PTSD) symptoms, family
relationship problems, and mental health problems in partners
and children of Veterans. This article reviews the recommenda-
tions regarding couple/family therapy offered in the newest
version of the Department of Veterans Affairs (VA)/Depart-
ment of Defense (DOD) VA/DOD Clinical Practice Guideline
for Management of Post-Traumatic Stress. We then provide a
heuristic for clinicians, researchers, and policy makers to con-
sider when incorporating couple/family interventions into Vet-
erans’ mental health services. The range of research that has
been conducted on couple/family therapy for Veterans with
PTSD is reviewed using this heuristic, and suggestions for
clinical practice are offered.
Key words: caregiver burden, clinical practice guidelines,
cognitive-behavioral therapy, couple/family therapy, emotion-
ally focused couple therapy, mental health, PTSD, rehabilita-
tion, strategic approach therapy, Veterans.
INTRODUCTION
To their credit and our benefit, Veterans and their fami-
lies have been the predominant contributors to our knowl-
edge about the role of posttraumatic stress disorder (PTSD)
symptoms in family functioning and vice versa. This
research documents a clear and convincing association
between PTSD symptoms and a range of family problems
(see Monson et al. [1] for review). In addition, Veterans’
PTSD symptoms have been associated with a myriad of
individual mental health problems in spouses and children
(see Renshaw et al. [2] for review). Yet, research on couple/
family therapies for Veterans with PTSD has lagged behind
individual psychotherapy treatment outcome efforts. This is
in spite of research showing that Veterans desire greater
family involvement in their treatment (e.g., Batten et al. [3])
and the presence of significant mental health problems in
Veterans’ loved ones who may individually profit from
family therapy. In addition, treatments for PTSD do not
necessarily improve couple and family functioning (e.g.,
Abbreviations: BCT = behavioral couple therapy, BFT =
behavioral family therapy, CBCT = cognitive-behavioral con-
joint therapy, CPG = Clinical Practice Guideline, CSO = con-
cerned significant other, DOD = Department of Defense, DTE =
directed therapeutic exposure, EFCT for Trauma = emotionally
focused couple therapy for trauma, LMC = lifestyl.
Physical activity and the prevention of depressionGiliano Campos
The document summarizes a systematic review examining whether physical activity (PA) can prevent the onset of depression. The review analyzed 30 prospective studies that assessed the relationship between baseline PA and subsequent depression. Twenty-five studies found that higher baseline PA was associated with a lower risk of developing depression later, providing evidence that PA may have a protective effect against future depression. Most of these studies were considered high quality. The review also found that as little as 10-29 minutes of daily PA or 150 minutes per week may help prevent depression. Greater amounts of PA provided even more protection. The majority of the evidence suggests PA can serve as a useful strategy for reducing depression risk from a public health perspective.
1 Clinical Problem Social Anxiety is described by .docxcroftsshanon
1
Clinical Problem
Social Anxiety is described by The Diagnostic and Statistical Manual of the American
Psychiatric Association (DSM-5) as a persistent fear of social situations where the person is
exposed to people or to possible scrutiny by others and fears that he/she will display
symptoms of anxiety or be perceived in a way that will be embarrassing and humiliating
(American Psychiatric Association, 2013). This topic was chosen as according to Kessler et
al. (2012) social anxiety is among the most common anxiety disorder affecting 13% of
individuals at some stage in their lives. From experience, and according to Krysta et al.
(2015) medication is the first line treatment for anxiety disorders due to accessibility.
Unfortunately, for people experiencing social anxiety most medications have adverse effects
such as increased agitation and sexual dysfunction (Rosen et al 1999) and some medication,
in particular benzodiazepines are highly addictive (Lader and Kyriacou, 2016). Townend et
al. (2008) report that CBT remains the psychological therapy with the widest and broadest
evidence base. Beck et al (1979) define Cognitive Behavioural Therapy (CBT) as a concept
where an individual’s emotions and behaviours are based on the way that they interpret the
world through their cognitions. NICE (2011) (cited in Clark, 2011) recommend psychological
therapies prior to medication for anxiety disorders however due to a lack of therapists in
mental health services this is not the case in clinical practice which led to the rationale for the
following research question.
2
Clinical question
Are psychological interventions more efficacious than pharmacological interventions to help
reduce social anxiety disorder (SAD) symptoms in adults?
Bragge (2010) explains that answerable clinical research questions have four essential
components known as PICO. This therapy type question was developed using these
components (P) Population: adults that experience social anxiety (I) Intervention:
Psychological interventions (C) Comparator: Pharmacological Interventions (O) Outcome:
reduction of social anxiety symptoms.
Search Strategy and Outcome
A systematic literature search was carried out using electronic databases which were
individually accessed via Queens Online, including MEDLINE, Science Direct, PschINFO
and Cochrane (see Appendix 1). Roberts and Dicenso (1999) suggest that questions in
relation to interventions and their effectiveness are best answered by randomized control
trials or based on the hierarchy of evidence, systematic reviews. BestBets.org was also
accessed for evidence based synopses.
The three papers the author deemed relevant to answer the clinical question above are as
follows;
Clark et al. (2003)
Nordahl et al (2016)
Davidson et al. (2004)
3
These three studies were chosen as their methodological design appeared to answer the
clinical questi.
1 Clinical Problem Social Anxiety is described by .docxjeremylockett77
1
Clinical Problem
Social Anxiety is described by The Diagnostic and Statistical Manual of the American
Psychiatric Association (DSM-5) as a persistent fear of social situations where the person is
exposed to people or to possible scrutiny by others and fears that he/she will display
symptoms of anxiety or be perceived in a way that will be embarrassing and humiliating
(American Psychiatric Association, 2013). This topic was chosen as according to Kessler et
al. (2012) social anxiety is among the most common anxiety disorder affecting 13% of
individuals at some stage in their lives. From experience, and according to Krysta et al.
(2015) medication is the first line treatment for anxiety disorders due to accessibility.
Unfortunately, for people experiencing social anxiety most medications have adverse effects
such as increased agitation and sexual dysfunction (Rosen et al 1999) and some medication,
in particular benzodiazepines are highly addictive (Lader and Kyriacou, 2016). Townend et
al. (2008) report that CBT remains the psychological therapy with the widest and broadest
evidence base. Beck et al (1979) define Cognitive Behavioural Therapy (CBT) as a concept
where an individual’s emotions and behaviours are based on the way that they interpret the
world through their cognitions. NICE (2011) (cited in Clark, 2011) recommend psychological
therapies prior to medication for anxiety disorders however due to a lack of therapists in
mental health services this is not the case in clinical practice which led to the rationale for the
following research question.
2
Clinical question
Are psychological interventions more efficacious than pharmacological interventions to help
reduce social anxiety disorder (SAD) symptoms in adults?
Bragge (2010) explains that answerable clinical research questions have four essential
components known as PICO. This therapy type question was developed using these
components (P) Population: adults that experience social anxiety (I) Intervention:
Psychological interventions (C) Comparator: Pharmacological Interventions (O) Outcome:
reduction of social anxiety symptoms.
Search Strategy and Outcome
A systematic literature search was carried out using electronic databases which were
individually accessed via Queens Online, including MEDLINE, Science Direct, PschINFO
and Cochrane (see Appendix 1). Roberts and Dicenso (1999) suggest that questions in
relation to interventions and their effectiveness are best answered by randomized control
trials or based on the hierarchy of evidence, systematic reviews. BestBets.org was also
accessed for evidence based synopses.
The three papers the author deemed relevant to answer the clinical question above are as
follows;
Clark et al. (2003)
Nordahl et al (2016)
Davidson et al. (2004)
3
These three studies were chosen as their methodological design appeared to answer the
clinical questi ...
This document provides a critique of 4 recent meta-analyses published in Health Psychology. It finds problems with transparency and completeness in how the meta-analyses were reported. It also notes a dependence on small, underpowered original trials of generally poor quality. The document questions the clinical validity and utility of conclusions drawn from these meta-analyses due to issues like clinical heterogeneity among studies and lack of consideration of methodological quality. Overall, it aims to encourage more rigorous standards for meta-analyses to avoid inaccurate or exaggerated conclusions.
Specificity of Treatment Effects Cognitive Therapy and Relaxa.docxrafbolet0
Specificity of Treatment Effects: Cognitive Therapy and Relaxation for
Generalized Anxiety and Panic Disorders
Jedidiah Siev and Dianne L. Chambless
University of Pennsylvania
The aim of this study was to address claims that among bona fide treatments no one is more efficacious
than another by comparing the relative efficacy of cognitive therapy (CT) and relaxation therapy (RT) in
the treatment of generalized anxiety disorder (GAD) and panic disorder without agoraphobia (PD). Two
fixed-effects meta-analyses were conducted, for GAD and PD separately, to review the treatment
outcome literature directly comparing CT with RT in the treatment of those disorders. For GAD, CT and
RT were equivalent. For PD, CT, which included interoceptive exposure, outperformed RT on all
panic-related measures, as well as on indices of clinically significant change. There is ample evidence
that both CT and RT qualify as bona fide treatments for GAD and PD, for which they are efficacious and
intended to be so. Therefore, the finding that CT and RT do not differ in the treatment of GAD, but do
for PD, is evidence for the specificity of treatment to disorder, even for 2 treatments within a CBT class,
and 2 disorders within an anxiety class.
Keywords: generalized anxiety disorder, panic disorder, cognitive therapy, relaxation therapy, treatment
specificity
There has been extensive debate and controversy in recent years
regarding the utility of examining active ingredients versus com-
mon factors in psychotherapy. Wampold and colleagues (e.g., Ahn
& Wampold, 2001; Wampold et al., 1997) and Luborsky and
colleagues (e.g., Luborsky et al., 2002) have claimed that all forms
of psychotherapy are equivalent; what matters are the quality of
the therapeutic alliance and other factors common to all treatments
such as the presentation of a treatment rationale. Their assertions
are based on meta-analyses that combine treatments of all types
and disorders of all types, largely for adult patients. Researchers
have challenged their conclusions on the grounds that the fact that
all treatments for all disorders when combined do not differ from
each other does not imply that a particular treatment for a partic-
ular disorder is not superior (Chambless, 2002). Proponents of a
common factors approach to psychotherapy limit their contentions
to bona fide treatments, defined as “those that were delivered by
trained therapists and were based on psychological principles,
were offered to the psychotherapy community as viable treatments
(e.g., through professional books or manuals), or contained spec-
ified components” (Wampold et al., 1997, p. 205). This reasoning,
however, presupposes that a treatment can be, in and of itself, bona
fide, with no clinical referent: for the treatment of what?
Ahn and Wampold (2001) noted that “a familiar criticism of
meta-analysis” is that “aggregating across diverse studies yields
spurious conclusions” (p. 254). Certainly in conducting a meta-
analysis, .
The document summarizes a study that aimed to map the underlying structure of the at-risk mental state (ARMS) by defining dimensions of subclinical psychopathology in ARMS subjects. 316 participants meeting criteria for ARMS were assessed using the CAARMS interview and other measures. Principal component analysis of the CAARMS items yielded five interpretable components ("Depression", "Disorganization", "Bodily-impairment", "Manic", and "Schizo-affective"). The "Depression" component was most strongly related to worse functioning and increased depressive symptoms. The identified components could provide a step towards a dimensional approach to assessing ARMS.
This document provides an overview of bibliometrics and conducting scholarly research. It discusses formulating hypotheses, identifying different types of scholarly articles, and searching techniques like using Boolean operators and subject headings. Specific topics covered include placebos, the placebo effect, turning questions into search statements, and the hierarchy of evidence. Practice exercises are provided on searching bibliographic databases and evaluating sources.
The document provides a commentary critiquing the notion that integrating psychotherapy and pharmacotherapy represents a logical or informed direction. It argues that pushing integration as "best practice" contradicts what is known about the effectiveness of pharmacological interventions and how people change in psychotherapy. The commentary examines three articles on this topic, finding they represent typical presentations of myths in professional literature that justify broad medical practice while diminishing the role of clients in the change process.
Improving Comprehensive Carefor OEF and OIF Vetsby Aslie.docxbradburgess22840
Improving Comprehensive Care
for OEF and OIF Vets
by Aslie Burnett
FILE
T IME SUBMIT T ED 20- MAR- 2015 10:4 4 AM
SUBMISSION ID 51867 4 598
WORD COUNT 64 25
CHARACT ER COUNT 39906
DISSERT AT ION_PROPOSAL.DOC (125.5K)
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Improving Comprehensive Care for OEF and OIF Vets
ORIGINALITY REPORT
PRIMARY SOURCES
vets.arizona.edu
Int ernet Source
www.ejpt.net
Int ernet Source
Karen H. Seal. "VA mental health services
utilization in Iraq and Af ghanistan veterans in
the f irst year of receiving new mental health
diagnoses", Journal of Traumatic Stress, 2010
Publicat ion
www.f as.org
Int ernet Source
Submitted to Maryville University
St udent Paper
store.samhsa.gov
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yellow-f ever.rki.de
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cstsf orum.org
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akf sa.org
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iris.lib.neu.edu
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www.acpmh.ipag.f r
Int ernet Source
onlinelibrary.wiley.com
Int ernet Source
Submitted to University of Western Australia
St udent Paper
Submitted to University of Southern Calif ornia
St udent Paper
scindeks.nb.rs
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cdn.intechopen.com
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Higher Education
St udent Paper
www.rand.org
Int ernet Source
gradworks.umi.com
Int ernet Source
patriotoutreach.org
Int ernet Source
Ticknor, Bobbie and Tillinghast, Sherry. "Virtual
Reality and the Criminal Justice System: New
Possibilities f or Research, Training, and
Rehabilitation", Journal of Virtual Worlds
Research, 2011.
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Michael E. Smith. "Bilateral hippocampal
volume reduction in adults with post-traumatic
stress disorder: A meta-analysis of structural
MRI studies", Hippocampus, 2005
Publicat ion
etd.lib.f su.edu
Int ernet Source
digital.library.adelaide.edu.au
Int ernet Source
cdn.govexec.com
Int ernet Source
Yelena Bogdanova. "Cognitive Sequelae of
Blast-Induced Traumatic Brain Injury: Recovery
and Rehabilitation", Neuropsychology Review,
02/17/2012
Publicat ion
Nanda, U., H. L. B. Gaydos, K. Hathorn, and N.
Watkins. "Art and Posttraumatic Stress: A
Review of the Empirical Literature on the
Therapeutic Implications of Artwork f or War
Veterans With Posttraumatic Stress Disorder",
Environment and Behavior, 201.
This document discusses issues related to evaluating the effectiveness of psychotherapy. It addresses questions around who should be asked to evaluate outcomes, when they should be asked, and how outcomes should be measured. It describes Hans Eysenck's early controversial claim that psychotherapy is ineffective and how subsequent meta-analyses found psychotherapy to be consistently effective. The document also distinguishes between efficacy studies conducted in controlled research settings and effectiveness studies conducted in real-world clinical practice settings. It reviews findings from efficacy studies on transdiagnostic therapies targeting underlying pathology. Finally, it discusses challenges in disseminating evidence-based therapies to practitioners and strategies like practice-oriented research to better bridge the gap between research and practice.
Health Psychology and Depression Research Proposal HW.docxbkbk37
This research proposal examines the self-perceptions and stigma that prevent elderly patients with depression from receiving adequate care. The proposal analyzes 5 peer-reviewed studies from the past 5-7 years on health psychology and depression. The studies show that stigmatizing attitudes towards depression in the elderly are common and act as barriers to treatment. Patients fear discrimination and have misconceptions about depression. General practitioners also often overlook depression or see it as normal in old age. The proposal aims to further understand how these issues impact elderly patients' access to medication, social support and therapy.
Running head VETERANS PTSD CAUSES, TREATMENTS, AND SUPPORT SYSTEM.docxrtodd599
Running head: VETERANS PTSD CAUSES, TREATMENTS, AND SUPPORT SYSTEMS 1
VETERANS PTSD CAUSES, TREATMENTS, AND SUPPORT SYSTEMS 3
Veterans PTSD Causes, Treatments, and Support systems
Yoan Collado
Carlos Albizu University
Veterans PTSD Causes, Treatments, and Support systems
Evaluations on Post Traumatic Stress Disorder (PTSD) among veterans is imperative for a positive health outcome. The evaluations and analysis of the results ensure that barriers to treatment are addressed and have access to the available support systems. Studies carried out have depicted the successes of the treatments and support programs in the health systems to veterans. Modifications on the systems have also been recommended to combat and control PTSD. Alternative approaches such as computerized systems, natural treatment methods, and home-based systems are also essential in providing a holistic approach in PTSD treatments. Treatment methods success ensures that veterans do not fall victim to depression, which can result in chronic diseases. This can be as a result of negative health behaviors and lifestyles. Understanding the consequences of PTSD among veterans will ensure that approaches utilized offer not only treatment methods but also offer support systems for general wellbeing.
The first source focuses on the treatment and success of three-week outpatient program by “evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD.” The study is evidence-based on statistics drawn from the program and modifications for optimal success rates. 191 veterans were the participants in the research comprising of a daily group and individual Cognitive Processing Therapy (Zalta et al., 2018). The data was analyzed from the sample cohorts in accordance with military and demographic characteristics. Measures in the study involved treatment engagement as well as comparison of pre-treatment and post-treatment changes (Zalta et al., 2018). The results showed progress in the evaluation of predictors and patterns in treatment changes. Procedures utilized involved group sessions with daily activities for the development of the treatment program. Self-report metrics were also applied in the procedures as control groups were challenging in the study. Modified and intensive outpatient (IOP) treatment to veterans showed high success levels in the program (Zalta et al., 2018).
The second source examines a new treatment in exploring the feasibility of computerized, placebo-controlled, and home-based executive function training (EFT) on psychological and neuropsychological functions. The source titled “Computer-based executive function training for combat veterans with PTSD” shows trials in assessing feasibility and predictors output. The study shows how the functions can be useful in brain activation combating PTSD in veterans. Symptoms experienced after treatment on PTSD cases are stimulated through neural and c.
1. Interpersonal Psychotherapy (IPT) is based on attachment theory and posits that psychological distress arises from an interaction between acute interpersonal stressors, biological and psychological vulnerabilities, and social context.
2. IPT targets interpersonal relationships and social support as the primary mechanisms of change, with the goal of improving communication and social networks. While IPT acknowledges biological factors, it does not directly target them.
3. Over time, IPT has become more rigidly defined in research settings, focusing on symptom change for specific diagnoses. This has limited creativity and innovation in the approach based on clinical experience. A new model is needed that better integrates clinical practice and research.
Similar to Expanding the Lens of EBP: A Common Factors in Agreement (20)
Deterioration in Psychotherapy: A Summary of Research by Jorgen FlorScott Miller
This study explored how 10 Norwegian psychologists think about patient deterioration in psychotherapy. The psychologists showed a lack of common terminology around deterioration and underestimated its occurrence. They received little education on deterioration and felt uncomfortable discussing it. The study highlights the lack of awareness around negative outcomes in education and practice. It aims to provide a better basis for quantitative research on how deterioration is interpreted.
Summary of current research on routine outcome measurement, feedback, the validity, reliability, and effectiveness of the ORS and SRS (or PCOMS Outcome Management System)
Qualitative study of therapists working at Stangehjelp in Norway who are applying the principles of deliberate practice in their efforts to deliver more effective treatment services.
Final Rational Empirical Model for Identifying and Addressing Alliance RupturesScott Miller
The document presents the final version of a Rational-Empirical Model from 2015. This model appears to combine rational and empirical elements in analyzing a topic. Unfortunately, without more context around the specific model and its purpose, the summary is limited to these high-level details about its nature and date.
Effect size of common versus specific factorsScott Miller
Graphic representation of the contribution made by common versus specific factors to the outcome of psychotherapy. The slide documents the negligible contribution of the method, competence, and adherence.
Description of research in Sweden on a program to help people leave the disability rolls and go back to work. Several years ago, leaders adopted CBT as the primary treatment model. All practitioners were trained and over a billion Swedish Crowns were spent. The result? No effect. In fact, the percentage of people disabled by depression increased.
Medipex innovation awards 2015 press releaseScott Miller
The document summarizes the winners of the eleventh annual Medipex NHS Innovation Awards and Showcase. Seven teams were awarded across five categories for their innovative projects that improve patient care and make NHS services more efficient. The winners included mobile apps to improve doctor training feedback and patient communication, and initiatives to deliver intravenous treatments and orthotics at home. The awards recognize pioneering ideas developed collaboratively between NHS staff, universities, charities, and businesses.
The Carlat Psychiatry Report (Interview with Scott Miller, April 2015)Scott Miller
The April 2015 issue of the Carlat Psychiatry Report, an unbiased report/review of "all things psychiatric." The issue contains a lengthy interview with Dr. Scott Miller on the subject of top performing clinicians.
Why most therapists are average (german, 2014)Scott Miller
Interview with Scott Miller, reviewing outcome research from the field of therapy and addressing the question of why most therapists don't improve with time and experience.
How to Improve Quality of Services by Integrating Common Factors into Treatme...Scott Miller
Presentation by Dr. Bruce Wampold about how the outcome and quality of psychotherapy can be improved by adding common factors to the treatment. Wampold documents the lack of difference in outcome between competing treatment methods AND the relatively large contribution made by common factors to outcome.
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Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Mercurius is named after the roman god mercurius, the god of trade and science. The planet mercurius is named after the same god. Mercurius is sometimes called hydrargyrum, means ‘watery silver’. Its shine and colour are very similar to silver, but mercury is a fluid at room temperatures. The name quick silver is a translation of hydrargyrum, where the word quick describes its tendency to scatter away in all directions.
The droplets have a tendency to conglomerate to one big mass, but on being shaken they fall apart into countless little droplets again. It is used to ignite explosives, like mercury fulminate, the explosive character is one of its general themes.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
2. APA NLM
tapraid5/pst-pst/pst-pst/pst00413/pst2534d13z xppws Sϭ1 9/12/13 22:55 Art: 2013-0748
2
LASKA, GURMAN, AND WAMPOLD
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
It is important to note the marginal scientific status of those constructs
(p. 82, emphasis added).
As discussed by philosophers of science, notably Kuhn (1962),
restricting the lens through which a phenomenon is examined (in
this case, psychotherapy) restricts what can be observed and the
manner in which “evidence” is interpreted. In other words, a
restricted scientific aperture means less of the evidentiary picture
is in focus.
The result is that the application of EBP toward the reduction of
mental illness is limited. The primary strategy for quality improvement in mental health today is to implement ESTs in clinical
practice (McHugh & Barlow, 2012). A straightforward and persuasive case has been made that ESTs that have been shown to be
efficacious in clinical trials should be disseminated widely and
used (Baker et al., 2008). We agree that disseminating ESTs into
practice settings should be one arm of a multifaceted “portfolio”
approach (Kazdin & Blasé, 2011) toward reducing the burden of
mental illness. We are not arguing that the field should discard the
use of ESTs. Yet, substantial evidence from other perspectives of
EBP, including the common factors (CF) approach, are frequently
marginalized as “unscientific,” or are given such low evidentiary
prioritization that important data are overlooked. The result is that
our ability to maximize practice outcomes has been limited.
Our purpose here is to expand the scientific understanding of the
received EST view and broaden the lens through which observations about psychotherapy are interpreted. According to the APA’s
Presidential Task Force on Evidence-Based Practice (2006):
asserts that (a) most therapists achieve commendable and desirable
outcomes, (b) improvement will flow from managing outcomes,
(c) any variable shown to influence outcome is scientifically
important, and therefore (d) data-gathering efforts should focus on
changing any therapist behaviors that influence outcome. We
begin with a brief review of the core predictions of both the EST
and CF approaches. Next, we review the evidence in context,
paying particular attention to some overlooked aspects of the EST
approach. Finally, we address how both programs approach quality
improvement and argue that the two perspectives should be integrated.
The EST Approach
The EST approach proposes that psychotherapeutic treatments
contain specific techniques that are purported to remediate identifiable deficits that form the diathesis of a given mental disorder
(Barlow, 2004; Chambless & Hollon, 1998; Chambless et al.,
1996). As described by Barlow (2004), ESTs also contain a variety
of components common to all psychotherapies, such as “the therapeutic alliance, the induction of positive expectancy of change,
and remoralization,” but contain important “specific psychological
procedures targeted at the psychopathology at hand” (p. 873).
Similarly, Baker et al. (2008), in their comments on clinical
science, constrained the scientific focus to these specific ingredients:
ESTs start with a treatment and ask whether it works for a certain
disorder or problem under specified circumstances. EBPP starts with
the patient and asks what research evidence (including relevant results
from RCTs) will assist the psychologist in achieving the best outcome
(p. 273).
Scientific plausibility refers to the extent to which an intervention
makes sense on substantive bases and whether there is formal evidence regarding its mechanisms . . . . However, the absence of a
demonstrated or plausible specific mechanism of action, especially for
a psychosocial intervention, leaves open the possibility that the intervention may merely be capitalizing on nonspecific credible ritual, or
placebo effects (emphasis added, p. 72).
Notably, the Task Force criteria highlight the importance of
clinical expertise and patient characteristics as central factors in
EBP, similarly to the definition of evidence-based medicine (Institute of Medicine, 2001), and “builds on the Institute of Medicine
definition by deepening the examination of clinical expertise and
broadening the consideration of patient characteristics” (p. 273).
The Task Force criteria acknowledge these factors exist within
“the limits of one’s knowledge and skills and attention to the
heuristics and biases— both cognitive and affective—that can affect clinical judgment” (p. 284). Yet, some have characterized the
Task Force’s inclusion of therapist and patient variables as “a
striking embrace of a prescientific perspective” (Baker et al., 2008,
p. 84). Although it may be “prescientific” for clinicians to uniformly disregard research evidence of any kind (as some small
minority do), it is decidedly and unequivocally not “prescientific”
for clinicians to approach the results of RCTs as only one of
several components of research evidence. We argue that this
rhetoric that explicitly devalues the role of other variables, including therapist variables and client preference, and that in practice
effectively renders other types of evidence (e.g., process-outcome,
qualitative, meta-analytic) as tertiary in quality improvement efforts, is not consistent with APA’s definition of EBP, and limits
the impact of EBP in clinical settings.
We believe the CF perspective is entirely consistent with the
APA’s outcome-focused approach toward EBP. The CF approach
Each EST posits a specific mechanism of change based on a
given scientific theory. For example, prolonged exposure (PE) for
PTSD (Foa, Hembree, & Rothbaum, 2007) is conceptually derived
from emotional processing theory (Foa & Kozak, 1986), and the
specific ingredients of PE (viz., imaginal and in vivo exposure) (a)
activate the “fear network,” (b) whereby clients habituate to their
fears, and thus, (c) extinguish the fear response. On the other hand,
interpersonal therapy (IPT) for PTSD (Markowitz, Milrod,
Bleiberg, & Marshall, 2009) is derived from interpersonal and
attachment theory (Bowlby, 1973; Sullivan, 1953) and “focuses on
current social and interpersonal functioning rather than exposure”
(Bleiberg & Markowitz, 2005, p. 181). Alternatively, when comparing Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012) and Cognitive Behavioral Therapy (CBT;
Beck, Rush, Shaw, & Emery, 1979), two common ESTs for
depression, experts in these treatments described these therapies as
“distinct models” (Hayes, Levin, Plumb, Villatte, & Pistorello,
2011, p. 16) that “show substantial differences in their philosophical foundations” (Hofmann & Asmundson, 2008, p. 12). Different
ESTs are based on different theories of change, and purport different mechanisms of action.
More recently, researchers have identified common symptoms
within a class of disorders (e.g., mood and anxiety), and have
begun to develop various “unified treatment protocols” (Moses &
Barlow, 2006). We believe transdiagnostic treatments are a posi-
AQ: 2
3. APA NLM
tapraid5/pst-pst/pst-pst/pst00413/pst2534d13z xppws Sϭ1 9/12/13 22:55 Art: 2013-0748
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
SCIENCE OF COMMON FACTORS
AQ: 3
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tive development, and in fact, overlap with various aspects of the
CF approach. Yet, the specifications of methodologies—that is,
rules that dictate how science is conducted—remain within the
EST paradigm, for example, RCTs of treatment packages based on
identifying specific ingredients are given top evidentiary prioritization.
There are two core EST predictions: (a) treatment specificity
and (b) disorder specificity. In terms of treatment specificity,
because two treatments target different mechanisms of change, the
conjecture is that one treatment will be more efficacious than the
other. That is, under the correct conditions, there will be sufficient
evidence to reject the null hypothesis of no differences. Alternatively, some researchers may conduct equivalence trials to show
that a new treatment is as effective as a standard treatment (e.g.,
Arch et al., 2012; Resick, Nishith, Weaver, Astin, & Feuer, 2002).
Regarding disorder specificity, the conjecture is that one treatment
will be more effective than another for treating a particular symptom of a disorder, e.g., “In this case, a treatment T1 may be more
efficacious than T2 for treating symptoms S1 but not for treating
symptoms S2.” (Hofmann & Lohr, 2010, p. 14).
The CF Approach
The CF approach (Frank & Frank, 1993; Wampold, 2001)
conceptualizes psychotherapy as a socially constructed and mediated healing practice. The CF model focuses on factors that are
necessary and sufficient for change: (a) an emotionally charged
bond between the therapist and patient, (b) a confiding healing
setting in which therapy takes place, (c) a therapist who provides
a psychologically derived and culturally embedded explanation for
emotional distress, (d) an explanation that is adaptive (i.e., provides viable and believable options for overcoming specific difficulties) and is accepted by the patient, and (e) a set of procedures
or rituals engaged by the patient and therapist that leads the patient
to enact something that is positive, helpful, or adaptive. Whereas
EST places primacy on different theories of change, a CF approach
states that the adoption of a credible theory is only one aspect of
many necessary common factors that contribute to behavior
change.
There are a few core predictions of the CF approach. The first
is that any therapy that contains all of the ingredients of the CF
approach (as outlined above) will be efficacious for the presenting
problem being treated. As Lambert recently noted, “. . . studies
comparing two bona fide therapeutic approaches that find significantly different outcomes may be more unusual than not” (2013a,
p. 196). A second prediction is that relationship factors such as
empathy, goal consensus and collaboration, the therapeutic alliance, and positive regard, should predict the outcome of psychotherapy. A corollary of this second prediction is that there will be
differences among therapists, that is, more effective therapists will
more skillfully provide these factors. A third prediction is that
treatments intended to be therapeutic will be superior to “supportive control” or psychological placebo conditions.
CF Myths
We wish to briefly identify five common misunderstandings of
the CF approach. First, it is important to note that the CF perspective does not suggest that a mere “relationship” with a therapist is
3
sufficient, as some have (mis)interpreted. As noted above, the
therapeutic alliance should predict outcome, but the alliance is
only one factor of several that are necessary from a CF perspective.
Second, “supportive counseling” is not synonymous with CF.
Typically, these treatments, elsewhere referred to as “intent-tofail” treatments (Westen, Novotny, & Thompson-Brenner, 2004),
are used to control for the common factors in RCTs. Many “supportive counseling” treatments contain no psychologically derived
rationale or proscribe therapists from actions that most therapists
would normally use, particularly when the therapists in these
conditions know that the treatment is a sham (Budge, Baardseth,
Wampold, & Fluckiger, 2010). For example, in a trial comparing
CBT and supportive psychotherapy for PTSD related to motor
vehicle accidents (Blanchard et al., 2003), therapists delivering
supportive therapy provided “little advice” and “care was taken not
to encourage any driving. If the participant asked directly about a
specific travel behavior, he or she was told to listen to his or her
body and be guided by how he or she felt” (p. 86). Third, the term
“bona fide,” as theoretically derived from CF theory and operationalized by Wampold et al. (1997), has been largely (mis)understood and incorrectly applied. For example, Hofmann and Smits
(2008), included supportive counseling, relaxation treatments, and
anxiety management as bona fide therapies in their meta-analysis
of adult anxiety disorders, although these treatments were not bona
fide treatments (i.e., did not meet the operationalized criteria
outlined in Wampold et al., 1997). Similarly, Ehlers et al., (2010),
critiqued the results of Benish, Imel, and Wampold (2007) based
on incorrect assumptions of bona fide therapies (see Wampold et
al., 2010 for response to Ehlers). Fourth, a “common factors
treatment” that some have argued is necessary for a valid test of
specific versus common factors (Barlow, 2010; Foa, 2013) overlooks the important point that the CF approach states that any
therapy with all CF ingredients will be efficacious. Lastly, under
the CF approach, therapists cannot simply do whatever they want,
however they want, and for as long as they want. The CF approach
is focused on improving practice outcomes and therapist competence. Achieving this aim requires a variety of evidence-based
techniques, which we address later in this article, that encourage
therapists to adjust their practices in specific ways and not practice
without purpose.
Evidence
The evidence related to ESTs has been summarized elsewhere
(Baker et al., 2008; Barlow, 2008; Foa, 2013; Lilienfield et al.,
2013), as has the evidence related to the CF approach (Imel &
Wampold, 2008; Wampold, 2001, 2007). In this section, we focus
on several aspects of the EST perspective that we believe have
been overlooked, as well as evidence for the CF approach that is
often criticized by proponents of ESTs.
The Post Hoc Issue
We claim that ESTs researchers resort to inconsistently applied
post hoc explanations when observations are not consistent with
core EST predictions. The result is not falsification of ESTs, but a
reduction in the explanatory power of treatment specificity. We
review several examples below, focusing on the issue of treatment
adherence.
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4
LASKA, GURMAN, AND WAMPOLD
In a large sample of therapists in the National Health Service in
England, Stiles and colleagues (Stiles, Barkham, Mellor-Clark, &
Connell, 2008; Stiles, Barkham, Twigg, Mellor-Clark, & Cooper,
2006) found no differences in outcomes among therapists who
indicated they were practicing cognitive– behavioral, personcentered, and psychodynamic therapies. However, Clark, Fairburn,
and Wessely (2007) criticized the studies on the basis that the
therapists who indicated that they were practicing CBT were not
actually doing so, at least to the degree necessary to reveal that this
treatment was superior. In a 1999 study, Tarrier et al. (1999)
compared imaginal exposure (IE) with cognitive therapy (CT) and
concluded, “A significantly greater number of patients receiving
IE worsened over treatment” (p. 17) compared with CT. However,
Devilly and Foa (2001) claimed that Tarrier et al. delivered IE
inappropriately, “Did the therapist note ‘hot spots’ where appropriate and habituate the participants to these?” (p. 115). One does
not have to venture far into the literature to find other examples
where a result is impugned post hoc regarding issues of adherence.
This is what might be called the adherence hypothesis: differences
will be detected provided the treatment is delivered in the specified
manner (Perepletchikova, Treat, & Kazdin, 2007). Indeed, this
conjecture is of such importance that Suris, Link-Malcolm, Chard,
Ahn, and North (2013) found that one therapist failed to adhere to
the treatment protocol and eliminated the data for that therapist
from the trial. This issue is problematic for a number of reasons.
First, it is often used post hoc to explain the lack of treatment
differences, but also to protect particular treatments from being
identified as inferior, which then renders the EST prediction as less
heuristically powerful. Concordantly, meta-analytic findings suggest that adherence in delivering a treatment is not related to
outcome (Webb, DeRubeis, & Barber, 2010), although the
adherence-outcome correlation needs further scrutiny (Leichsenring et al., 2011).
In an example of null findings, Ehlers et al. (2010) attributed the
lack of differences between CBT and present-centered therapy
(PCT) found by McDonagh et al. (2005) and Schnurr et al. (2003)
to the fact that the patients in these trials belonged to “difficult to
treat multiple trauma populations” (p. 271), an explanation that
was not mentioned by the authors of the primary studies and more
importantly was not stated a priori. Even when rated adherence to
both treatments is sufficient, as it was in a comparison of behavioral marital therapy (BMT) and insight-oriented marital therapy
(IOMT) that found that IOMT had significantly fewer divorces
after therapy (Snyder, Wills, & Grady-Fletcher, 1991), an advocate
for the inferior treatment (BMT) invoked a post hoc explanation.
Jacobson (1991) claimed that therapists in the BMT condition did
not sufficiently provide empathy and emotional nurturance and did
not adequately foster hope, actions that were not specific to the
treatment; that is, there was purportedly an inequivalence of
the CF. Interestingly, the most rigorous RCT ever conducted (viz.,
the National Institute of Mental Health Treatment of Depression
Collaborative Research Program) in its time could not inoculate
the results against claims that a treatment was at a disadvantage for
some reason (Elkin, Gibbons, Shea, & Shaw, 1996; Jacobson &
Hollon, 1996).
Discussion of these factors should not be taken as criticism ipso
facto, as every scientific investigation has some flaws (Cook &
Campbell, 1979). All observations naturally come with baggage
owing to particular experimental arrangements (Serlin & Lapsley,
1985). Nevertheless, a theory must be able to generate a conjecture
that results in certain observations under specified conditions.
Therefore, it can be argued that invoking explanations post hoc by
a treatment advocate to protect a treatment from being found
inferior is simply “partisan politics” and should not be taken
seriously as science. However, science is a community project and
if such explanations are invoked in scientific journals they become
part of the scientific discourse, particularly when it is EST scientists who are invoking such explanations.
We believe CF explains these issues, and in this regard has equal
(or possibly greater) heuristic power. The CF approach posits that
specific ingredients are not necessary, and therefore post hoc
explanations are not needed because null results have been predicted. When treatment differences are found, post hoc explanations are also not needed because CF predicts that over the corpus
of results, some treatment differences will be found by chance.
Is One Treatment More Effective Than
Another Across All Disorders?
According to the APA Resolution on Psychotherapy Effectiveness, “comparisons of different forms of psychotherapy most often
result in relatively nonsignificant difference, and contextual and
relationship factors often mediate or moderate outcomes.” We
concur with APA’s interpretation of the evidence (however, see
Hunsley & Diguilio, 2002; Siev, Huppert, & Chambless, 2009 for
counterargument). As noted above, EST predicts that some treatments will be more effective than other treatments, which is the
logical opposite of CF, which states that all bona fide treatments
are equally efficacious. The null hypothesis of the EST prediction
is exactly the null tested in meta-analyses of direct comparisons of
treatments (see Wampold et al., 1997; Wampold & Serlin, in
press), thus providing a direct test of a crucial aspect of these
conjectures. Wampold et al. (1997) conducted such a metaanalysis of nearly 300 direct comparisons of treatments intended to
be therapeutic and found insufficient evidence to reject the null
hypothesis. Although there were comparisons within this data set
that resulted in rejection of the null (i.e., produced statistically
significant differences), the number was about equal to what would
be expected by chance owing to sampling error. Indeed, the
observed aggregate effect was less than what would be expected
under the null, suggesting not a hint of an effect (Wampold &
Serlin, in press). This meta-analysis had more than adequate power
to detect relatively small differences among a small proportion of
comparisons (Wampold & Serlin, in press) and therefore provides
evidence that would seem to be in line with the predictions of the
CF perspective.
It was claimed that many of the comparisons in the Wampold et
al. (1997) meta-analysis were among variations of CBT treatments
and therefore not likely to yield differences (Crits-Christoph,
1997), an observation that generates many responses. First, typically researchers who posed the comparisons were attempting to
find differences that would demonstrate the importance of specified mechanisms of change. Therefore, under the EST prediction,
differences would be expected. Second, Wampold et al. (1997)
found that the similarity of the treatments being compared was not
related to the size of the effect (e.g., comparisons of treatments that
were different did not produce larger effects than did comparisons
of treatments that were similar). Third, regardless of the nature of
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SCIENCE OF COMMON FACTORS
the comparisons, there is insufficient evidence to reject the null
hypothesis of no differences, a result that albeit tentative, must be
retained at this point in time. Fourth, several meta-analyses that
have compared active treatments contain a wide variety of types of
treatments and many treatments other than CBT and have found no
differences (Benish et al., 2007; Cuijpers, van Straten, Andersson,
& van Oppen, 2008; Cuijpers et al., 2012; Imel, Wampold, Miller,
& Fleming, 2008; Powers, Halpern, Ferenschak, Gillihan, & Foa,
2010). As well, several meta-analyses have directly compared
CBT with other types of treatment and found no differences
(Baardseth et al., 2013; Leichsenring & Leibing, 2003; Shedler,
2010; Wampold, Minami, Baskin, & Tierney, 2002). One metaanalysis (Tolin, 2010) did find that CBT was superior to other
treatments for depression and anxiety. This meta-analysis is discussed below.
From a CF point of view, which posits that there will be no
differences between treatments, Tolin appears to provide a refutation. But if dozens of meta-analyses finding no differences have
not refuted treatment specificity (as some have argued), then one
finding of such differences cannot refute the CF perspective.
There is more to be learned from the Tolin meta-analysis. The
effect size for depression for the superiority of CBT was small
(viz., 0.21) and only for symptom-specific measures (see Baardseth et al., 2013). Tolin’s effect for depression contradicts several
other meta-analyses that contained many more studies (Cuijpers et
al., 2008, 2012; Wampold et al., 2002), and the effect was not
present for outcomes other than the symptom-specific measures
(Baardseth et al., 2013). The effect for the superiority of CBT for
anxiety was moderate (viz., 0.43), but was based on only four
studies, two of which were published before 1972. What is curious
here was that it appears that Tolin defined CBT broadly to contain
many treatments that many would argue are not CBT and are not
scientific (e.g., eye-movement desensitization and reprocessing,
EMDR; see Herbert et al., 2000; McNally, 1999), suggesting an
ambiguity with regard to CBT as well as other treatments. Consequently, Baardseth et al. (2013) used an empirical definition of
CBT that relied on a consensus of experts from the Association for
Behavioral and Cognitive Therapies (ABCT) to determine what is
and is not CBT for anxiety disorders, and located 13 studies that
directly compared CBT with other treatments (vis-a-vis 4 for
`
Tolin), and found no differences between CBT and non-CBT
treatments for anxiety.
Is One Treatment More Effective Than Another for a
Particular Disorder?
Again we believe the evidence suggests “no.” A criticism of the
CF approach has been that it makes little sense to examine comparisons across disorders (e.g., DeRubeis, Brotman, & Gibbons,
2005). Ignoring disorder “is akin to asking whether insulin or an
antibiotic is better, without knowing the condition for which these
treatments are to be given . . . Alternatively, researchers should
begin with a problem and ask how treatments compare in their
effectiveness for that problem” (p. 175). When treatments are
directly compared, most have found no differences, including for
depression (Cuijpers et al., 2008, 2012), alcohol use disorders
(Imel et al., 2008), PTSD (Benish et al., 2007; Powers et al., 2010),
anxiety disorders in general (Baardseth et al., 2013), eating disorders (Spielmans et al., in press), and childhood disorders (Miller,
5
Wampold, & Varhely, 2008; Spielmans, Pasek, & McFall, 2007).
There are notably few meta-analyses of direct comparisons that
have rejected the null. We have already reviewed Tolin. Another
showed that CBT was superior to relaxation therapy for panic
disorder (although the effect was due to one study—see Wampold,
Imel, & Miller, 2009).
By way of contrast, for the treatment of a small subset of
disorders, the CF model may have less explanatory power. For
example, in the case of specific phobia and panic disorder, and
possibly social phobia, evidence suggests improvement cannot
occur without exposure to the fearful stimulus taking place.
Whether exposure is accomplished in vivo, imaginally, via virtual
reality procedures or other methods (Antony & Roemer, 2011),
and whether exposure occurs intentionally within structured
manual-guided treatment sessions provided by a behavior therapist
or less systematically by, for example, risk-taking in everyday life,
exposure appears to be essential for these disorders (although
apparently not for other anxiety disorders, see Baardseth et al.,
2013; Frost, Laska, & Wampold, in press). It is clear experiential
avoidance in some form must be addressed in therapy for some
anxiety disorders (Barlow et al., 2011; Hayes et al., 2012), as even
Jerome Frank, the originator of the CF perspective, agreed (Frank
& Frank, 1993). But we would argue that an inclusive EBP
approach would dictate that such decisions as with whom, at what
stage of change, and how systematically therapeutic exposure
might most helpfully take place, be left up to discussions between
therapist and client.
How Important Is the Alliance as a
Predictor of Outcome?
According to Baker et al. (2008), “In theory, some aspects of
nonspecific effects are malleable or teachable: for example, behaviors that contribute to the therapeutic alliance (the therapist–
patient relationship). Even these hold little promise that they
represent special opportunities for clinical psychology, however”
(emphasis added, p. 82). Most psychologists, including proponents
of ESTs, acknowledge the importance of the alliance. Yet, as
exemplified by Baker et al., may disagree on the relative importance of the alliance as a mediating variable. Here, we review the
evidence pertaining to the alliance– outcome relationship in hopes
to demonstrate the importance of this variable in improving EBP.
The therapeutic alliance is composed of three components: (a)
bond between therapist and patient, (b) agreement about the goals
of therapy, and (c) agreement about the tasks of therapy (Bordin,
1979) and is a central component of the CF program (Wampold,
2001; Wampold & Budge, 2012). The most recent meta-analysis,
based on hundreds of studies, reveals a robust and moderate
correlation (between .25 and .30) between the alliance and outcome (Horvath, Del Re, Flückiger, & Symonds, 2011), although
this may be an underestimate owing to measurement issues (CritsChristoph, Gibbons, Hamilton, Ring-Kurtz, & Gallop, 2011). This
evidence has been criticized, however, on the basis that it is
correlational, and thus, the alliance may not be causal to outcomes,
as (a) it may be the patient’s contributions to the alliance that are
important (i.e., patients with better prognoses are able to form
better alliances and have better outcomes), (b) early symptom
change creates the alliance, and (c) the alliance may help patients
feel better (i.e., general well-being) but will not affect symptom-
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6
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atology (Baker et al., 2008; DeRubeis et al., 2005; Siev et al.,
2009). Several studies from a CF approach have been conducted to
investigate these hypotheses. Baldwin, Wampold, and Imel (2007)
used multilevel models to disentangle therapist and patient contributions to the alliance and found that it was the therapists’ contributions to the alliance that predicted outcome rather than the
patients’ contribution. That is, therapists who were able to form
better alliances generally with their patients had better outcomes;
however, patients who were able to form a better alliance with a
given therapist did not have better outcomes than patients with
poorer alliances with the same therapist, a result that has been
replicated in primary studies (Dinger, Strack, Leichsenring,
Wilmers, & Schauenburg, 2008; Zuroff, Kelly, Leybman, Blatt, &
Wampold, 2010) and meta-analytically (Del Re, Flückiger, Horvath, Symonds, & Wampold, 2012). Moreover, there is accumulating evidence that the alliance is predictive of patient change
after controlling for early symptom change (e.g., Baldwin et al.,
2007; Crits-Christoph et al., 2009; Crits-Christoph et al., 2011;
Falkenström, Granström, & Holmqvist, 2013; Webb et al., 2011).
Finally, the alliance is not weaker in ESTs, in disorder-specific
manualized treatments, for symptoms measures, for cognitive or
behavioral treatments, or in RCTs (vs. naturalistic studies) (Fluckiger, Del Re, Wampold, Symonds, & Horvath, 2012). Nor is it
weaker in family therapy, with one hallmark study (Alexander,
Barton, Schiavo, & Parsons, 1976) of the behavioral treatment of
delinquent adolescents finding that therapists’ relationship skills
accounted for 59% of the outcome variance. That is to say, it
appears that the alliance is an important factor in psychotherapy
outcomes. Therefore, an inclusive EBP approach would not disregard a body of evidence simply because one believes it has “little
promise” for clinical psychology.
How Important Is the Individual Therapist as a
Predictor of Outcome?
According to the most recent review of the therapist effects
literature (Baldwin & Imel, 2013), approximately 5% of outcome
variance is attributable to therapists. Given that the treatment
method accounts for roughly 1% of total outcome variance
(Wampold, 2001; see Table 1 for list of effect sizes for different
psychotherapeutic variables), therapist differences certainly hold
their own as variables of scientific importance and for the improvement of the quality of care.
One of the conjectures of the CF approach is that therapists are
important to the success of the treatment (a conjecture with which
many proponents of ESTs also agree) and trials that do not examine therapist effects are consequently biased in that they overestimate treatment effects (Wampold & Serlin, 2000). Moreover,
using therapists who have an allegiance to other treatments also
biases the outcomes. The CF approach predicts that there will be
variation among therapists in terms of their outcomes, as some
therapists are more skilled, even if they are delivering the same
treatment with adequate adherence. Therapist effects have been
observed in both clinical trials and naturalistic settings for individual therapy (see Baldwin & Imel, 2013, for a review), and
family/couple therapy (Alexander et al., 1976; Blow, Sprenkle, &
Davis, 2007), although these results have been challenged (CritsChristoph et al., 1991; Elkin, Falconnier, Martinovich, & Mahoney, 2006; Siev et al., 2009). The primary criticism is that the
variability among therapists is owing to variability in the manner
in which the treatment is delivered: If therapists give the treatment
as designed (with adequate adherence and competence), then therapist effects would disappear (Shafran et al., 2009). This appears
to be an adherence issue, and yet adherence (as well as rated
competence) appears to not be related to outcome (Webb et al.,
2010; but see Leichsenring et al., 2011). Importantly, we have
begun to identify the actions of more effective therapists and they
appear to be related to aspects of the CF approach. More effective
therapists, as mentioned above, generally form better alliances
with their patients (Baldwin et al., 2007) and have better facilitative interpersonal skills (Anderson, Ogles, Patterson, Lambert, &
Vermeersch, 2009), and provide an emotionally activating relationship (Laska, Smith, Wislocki, Minami, & Wampold, 2013), as
predicted by the CF perspective.
Table 1
Effect Sizes for Common Factors and Specific Ingredients
Factor
Number of Number of Effect size % of variability
studies
patients Cohen’s d in outcomes
Common factors
Alliancea
Empathya
Goal consensus/collaborationa
Positive regard/affirmationa
Congruence/genuinenessa
Therapistsb
190
59
15
18
16
46
2,630
3,599
1,302
1,067
863
14,519
.57
.63
.72
.56
.49
.46
7.5
9.0
11.5
7.3
5.7
5.0
Specific ingredients
Differences between treatmentsc
Specific ingredients (dismantling)d
Adherence to protocole
Rated competence in delivering particular treatmente
295
30
28
18
Ͼ5,900
871
1,334
633
Ͻ.20
.01
.04
.14
Ͻ1.0
0.0
Ͻ0.1
0.5
a
Norcross and Lambert (2011). b Baldwin and Imel, 2013. c Wampold et al. (1997); confirmed by various
other meta-analyses for specific disorders. d Bell et al., in press (targeted variables); see also Ahn and
Wampold (2001). e Webb, DeRubeis, and Barber (2010).
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SCIENCE OF COMMON FACTORS
Are All Components of an EST Necessary?
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AQ: 9
The EST prediction is that all the ingredients of a treatment are
necessary, as they target specific mechanisms of change, whereas
the CF program states the opposite. We examine this conjecture by
focusing on treatments for depression and PTSD.
According to the cognitive model, “changes in cognitions causally predict changes in psychopathology” (Hofmann, 2013), although it appears that this treatment may not be effective because
of the cognitive components, as demonstrated by a dismantling
study (Jacobson et al., 1996) and replicated by Dimidjian et al.
(2006) (however, see Hofmann, 2008 for counterargument). The
purpose of the Jacobson study was to “provide an experimental test
of the theory of change put forth by Beck et al. (1979) to explain
the efficacy of cognitive– behavioral therapy (CT) for depression”
(p. 295), and it was hypothesized that “according to the cognitive
theory of depression, CT should work significantly better than AT
[modifying automatic thoughts ϩ behavioral activation], which in
turn, should work significantly better than BA [behavioral activation] only” (p. 296). Contrary to expectations, the outcomes of the
BA condition were comparable with CT at termination and followup, and the authors concluded.
These findings run contrary to hypotheses generated by the cognitive
model of depression put forth by Beck and his associates (1979), who
proposed that direct efforts aimed at modifying negative schema are
necessary to maximize treatment outcome and prevent relapse (p.
296).
Concordantly, as noted by Dimidjian et al., “This growing body of
research raises questions about the necessity of directly targeting
negative thinking to achieve treatment response” (p. 667).
Regarding PTSD, a number of treatments have been found to be
efficacious and have been classified as ESTs, including PE and
cognitive processing therapy (CPT; Resick & Schnicke, 1992).
However, EMDR has also been shown to be as effective as PE and
CBT (Seidler & Wagner, 2006), a finding that is somewhat problematic because EMDR has been described as “pseudoscience”
and has been compared with Mesmerism (McNally, 1999). To
accommodate EMDR as an EST, a distinction between treatments
that were “trauma-focused” and those that were not was invoked to
maintain a hierarchy among treatments (Ehlers et al., 2010). Yet,
trauma-focused treatments have not been found to be more efficacious than nontrauma-focused treatments that were intended to
be therapeutic (Wampold et al., 2010). PCT, a treatment developed
as a control for PE and CBT that contains no exposure and no
cognitive components, and is not trauma-focused, became as effective as other ESTs for PTSD when it was provided by therapists
who were trained to deliver it faithfully (Classen et al., 2011;
McDonagh et al., 2005; Schnurr et al., 2007), and is now classified
by the Society of Clinical Psychology as a research-supported
treatment with “strong research support” (Hajcak & Starr, n.d.;
Frost, Laska, & Wampold, in press). Moreover, dismantling studies of ESTs for PTSD reveal that when the purported ingredients
of the treatment are removed, the treatment remains efficacious
(Bryant et al., 2008; Resick et al., 2008).
Furthermore, two meta-analyses of dismantling studies have
showed that removing critical specific ingredients did not attenuate
the effects of the treatment. Ahn & Wampold (2001) included 27
studies and found no difference when components were removed
7
or added. More recently, Bell, Marcus, & Goodlad (in press)
conducted a meta-analysis of 66 different dismantling studies and
replicated the results of Ahn and Wampold. Although tentative at
this time, there is insufficient evidence to reject the null hypothesis
of no differences.
Conclusions
We claim there is no construction of science that at this time
should privilege the EST perspective over the CF approach. Decisions about whether to abandon a research program are made by
the scientific community and clearly clinical psychology has not
abandoned the EST perspective; indeed, it is the received view at
the present time. However, “the problem fever of science is raised
by the proliferation of rival theories rather than by counterexamples or anomalies” (Lakatos, 1970, p. 121) and consequently the
validity of the EST approach requires that it be examined vis-a-vis
`
rival theories, the most prominent of which is CF. We believe both
perspectives, which are not mutually exclusive, provide useful
heuristics for testing the mechanisms of change in psychotherapy,
and both are needed if we are to make impact on reducing the
burden of mental illness for consumers of psychotherapy, a topic
to which we now turn.
Implications of the EST and CF Approaches for Policy
In this section, we examine the policy implications for improving the quality of care from both the EST and CF perspectives. Our
purpose here is to suggest that policy guided by the EST approach
is useful, but that certain limitations have been overlooked.
EST and Quality Improvement
We believe transporting ESTs into practice settings should be
one aspect of EBP. Yet, the prioritization of ESTs as the only
“ethical” EBP requires some reexamination. For example, as noted
by Chambless and Crits-Christoph (2006).
Thus, in the face of evidence that Tx A works, it is not sufficient for
the practitioner who prefers Tx B to rest on the fact that no one has
shown that TxB is ineffective. Tx A remains the ethical choice until
the success of Tx B is documented (emphasis added, p. 193).
However rational this seems, caution must be exercised when
adopting this strategy.
EST implementation involves training (and supervising, as we
shall see) therapists to deliver ESTs in practice settings, in lieu of
the treatments they are currently practicing. The essential premise
is that having therapists deliver an EST, rather than the currently
delivered treatment, will result in better outcomes. This premise
rests on the EST conjecture that some treatments are more effective than others, which as we have argued, is questionable. However, there is evidence that the marginal utility of transporting
ESTs may be small. In a large data set of 12,743 patients collected
in a managed care setting, therapists treating depressed patients
obtained outcomes that were comparable with benchmarks set in
clinical trials, and did so in fewer sessions (Minami et al., 2008,
see also Saxon & Barkham, 2012). That is to say, practicing
therapists appear to be achieving, on average, commendable outcomes, a fact that seems to be generally ignored by many. More-
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LASKA, GURMAN, AND WAMPOLD
over, there are few controlled trials in naturalistic settings comparing the delivery of ESTs to treatment-as-usual (TAU) in which
the TAU involves comparable doses of psychotherapeutic services.
Most of the comparisons of EST and TAU involve a TAU that is
not a legitimate psychotherapy service, such as referral to primary
care physician (Wampold et al., 2011; Weisz, Jensen-Doss, &
Hawley, 2006). When ESTs are compared with TAU that involves
comparable doses of therapy, there is insufficient evidence to
conclude that ESTs are superior for depression and anxiety in
either adult or youth clients (Spielmans, Gatlin, & McFall, 2010;
Wampold et al., 2011). In other words, there is insufficient evidence at this point in time to suggest that implementing ESTs will
significantly improve on the quality of mental health services
already in place.
When differences are found in effectiveness trials, the positive
benefits may have little to do with the specific treatments being
transported, and more to do with changing unproductive aspects of
systems of care (e.g., identifying and removing iatrogenic treatments, providing less competent therapists with a theoretical rationale, extra training and supervision for therapists in the experimental condition, etc.). For example, in an effectiveness trial of
CBT for depression (Simons et al., 2010), therapists in the TAU
condition received no workshop, no extra training, and no supervision or consultation, whereas therapists in the CBT condition
received a 2-Day 12-hr workshop, and 16 1-hr group telephone
consultations for 1 year. Furthermore, claims that ESTs improve
care beyond TAU simply because a significant prepost effect was
found for the EST are spurious absent any preintervention outcome
data.
A second issue is related to therapists. Some have argued that
therapist effects can be eliminated through proper training and
adequate adherence (Crits-Christoph et al., 1991), yet RCTs of
ESTs do not use a random sample of therapists. Rather, therapists
in clinical trials typically are selected for their expertise and are
removed from the study if they cannot deliver treatment skillfully
(see Suris et al., 2013). The assumption is that transporting ESTs
to practice settings will be uniformly effective if therapists deliver
the protocol with adequate fidelity. Yet, growing evidence suggests otherwise. There is evidence that therapist variability is
significant even in practice settings in which therapists receive
extensive training and supervision in an EST by a nationally
recognized trainer (Laska et al., 2013).
Unfortunately, the assumption of therapist uniformity has persisted for decades. As noted by Donald Kiesler (1966) almost 50
years ago.
Despite this token admission of therapist differences, the Uniformity
Assumption still abounds in much psychotherapy research. Patients
are still assigned to “psychotherapy” as if it were a uniform homogeneous treatment, and to psychotherapy with different therapists as if
therapist differences were irrelevant . . . If psychotherapy research is
to advance, it must first begin to identify and measure these therapist
variables so relevant to eventual outcome (personality characteristics,
technique factors, relationship variables, role expectancies, and the
like) (pp. 112–113).
Although the methodological rigor of psychotherapy research has
come a long way over the last several decades, we may have lost
our way in asking some of the most important questions. Perhaps
there is no more compelling and relevant area for advancing the
study of which therapist variables to “identify and measure,” than
the study of what expert therapists, of any theoretical persuasion,
actually do, as urged over 40 years ago by Bergin and Strupp
(1972).
Cost. Under the EST approach, treatments are designed to be
disorder-specific. In naturalistic settings, clients typically present
with a wide range of comorbid conditions and therapists treat
patients with a variety of disorders. Thus, to meet the needs of
individuals under the current model, providers would need to be
trained in multiple ESTs for various disorders (e.g., ACT for
Depression, PE for PTSD, CBT for panic disorder). This concern
is highlighted by McHugh and Barlow (2010):
For example, even at specialty outpatient clinical service settings,
clinicians would need to receive training in multiple individual protocols to be able to treat the target patient population using ESTs. A
community mental health center that serves a wider variety of clinical
presentations would require training in even more protocols. Attempting to maintain fidelity to each of these individual treatments would
present an enormous challenge to a clinical care system. Given the
cost of didactic (e.g., workshop, written materials) and competence
(e.g., supervision and feedback) training, implementing multiple treatments to a facility is often not a feasible consideration (p. 951).
The costs are indeed great. Suppose a therapist in practice, who
has not been trained in an EST, heeds the advice of Chambless and
Crits-Christoph as stated above. Because this therapist sees many
depressed patients, she decides to be trained in CBT for depression, the gold standard of treatments for depression. The cost of
participating in a 3-day CBT Level I workshop for depression
offered by the Beck Institute for Cognitive Therapy is $1,200
(http://www.beckinstitute.org/cbt-for-depression-and-suicidality/)
to which one must add travel costs (airfare, hotel, and meals, say
conservatively another $1,200 for someone who does not live near
Philadelphia) and opportunity costs (i.e., lost income for at least 3
days, say at $100/hr, or conservatively $1,800), for a total of
$4,200. In addition, once therapists have completed the workshop,
ongoing supervision (competence training) is required at an additional cost to the individual therapist. Moreover, dissemination
experts claim that there will be “drift” in adherence to treatment
protocols, and so the practitioner would need to have refresher
courses to adequately provide the treatment (Waller, 2009). Keeping in mind that the practitioner would need to learn several, and
perhaps many, ESTs to deliver such treatments to most of his or
her patients, the time and cost will be great. There might be some
cost savings for scale, say for a clinic that might contract for group
training. For a system of care, however, the cost could be great—
the Department of Veterans Affairs spent over $20 million dollars
to roll out ESTs between 2007 and 2010 (Ruzek, Karlin, & Zeiss,
2012). These costs must be considered in comparison to the actual
benefit to an individual practitioner, clinic, or system of care, all of
which are largely unknown.
Unfortunately, the costs are not limited to practitioners, clinics,
and systems of care. Because the EST approach is the received
view by many clinical scientists, we were interested in knowing
how much is spent comparing two treatments intended to be
therapeutic and what the marginal utility of such research is, in
terms of knowledge. That is, what have we learned, and at what
cost? We conducted a systematic search of several journals and
relevant meta-analyses to find published comparative clinical trials
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F1
that were funded by the NIMH between the years 1992 and 2009
for the treatment of anxiety and depression (Laska, 2012). We
found eight such studies, which included 483 patients and nine
direct comparisons (see Figure 1), with a total cost of $11,760,874.
A meta-analysis revealed that the null hypothesis that the true
effects were zero could not be rejected, using the methods developed by Wampold and Serlin (in press). The only study with an
effect statistically different from zero was Markowitz et al. (1998),
which found IPT to be superior to CBT for depressed HIV patients.
That is to say, for over $11 million, one null hypothesis was
rejected, the overall effect was zero, and the actionable evidence is
questionable: Should practitioners treating HIV depressed patients
with CBT be retrained to provide IPT?
The dollar costs of disseminating multiple ESTs for multiple
disorders to individual clinicians and health care systems are
certainly prohibitive and make such efforts challenging. Yet, there
lurks another aspect of the practicability of such aims that is rarely
acknowledged. Although the feasibility of providing a clinical
intervention usually emphasizes patient acceptability (e.g., APA
Presidential Task Force on Evidence-Based Practice, 2006), both
the interventions themselves and their supporting empirical base
must be acceptable to practitioners. Just as different treatment
approaches may “fit” the person of the therapist better than others,
even the most compelling treatment research, whether based in the
EST or CF tradition, will have little impact on clinical practice if
it does not match the “fit” between the therapist’s preferred
method of therapy and her Self (Gurman, 2011). There is substantial evidence (e.g., Orlinsky, Botermanns & Ronnestad, 2001) that
psychotherapy research, including RCT-focused research (Stewart,
Stirman, & Chambless, 2012) generally has limited influence on
how therapists practice. Rather than viewing the gap between
RCTs and practice as “resistance” by clinicians, as some (Lilienfeld et al., 2013) have described the situation, we and our clients
may be better served by acknowledging that, as shown here, there
are many empirically legitimate ways to both practice and investigate psychotherapy. Skynner’s (1980) quip that we need “different thinks for different shrinks” (p. 274) is consistent with the CF
approach discussed here.
CF and Quality Improvement
The premises of quality improvement from the CF perspective
are consistent with “practice-based evidence” (Barkham, Hardy, &
Mellor-Clark, 2010; Duncan, Miller, Wampold, & Hubble, 2010),
9
also aptly referred to as “progress research” (Pinsof & Wynne,
2000). In this approach, patient progress is assessed regularly, and
these data are used to improve the quality of care. That is to say,
the evidence is derived from actual practice, mirroring best practices in quality improvement in other fields. Our purpose here is
not to suggest specific competency standards for therapists or to
offer technical protocols for the administration of quality improvement systems. Rather, it is to advance the argument that the CF
approach provides a scientifically grounded foundation for
practice-based quality improvement that should complement RCTbased approaches to enhancing clinical care. Thus, for example,
the possibility that a clinical focus on the five central components
of the CF approach described earlier might improve outcomes
deserves further investigation, even as technical refinements of
RCT-based methods continue.
Feedback. Feedback systems typically consist of one or more
self-report measures completed by clients regularly, and these data
are then used in real time to provide individually tailored treatment
decisions. By way of analogy, feedback systems have been described as a “mental health vital signs lab test” (Lambert, 2013b).
Both “rationally derived methods,” which set predetermined criteria for clinically significant improvement, and “empirically derived methods,” which compare expected versus actual rates of
change (see Castonguay, Barkham, Lutz, & McAleavey, 2013),
have been adopted in systems of care.
One area in which feedback systems have the potential to make
a significant impact is in regards to the “Lake Wabegon” effect.
Studies have shown that therapists, regardless of approach, are
poor at self-assessment and too often have a biased picture of
treatment progress. For example, in one study, roughly 90% of
therapists rated themselves in the top 25% of outcomes (Walfish,
McAlister, O’Donnell, & Lambert, 2012). Feedback systems protect against this self-assessment bias and introduce data-driven
methods into the therapy process. Simply providing therapists with
feedback about the progress of their patients has shown to prevent
treatment failures and improve outcomes (Lambert & Shimokawa,
2011; Shimokawa, Lambert, & Smart, 2010). Moreover, providing
feedback reduces treatment length for patients making expected
progress, but also keeps patients at risk for failure in therapy from
dropping out. In one example where the Partners for Change
Outcome Management System (PCOMS) was implemented by the
Center for Family Services (CFS) in Palm Beach, Flordia, Bohanske and Franczak (2010) note:
For example, average length of stay decreased more than 40%. Cancellation and no-show rates dropped by 40% and 25%, respectively.
Most impressive of all, the percentage of clients in long term treatment that experienced little to no measured improvement fell by 80%!
In 1 year, CFS saved nearly $500,000, funds that were used to hire
additional staff and provide more services (p. 308).
Figure 1.
Forest plot of effects of NIMH-funded comparative trials.
Indeed, the Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-based
Programs and Practices (NREPP) only includes programs and
practices that meet strict standards (see http://www.nrepp.samhsa
.gov/). Lambert’s OQ Analyst, Miller’s (PCOMS), and Norcross’
Evidence-Based Therapy Relationships are included in NREPP,
indicating that aspects of the CF model can be translated into
viable evidence-based programs and practices.
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LASKA, GURMAN, AND WAMPOLD
Alliance. Real-time feedback systems that include attention to
CF factors may have great potential to address the central matter of
how change happens in therapy by considering a wider range of
potential mediators of change than is typically attended to in
RCT-based models. The use of practice-based evidence is progressing importantly toward giving therapists information about
various elements in the CF approach, particularly the alliance.
Lambert (2009) has developed clinical support tools that assess
alliance, readiness for change, and social support. Miller and
colleagues (Duncan, 2012) have developed the Session Rating
Scale to assess the quality of the session and the alliance, so that
therapist can monitor not only the outcomes of therapy but also the
progress of therapy. Pinsof et al. (2009) developed an inventory to
assess treatment progress and the therapeutic alliance focused on
varying therapy systems, that is, couples and families as well as
individuals. Given that a strong therapeutic alliance is one of the
most robust predictors of outcome, continued data-driven efforts in
this area has the potential to greatly improve care.
Therapists. Examination of therapist effects in practice settings indicate that most therapists achieve desirable outcomes,
which is to say that they meet the benchmarks for various disorders
(Minami et al., 2008; Minami, Wampold, Serlin, Kircher, &
Brown, 2007; Wampold & Brown, 2005). What is most important
from the CF perspective is investigating those therapists who
achieve expected outcomes to identify what it is they are doing.
Given that most RCTs typically include less than 12 therapists,
rendering examination of therapist effects difficult, quality improvement efforts from a CF perspective should focus on those
therapist behaviors in naturalistic settings that contribute to expected outcomes. Why is it that therapist differences have been
acknowledged for over 40 years, yet as a field we are not much
further in understanding the role of therapist variables than when
Kiesler first acknowledged the “uniformity assumption” almost
half a century ago? If we continue to disregard the importance of
the therapist, a full one half of the clinical dyad, we drastically
limit our ability to reduce the burden of mental illness. In order for
EBP to achieve the aim of reducing mental illness, greater emphasis must be placed on the therapist, regardless of theoretical orientation or system of care in which he or she is examined.
Additionally, in naturalistic data sets it is clear that the patients
of some therapists consistently fail to make expected progress
(Minami et al., 2008; Saxon & Barkham, 2012; Wampold &
Brown, 2005). The quality of service would be dramatically improved by assisting these therapists to achieve better outcomes.
Managers of care could identify these therapists and provide
additional training or supervision. However, the training provided
should be designed to address particular skill deficits. From our
perspective, the training and supervision might well involve a
focus on relationship skills, if it is determined that those are
lacking. However, in our experience some therapists fail to deliver
a clear, cogent, and consistent treatment, which is one of the
important aspects of the CF approach (Wampold & Budge, 2012).
From the CF perspective, the particular treatment is not inherently
crucial for most disorders, and adherence to the protocol is not
crucial, but providing a cogent and acceptable explanation for the
patient’s difficulties and engaging the patient in healthy actions
through a treatment structure is crucial. Thus, training in an EST
may indeed be helpful, if there is evidence that a particular
therapist is not achieving desirable outcomes because he or she is
not providing an adequate treatment structure. If all attempts to
assist a therapist to meet some consensual minimal outcome standards fail, then the profession, as well as the manager of care,
needs to determine whether in the best interest of patients, the
therapist should be “counseled” to find another line of work. This
would be a controversial action but one that is accord with professional standards and accountability. By way of offering some
context for this recommendation, we note that Saxon and Barkham
(2012) found that of 119 therapists in practice, 19 had outcomes
considered “below average” and if their 1,947 patients had been
seen by “average” therapists an additional 265 patients would have
recovered (see also Baldwin & Imel, 2013).
Training. The ideal training program, in our view, should
contain elements of the both the EST and the CF perspectives.
Psychotherapy trainees should be trained to provide ESTs as well
as be trained in feedback systems, and how to form and repair
strong working alliances, express empathy, and collaborate on
treatment goals. We recommend going one step further, however,
to provide “competency-based” certification. That is, to be certified, trainees would need to attain outcomes with various types of
patients that meet a given standard (e.g., the benchmark for a
particular disorder or type of patient). Such a competency-based
system would help to attenuate the schism between Baker et al.’s
(2008) proposed Psychological Clinical Science Accreditation
System (PCSAS) and the American Psychological Association
(APA) accreditation. Standards of accountability would dictate
that students graduating from PCSAS or APA-accredited programs
should have demonstrated that they are competent therapists by
achieving commendable outcomes, regardless of the emphasis of
their training programs and regardless of treatment approach.
Such a balanced approach to clinical training, open to scientific
input from both the CF and EST points of view, would be in full
accord with both the standards for EBP set forth by the APA
(2006) and the important recently emerging emphasis on transdiagnostic understanding of emotional and behavioral problems
(Barlow et al., 2011) and related unifying principles of psychotherapeutic change.
Conclusions—and a Challenge
Increasingly, psychotherapy theory and research of late has
focused on how the CF and the specific ingredients work together
to produce the benefits of therapy (Hoffart, Borge, Sexton, Clark,
& Wampold, 2012; Owen & Hilsenroth, 2011; Pesale, Hilsenroth,
& Owen, 2012; Ulvenes et al., 2012; Wampold & Budge, 2012).
Much of this research shows that the CF do their work differently
in different therapies— but clearly, both the CF and the specific
ingredients need to be integrated.
We have presented the science of two research perspectives and
suggested some ways to improve the quality of psychotherapeutic
care, including the use of feedback systems as a unifying means of
establishing accountability for treatment outcomes. In many quarters, the EST approach is the received view. We have attempted to
make the case for an alternative and complementary CF approach,
which has significant consequences for improving mental health
services. Rather than argue about which perspective is more or less
scientific, we issue the following challenge: How can we integrate
the two models of empirical inquiry in a way that the field can
move forward?
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