Showing papers in "Clinical Psychology-science and Practice in 2002"

The Paradox of Self-Stigma and Mental Illness

Abstract: Published narratives by persons with serious mental illness eloquently describe the harmful effects of stigma on self-esteem and self-efficacy. However, a more careful review of the research literature suggests a paradox; namely, personal reactions to the stigma of mental illness may result in significant loss in self-esteem for some, while others are energized by prejudice and express righteous anger. Added to this complexity is a third group: persons who neither lose self-esteem nor become righteously angry at stigma, instead seemingly ignoring the effects of public prejudice altogether. This article draws on research from social psychologists on self-stigma in other minority groups to explain this apparent paradox. We describe a situational model of the personal response to mental illness stigma based on the collective representations that are primed in that situation, the person's perception of the legitimacy of stigma in the situation, and the person's identification with the larger group of individuals with mental illness. Implications for a research program on the personal response to mental illness stigma are discussed.

The Psychotherapy Dose‐Response Effect and Its Implications for Treatment Delivery Services

Abstract: To date, few studies have been published on the doseresponse relationship, but there is general consensus that between 13 and 18 sessions of therapy are required for 50% of patients to improve. Reviewing the clinical trials literature reveals that in carefully controlled and implemented treatments, between 57.6% and 67.2% of patients improve within an average of 12.7 sessions. Using naturalistic data, however, revealed that the average number of sessions received in a national database of over 6,000 patients was less than five. The rate of improvement in this sample was only about 20%. These results suggest that patients, on average, do not get adequate exposure to psychotherapy, nor do they recover from illness at rates observed in clinical trials research.

Expanding Our Conceptualization of and Treatment for Generalized Anxiety Disorder: Integrating Mindfulness/Acceptance-Based Approaches With Existing Cognitive-Behavioral Models

Abstract: Generalized anxiety disorder (CAD) is a chronic, pervasive disorder for which we have yet to develop sufficiently efficacious interventions. In this article we propose that recent research and theory regarding this disorder supports the integration of acceptance-based treatments with existing cognitive-behavioral treatments for CAD to improve the efficacy and clinical significance of such approaches. The bases for this proposal (from both the CAD and the acceptance-based treatment literature) are reviewed, and a new treatment stemming from this conceptual integration is described.

The Dodo Bird Verdict Is Alive and Well—Mostly

Abstract: We examined 17 meta-analyses of comparisons of active treatments with each other, in contrast to the more usual comparisons of active treatments with controls. These meta-analyses yielded a mean uncorrected absolute effect size for Cohen's d of .20, which is small and non-significant (an equivalent Pearson's r would be. 10). The smallness of this effect size confirms Rosenzweig's supposition in 1936 about the likely results of such comparisons. In the present sample, when such differences were corrected for the therapeutic allegiance of the researchers involved in comparing the different psychotherapies, these differences tend to become even further reduced in size and significance, as shown previously by Luborsky, Diguer, Seligman, et al. (1999).

Early intervention for trauma: Current status and future directions.

Abstract: Although psychological debriefing (PD) represents the most common form of early intervention for recently traumatized people, there is little evidence supporting its continued use with individuals who experience severe trauma. This review identifies the core issues in early intervention that need to be addressed in resolving the debate over PD. It critiques the available evidence for PD and the early provision of cognitive-behavioral therapy (CBT). Based on available evidence, we propose that psychological first aid is an appropriate initial intervention, but that it does not serve a therapeutic or preventive function. When feasible, initial screening is required so that preventive interventions can be used for those individuals who may have difficulty recovering on their own. Evidence-based CBT approaches are indicated for people who are at risk of developing posttraumatic psychopathology. Guidelines for managing acutely traumatized people are suggested and standards are proposed to direct future research that may advance our understanding of the role of early intervention in facilitating adaptation to trauma.

Applying an Emotion Regulation Framework to Integrative Approaches to Generalized Anxiety Disorder

Abstract: Integrative conceptualizations like that proposed byRoemer and Orsillo provide exciting new directions forunderstanding and treating generalized anxiety disorder(GAD). However, these approaches may be furtherstrengthened by adoption of an emotion regulationperspective. Persons with GAD may have difficulty un-derstanding their emotional experience and may pos-sess few skills to modulate their emotions. They mayexperience emotions as subjectively aversive and useworry and maladaptive interpersonal behaviors as de-fensive strategies to control, avoid, or blunt emotionalexperience. An emotion regulation perspective suggestsadding treatment components to help clients becomemore comfortable with arousing emotional experience,more able to access and utilize emotional informationin adaptive problem solving, and better able to modu-late emotional experience and expression according tocontextual demands.Key words: emotion regulation, generalized anxietydisorder. [Clin Psychol Sci Prac 9:85–90, 2002]

Let's Face Facts: Common Factors Are More Potent Than Specific Therapy Ingredients

Abstract: Luborsky et al.'s findings of a non-significant effect size between the outcome of different therapies reinforces earlier meta-analyses demonstrating equivalence of bonafide treatments. Such results cast doubt on the power of the medical model of psychotherapy, which posits specific treatment effects for patients with specific diagnoses. Furthermore, studies of other features of this model—such as component (dismantling) approaches, adherence to a manual, or theoretically relevant interaction effects—have shown little support for it. The preponderance of evidence points to the widespread operation of common factors such as therapist-client alliance, therapist allegiance to a theoretical orientation, and other therapist effects in determining treatment outcome. This commentary draws out the implications of these findings for psychotherapy research, practice, and policy.

Informant-Reports of Personality Disorder: Relation to Self-Reports and Future Research Directions

Abstract: Most instruments that assess personality disorder rely principally on self-report. However, there are major limitations to using self-report for the diagnosis of personality pathology. First, the self provides only one opinion. Second, like everyone else, people with personality disorders are frequently unable to view themselves realistically and are unaware of the effect of their behavior on other people. Using informant data, therefore, may improve the reliability and validity of diagnostic assessment. A review of the literature reveals that agreement between informant- and self-reports of personality disorder is modest at best, even though informants tend to agree with each other. Self-informant concordance appears to be higher for older subjects and for Cluster B traits (excluding narcissism). Further research should focus on methods of resolving discrepancies between self- and informant-reports of personality disorder and determining when self or informant data are more valid.

Child Sexual Abuse and Sexual Revictimization

Abstract: Research identifying rates and effects of adult/adolescent sexual revictimization among child sexual abuse victims was reviewed. Approximately one-third of child sexual abuse victims report experiencing repeated victimization. Child sexual abuse victims have a 2 to 3 times greater risk of adult revictimization than women without a history of child sexual abuse. Physical contact in abuse and revictimization in adolescence were found to lead to the greatest risk of revictimization. Repeated victims had more symptoms of Post Traumatic Stress Disorder (PTSD) and dissociation than women with a history of child sexual abuse alone. Theories of revictimization and mediating variables were also reviewed. Clearer definitions of repeated victimization are needed and future research should include studies that follow child sexual abuse victims prospectively.

Toward Large‐Scale Implementation of Empirically Supported Treatments for Children: A Review and Observations by the Hawaii Empirical Basis to Services Task Force

Abstract: This article details the context and findings of a review conducted by a state-established panel established to examine the efficacy and effectiveness of child treatments for Anxiety Disorders, Depression, Attention Deficit Hyperactivity Disorder, Conduct and Oppositional Disorders, and Autistic Disorder. The review emphasizes not only the specific results obtained, but also the process by which a university, Department of Health, and family partnership was established to address specific issues of relevance to statewide implementation of empirically based services. The review of treatment efficacy is consistent with the recent child treatment literature, and these findings were extended through a systematic cataloguing of effectiveness parameters across more than one hundred treatment outcome studies. The importance of such findings and the process by which they were obtained are discussed in the context of a statewide effort to improve mental health practice for children through the extension and application of much of the work by Division 12 of the American Psychological Association with respect to empirically supported treatments.

An Information-Processing Analysis of Mindfulness: Implications for Relapse Prevention in the Treatment of Substance Abuse

Abstract: This article provides a cognitive framework for integrating mindfulness meditation into substance abuse treatment. We review recent developments in cognitive theory and treatment research that point toward mind-fulness meditation as a useful additional strategy for reducing relapse. Although the idea of using meditation to reduce substance use is not new, there are several reasons for further exploring the relevance of mindful-ness for addiction treatment. This article reviews the cognitive-behavioral formulation of relapse, evaluations of mindfulness meditation as a component of the treatment of psychopathology, and the role of information processes in relapse. We also present an information-processing analysis of how mindfulness can help prevent relapse and discuss its utility and clinical implications.

One Size Cannot Fit All: A Stage Model for Psychotherapy Manual Development

Abstract: There has been controversy surrounding the roles and value of psychotherapy manuals in clinical practice since their inception. It has been underrecognized that the appropriate roles and content of manuals should evolve with the stage of development of a given treatment. This article proposes a stage model in which manuals are seen as evolving with the level of development of the treatment, from the basic outlines necessary for preliminary evaluation of the treatment in early pilot studies (stage I), to highly defined guidelines that demark the internal and external boundaries of treatment for efficacy studies (stage II), and finally to elaborated systems appropriate for use with diverse clinical populations (stage III). We propose guidelines for the content of manuals at the various stages, as well as strategies for developing “clinician-friendly” manuals to facilitate broader use of empirically supported treatments.

Methods for Disseminating Research Products and Increasing Evidence-Based Practice: Promises, Obstacles, and Future Directions

Abstract: Although several different rationales for psychotherapy dissemination research have been well articulated, the most effective means for bringing research products to clinical practice have yet to be determined. Two commonly proposed methods are the dissemination of empirically supported treatments and the dissemination of general evidence-based stances to clinical decision making. Obstacles to either approach include (a) practical constraints on practitioners' ability to use research products, (b) lack of research on process and outcome of both empirically supported treatments and existing services in different practice contexts, (c) lack of research on acceptability of research products to end users including practitioners, clients, and administrators, (d) lack of research on training in the integration of science and practice at the undergraduate, graduate, and postgraduate levels, (e) systemic economic contingencies that favor or punish evidence-based decision making, and (f) the tendency to construct dissemination as a hierarchical and unidirectional process of transmission from research to clinical practice. Each obstacle is considered in detail and followed by recommendations for ways to broaden the scope of dissemination efforts.

Life in the future versus life in the present

Abstract: Roemer and Orsillo have provided an integrative perspective for developing more effective therapies for generalized anxiety disorder, based on existing knowledge about the disorder, cognitive behavioral approaches to its treatment, and conceptualizations and treatment methods from the acceptance/mindfulness tradition. The present commentary expands upon the notion of the adaptive value of focused attention on present-moment experience and cognitive perspectives that can facilitate that process.

GAD, metacognition, and mindfulness: An information processing analysis.

Abstract: In this commentary I discuss the integration of mindful procedures in cognitive therapy of generalized anxiety disorder (GAD) and attempt to answer questions concerning the effects of mindfulness on information processing and on mechanisms purported to maintain GAD in the metacognitive model of this disorder. Different techniques that promote mindfulness can be identified, including mindfulness meditation and attention training. These techniques are intended to disrupt repetitive styles of dysfunctional thinking. I argue that the effect of mindfulness strategies on information processing in emotional disorder can be conceptualized in metacognitive terms as (a) activating a metacognitive mode of processing; (b) disconnecting the influence of maladaptive beliefs on processing; (c) strengthening flexible responding to threat; and (d) strengthening metacognitive plans for controlling cognition. Although mindfulness meditation may have general treatment applications, the metacognitive model of GAD suggests caution in using this treatment in GAD. It is unclear which dimension of worry should be targeted, and mindfulness meditation does not contain information that can lead to unambiguous disconfirmation of erroneous beliefs about worry.

Acceptance, Mindfulness, and Science

Abstract: The inclusion of technologies drawn from spiritual and religious traditions into empirical clinical psychology is a positive step forward, but it also helps reveal problems in the technological model of treatment development. The technological model does not necessarily lead to a more coherent, innovative, and progressive discipline, which requires the development of more adequate theory, not merely more adequate technology. If technologies drawn from spiritual and religious traditions are to be included in modern scientific psychology, the field must be free to interpret and transform them theoretically, without being limited by their religious and spiritual past.

What to Do When Manuals Fail? The Dual Model of Psychotherapy

Abstract: Although multicenter clinical trials have impressively attested to the efficacy of psychological interventions for common psychological disorders, some individual patients still do not profit from treatment. In this article, we present a theoretical model and some supportive results to explain this unsatisfactory state. Apart from early treatment dropout, some patients are not engaged in treatment and lack the prerequisite behavior (“patient basic behavior”) for successfully applying protocol-specified intervention techniques. According to the dual model of therapy, therapists have two tasks: to apply treatment techniques/procedures and to motivate patients for treatment by strengthening patient basic behavior if necessary. Our results show that therapists attend and react to therapeutic process problems by changing from a method-oriented treatment strategy to a process- or patient-oriented strategy. This change, however, occurs too soon, too often, and occasionally for the wrong reason. We must therefore develop empirically based criteria to inform therapists when to react, what to look for, and what to do to motivate the patient. We conclude that treatment outcome research and process research are both valuable and complementary aspects of psychotherapy research.

Beware the Dodo Bird: The Dangers of Overgeneralization

Abstract: Luborsky et al.'s conclusion that there are no meaningful differences in the efficacy of various psychothera-pies should be reconsidered for the following reasons: (a) errors in data analysis, (b) exclusion of research on many types of clients (e.g., children and adolescents), (c) faulty generalization to comparisons between therapies that have never been made, and (d) erroneous assumption that the average difference between all sorts of treatments for all sorts of problems can be assumed to represent the difference between any two types of treatment for a given problem. Concern for clients' welfare demands that psychologists be very wary of accepting the Dodo bird verdict.

The Dodo Bird Is Extinct

Abstract: It may be quite inaccurate and certainly it is premature to identify the dodo bird as the mascot for psychotherapy research. The dodo bird is not as alive and well as some may wish. The complexity of determining the presence of specific effects has been underestimated and, more importantly, the evidence of specific effects in treatments have been largely ignored by those who adopt a dodo bird's perspective. The article by Lubor-sky et al. in this issue illustrates these misperceptions and exclusions. Here I review some of the evidence for the premature ascendance of the dodo bird and raise questions about the nature of current research methodologies for assessing the presence of specific effects and especially for disclosing differential treatment contributors to treatment outcome.

Are Compulsive Checkers Impaired in Memory? A Meta‐Analytic Review

Abstract: Researchers have hypothesized that compulsive checkers suffer from impairment in explicit memory (e.g., Sher, Frost, & Otto, 1983), low confidence in explicit memory (e.g., McNally & Kohlbeck, 1993), or both. However, empirical findings have been equivocal, possibly due to variability in effect sizes produced by small samples. Combining data across studies may yield more meaningful conclusions than can be surmised from a narrative review. Following a brief review of the literature on checking and memory, we present meta-analytic results suggesting that checkers are impaired on many types of memory tasks (e.g., verbal free recall, verbal cued recall, and recall of actions) and are less confident in recognition than noncheckers. We discuss implications of these findings, suggestions for future research, and limitations of this analysis.

Are Specific and Generalized Social Phobias Qualitatively Distinct

Abstract: This article reviews studies of the generalized (CSP) and specific (SSP) subtypes of social phobia, including their onset, course, etiology, comorbid conditions, types of situations feared, reactions (i.e., cognitive, physiological, and behavioral) to feared situations, and response to treatment. Because the differences between CSP and SSP seem difficult to reconcile with a strictly quantitative perspective, we propose a qualitative distinction. The characteristics of SSP are seen as similar to those of specific phobias, but those of CSP are not. We offer a speculative interpersonal model of CSP that emphasizes beliefs about the self being unlovable, behaviors that elicit negative self-evaluations in others, and a pattern of mutual social-distancing behaviors. We discuss the implications of a qualitative distinction between CSP and SSP and offer avenues for future inquiry.

Implicit and Untested Assumptions About the Role of Psychotherapy Treatment Manuals in Evidence‐ Based Mental Health Practice

Abstract: We consider Carroll and Nuro's (this issue) model of treatment manual development in the broader context of attempts to bring accountability and evidence- based practice to clinical services. The current Zeitgeist surrounding treatment manual dissemination is guided by several implicit and largely untested assumptions. We describe each assumption, consider how it guides current thinking about dissemination of empirically supported treatments, and briefly summarize relevant research. We conclude that treatment manual development and dissemination, while clearly a worthwhile pursuit, is only one way to merge science and practice.

The Tangled and Thorny Path of Science to Practice: Tensions in Interpreting and Applying “Evidence”

Abstract: As Chorpita et al. discuss, implementing scientific evidence into practice is a complex process. This commentary addresses additional issues to those mentioned in their article, issues related to the nature of evidence and its interpretation. Since the evidence base is inherently subjective and ever-changing, it is critically important to describe the decision-making processes involved in the interpretation and application of evidence. Increasing efforts should also be made to consider the context at the provider, patient, system and community levels in decision-making processes about scientific evidence as well as during the implementation of evidence in practice settings. This will enable the assessment of the fit between the evidence and local populations and settings. Attention to process factors and context should ideally occur during the creation, adaptation, and implementation of evidence. Attention to the complexities of scientific evidence and the process of its systematic review and implementation into real world practice settings will improve the translation of evidence into community practice.

The Death of Treatment as Usual: An Excellent First Step on a Long Road

Abstract: The failure of system reforms to affect child and family outcomes and the lack of positive findings concerning treatment as usual has led to pressure to reform treatment in the community through the adoption of evidence-based treatments. While this is generally a positive direction for the future, reformers should also consider the quality of evidence supporting these treatments and the dependence on traditional diagnostic approaches as limitations to this approach. Moreover, reformers should recognize the importance of learning from clinicians and consumers, the inclusion of a common factors approach and the critical role of measurement in the reform process.

Facilitating Symptom Reduction and Behavior Change in GAD: The Issue of Control

Abstract: In this commentary we review the theoretical positions of Roemer and Orsillo and identify several key issues First, the specificity of their arguments to generalized anxiety disorder (CAD) compared to the other anxiety disorders are explored For example, the proposed distinctions between worry in CAD and worry associated with the other anxiety disorders are examined in light of available empirical evidence Second, the proposed disjunctions between mental content and both actual experience and emotional/physiological responding are placed in the context of current theoretical and empirical work Finally, possible therapeutic mechanisms of change for mindfulness/acceptance-based treatments and the roles of control and predictability in anxiety disorder treatment are discussed

Increasing the Relevance of Evidence‐Based Treatment Review to Practitioners and Consumers

Abstract: Numerous obstacles complicate efforts to identify evidence-based treatments and disseminate them to practicing clinicians, and thus to their clients. The multi-disciplinary, statewide effort by Bruce Chorpita and the Hawaii Task Force addresses a number of these obstacles very thoughtfully, taking significant steps toward bridging mental health research and practice. We highlight lessons derived from their work that can be applied by other groups engaged in evidence review and we note methodological challenges that continue to require close attention by all of us engaged in evidence review and treatment classification.

What Happens After the Innovation Is Identified

Abstract: Although the identification of efficacious and effective mental health treatments represents a potentially important synthesis of research literatures, such identification is but a first step in the transport of evidence-based treatments to field settings. Based on multidisciplinary research on the diffusion of innovation articulated by Rogers, this commentary briefly describes characteristics of the innovation and of the social system that may influence the adoption of mental health innovations.

Treatment manuals for the real world: Where do we build them?

Abstract: Carroll and Nuro (this issue) outline a model for development of psychotherapy manuals that parallels the recently articulated stage model of psychotherapy research. The authors outline excellent considerations for treatment manuals in early, middle, and late stages of development. As manual testing moves from pilot studies and efficacy tests in university settings to transportability studies in clinical settings, the complexity of the manuals increases. These considerations also raise the broader question, however, of whether the stages of psychotherapy research as commonly implemented are best suited for developing treatments appropriate for “real-world” clinical settings. I suggest that all stages of research are perhaps better conducted in clinical as opposed to university settings. A change in research infrastructure would be challenging at first but could ultimately accelerate development of psychotherapy technologies.

Prescriptive Authority for Psychologists: A Looming Health Hazard?

Abstract: Although many psychologists support prescription privileges, the historical training paradigm in psychology includes limited scientific education directly relevant to prescribing medications. Issues related to prescriptive authority for psychologists, including training gaps, attitudes, accreditation, and regulation, are discussed. Current proposals for training psychologists to prescribe deleted the prerequisite coursework in the biological and physical sciences that had been identified by the American Psychological Association's Ad Hoc Task Force on Psychopharmacology. Current proposals do not delineate clear requirements for several key aspects of supervised practical training. Such training limitations raise basic questions about how much additional scientific and medical training would be necessary to ensure that psychologists could provide an acceptable quality of clinical pharmacologic care.

Treatment Manuals: Necessary, but Far From Sufficient

Abstract: This commentary suggests that the transport of evidence-based mental health treatments to field settings is a complex and multi-layered process. Although treatment manuals may represent one important component of that process, researchers are often ignoring many other critical components.