Toward a more clinically valid approach to therapy research

Prevalence of DSM-IV disorder in a representative, healthy birth cohort at school entry: sociodemographic risks and social adaptation

OBJECTIVE

The aims of this paper are as follows: to present past-year prevalence data for DSM-IV disorders in the early elementary school years; to examine the impact of impairment criteria on prevalence estimates; to examine the relation of sociodemographic and psychosocial risk factors to disorders; and to explore associations between "internalizing" and "externalizing" disorders and social competence and family burden as further validation of the impairing nature of these disorders.

METHOD

As part of a longitudinal representative population study of children born healthy between July 1995 and September 1997 in the New Haven-Meriden Standard Metropolitan Statistical Area of the 1990 Census (n = 1,329), parents of a subsample enriched for child psychopathology (n = 442; 77.6% response rate, 69.5% of eligible sample) were interviewed in the child's kindergarten or first-grade year with the Diagnostic Interview Schedule for Children, Version IV (DISC-IV). Parents were surveyed about sociodemographic and psychosocial characteristics, and both parents and teachers were surveyed about social competence.

RESULTS

Approximately one in five (21.6 %) children met criteria for psychiatric disorder(s) with impairment. Sociodemographic and psychosocial correlates included persistent poverty beginning in early childhood, limited parental education, low family expressiveness, stressful life events, and violence exposure. Finally, diagnostic status was significantly associated with poorer social competence and family burden.

CONCLUSIONS

That approximately one in five children evidenced a psychiatric disorder with impairment during the transition to formal schooling highlights the importance of integrating psychiatric epidemiological and developmental approaches to inform conversations about school readiness and intervention planning.

Sex offender treatment: consumer satisfaction and engagement in therapy

Convicted sex offenders attending an outpatient treatment program in Connecticut were surveyed about their experiences in therapy, their perceived importance of treatment content, their satisfaction with the help they receive, and their engagement in therapeutic services. There were strong correlations between perceived importance of content items and satisfaction with services. A robust correlation was also found between engagement and satisfaction. Clients rated accountability and victim empathy as the most important components of treatment. Other popular content areas were thinking errors, relapse prevention concepts, uncovering motivations to offend, and controlling deviant arousal. Most sex offenders valued the peer support and confrontation offered by group therapy. Though reduced recidivism is clearly the crucial measure of treatment success, clients who are engaged in the treatment process and develop healthy interpersonal skills by participating in therapy may be less likely to engage in abusive behavior. Implications for practitioners are discussed.

Interesting practitioners in training in empirically supported treatments: research reviews versus case studies

It has been repeatedly demonstrated that clinicians rely more on clinical judgment than on research findings. We hypothesized that psychologists in practice might be more open to adopting empirically supported treatments (ESTs) if outcome results were presented with a case study. Psychologists in private practice (N=742) were randomly assigned to receive a research review of data from randomized controlled trials of cognitive-behavioral treatment (CBT) and medication for bulimia, a case study of CBT for a fictional patient with bulimia, or both. Results indicated that the inclusion of case examples renders ESTs more compelling and interests clinicians in gaining training. Despite these participants' training in statistics, the inclusion of the statistical information had no influence on attitudes or training willingness beyond that of the anecdotal case information.

Empirically supported treatments in rural community mental health centers: a preliminary report on current utilization and attitudes toward adoption

Rural community mental health centers (CMHCs) face numerous problems that might be alleviated by the dissemination of empirically supported treatments (ESTs). The current study lays the groundwork for EST dissemination by examining current treatment practices in rural clinics as well as the attitudes of decision makers toward ESTs and perceived barriers to their adoption. Twenty-five rural and 38 non-rural clinical directors responded to a mailed survey. Rural respondents were as likely as non-rural respondents to report EST use in their clinic for most anxiety disorders, and more likely to report use of an EST for major depressive disorder and obsessive-compulsive disorder. However, ESTs represent a relatively small proportion of the treatments reported for depression and anxiety disorders. Attitudes toward manualized ESTs did not differ between groups. Further, rural and nonrural clinics did not see the barriers to the adoption of ESTs as insurmountable. These preliminary results suggest that rural CMHCs are open to the use of ESTs and should be included in widespread dissemination initiatives.

Clinical effectiveness of a cognitive behavioral group treatment program for anxiety disorders: a benchmarking study

Previous research has established efficacy of cognitive behavioral therapy (CBT) for anxiety disorders, yet it has not been widely assessed in routine community clinic practices. Efficacy research sacrifices external validity to achieve maximum internal validity. Recently, effectiveness research has been advocated as more ecologically valid for assessing routine clinical work in community clinics. Furthermore, there is a lack of effectiveness research in group CBT. This study aims to extend existing research on the effectiveness of CBT from individual therapy into group therapy delivery. It aimed also to examine outcome using not only symptom measures, but also measures of related symptoms, cognitions, and life quality and satisfaction. Results from a cohort of patients with various anxiety disorders demonstrated that treatment was effective in reducing anxiety symptoms to an extent comparable with other effectiveness studies. Despite this, only 43% of individuals showed reliable change, and 17% were 'recovered' from their anxiety symptoms, and the post-treatment measures were still significantly different from the level of anxiety symptoms observed in the general population.

An effectiveness study of group therapy for anxiety disorders

This work examines the transportability of group cognitive-behavioral therapy (GCBT) for a wide range of anxiety disorders to a college counseling center. Participants were 31 clients with a primary diagnosis of generalized anxiety disorder, panic disorder with agoraphobia, social phobia, specific phobia, or obsessive-compulsive disorder who identified dysfunction in one or more of eight daily function areas. Clients were not excluded on the basis of medication use, severity or frequency of panic attacks, age, or comorbidity. Of the 31 participants, there were 17 treatment completers, defined by a minimum of 20 sessions in a flexibly bounded psychotherapy group, who achieved significant reductions in levels of anxiety-related dysfunction. The present study suggests that group cognitive behavioral therapy can be transported to a college counseling center.

Comparison of therapeutic action, style and content in cognitive-behavioural and psychodynamic group therapy under clinically representative conditions

It is still an open question whether psychotherapists adhere to their therapeutic conceptions in routine practice (clinician's treatment adherence) and thus to what extent the two most common approaches, cognitive-behavioural (CBT) and psychodynamic therapy (PDT), differ from each other as theoretically expected (treatment differentiation). This holds true especially in case of group therapy.The study compares essential process components of CBT and PDT group treatments under clinically representative conditions using non-participating observer ratings. Results demonstrate that CBT group therapists use more cognitive, behavioural and psychoeducational strategies, foster self-efficacy to a larger extent and are more supporting and empathetic. PDT group therapists use more interpretative and confrontative interventions and focus on interactional and dynamic aspects. The results strongly support that not only in individual psychotherapy-as shown in prior research-but also in the group setting do CBT and PDT reveal very distinct profiles and that therapists primarily abide by their theoretical training also in clinical practice. They allow one to identify differential process components of the group setting and to trace back parameters of outcome to the process of CBT and PDT for clinical routines.

Treatment of severe, treatment-refractory obsessive-compulsive disorder: a study of inpatient and community treatment

INTRODUCTION

This research reports on a prospective outcome study of two cohorts of patients with severe, chronic, resistant obsessive-compulsive disorder (OCD).

METHODS

One cohort consisted of a total of 52 patients treated in an inpatient setting, while the second group comprised 65 patients treated in a community-outpatient setting. Treatment consistent primarily of intensive graded exposure and self-imposed response prevention augmented with cognitive restructuring.

RESULTS

The groups demonstrated significant improvement over the course of treatment. In the inpatient and community groups, there was significant improvement over the first 12 weeks of treatment, and further improvement between 12 and 24 weeks.

CONCLUSION

These results suggest that even for patients who have demonstrated treatment-resistance, there may be benefit in intensive behavioral treatment of OCD. In addition it was found that even for those patients with the most profound refractory OCD and complicating factors inpatient stays of up to 24 weeks were effective in reducing symptoms.

[New directions for psychotherapy research: an evaluation of a research protocol and a methodological and technical framework proposal]

INTRODUCTION

A recent report of the French research institute INSERM, based on a comprehensive review of the work done on the evaluation of psychotherapies Psychothérapies: trois approches évaluées, has shown the lack of research in France on this topic, notably in psychodynamic psychotherapy. The development of such research is needed. The first part of the paper deals with the limits of the third generation of studies on psychotherapy (medical model, use of RCT, DSM...) on which the INSERM report is based and reviews the existing propositions for a fourth generation of research in the field. METHODOLOGICAL FINDINGS: In the second part, a process-outcome research protocol developed by the authors, according to these new proposals as well as several on-going researches [J Clin Psychol, 27 2 (1998) 217-26, J Pragm Case Stud 3 (2000)(2), Arch Gen Psychiatry 59 (2002) 505-10, Psychother Res 12 3 (2002) 251-72 and Br J Psychiatry 165 (1994) 4-8] is presented. The proposed methodology is based on controlled single case studies. Quantitative and qualitative data are associated for the definition of the diagnosis, as well as initial, intermediate and final measures. Process analysis is used to describe the main characteristics of the on-going psychotherapy at different moments in time. It is thus possible to gain access to what is really done during the therapy and not only to what is supposed to be done, based on a manual or even on the name of the theory used by the therapist.

DESIGN OF THE STUDY

This methodology was tested during a one-year pilot study, in true conditions of psychotherapy with outpatients. The different phases of the analysis are presented: several tools dedicated to the observation, formalisation and data analysis are integrated in a coherent iterative process during the whole therapy. The interests and limits of each tool (ESM, DSM, PPQS, Hoglend, CORE...) are described together with the first results of the pilot study.

DISCUSSION

The overall architecture of a database designed to collect, search and analyse data is provided in the last part of the paper.

CONCLUSION

This framework offers two possibilities at the same time: it provides therapists with the ability to follow the evolution of their cases and to compare them with similar cases. It provides researchers with the ability to drive true comparative analysis, based on psychotherapies conducted in real situations and on detailed-enough descriptions to obtain significant outcomes.

Pesquisas em psicoterapia: seções especiais de periódico (1995 a 2005)

O artigo apresenta pesquisas em psicoterapia para completar uma visão qualitativa das tendências da área. Analisa sete seções especiais sobre o tema publicadas no período de 1995 a 2005 em um conceituado periódico da American Psychological Association (APA). Verifica que as grandes ênfases da área - busca de evidência científica e articulação da pesquisa com a prática clínica - permanecem no foco das discussões, principalmente o debate sobre os ensaios clínicos controlados. Constata produção menos intensa no período, mas condições mais objetivas de uma possível aproximação entre os pesquisadores e os clínicos. Os desafios persistem, agora buscando novos caminhos.

What should we mean by empirical validation in hypnotherapy: evidence-based practice in clinical hypnosis

This paper briefly surveys the trend of and controversy surrounding empirical validation in psychotherapy. Empirical validation of hypnotherapy has paralleled the practice of validation in psychotherapy and the professionalization of clinical psychology, in general. This evolution in determining what counts as evidence for bona fide clinical practice has gone from theory-driven clinical approaches in the 1960s and 1970s through critical attempts at categorization of empirically supported therapies in the 1990s on to the concept of evidence-based practice in 2006. Implications of this progression in professional psychology are discussed in the light of hypnosis's current quest for validation and empirical accreditation.

Novice, seasoned and veteran counselors' views of addiction treatment manuals: the influence of counselor characteristics on manual usefulness

A preliminary study was conducted to examine substance abuse counselors' views of empirically supported treatments (ESTs). A survey of 72 substance abuse counselors was used to explore counselor qualities and overall responses to ESTs. There were no significant differences in views of ESTs for novice, seasoned and veteran counselors, but veteran counselors reported that supervision was less likely to influence their views of manual usefulness. Counselors' recovery status and theoretical orientation influenced novice, seasoned and veteran counselors' views of ESTs and manual usefulness. Implications for undergraduate, graduate and continuing education are discussed.

On the next generation of process research

This set of articles offers examples of innovative and exciting trends in psychotherapy process research. We briefly review the state-of-the-art of psychotherapy research, highlighting some limitations of current approaches in the field and the pressing need to move beyond the current state of affairs. We note that the methods advocated and put to use by the authors in this issue are quite likely to lead the field in a more desirable direction. Specifically, these methods allow a more complex and contextual way to examine the process of change and relapse. Taken together, the methods proposed here come closer than previous research procedures to capturing the realities that clinicians face in their real-life interventions. For this reason, we hope that the future of process research will include more studies of this type.

Intensive cognitive-behavioral group treatment (CBGT) of social phobia: a randomized controlled study

The effects of intensive cognitive-behavioral group treatment (CBGT) for social phobia (DSM-IV) were studied in 26 patients randomly assigned either to a treatment group (TG) or to a 6-month waiting list control group (WG). Treatment involved 2 weeks of daily treatment sessions separated by 1 week of homework assignments. TG was superior to WG at all assessment points, i.e., at 3 weeks and at 3 and 6 months of post-treatment. After 6 months, significant treatment effects were found in the majority of social phobia measures indicating decreased levels of social anxiety and avoidance, safety-behaviors and symptoms influence on daily life. The WG received treatment following the waiting list period and was combined with the TG in order to evaluate the outcome in a larger sample. Treatment gains at 3 weeks were maintained or improved at 1-year follow-up. Average effect sizes of social phobia measures ranged from 0.56 at post-treatment, 0.68 at 3 months and 0.81 at 6 months and 1 year, respectively.

Fixed values and a flexible partial hospital program model

Since the 1990s, societal and economic factors have constrained mental health care service delivery in the United States. Partial hospital (PH) programs have been presented with the challenge of using limited resources to treat complex patients in very short time frames; yet predominant psychosocial models and evidence-based treatment approaches have not adjusted sufficiently to the combined demands of patient care and the new health care environment. An updated PH model can advance existing psychosocial theory and practice. The basic assumption of the model is that both clinical and organizational aspects of a PH program must be inherently adaptable to maintain consistent effectiveness. The set of fixed values described here are instrumental in establishing priorities, guiding decision making, and creating a proactive, flexible organization. These values are drawn from the history of psychosocial and milieu treatments from the 1930s to the present and from assumptions and practices of cognitive-behavioral therapy, and are augmented by insights from psychodynamic psychiatry, business management, and leadership. The PH treatment approach aims to translate evidence-based cognitive-behavioral treatments into pragmatic interventions with emphases on psychoeducation and skills training. The context is brief treatment (i.e., one to two weeks) for mood, anxiety, and personality disordered patients in a private sector, managed care environment. Elements of this model may be generalized to inpatient, residential, and intensive outpatient programs, as well as to those that are starting up or being reorganized.

Empirically and clinically useful decision making in psychotherapy: Differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.

Reflections on the Challenges of Effective Dissemination of Behavioural Family Intervention: Our Experience with the Triple P - Positive Parenting Program

This paper draws on learnings from dissemination and diffusion research to discuss predictors of dissemination outcomes, obstacles to effective dissemination, and phases of dissemination failure. A model is presented of effective dissemination of a multilevel system of intervention known as the Triple P-Positive Parenting Program (Triple P). This model takes a systems-contextual approach, addressing program design, skills training, practitioner confidence and self-regulation, and workplace support. Recommendations are made for agencies adopting evidence-based programs, particularly in relation to the selection, establishment and maintenance of new programs as well as guiding ongoing program development. Future directions for research into the dissemination of evidence-based practice are also discussed.

Zur Entwicklung von Entscheidungsregeln in der Psychotherapie

Zusammenfassung. Theoretischer Hintergrund und Fragestellung: Das Monitoring von Psychotherapieverläufen, d.h. die wiederholte Messung der durch die psychotherapeutische Behandlung bewirkten Veränderungen beim einzelnen Patienten und der Vergleich mit statistisch vorhergesagten Veränderungen, kann die Entscheidungsprozeduren hinsichtlich des therapeutischen Vorgehens, gerade in etablierten Wissenschaftler-Praktiker-Netzwerken, maßgeblich unterstützen. Die vorliegende Arbeit adaptiert eine bereits in der Lawinenforschung etablierte Strategie zur Vorhersagen auf der Basis ähnlicher Gruppen, um ein enstprechendes differenzielles Vorhersagesystem für psychotherapeutische Behandlungsverläufe zu entwickeln. Methode und Ergebnisse: Die Studie basiert auf insgesamt 618 Patientinnen und Patienten mit breitem Diagnosespektrum, welche entweder mit einem kombiniert bewältigungs- und klärungsorientierten (n = 356) oder einem rein bewältigungsorientierten Vorgehen (n = 262) behandelt wurden. Bei diesem Vorgehen wurden die Patienten in einem ersten Schritt in homogene Subgruppen eingeteilt, um in einem zweiten Schritt mit Hilfe von Wachstumsanalysen ihren Psychotherapieverlauf vorherzusagen und mit dem tatsächlichen Verlauf vergleichen zu können. Die Validität der statistischen Vorhersagemodelle für die einzelnen Patienten und Behandlungsmodalitäten wurde mit einer sequenzanalytischen Verfahren überprüft. Schlussfolgerungen: Mögliche Anwendungen und Implikationen für die klinische Praxis, welche sowohl mehr Informationen über die Patienten zur Verfügung stellen als auch damit klinische Entscheidungsprozesse verbessern können, werden diskutiert. Momentane Grenzen des Ansatzes sowie notwendige weitere Forschungsaspekte werden aufgezeigt.

Can the Randomized Controlled Trial Literature Generalize to Nonrandomized Patients?

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of outpatients, the authors matched information obtained from charts of patients who had been screened out of RCTs to inclusion and exclusion criteria from published RCT studies. Most of the patients in the sample who had primary diagnoses represented in the RCT literature were judged eligible for at least 1 RCT. However, many patients in the sample with substance use disorders or social anxiety disorder were not eligible for at least 2 RCTs. Common reasons that patients did not match with at least 2 published RCTs for psychotherapy included (a) patients were in partial remission, (b) patients failed to meet minimum severity or duration criteria, (c) patients were being treated with antidepressant medication, and (d) the disorder being studied was not primary (mostly for social anxiety patients). The implications of these findings for future research and clinical practice are discussed.

Effects of Behavioral Marital Therapy: A Meta-Analysis of Randomized Controlled Trials

This meta-analysis summarizes results from 30 randomized experiments that compare behavioral marital therapy with no-treatment control with distressed couples. Results showed that behavioral marital therapy is significantly more effective than no treatment (d=.585). Although behavioral marital therapy research studies tend to be conducted under conditions that are less clinically representative than other samples of studies, representativeness was not significantly related to outcome. However, evidence also suggested that publication bias may exist in this literature whereby small sample studies with small effects are systematically missing compared with other studies. This bias may inflate the effects of behavioral marital therapies reported in previous meta-analyses, though we also explore a number of alternative explanations for this small sample bias.

The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials

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

Are samples in randomized controlled trials of psychotherapy representative of community outpatients? A new methodology and initial findings

To determine the extent to which published randomized controlled trials (RCTs) of psychotherapy can be generalized to a sample of community outpatients, the authors used a method of matching information obtained from outpatient charts to inclusion and exclusion criteria from published RCT studies. They found that 80% of the patients in their sample who had diagnoses represented in the RCT literature were judged eligible for at least 1 published RCT; however, 58% of the patients had primary diagnoses such as adjustment disorder or dysthymia, which were not represented in the existing psychotherapy outcome literature. The most common reasons that patients in their sample did not match with published RCTs for psychotherapy are listed, and the implications of these findings for research and practice are discussed.

The feasibility and effectiveness of an expressive writing intervention for rheumatoid arthritis via home-based videotaped instructions

BACKGROUND

Expressive emotional writing has demonstrated efficacy for improving health status in a wide variety of healthy persons and recently in patients with chronic disease.

PURPOSE

This study was a randomized, controlled effectiveness trial with 4 arms: 2 active treatment writing groups, 1 inactive writing group, and 1 attention control group. It represents the first attempt to translate the expressive writing intervention into a low-cost, community-based intervention in the form of a videotaped program.

METHODS

Feasibility of the approach and patient adherence were examined in a community rheumatology practice with rheumatoid arthritis patients (N = 373).

RESULTS

The videotape format was able to convey the intervention instructions accurately and produced the expected and differential ratings of stressfulness and emotional provocation across the 3 writing programs. Seventy-nine percent of eligible patients agreed to take the program home; 49% of these patients reported that they followed the protocol. Physician Disease Activity Rating and the Physical Component Summary of the SF36v2 Health Survey were assessed pre and post program.

CONCLUSIONS

Intent-to-treat analyses found no effect of the treatment. Pretreatment differences among the protocol-adherent patients complicated treatment outcome interpretation. The standard writing instructions did not yield an effect; a modified set of instructions to extract meaning from the traumatic event yielded equivocal results. Contrasts between efficacy and effectiveness trials and the challenge of achieving significant outcomes in effectiveness trials are discussed.

It's more than a black box; it's a Russian doll: defining rehabilitation treatments

Research on treatment efficacy and effectiveness requires that the treatments of interest be objectively defined. Such definitions are relatively straightforward for pharmacologic and surgical treatments, in which the active ingredients can be specified in terms of chemical structure or anatomic result. Definitions of treatment are more difficult for the many experience-based interventions employed in rehabilitation. This has led to the criticism that much clinical rehabilitation research has characterized the treatments of interest as a "black box," allowing little insight into the active ingredients contained therein. Moreover, rehabilitation care may involve the simultaneous application of multiple different treatments, raising the question of whether to define the individual components or the service delivery system. In this article, we consider how the levels of analysis considered in rehabilitation (disease, impairment, activity, and participation) and the role of theory shape the definition of treatment, and we address the need to develop protocol-based treatments and tools to objectively verify their contents. Rigorous definition of rehabilitation treatments, supported by theory, will facilitate needed efficacy research, will allow replication of that research, and will ultimately foster dissemination of effective treatments into clinical practice.

Psychology should list empirically supported principles of change (ESPs) and not credential trademarked therapies or other treatment packages

Current systems for listing empirically supported therapies (ESTs) provide recognition to treatment packages, many of them proprietary and trademarked, without regard to the principles of change believed to account for their effectiveness. Our position is that any authoritative body representing the science and profession of psychology should work solely toward the identification of empirically supported principles of change (ESPs). As challenging as it is to take this approach, a system that lists ESPs will keep a focus on issues central to the science and practice of psychology while also insulating the profession from undue entrepreneurial influences.

Randomized controlled trials in psychiatry. Part II: their relationship to clinical practice

OBJECTIVE

To discuss the extent to which the results of randomized controlled trials (RCTs) in psychiatry can be generalized to clinical practice.

METHOD

Threats to internal and external validity in psychiatric RCTs are reviewed.

RESULTS

Threats to internal validity increase the possibility of bias. Psychiatric RCTs have problems with small samples, arbitrary definitions of caseness, disparate definitions of outcome and high spontaneous recovery rates. Particular issues arise in psychotherapy RCTs. Threats to external validity reduce the extent to which the results of a RCT produce a correct basis for generalization to other circumstances. These include high rates of comorbidity and sub syndromal pathology in normal clinical practice, manual-based treatment protocols and varying definitions of successful treatment.

CONCLUSIONS

Randomized controlled trials remain the most robust design to investigate the effectiveness of treatments. They should be applied to important clinical questions; and carried out, as far as possible, with typical patients in the clinical conditions in which the treatment is likely to be used.

Effectiveness of cognitive therapy for depression in a community mental health center: a benchmarking study

The current study examined the feasibility and effectiveness of transporting an empirically supported treatment for depression, cognitive therapy (CT), to a community mental health center setting. CT was delivered to 192 adult outpatients with major depression, and a benchmarking strategy compared results with those of 2 randomized controlled trials (RCTs). The 3 samples were largely similar in terms of initial severity of depression, and CT was as effective in reducing depressive symptoms in the current sample as in the RCTs. More favorable outcome was associated with less severe initial depression, more therapy sessions, more years of education, and absence of a comorbid personality disorder. This study demonstrates that an empirically supported treatment can be transported effectively to a clinical setting.

Applying Treatment Outcome Research in Clinical Practice: Techniques for Adapting Interventions to the Real World

Despite the growing literature on empirically supported therapies, these interventions are rarely used in clinical settings. Although researchers lament the poor transfer of techniques from controlled trials to clinics, little has been written to guide the adaptation of manualised treatments for real-life clinical practice. The goal of this paper is to provide suggestions for the clinical use of research-tested treatments, with specific examples from the treatment of child depressive disorders. Strategies for applying manuals flexibly, adapting treatments to address comorbidity, attending to individual differences, and overcoming training obstacles are highlighted.