Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care

Introduction to the special issue on Cognitive bias modification: Taking a step back to move forward?

Cognitive bias modification (CBM) research holds important theoretical and clinical potential. CBM represents one of the most exciting translational developments in experimental psychopathology research in recent years. Despite theoretical and methodological advances in the past 15 years, the clinical efficacy of CBM, to-date, has been disappointing. However, it is important to remember that the CBM therapeutics literature is only in its early stages of scientific development. We argue that the potential for novel approaches to CBM to contribute to disseminable psychological interventions is strong and has yet to be realized. Accordingly, we propose 5 inter-related steps that may help advance the basic and clinical science of CBM: (1) Innovation and refinement of the methodology to modify information-processing bias; (2) Advancing understanding of the nature of processing biases in order to guide their modification; (3) Conceptualizing and studying the moderating and mediating mechanisms underlying the modification of information-processing bias and their effects on maladaptation; (4) Focus on augmenting existing validated treatments, by targeting psychobehavioral processes proximally linked to information-processing biases; (5) Encouraging publication of methodologically strong, mixed and unexpected findings. Finally, we introduce papers in the special issue with respect to each of these future directions. These papers provide important new conceptual and methodological perspectives to advance CBM research.

Caregiver Perceptions of Clinical Decision-Making for the Treatment of Children

Many sources of information impact one's clinical decision-making (CDM) (e.g. clinical intuition, previous experience, research results). Relatively little is known about the clients' perspectives of these factors. The current study is an examination of perceptions of the favorability of various CDM influences held by caregivers of children presenting for mental health treatment (n = 371). Responses to a questionnaire showed that caregivers overwhelmingly favored a treatment decision based on current scientific research, with one's clinical experience being the second most favored influence. Other influences, such as colleague consultation and clinical intuition, were less favorable.

How important are the common factors in psychotherapy? An update

The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and competence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.

Why Ineffective Psychotherapies Appear to Work: A Taxonomy of Causes of Spurious Therapeutic Effectiveness

The past 40 years have generated numerous insights regarding errors in human reasoning. Arguably, clinical practice is the domain of applied psychology in which acknowledging and mitigating these errors is most crucial. We address one such set of errors here, namely, the tendency of some psychologists and other mental health professionals to assume that they can rely on informal clinical observations to infer whether treatments are effective. We delineate four broad, underlying cognitive impediments to accurately evaluating improvement in psychotherapy-naive realism, confirmation bias, illusory causation, and the illusion of control. We then describe 26 causes of spurious therapeutic effectiveness (CSTEs), organized into a taxonomy of three overarching categories: (a) the perception of client change in its actual absence, (b) misinterpretations of actual client change stemming from extratherapeutic factors, and (c) misinterpretations of actual client change stemming from nonspecific treatment factors. These inferential errors can lead clinicians, clients, and researchers to misperceive useless or even harmful psychotherapies as effective. We (a) examine how methodological safeguards help to control for different CSTEs, (b) delineate fruitful directions for research on CSTEs, and (c) consider the implications of CSTEs for everyday clinical practice. An enhanced appreciation of the inferential problems posed by CSTEs may narrow the science-practice gap and foster a heightened appreciation of the need for the methodological safeguards afforded by evidence-based practice.

From Big Data to Knowledge in the Social Sciences

One of the challenges associated with high-volume, diverse datasets is whether synthesis of open data streams can translate into actionable knowledge. Recognizing that challenge and other issues related to these types of data, the National Institutes of Health developed the Big Data to Knowledge or BD2K initiative. The concept of translating "big data to knowledge" is important to the social and behavioral sciences in several respects. First, a general shift to data-intensive science will exert an influence on all scientific disciplines, but particularly on the behavioral and social sciences given the wealth of behavior and related constructs captured by big data sources. Second, science is itself a social enterprise; by applying principles from the social sciences to the conduct of research, it should be possible to ameliorate some of the systemic problems that plague the scientific enterprise in the age of big data. We explore the feasibility of recalibrating the basic mechanisms of the scientific enterprise so that they are more transparent and cumulative; more integrative and cohesive; and more rapid, relevant, and responsive.

Reconciling evidence-based practice and cultural competence in mental health services: introduction to a special issue

The calls for evidence-based practice (EBP) and cultural competence (CC) represent two increasingly influential mandates within the mental health professions. Advocates of EBP seek to standardize clinical practice by ensuring that only treatment techniques that have demonstrated therapeutic outcomes under scientifically controlled conditions would be adopted and promoted in mental health services. Advocates of CC seek to diversify clinical practice by ensuring that treatment approaches are designed and refined for a multicultural clientele that reflects a wide variety of psychological orientations and life experiences. As these two powerful mandates collide, the fundamental challenge becomes how to accommodate substantive cultural divergences in psychosocial experience using narrowly prescriptive clinical practices and approaches, without trivializing either professional knowledge or cultural difference. In this Introduction to a special issue of Transcultural Psychiatry, the virtue of an interdisciplinary conversation between and among anthropologists, psychologists, psychiatrists, and social work researchers in addressing these tensions is extolled.

Humanistic psychotherapy research 1990-2015: from methodological innovation to evidence-supported treatment outcomes and beyond

OBJECTIVE

Over the past 25 years, humanistic psychotherapy (HP) researchers have actively contributed to the development and implementation of innovative practice-informed research measures and coding systems.

METHOD

Qualitative and quantitative research findings, including meta-analyses, support the identification of HP approaches as evidence-based treatments for a variety of psychological conditions.

RESULTS

Implications for future psychotherapy research, training, and practice are discussed in terms of addressing the persistent disjunction between significant HP research productivity and relatively low support for HP approaches in university-based clinical training programs, funding agencies, and government-supported clinical guidelines.

CONCLUSION

Finally, specific recommendations are provided to further enhance and expand the impact of HP research for clinical training programs and the development of treatment guidelines.

Case-Series Evaluating a Transdiagnostic Cognitive-Behavioural Treatment for Co-occurring Anxiety Disorders

BACKGROUND

Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioural interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating co-occurring anxiety disorders.

AIMS

To evaluate the efficacy of a transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders.

METHOD

An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13-session modular transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD.

RESULTS

Five of the six participants completed treatment. At posttreatment assessment the five treatment completers achieved diagnostic and symptomatic change, with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the 3-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre to postintervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at 3-month follow-up.

CONCLUSIONS

Results suggest that transdiagnostic cognitive behavioural interventions can be of benefit to patients with co-occurring anxiety disorders.

Ceragenin mediated selectivity of antimicrobial silver nanoparticles

The understanding that common broad-spectrum antimicrobials disrupt natural microbial flora important in acquiring nutrients and preventing infection has resulted in a paradigm shift favoring more selective antimicrobials. This work explores silver nanoparticles conjugated with ceragenin, or cationic antimicrobials (CSA-SNPs), as a potential Gram-positive selective antimicrobial. Herein, CSA-SNPs are characterized using transmission electron microscopy (TEM), dynamic light scattering (DLS), zeta potential, and high-performance liquid chromatography-electrospray time-of-flight mass spectrometry (HPLC-ESI-TOF-MS). The antimicrobial properties are determined through minimum inhibitory concentration/minimum bactericidal concentration (MIC/MBC) and time-kill studies. Spatial selectivity of the conjugate nanoparticle was evaluated using confocal imaging, MATLAB statistical analysis, and video monitored interactions between bacteria and CSA-SNPs via laser trapping techniques. Cytotoxicity was also determined by live/dead staining and flow cytometry. Average particle size, as determined through TEM analysis, and hydrodynamic diameter, as determined via DLS, are 63.5 ± 38.8 and 102.23 ± 2.3 nm, respectively. The zeta potential of the SNP before and after CSA attachment is -18.23 and -8.34 mV, respectively. MIC/MBC data suggest that CSA-SNPs are 8 times more effective against Staphylococcus aureus than SNPs alone. Furthermore, MATLAB analysis of confocal imaging found that 70% of CSA-SNPs are within 2 μm of S. aureus, whereas this percentage falls to below 40% with respect to Escherichia coli. These results are bolstered further by laser trapping experiments demonstrating selective adherence of CSA-SNPs conjugates with bacterial strains. Cytotoxicity studies of CSA-SNPs against 3T3 fibroblasts indicate 50% cell viability at 50 ppm.

The gap between science and practice: how therapists make their clinical decisions

Recent surveys have found that many patients are not receiving empirically supported treatments and that therapists may not update their knowledge of research. Studies have found that therapists prefer to use their clinical experience rather than research findings to improve their practice, although cognitive behavioral (CB) practitioners have been found to use research more frequently than therapists of other theoretical orientations. The organization in which therapists work has been shown to impact attitudes toward working practices, but studies have not examined whether workplace requirements to use research affect therapists' practice. Studies to date have mainly been conducted in North America. These findings may not be generalizable to the United Kingdom where there is a National Health Service (NHS), which requires the use of empirically supported treatments. The first part of this study aimed to investigate which factors were influential in therapists' choice of theoretical orientation and to see whether CB practitioners differed from other therapists in the factors that influenced their choice of theoretical orientation. The second part tested whether therapists' theoretical orientation or their workplace influenced the frequency with which they used research in their clinical decision-making. The final part investigated whether being a CB practitioner or working in the NHS was associated with having a favorable attitude toward research. An online survey was sent to 4,144 psychological therapists in England; 736 therapists responded (18.5%). Therapists reported that research had little influence over their choice of theoretical orientation and clinical decision-making compared to other factors, specifically clinical experience and supervision. CB practitioners and NHS therapists, regardless of their orientation, were significantly more likely to use research than other therapists and were more likely to have a positive attitude toward research.

Disseminating Behavioural Activation for Depression via Online Training: Preliminary Steps

Background: Despite the availability of evidence-based treatments for depression, large gaps exist between empirical research and clinical practice. Aims: To make preliminary steps toward the dissemination of Behavioural Activation (BA) via online training by examining clinicians’ interest in learning BA via online training and the effects of a preliminary version of BA online training. Method: In study 1, practising clinicians (n = 540) completed a survey that assessed attitudes towards learning BA using an online training format. In study 2, we conducted a small, pilot randomized controlled trial (n = 46) to examine preliminary efficacy of teaching BA principles and treatment strategies with a precursor version of BA online training. Results: Study findings suggest that clinicians have interest in learning about BA via online training and that clinicians participating in BA online training evidence high satisfaction and significant gains in self-efficacy using BA and knowledge of BA terms and concepts. Conclusions: These results support the importance of efforts to disseminate BA and the viability of online training as an easily accessible and affordable training option.

Reenvisioning Clinical Science: Unifying the Discipline to Improve the Public Health

We present a vision of clinical science, based on a conceptual framework of intervention development endorsed by the Delaware Project. This framework is grounded in an updated stage model that incorporates basic science questions of mechanisms into every stage of clinical science research. The vision presented is intended to unify various aspects of clinical science toward the common goal of developing maximally potent and implementable interventions, while unveiling new avenues of science in which basic and applied goals are of equally high importance. Training in this integrated, translational model may help students learn how to conduct research in every domain of clinical science and at each stage of intervention development. This vision aims to propel the field to fulfill the public health goal of producing implementable and effective treatment and prevention interventions.

A war over mental health professionalism: Scientology versus psychiatry

Over 60 years ago, founder L. Ron Hubbard began what has become Scientology's greatest battle. Scientology emerged from Dianetics, which Hubbard hoped would replace the psychiatric profession. In this article, we discuss how Scientology attempted to position itself as a rival profession to psychiatry and the consequences of those attempts. Scientology's battle with psychiatry gained some success from the social conditions during which it emerged, but it continues in a time that has seen increasing success with various psychiatric treatments. As such, Scientology's direct influence on the psychiatric profession may be difficult to measure, but its actions have coincided with substantial challenges to psychiatry.

The importance of theory in cognitive behavior therapy: a perspective of contextual behavioral science

For the past 30 years, generations of scholars of cognitive behavior therapy (CBT) have expressed concern that clinical practice has abandoned the close links with theory that characterized the earliest days of the field. There is also a widespread assumption that a greater working knowledge of theory will lead to better clinical outcomes, although there is currently very little hard evidence to support this claim. We suggest that the rise of so-called "third generation" models of CBT over the past decade, along with the dissemination of statistical innovations among psychotherapy researchers, have given new life to this old issue. We argue that theory likely does matter to clinical outcomes, and we outline the future research that would be needed to address this conjecture.

The theory-practice gap in cognitive behavioral therapy: reflections and a modest proposal to bridge the gap

This paper examines the issues related to the gap between theory and practice in the area of cognitive-behavioral therapy. The article begins with a review of the evidence for such a gap, and having demonstrated that the gap exists, provides a discussion of some of the factors that are likely important in its genesis and maintenance. The article then focuses on potential strategies to reduce the theory-practice gap that go beyond the common recommendation for both efficacy and effectiveness research. In particular, we provide recommendations for protocol planning and design, training and competency maintenance, dissemination research, and implementation and policy change. We conclude with the proposition that theory and research should not only inform practice, but that practice should have a reciprocal benefit on theory and research.

The theory-practice gap in cognitive-behavior therapy

This special series is devoted to understanding the theory-practice gap in cognitive-behavior therapy (CBT). Although CBT enjoys considerable empirical support, and is widely recognized as an efficacious approach to a diversity of psychiatric disorders and includes many different forms of treatment, it is unclear whether clinicians are familiar with the underlying theories of the treatments they are practicing. Moreover, it is unclear to what degree an understanding of the theory is necessary for effective practice. Gaining clarity on the role of understanding underlying theory and identifying potential disparities between theory and practice may have implications for the way graduate training programs are structured and current professionals approach continuing education. A brief exploration of these implications will be offered by introducing issues related to the scientist-practitioner model and dissemination of efficacious treatments, in addition to an outline of potential advantages and disadvantages of knowing underlying theory. This special series will then feature several major approaches to treatment wherein the role of theory and practice are discussed.

More practice, less preach? the role of supervision processes and therapist characteristics in EBP implementation

Identifying predictors of evidence-based practice (EBP) use, such as supervision processes and therapist characteristics, may support dissemination. Therapists (N = 57) received training and supervision in EBPs to treat community-based youth (N = 136). Supervision involving modeling and role-play predicted higher overall practice use than supervision involving discussion, and modeling predicted practice use in the next therapy session. No therapist characteristics predicted practice use, but therapist sex and age moderated the supervision and practice use relation. Supervision involving discussion predicted practice use for male therapists only, and modeling and role-play in supervision predicted practice use for older, not younger, therapists.

The research-practice gap: bridging the schism between eating disorder researchers and practitioners

OBJECTIVE

The field of eating disorders (EDs) treatment has been beset by a marked disjunction between scientific evidence and clinical application. We describe the nature and scope of the research-practice gap in the ED field.

METHOD

We draw on surveys and broader literature to better understand the research-practice gap in ED treatment and reasons for resistance to evidence-based practice.

RESULTS

We identify three sources of the research-practice gap: (1) attitudinal factors, (2) differences in the definition of "evidence," and (3) cognitive factors, especially naïve realism and confirmation bias. We affirm the role of science as a safeguard against human fallibility and as a means of bridging the research-practice gap, and delineate key principles of scientific thinking for ED researchers and practitioners.

DISCUSSION

We conclude with proposals for narrowing the research-practice gap in ED treatment and enhancing the quality of interventions for ED clients.

Evolving from Methodological to Conceptual Unification

The absence of a philosophical system that can effectively address the profound problems that exist at the heart of psychology has resulted in the discipline becoming increasingly defined and unified simply by its commitment to the scientific method. This article articulates why unification via method is a weak intellectual solution and explains how the Unified Theory ( Henriques, 2011 ) provides the needed framework so that the field can evolve from its current unity via method to a more mature conceptual unity that clearly defines psychology, grounds it in a scientific worldview, and assimilates and integrates its key insights into a coherent whole.

Testing use of payers to facilitate evidence-based practice adoption: protocol for a cluster-randomized trial

Background

More effective methods are needed to implement evidence-based findings into practice. The Advancing Recovery Framework offers a multi-level approach to evidence-based practice implementation by aligning purchasing and regulatory policies at the payer level with organizational change strategies at the organizational level.

Methods

The Advancing Recovery Buprenorphine Implementation Study is a cluster-randomized controlled trial designed to increase use of the evidence-based practice buprenorphine medication to treat opiate addiction. Ohio Alcohol, Drug Addiction, and Mental Health Services Boards (ADAMHS), who are payers, and their addiction treatment organizations were recruited for a trial to assess the effects of payer and treatment organization changes (using the Advancing Recovery Framework) versus treatment organization changes alone on the use of buprenorphine. A matched-pair randomization, based on county characteristics, was applied, resulting in seven county ADAMHS boards and twenty-five treatment organizations in each arm. Opioid dependent patients are nested within cluster (treatment organization), and treatment organization clusters are nested within ADAMHS county board. The primary outcome is the percentage of individuals with an opioid dependence diagnosis who use buprenorphine during the 24-month intervention period and the 12-month sustainability period. The trial is currently in the baseline data collection stage.

Discussion

Although addiction treatment providers are under increasing pressure to implement evidence-based practices that have been proven to improve patient outcomes, adoption of these practices lags, compared to other areas of healthcare. Reasons frequently cited for the slow adoption of EBPs in addiction treatment include, regulatory issues, staff, or client resistance and lack of resources. Yet the way addiction treatment is funded, the payer’s role—has not received a lot of attention in research on EBP adoption.

This research is unique because it investigates the role of payers in evidence-based practice implementation using a randomized controlled design instead of case examples. The testing of the Advancing Recovery Framework is designed to broaden the understanding of the impact payers have on evidence-based practice (EBP) adoption.

Trial registration

http://NCT01702142 (ClinicalTrials.gov registry, USA)

Why many clinical psychologists are resistant to evidence-based practice: root causes and constructive remedies

Psychotherapists are taught that when a client expresses resistance repeatedly, they must understand and address its underlying sources. Yet proponents of evidence-based practice (EBP) have routinely ignored the root causes of many clinical psychologists' reservations concerning the use of scientific evidence to inform clinical practice. As a consequence, much of the resistance to EBP persists, potentially widening the already large scientist-practitioner gap. Following a review of survey data on psychologists' attitudes toward EBP, we examine six sources underpinning resistance toward EBP in clinical psychology and allied domains: (a) naïve realism, which can lead clinicians to conclude erroneously that client change is due to an intervention itself rather than to a host of competing explanations; (b) deep-seated misconceptions regarding human nature (e.g., mistaken beliefs regarding the causal primacy of early experiences) that can hinder the adoption of evidence-based treatments; (c) statistical misunderstandings regarding the application of group probabilities to individuals; (d) erroneous apportioning of the burden of proof on skeptics rather than proponents of untested therapies; (e) widespread mischaracterizations of what EBP entails; and (f) pragmatic, educational, and attitudinal obstacles, such as the discomfort of many practitioners with evaluating the increasingly technical psychotherapy outcome literature. We advance educational proposals for articulating the importance of EBP to the forthcoming generation of clinical practitioners and researchers, and constructive remedies for addressing clinical psychologists' objections to EBP.

The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research

The biomedical model posits that mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities. A biologically-focused approach to science, policy, and practice has dominated the American healthcare system for more than three decades. During this time, the use of psychiatric medications has sharply increased and mental disorders have become commonly regarded as brain diseases caused by chemical imbalances that are corrected with disease-specific drugs. However, despite widespread faith in the potential of neuroscience to revolutionize mental health practice, the biomedical model era has been characterized by a broad lack of clinical innovation and poor mental health outcomes. In addition, the biomedical paradigm has profoundly affected clinical psychology via the adoption of drug trial methodology in psychotherapy research. Although this approach has spurred the development of empirically supported psychological treatments for numerous mental disorders, it has neglected treatment process, inhibited treatment innovation and dissemination, and divided the field along scientist and practitioner lines. The neglected biopsychosocial model represents an appealing alternative to the biomedical approach, and an honest and public dialog about the validity and utility of the biomedical paradigm is urgently needed.

Development of a Multilevel Framework to Increase Use of Targeted Evidence-Based Practices in Addiction Treatment Clinics

Implementing specific evidence-based practices (EBPs) across a set of addiction treatment providers have been a persistent challenge. In the Advancing Recovery(AR) demonstration project, single state agencies, the entities that distribute federal funds for substance use disorder prevention and treatment services, worked in partnership with providers to increase the use of EBPs in the treatment of addiction. The project supported two cohorts of six 2-year awards. Field observations from the first year of implementation guided development of a multilevel framework (the Advancing Recovery Framework). Government entities and other payers can use the framework as a guide for implementing evidence-based clinical practices within treatment networks. The Advancing Recover Framework calls for a combination of policy and organizational changes at both the payer (government agency) and provider levels. Using the Advancing Recovery Framework, 11 of the 12 AR payer/provider partnerships increased use of clinical EPBs. This article identifies key payer policy changes applied during different phases of EBP program implementation. The public health benefit of the demonstration project was broader use of medication-assisted therapy and continuing care in addiction treatment services.

Family treatment for bipolar disorder and substance abuse in late adolescence

The initial onset of bipolar disorder occurs in childhood or adolescence in about 50% of patients. Early-onset forms of the disorder have a poorer prognosis than adult-onset forms and are frequently characterized by comorbid substance abuse. Clinical trials research suggests that family psychoeducational approaches are effective adjuncts to medication in stabilizing the symptoms of bipolar disorder in adults and youth, although their efficacy in patients with comorbid substance use disorders has not been systematically investigated. This article describes the family-focused treatment (FFT) of a late adolescent with bipolar disorder and polysubstance dependence. The treatment of this patient and family required adapting FFT to consider the family's structure, dysfunctional alliance patterns, and unresolved conflicts from early in the family's history. The case illustrates the importance of conducting manual-based behavioral family treatments with a psychotherapeutic attitude, including addressing unstated emotional conflicts and resistances that may impede progress.

How Do Relationship Maintenance Behaviors Affect Individual Well-Being?

How do relationship maintenance behaviors affect individual well-being? Given that people who invest time and effort toward achieving important goals see their outcomes as more reflective of their skills and abilities than do people who invest less time and effort, engaging in relationship maintenance behaviors may lead people to experience increased individual well-being when those behaviors appear to be successful but decreased well-being when they appear to be unsuccessful. A diary study of romantic relationships, a diary study of friendships, and a longitudinal study of newlyweds provided support for this prediction. In all three studies, relationship maintenance behaviors were negatively associated with depressive mood when followed by relatively high relationship quality, but positively associated with depressive mood when followed by relatively low relationship quality. Accordingly, relationship maintenance processes are not inherently beneficial or harmful; their intrapersonal implications depend on the context in which they occur.

Exploring unexplained variation

In a 1974 commencement address, Richard Feynman described scientific integrity as a kind of utter honesty, a kind of leaning over backwards to tell the whole truth. We argue that investigators could tell more of the truth and increase the value of their papers by highlighting and discussing unexplained variation, a major source of which is individual differences. An argument that unexplained individual differences must have many sources is presented, and means of representing that variation are illustrated. We believe that such a change in reporting of research results is likely to advance the progress of scientific psychology, but perhaps the most compelling argument for what we propose is simply that telling the whole story as fully as possible is good scientific practice. The Appendix provides two examples of what we are urging, taken from recent psychological literature.

A translational model of research-practice integration

We propose a four-level, recursive Research-Practice Integration framework as a heuristic to (a) integrate and reflect on the articles in this Special Section as contributing to a bidirectional bridge between research and practice, and (b) consider additional opportunities to address the research-practice gap. Level 1 addresses Treatment Validation studies and includes an article by Lochman and colleagues concerning the programmatic adaptation, implementation, and dissemination of the empirically supported Coping Power treatment program for youth aggression. Level 2 translation, Training in Evidence-Based Practice, includes a paper by Hershenberg, Drabick, and Vivian, which focuses on the critical role that predoctoral training plays in bridging the research-practice gap. Level 3 addresses the Assessment of Clinical Utility and Feedback to Research aspects of translation. The articles by Lambert and Youn, Kraus, and Castonguay illustrate the use of commercial outcome packages that enable psychotherapists to integrate ongoing client assessment, thus enhancing the effectiveness of treatment implementation and providing data that can be fed back to researchers. Lastly, Level 4 translation, the Cross-Level Integrative Research and Communication, concerns research efforts that integrate data from clinical practice and all other levels of translation, as well as communication efforts among all stakeholders, such as researchers, psychotherapists, and clients. Using a two-chair technique as a framework for his discussion, Wolfe's article depicts the struggle inherent in research-practice integration efforts and proposes a rapprochement that highlights advancements in the field.

Bridging the gap between clinical research and clinical practice: introduction to the special section

This Special Section, developed by the American Psychology Association's Division 12 (Clinical) 2011 Committee on Science and Practice, highlights different ideas to help bridge the gap between clinical research and clinical practice, and notes recent innovations that help make research-practice integration feasible. The articles consider how to break down the barriers to enhance researcher-practitioner dialogue, as well as how to make ongoing outcome assessment feasible for clinicians. Moreover, the articles address how to promote training in evidence-based practice, and how to translate efficacy research into clinical practice and clinical insight into empirical study to better establish a two-way bridge between research and practice. Ultimately, we hope this series can speak to many different types of psychologists, whether they work mainly as researchers or practitioners, so they can see new ways to integrate and learn from both research and practice.

Online self-administered training for post-traumatic stress disorder treatment providers: design and methods for a randomized, prospective intervention study

This paper presents the rationale and methods for a randomized controlled evaluation of web-based training in motivational interviewing, goal setting, and behavioral task assignment. Web-based training may be a practical and cost-effective way to address the need for large-scale mental health training in evidence-based practice; however, there is a dearth of well-controlled outcome studies of these approaches. For the current trial, 168 mental health providers treating post-traumatic stress disorder (PTSD) were assigned to web-based training plus supervision, web-based training, or training-as-usual (control). A novel standardized patient (SP) assessment was developed and implemented for objective measurement of changes in clinical skills, while on-line self-report measures were used for assessing changes in knowledge, perceived self-efficacy, and practice related to cognitive behavioral therapy (CBT) techniques. Eligible participants were all actively involved in mental health treatment of veterans with PTSD. Study methodology illustrates ways of developing training content, recruiting participants, and assessing knowledge, perceived self-efficacy, and competency-based outcomes, and demonstrates the feasibility of conducting prospective studies of training efficacy or effectiveness in large healthcare systems.

Cognitive-behavioral guided self-help for eating disorders: effectiveness and scalability

Given the well-documented shortage of cognitive-behavioral therapy (CBT) for eating disorders, there is a compelling need for advances in dissemination. Guided self-help based on cognitive-behavioral principles (CBTgsh) provides a robust means of improving implementation and scalability of evidence-based treatment for eating disorders. It is a brief, cost-effective treatment that can be implemented by a wide range of mental health providers, including non-specialists, via face-to-face contact and internet-based technology. Controlled studies have shown that CBTgsh can be an effective treatment for binge eating disorder and bulimia nervosa, although it is contraindicated for anorexia nervosa. Several studies have shown that CBTgsh can be as effective as more complex specialty therapies and that it is not necessarily contraindicated for patients with comorbid conditions. Mental health providers with relatively minimal professional credentials have in some studies obtained results comparable to specialized clinicians. Establishing the nature of optimal "guidance" in CBTgsh and the level of expertise and training required for effective implementation is a research priority. Existing manuals used in CBTgsh are outdated and can be improved by incorporating the principles of enhanced transdiagnostic CBT. Obstacles to wider adoption of CBTgsh are identified.

Integrating research into clinical internship training bridging the science/practice gap in pediatric psychology

Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a "capstone experience"; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the "business of science." Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists.

Unique Roles for Students in Practitioner-Focused Doctoral Programs: Mentoring Practices for an Evolving Landscape

Studies suggest that training that culminates in the doctor of psychology (PsyD) degree is characterized by heterogeneity. However, elements of most of these practitioner-focused doctoral programs (e.g., larger class sizes, shorter periods of training, less funding for students), as well as the widely varying professional outcomes that they lead to, offer unique challenges and opportunities regarding mentoring. This article aims to (a) trace the development and current status of controversies surrounding the PsyD model; (b) determine the unique roles in which graduates of well-designed and scientifically grounded PsyD programs may be equipped to serve; and (c) drawing on the (limited) extant literature, offer recommendations for mentoring and other elements of training for these practitioner-focused programs. Finally, we offer suggestions for future empirical studies to shed light on the relative value of various training practices.

Understanding and preventing military suicide

The continual rise in the U.S. military's suicide rate since 2004 is one of the most vexing issues currently facing military leaders, mental health professionals, and suicide experts. Despite considerable efforts to address this problem, however, suicide rates have not decreased. The authors consider possible reasons for this frustrating reality, and question common assumptions and approaches to military suicide prevention. They further argue that suicide prevention efforts that more explicitly embrace the military culture and implement evidence-based strategies across the full spectrum of prevention and treatment could improve success. Several recommendations for augmenting current efforts to prevent military suicide are proposed.