An opportunity to bridge the gap between clinical research and clinical practice: implications for clinical training

The quality of four psychology practice guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II

RATIONALE, AIMS AND OBJECTIVES

Clinical Practice Guidelines (CPGs) have been shown to improve healthcare services and clinical outcomes. However, they are useful resources only to the degree that they are developed according to the most rigorous standards. Multiple studies have demonstrated significant variability between CPGs with regard to specific indicators of quality. The Ordre des psychologues du Québec (OPQ), the College of psychologists of Quebec, has published several CPGs that are intended to provide empirically supported guidance for psychologists in the areas of assessment, diagnosis, general functioning, treatment and other decision-making support. The aim of this study was to evaluate the quality of these CPGs.

METHODS

The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was used to assess the quality of the CPGs.

RESULTS

Our results show that although there have been some modest improvements in quality of the CPGs over time, there are important methodological inadequacies in all CPGs evaluated.

CONCLUSIONS

The findings of this study demonstrate the need for more methodological rigour in CPGs development as such, recommendations to improve CPG quality are discussed.

Revived call for consensus in the future of psychotherapy

The emblem of success in psychotherapy research and practice has long been innovation. Although such ingenuity is commendable, it has nonetheless perpetuated fragmentation across the field. At least four decades ago, it was suggested that achieving consensus on what constitutes psychotherapy's theoretical, empirical, and practical 'core' might allow the discipline to evolve beyond its siloed state, as is reflective of mature science. Yet, division remains the rule versus exception, owing in large part to power struggles among disparate schools of therapy and quarrels over whether theory-specific or theory-common factors most account for therapeutic change. We outline here a vision for psychotherapy's future that is defined by consensus rather than disintegration. Namely, we reiterate the need for the field to invest in clinical strategies that transcend ostensibly incompatible theoretical models. We also argue that psychotherapy research should build on the growing evidence for such clinical strategies in an effort to establish core, evidence-based principles of therapeutic change. We then discuss how establishing consensus will require reconciliation among the mounting evidence for flexible, principle-informed practice with the current realities of training, dissemination, and implementation paradigms. Finally, we articulate ways in which practicing clinicians will serve a vital role in carrying out, and amending as needed, actionable efforts toward psychotherapy consensus.

Psychotherapy and youth suicide prevention: An interpretative phenomenological analysis of specialist clinicians' experiences

The study explored psychologists' experiences in delivering short-term psychotherapy for suicidal adolescents and sought to clarify how these experiences fit with empirically supported interventions and the interpersonal psychological theory of suicide. Semistructured interviews were conducted with 12 psychologists' who provided short-term psychotherapy in a suicide prevention programme for youth (12- to 25-year-olds). Interview transcripts were analysed using interpretative phenomenological analysis. Three superordinate themes were identified: (i) understand the experience and context of the suicidality and the importance of a formulation-based approach to engagement and individualized treatment planning; (ii) involve broad support systems, and in particular families, to help the young person reduce feelings of burdensomeness and increase safety, connectedness and belonging; and (iii) improve affect regulation and reflective functioning, important not only for the young person but also for the support system to maximize the positive impact of supports via emotional coregulation and effective problem-solving. Interventions and approaches as well as the potential underlying processes of change being targeted are discussed in light of these findings. As an example, the development of a suicide safety plan was an intervention that traversed these themes. When used as a process tool, it helped foster a collaborative, formulation, dimensional and biopsychosocial approach to treat psychopathology and suicidality and extended beyond the therapist-client dyad. Moreover, treatment needs to be extended beyond the therapist-client dyad to allow therapists to facilitate a systemic treatment response, as this was seen as a major component of interventions for suicidal youth.

Development and Validation of a Functional Behavioural Assessment Ontology to Support Behavioural Health Interventions

Background

In the cognitive-behavioral approach, Functional Behavioural Assessment is one of the most effective methods to identify the variables that determine a problem behavior. In this context, the use of modern technologies can encourage the collection and sharing of behavioral patterns, effective intervention strategies, and statistical evidence about antecedents and consequences of clusters of problem behaviors, encouraging the designing of function-based interventions.

Objective

The paper describes the development and validation process used to design a specific Functional Behavioural Assessment Ontology (FBA-Ontology). The FBA-Ontology is a semantic representation of the variables that intervene in a behavioral observation process, facilitating the systematic collection of behavioral data, the consequential planning of treatment strategies and, indirectly, the scientific advancement in this field of study.

Methods

The ontology has been developed deducing concepts and relationships of the ontology from a gold standard and then performing a machine-based validation and a human-based assessment to validate the Functional Behavioural Assessment Ontology. These validation and verification processes were aimed to verify how much the ontology is conceptually well founded and semantically and syntactically correct.

Results

The Pellet reasoner checked the logical consistency and the integrity of classes and properties defined in the ontology, not detecting any violation of constraints in the ontology definition. To assess whether the ontology definition is coherent with the knowledge domain, human evaluation of the ontology was performed asking 84 people to fill in a questionnaire composed by 13 questions assessing concepts, relations between concepts, and concepts’ attributes. The response rate for the survey was 29/84 (34.52%). The domain experts confirmed that the concepts, the attributes, and the relationships between concepts defined in the FBA-Ontology are valid and well represent the Functional Behavioural Assessment process.

Conclusions

The new ontology developed could be a useful tool to design new evidence-based systems in the Behavioral Interventions practices, encouraging the link with other Linked Open Data datasets and repositories to provide users with new models of eHealth focused on the management of problem behaviors. Therefore, new research is needed to develop and implement innovative strategies to improve the poor reproducibility and translatability of basic research findings in the field of behavioral assessment.

Introduction: Applying Clinical Psychological Science to Practice

Mental illness is a prevalent and extraordinarily complex phenomenon. Psychologists have developed distinct approaches toward understanding and treating mental illness, rooted in divergent epistemology. This introduction to the Special Issue on Clinical Psychological Science and Practice provides a brief overview of the scientist-practitioner gap, and explores one step (of many) toward bridging this divide. Seven compelling case illustrations featured in this Special Issue apply empirical findings to case formulation, treatment selection, and assessment across complex and varied clinical presentations. This issue thereby demonstrates the feasibility of integrating research and clinical expertise in mental healthcare.

Implementation and Evaluation of Evidence-Based Psychotherapeutic Practices for Youth in a Mental Health Organization

The current initiative and program evaluation study is a demonstration of the research to practice process in youth-focused psychotherapy. We collaborated within a community-university partnership to create practice and research infrastructure in order to develop, implement, and evaluate two new models of service founded on evidence-based psychotherapeutic practice parameters. The two new service models incorporated validated interventions to address behavior problems in elementary age children, and depression in adolescents, which were delivered in separate but similarly run intensive outpatient programs within a mental health setting. We utilized a rigorous training, technical assistance, fidelity monitoring, and outcome measurement strategy to promote the integrity and quality of services provided. The resultant programs were delivered with acceptable to high fidelity and effects on youth and parenting measures collected during program and from pre to post showed a decrease in targeted problems in youth and positive benefits for families. This initiative and program evaluation adds to the accumulating research-to-practice literature in children's mental health.

International education and training for clinical child and adolescent psychology

Psychological problems in youth and adequate mental health service delivery to children, adolescents, and families are critical public health dilemmas around the world. Central to effectively addressing the mental health needs of youth and families is focusing attention on the evaluation and development of specialized training programs in clinical child and adolescent psychology. All countries to more or less degree face challenges, but lower-income countries have additional limitations (e.g., scarce resources for training, high demand for services, cultural barriers) to establishing clinical psychology programs and specialized services for children and adolescents. This article discusses the status of efforts in the United States to define clinical child and adolescent psychology and develop standard training recommendations for mental health providers who work with youth and families, international considerations for intervention implementation and training, and future directions in the field of clinical child and adolescent psychology.

Implications of RDoC for the research and practice of psychotherapy

The field of psychotherapy is at an important juncture. Recent changes in the field include (a) the skeptical reception of the fifth edition of the Diagnostic and Statistical Manual and (b) NIMH's prioritization of an alternative classification system to guide translational and intervention research. Moreover, (c) the field continues to be held accountable to governmental agencies and third-party payers to demonstrate its empirical basis. Thus, psychological research as it relates to the practice of psychotherapy is at a crossroads. In this article, we provide a brief overview of several generations of psychotherapy outcome research, including the consequences that followed in the 1980s as psychotherapy research moved toward randomized controlled trials for clinical disorders. We delineate the inherent strengths and limitations of this movement and address how the NIMH has recently responded with the Research Domain Criteria (RDoC). We then address philosophical and practical implications of the emphasis on a neuroscientific conceptualization of psychological problems. Finally, we discuss opportunities for a next generation of convergent science that incorporates, rather than replaces, psychosocial variables across stages of translational research and treatment development.

CONVERGENCE OF DEPRESSION AND ANXIETY SYMPTOMS IN FRIENDSHIP DYADS

Despite psychometric rationale to include multiple informants, psychological assessment typically involves data collected from the patient (target) only, particularly with regard to depressive and anxious symptomatology. This study addressed this gap in the literature by assessing convergence between targets and their close friends (informants) in an ethnically diverse sample of young adults. One hundred and thirty-nine friendship dyads completed a packet of questionnaires including different versions administered to the targets and informants, with targets completing the standard questionnaire battery focused on their own symptoms and informants completing questionnaires on their view of the target participants' symptoms, rather than their own characteristics. Measures were included to assess a wide range of symptomatology, including behavioral, cognitive, and physiological symptoms of anxiety and depression. The target-informant correlations were largely significant and of small-to-medium magnitude. In addition, target-informant agreement was higher in more visible symptoms (e.g., behavioral) than in less visible symptoms (e.g., physiological) of anxiety and depression. Interestingly, level of closeness in the relationship did not influence the magnitude of correlations. Implications for future research and integration into clinical assessment practices are discussed.

Therapist predictors of treatment delivery fidelity in a community-based trial of 12-step facilitation

BACKGROUND AND AIMS

Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. We examined associations between treatment fidelity and therapist education, experience, treatment orientation and perceived skills in a randomized, multi-site trial of Twelve Step Facilitation (TSF).

METHODS

Raters scored audio-recorded, TSF sessions (n = 966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy and global session performance.

RESULTS

Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes toward 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions.

CONCLUSIONS

Results have implications for therapist selection, training and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills.

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.

What should we expect from psychotherapy?

In addressing the very general question of what we should expect from psychotherapy, this article begins by discussing what constitutes relevant evidence on which to base the efficacy and effectiveness of psychotherapy. In this context, an important distinction is made between empirically supported treatments and evidence-based practice. Although there is evidence that psychotherapy does indeed work, there are also findings that there are times when our patients are harmed by our interventions. It is noted that the therapeutic alliance plays an extremely important role in the change process, and that ruptures in the alliance can contribute to our therapeutic failures. In pointing to directions for the future, modifications of how we investigate the outcome of treatment, as well as how to close the gap between research and practice, are offered.

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.

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.