Let your intuition be your guide? Individual differences in the evidence-based practice attitudes of psychotherapists

Prevalence of questionable health behaviours in Serbia and their psychological roots: protocol for a nationally representative survey

INTRODUCTION

We will launch a national survey in Serbia to document the prevalence of two types of questionable health behaviours: (1) intentional non-adherence to medical recommendations and (2) use of traditional, complementary and alternative medicine practices, as well as the relation between the two. We will also investigate their psychological roots, including (a) 'distal' predictors such as HEXACO personality traits (plus Disintegration) and thinking dispositions (rational/experiential thinking and cognitive reflexivity), and (b) 'proximal' predictors under the umbrella 'irrational mindset' (set of unfounded beliefs consisting of conspiratorial thinking, superstition, magical health beliefs as well as selected cognitive biases), which have more content-wise overlap with the health behaviours.

METHODS AND ANALYSIS

In this cross-sectional study, a research agency will collect data from a nationally representative sample (n=1043; age 18-75 years; estimated start/end-June/November 2021) recruited online (approximately, 70% of the sample, aged 18-54; 11 years) and face-to-face (approximately, 30% of the sample, aged 55-75 years). Participants will complete a battery of tests assessing questionable health behaviours, basic personality traits, thinking dispositions, irrational mindset, sociopolitical beliefs, sociodemographic and health-related variables. Prevalence rates will be calculated using descriptive statistics. To explore the relation between (psychological) predictors and questionable health behaviours, we will use hierarchical regression and partial mediation models (path analysis or full SEM models).

ETHICS AND DISSEMINATION

Ethical Committees of the Faculty of Philosophy in Belgrade (#935/1), Faculty of Special Education and Rehabilitation (#139/1) and Faculty of Media and Communications (#228) approved the protocol. Only participants who provide informed consent will participate in the study. A research report based on the study results will be submitted to peer-reviewed journals and results will be made available to stakeholders through reports on the project website https://reasonforhealth.f.bg.ac.rs/en/ and disseminated via social media.

TRIAL REGISTRATION NUMBER

NCT05808660.

Tracking variations in daily questionable health behaviors and their psychological roots: a preregistered experience sampling study

People resort to various questionable health practices to preserve or regain health - they intentionally do not adhere to medical recommendations (e.g. self-medicate or modify the prescribed therapies; iNAR), or use traditional/complementary/alternative (TCAM) medicine. As retrospective reports overestimate adherence and suffer from recall and desirability bias, we tracked the variations in daily questionable health behaviors and compared them to their retrospectively reported lifetime use. We also preregistered and explored their relations to a wide set of psychological predictors - distal (personality traits and basic thinking dispositions) and proximal (different unfounded beliefs and biases grouped under the term irrational mindset). A community sample (N = 224) tracked daily engagement in iNAR and TCAM use for 14 days, resulting in 3136 data points. We observed a high rate of questionable health practices over the 14 days; daily engagement rates roughly corresponded to lifetime ones. Both iNAR and TCAM were weakly, but robustly positively related. Independent of the assessment method, an irrational mindset was the most important predictor of TCAM use. For iNAR, however, psychological predictors emerged as relevant only when assessed retrospectively. Our study offers insight into questionable health behaviors from both a within and between-person perspective and highlights the importance of their psychological roots.

A web-survey assessed attitudes toward evidence-based practice among psychotherapists in Austria

Evidence-based practice (EBP) means integrating the best available scientific evidence with clinical experience and patient values. Although perceived as important by many psychotherapists, there still seems to be reluctance to use empirically supported therapies in clinical practice. We aimed to assess the attitudes of psychotherapists in Austria toward EBP in psychotherapy as well as factors influencing the implementation of EBP. We conducted an online survey. To investigate attitudes toward EBP, we used two subscales (“Limitations” and “Balance”) of a translated and validated short version of the Evidence-Based Practice Attitude Scale-36 (EBPAS-36). Participants provided perceived barriers and facilitators as answers to open-ended questions. We analyzed the responses mainly using descriptive statistics. Open answers were analyzed using a thematic analysis. In total, 238 psychotherapists completed our survey (mean age 51.0 years, standard deviation [SD] = 9.9, 76.9% female). Psychotherapists scored on average 2.62 (SD = 0.89) on the reversed EBPAS-36 subscale “Limitations,” indicating that the majority do not perceive EBP as limiting their practice as psychotherapists. They scored 1.43 (SD = 0.69) on the reversed EBPAS-36 subscale “Balance,” indicating that psychotherapists on average put a higher value on the art of psychotherapy than on evidence-based approaches. Organizational factors such as lack of time and access to research studies as well as negative attitudes toward research and a lack of skills and knowledge kept respondents from implementing EBP. Our study highlights that EBP is still not very popular within the psychotherapy community in Austria. The academization of psychotherapy training might change this in the future.

Therapists’ Views of Mechanisms of Change in Psychotherapy: A Mixed-Method Approach

The question of what works in psychotherapy has been a subject of debate in the recent years, occupying both clinicians and researchers. In this study, we aimed to assess the current perspectives held by clinicians regarding the processes which produce changes in psychotherapy, as well as the predictors of specific views. Licensed therapists (n = 107), consisting mainly of psychodynamically and integratively oriented psychologists, were asked to write in their own words what they think works in psychotherapy. Thematic analysis was employed to assess the main mechanisms of change as perceived by the therapists. Differences in the prevalence of specific themes were assessed using Friedman and Wilcoxon signed-rank tests. Univariate logistic regressions were employed to assess the factors that predict the probability of reporting a specific mechanism of change. The results indicated that the therapeutic bond was the most highly reported mechanism of change, followed by theory-driven mechanisms of change, therapist characteristics, therapist professionalism, and client motivation. Male therapists were more likely to indicate the professionalism as a mechanism of change compared to female therapists. Higher education was associated with lower reports of therapists’ characteristics as the mechanisms of change. These results suggest that therapists acknowledge the importance of the working alliance, and that the perception of the mechanism of change is associated with various factors which comprise therapist orientation. Limitations and directions for future research are discussed.

Psychology students' attitudes towards research: the role of critical thinking, epistemic orientation, and satisfaction with research courses

The current study aimed to determine how attitudes towards research are related to epistemic orientation, critical thinking, and satisfaction with research courses in psychology university students. Control variables included respondents' gender, current academic degree (undergraduate or postgraduate), number of research methods courses completed, number of research projects completed, and academic score. A quantitative, cross-sectional design was used, with a non-probabilistic sample size of 137 students. Correlational findings suggest that students with high scores in critical thinking domains and empiric and rational dispositions, tend to achieve higher academic grades. Rationality and reflexive skepticism were related to the number of research projects completed by the student. While an intuitive disposition is inversely related to academic scores and the number of research courses completed. Results from a hierarchical linear regression model suggest that attitudes towards research are significantly and positively affected by students' satisfaction with research courses, empiric epistemic orientation, and critical openness. On the other hand, an intuitive epistemic orientation has significant detrimental effects on attitudes towards research. Rational epistemic orientation and skeptic reflexiveness yielded non-significant coefficients. Overall, the model containing all independent variables accounted for 47.4% of the variance in attitudinal scores; this constitutes a large effect size. Results are discussed in light of previous research and their implications for the teaching of psychology in higher education.

Systematic review to examine the methods used to adapt evidence-based psychological treatments for adults diagnosed with a mental illness

QUESTION

The context for the implementation of evidence-based psychological treatments (EBPTs) often differs from the context in which the treatment was developed, which necessitates adaptations. In this systematic review we build on, and add to, prior approaches by examining the method used to guide such adaptations. In particular, we sought to elucidate the extent to which an empirical process is used.

STUDY SELECTION AND ANALYSIS

We focused on publications describing adaptations made to EBPTs for adults diagnosed with a mental illness. We searched PubMed, PsycINFO, Embase and Web of Science from database inception to July 2018. Two raters independently coded the articles for the method used to conduct the adaptation, the reason for and nature of the adaptation, and who made the adaptation.

FINDINGS

The search produced 20 194 citations, which yielded 152 articles after screening. The most commonly used methods for planned adaptations were literature review (57.7%), clinical intuition (47.0%) and theory (38.9%). The use of data from stakeholder interviews ranked fourth (21.5%) and the use of other types of data (eg, pilot study, experiment, survey, interview) ranked last at fifth (12.1%). Few publications reporting ad hoc adaptations were identified (n=3).

CONCLUSIONS

This review highlights a need to (a) educate providers and researchers to carefully consider the methods used for the treatment adaptation process, and to use empirical methods where possible and where appropriate, (b) improve the quality of reporting of stakeholder interviews and (c) develop reporting standards that articulate optimal methods for conducting treatment adaptations.

The Adoption of New Treatment Modalities by Health Professionals and the Relative Weight of Empirical Evidence in Favor of Virtual Reality Exposure Versus Mindfulness in the Treatment of Anxiety Disorders

Anxiety disorders are among the most prevalent mental disorders, and cognitive-behavioral therapy (CBT) with exposure exercises is considered as the gold-standard psychological intervention. New psychotherapeutic modalities have emerged in the last decade and, among them, mindfulness has been rapidly adopted by therapists. The adoption rate is slower for the use of virtual reality (VR) to conduct exposure. The goal of the present position paper is to contrast, for the treatment of anxiety disorders, the weight of empirical evidences supporting the use of exposure in VR with the use of mindfulness-based therapy (MBT). Based on the most recent meta-analyses, we found that CBT with exposure conducted in VR was more thoroughly researched and supported than MBT, receiving validation from roughly twice as many studies with high control (i.e., randomized, active controls with clinical samples). However, this conclusion is nuanced by reviewing gaps in the literature for both therapies. Potential factors influencing clinicians' choice of treatment and suggestions for future research directions are proposed.

Evidence-Based Spiritual Care Practice in the Canadian Context: Twenty Years Later

Reviews developments, strengths and challenges in evidence-based spiritual care practice (EBSCP) using a hermeneutical method which compares and interprets a variety of written texts. EBSCP originated from evidence-based medicine (EBM) developed at McMaster University and was adopted as evidence-based practice (EBP) by multiple professional disciplines. EBSCP was first addressed in Canada and American spiritual care researchers in the US have since advanced EBSCP. Questions are raised about processes of integrating EBSCP in a Canadian context as well as areas for future research.

A conceptual model for generating and validating in-session clinical judgments

OBJECTIVE

Little attention has been paid to the nuanced and complex decisions made in the clinical session context and how these decisions influence therapy effectiveness. Despite decades of research on the dual-processing systems, it remains unclear when and how intuitive and analytical reasoning influence the direction of the clinical session.

METHOD

This paper puts forth a testable conceptual model, guided by an interdisciplinary integration of the literature, that posits that the clinical session context moderates the use of intuitive versus analytical reasoning.

RESULTS

A synthesis of studies examining professional best practices in clinical decision-making, empirical evidence from clinical judgment research, and the application of decision science theories indicate that intuitive and analytical reasoning may have profoundly different impacts on clinical practice and outcomes.

CONCLUSIONS

The proposed model is discussed with respect to its implications for clinical practice and future research.

Does patient reluctance towards exposure and psychologists' attitudes about evidence based practice influence treatment recommendations for panic disorder? An experimental investigation

This study examined the effects of patient reluctance towards exposure on practitioners' subsequent treatment recommendations. Participants (N=236) were doctoral level psychologists who received a vignette of a patient with panic disorder, which either did (experimental group) or did not (control group) mention patient reluctance towards exposure. Evidence Based Practice (EBP) attitudes were also assessed and taken into account. A significant main effect of reluctance, averaged across all levels of EBP attitudes, and theoretical orientations was obtained (OR=2.85, 95% CI=[1.51, 5.39], p=0.001, RR=1.46), with controls 1.46 times more likely to recommend exposure. A significant main effect of EBP attitudes was also obtained (p<0.001). The odds of recommending exposure increased by 11% with each increase of positive EBP attitudes, across both levels of patient reluctance and theoretical orientation.

Therapist report of adaptations to delivery of evidence-based practices within a system-driven reform of publicly funded children's mental health services

OBJECTIVE

This study examined clinical adaptations reported by community therapists to multiple evidence-based practices (EBPs) currently implemented in children's mental health services. Based on an item set informed by Stirman and colleagues' model (2015), 2 factors emerged describing Augmenting adaptations and Reducing/Reordering adaptations. We used multilevel modeling to examine therapist- and practice-level predictors of therapist reports of each type of adaptation.

METHOD

Data were drawn from an online survey, including a novel therapist report measure of EBP adaptations, completed by 572 therapists (89.2% female, Mage = 37.08 years, 33.4% non-Hispanic White) delivering EBPs in the context of a system-driven, fiscally mandated implementation effort.

RESULTS

Analyses revealed that the 2 types of therapist adaptations (Augmenting and Reducing/Reordering) could be readily discriminated, with therapists reporting significantly more Augmenting than Reducing/Reordering adaptations. Therapists of Hispanic/Latino ethnicity and with fewer years of experience reported more extensive Augmenting adaptations, but no therapist background characteristics were associated with Reducing/Reordering adaptations. Therapists' general attitudes that EBPs diverged from their personal approach to therapy were associated with reporting more Augmenting and Reducing/Reordering adaptations. In contrast, negative perceptions toward the specific EBP predicted Reducing/Reordering adaptations, but not Augmenting adaptations.

CONCLUSIONS

Community therapist reports suggest that most adaptations undertaken involve engaging with the practice to augment the fit of the EBPs for local contexts; however, when practices were perceived negatively, therapists were more likely to make adaptations reducing or rearranging components. (PsycINFO Database Record

Prática Baseada em Evidências em Psicologia e a História da Busca pelas Provas Empíricas da Eficácia das Psicoterapias

Resumo Tradicionalmente, a escolha pelo tipo de intervenção psicoterápica para diferentes quadros clínicos depende fundamentalmente da experiência profissional do terapeuta e de sua predileção por determinadas estratégias clínicas. Todavia, esse cenário tem se modificado no contexto da prática baseada em evidências. Apesar do extenso e acalorado debate na literatura internacional da Psicologia nos últimos anos, o tema da prática baseada em evidências tem sido pouco discutido na Psicologia brasileira. Em vista disso, este artigo tem por objetivo apresentar o paradigma de prática baseada em evidências em Psicologia sob uma perspectiva histórica, enfatizando o embate entre os diferentes posicionamentos sobre o assunto e os esforços da American Psychological Association em elaborar um modelo representativo das diversas perspectivas teóricas, metodológicas, conceituais e práticas com o intuito de preencher a lacuna entre ciência e prática ainda existente na Psicologia Clínica. Espera-se que este artigo possa contribuir para uma maior participação da Psicologia brasileira nesse movimento.

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.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

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 evidence-based practice of psychotherapy: facing the challenges that lie ahead

What does the future hold for psychotherapy research and practice? We review some key influences, including declining psychotherapy utilization, increasing impact of evidence-based medical practices, over-medicalizing of mental health problems, and changing priorities from grant funding agencies. These factors hold potential opportunities but also major pitfalls that will need to be carefully navigated related to implementation/dissemination issues, interdisciplinary collaborations, and psychosocial versus biomedical perspectives related to the nature and treatment of psychopathology. In addition, we review and comment on the other articles contained in this special issue pertaining to the future of evidence-based psychotherapy.

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.

Causation and evidence-based practice: an ontological review

This paper explores the nature of causation within the framework of evidence-based practice (EBP) for health care. The aims of the paper were first to define and evaluate how causation is presently accounted for in EBP; second, to present an alternative causal account by which health care can develop in both its clinical application and its scientific research activity. The paper was premised on the idea that causation underlies medical and health care practices and impacts on the way we understand health science research and daily clinical practice. The question of what causation is should therefore be of utmost relevance for all concerned with the science, philosophy and progress of EBP. We propose that the way causation is thought of in contemporaneous health care is exposed by evidential frameworks, which categorize research methods on their epistemological strengths. It is then suggested that the current account of causation is limited in respect of both the functionality of EBP, and its inherent scientific processes. An alternative ontology of causation is provided, which has its roots in dispositionalism. Here, causes are not seen as regular events necessitating an effect, but rather phenomena that are highly complex, context-sensitive and that tend towards an effect. We see this as a better account of causation for evidence-based health care.