Psychological interventions in the era of managed competition

The Active Client: Therapy as Self-Help

A model of how therapy works is proposed that locates the source of therapeutic change in the client, while the therapist is the provider of opportunities, ideas, and experiences. Ultimately all therapy is self-help. This model is contrasted with the medical-like model of therapy as treatment and hopes to account for research findings of equal effectiveness among different therapies. Although the active client model developed from existential-humanistic ideas, it can be compatible with all approaches.

Adopting a population-level approach to parenting and family support interventions

Evidence-based treatments and preventive interventions in the child and family area have not met with widespread adoption by practitioners. Despite the high prevalence of child behavioral and emotional problems, many parents and families in need are not receiving or participating in services, and when they do, the most efficacious interventions are not what is usually provided. Simultaneously addressing the issues of low penetration and insufficient dissemination of evidence-based programming requires a population approach to parenting and family support and intervention. Process issues are important, particularly in relation to engagement of stakeholders, recruitment of practitioners, consideration of organizational factors, and use of media and communication strategies. This article discusses why there is a need for a population-based approach, provides a framework of how to conceptualize such an approach, and describes an example from our own work of a recently initiated prevention trial that illustrates a population-based approach in action. The rationale, structure, and goals of the Triple P System Population Trial are described in the context of the aforementioned population framework.

Evidence-based practice in psychology

The evidence-based practice movement has become an important feature of health care systems and health care policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an integration of science and practice, the Task Force's report describes psychology's fundamental commitment to sophisticated EBPP and takes into account the full range of evidence psychologists and policymakers must consider. Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. The report provides a rationale for and expanded discussion of the EBPP policy statement that was developed by the Task Force and adopted as association policy by the APA Council of Representatives in August 2005.

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.

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.

Why empirically supported psychological treatments are important

The emergence of managed care and similar reimbursement systems that require greater accountability and the development of clinical practice guidelines have increased the importance of evidence-based clinical practice. As a result of these two trends, it appears as though the future of psychotherapy will require clinicians to deliver a psychological intervention that is supported by research. Such treatments exist for a variety of the most common presenting problems (e.g., anxiety disorders, depression) but to date have frequently gone unrecognized and underutilized. The current article will discuss the importance of identifying, promoting, and disseminating empirically supported therapies with an emphasis on the efforts of the American Psychological Association Society of Clinical Psychology's Committee on Science and Practice.

The prevalence and impact of large sudden improvements during adolescent therapy for depression: a comparison across cognitive-behavioral, family, and supportive therapy

This study assessed the treatment specificity and impact on outcome of large, abrupt symptomatic improvements occurring prior to and during cognitive-behavioral, family, and supportive therapy. Eighty-seven depressed adolescents receiving at least 8 therapy sessions were included. Abrupt large decreases in depressive symptoms were identified by changes in weekly Beck Depression Inventory scores. Overall, 28% experienced a pretreatment gain and 39% a sudden within-treatment gain. Both types of gains were associated with superior outcome on self-report and interviewer ratings of depression. Among those participants failing to experience a pretreatment or sudden within-treatment gain, cognitive-behavioral therapy produced the superior outcomes. These findings suggest pretreatment and sudden within-treatment gains are important therapeutic events worthy of further investigation.

Therapists, therapist variables, and cognitive-behavioral therapy outcome in a multicenter trial for panic disorder

The relationship between therapists and treatment outcome was examined in 14 highly trained therapists who participated in the Multicenter Collaborative Study for the Treatment of Panic Disorder. Overall, therapists yielded positive outcomes in their caseloads; yet, therapists significantly differed in the magnitude of change among caseloads. Effect sizes for therapist impact on outcome measures varied from 0% to 18%. Overall experience in conducting psychotherapy was related to outcome on some measures, whereas age, gender, gender match, and experience with cognitive-behavioral therapy (CBT) were not. Therapists with above- and below-average outcomes were rated similarly on measures of adherence and competency. The results suggest that therapists make a contribution to outcome in CBT for panic disorder, even when patients are relatively uniform, treatment is structured, and outcome is positive. Implications for future clinical outcome studies and for training clinicians are discussed.

The future of psychotherapy outcome research: science or political rhetoric?

Although the relationship between research and clinical psychology has at times been conflicted, it has also been productive. Psychologists from both specialties have benefited from each others' work. The area of psychotherapy outcome research represents an important interface between the fields of clinical and research psychology. In an era of scarce resources and demands for accountability, there is pressure for researchers to justify the value of clinical practices. Recently, numerous articles have appeared recommending changes to the way psychotherapy research is conducted. The authors of these articles emphasize with urgency the importance of conducting and reporting research in a manner that will influence the decisions of policymakers and sanction funding for psychotherapy services. This article is an exploration of the impact of these recommendations, whose objective appears to be the promotion of psychological techniques for inclusion in clinical practice guidelines. It is argued that such recommendations may be in conflict with the philosophy and methods of science and may adversely affect public perception, perhaps leading psychologists to be seen as political lobbyists rather than clinicians and researchers.

The effects of psychological therapies under clinically representative conditions: a meta-analysis

Recently, concern has arisen that meta-analyses overestimate the effects of psychological therapies and that those therapies may not work under clinically representative conditions. This meta-analysis of 90 studies found that therapies are effective over a range of clinical representativeness. The projected effects of an ideal study of clinically representative therapy are similar to effect sizes in past meta-analyses. Effects increase with larger dose and when outcome measures are specific to treatment. Some clinically representative studies used self-selected treatment clients who were more distressed than available controls, and these quasi-experiments underestimated therapy effects. This study illustrates the joint use of fixed and random effects models, use of pretest effect sizes to study selection bias in quasi-experiments, and use of regression analysis to project results to an ideal study in the spirit of response surface modeling.

A national survey of practicing psychologists' attitudes toward psychotherapy treatment manuals

There has been considerable debate and little empirical data on the role of psychotherapy treatment manuals in clinical practice. Attitudes toward treatment manuals are a potentially important determinant of how likely practitioners are to use manual-based treatments in clinical practice. A total of 891 practicing psychologists nationwide were surveyed about their attitudes toward treatment manuals and their ideas about the content of manuals. Practitioners held widely varying attitudes toward treatment manuals, and ideas about what constitutes a manual were associated with attitudes in a predictable way. Recommendations are made for how to gather more useful information about practitioners' attitudes toward the many changes affecting current models of clinical practice.

Utilization of empirically supported psychotherapy treatments for individuals with eating disorders: A survey of psychologists

OBJECTIVE

The purpose of this study was to assess the primary methods used by psychotherapists in treating individuals with eating disorders and to determine the extent to which certain empirically supported psychotherapies (i.e., cognitive behavioral therapy [CBT] and interpersonal psychotherapy [IPT]) are used in clinical settings.

METHOD

Surveys developed for this study were sent to 500 psychologists randomly selected from a list of all licensed doctoral-level psychologists in an upper midwestern state.

RESULTS

Despite the findings that CBT techniques were reported to be frequently used, most respondents identified something other than CBT or IPT as their primary theoretical approach. In addition, the majority of respondents indicated not having received training in the use of manual-based, empirically supported treatment approaches for working with individuals with eating disorders, although most reported a desire to obtain such training.

CONCLUSIONS

Although commonly referred to as the "treatments of choice" in research literature, manual-based, empirically supported approaches to working with individuals with eating disorders has not received adequate dissemination.

Individual psychotherapy outcome and process research: challenges leading to greater turmoil or a positive transition?

Psychotherapy is facing challenges that relate to the emergence of managed health care, the possibility of a national health care system, and advances in biological psychiatry. These situations have created pressure to achieve a more accurate assessment of psychotherapeutic effectiveness. Psychotherapy has been proven to be generally effective; however, there is uncertainty as to why. The field is currently experiencing apparent turmoil in three areas: (a) theory development for psychotherapeutic effectiveness, (b) research design, and (c) treatment technique. This chapter reviews the dynamics within each of the areas and highlights the progress made in treating mental disorders. We conclude that recent advances in research design may provide a transition that will bring psychotherapy closer to becoming a unified paradigm with an acceptable theory of effectiveness.

Patient Impairment Lexicon: a psychometric analysis

Growth in managed care has magnified the needs for assessment of treatment efficacies and standardized communication regarding treatment needs. Addressing both needs requires a common terminology describing the scope of treatable mental health impairments. The Diagnostic and Statistical Manual of Mental Disorders-IV provides a common categorical language for describing clinical disorders, but its categories are not discrete and do little to facilitate communication regarding specific treatment needs. Goodman, Brown, and Deitz developed a Patient Impairment Lexicon intended to address these limitations. The current vignette study provided initial psychometric assessment of this nomenclature, specifically examining interrater reliability, temporal stability, and content validity. Findings are discussed with respect to both applications in managed care and psychometric research.

A critical review of pharmacotherapy for youth with anxiety disorders: things are not as they seem

Given the increasing trend in clinical child psychology and psychiatry toward cost-effective and pharmacological treatment, a review of key factors that influence treatment outcomes in this area seems warranted. This is especially important for the rapidly changing area of childhood anxiety disorders. In this article, we look at different change producing procedures to illustrate the claim that pharmacological studies are not necessarily what they seem. Specifically, pharmacological outcome studies are classified and reviewed on the basis of varying "secondary" treatments described in method sections. Three groups and efficacy rates were determined: (a) pharmacotherapy only (42.83%), (b) pharmacotherapy plus general/supportive psychotherapy (27.74%), and (c) pharmacotherapy plus a behavior therapy component (65.28%). We also discuss the implications of these findings for research as well as other methodological and theoretical concerns regarding the reviewed articles. These concerns include (a) methods used to diagnose participants, (b) methods used to assess improvement, (c) emphasis on diagnostic categories, (d) exclusionary criteria and comorbidity, (e) participant attrition and follow-up, and (f) key developmental and social contextual variables.

Treatment-outcome research in panic disorder: dilemmas in reconciling the demands of pharmacological and psychological methodologies

Panic disorder with or without agoraphobia has been the subject of sustained treatment-outcome research. Studies have been conducted by both pharmacologically- and psychologically-oriented researchers each employing their own methodologies. Problems arise in attempting to reconcile the demands of these two treatment-outcome methodologies, whilst at the same time ensuring that research designs reflect the reality of wider clinical practice. In the following discussion a series of studies comparing pharmacological and psychological treatments for panic disorder and agoraphobia are reviewed. The review highlights areas where the competing demands of research design and clinical applicability lead to dilemmas for the researcher. Attempts to overcome such dilemmas are described and alternative solutions discussed.

The efficacy of psychosocial treatments in primary care. A review of randomized clinical trials

Depression and anxiety are the most common psychiatric disorders among ambulatory medical patients and are associated with significant functional disability. However, they remain underrecognized and/or inadequately treated. The AHCPR Depression Guideline Panel recently reviewed the efficacy of pharmacologic interventions for mood disorders in the primary care section, but there are as yet no comparable analyses of the efficacy of psychosocial interventions for primary care patients experiencing depression or anxiety. This review of randomized, controlled trials conducted in primary care settings generally supports the efficacy of psychosocial treatments (PSTs) provided to ambulatory medical patients with psychiatric disorders. However, methodologic deficiencies in these trials (i.e., diagnostic classification of study subjects, attrition patterns, and criteria for assessing treatment response) limit the generalizability of their findings to routine practice. Studies evaluating the effect of PSTs on health care cost and utilization found changes in physicians' prescribing practices, patients' use of psychotropic medication, and number of patient visits to primary care physicians. However, results varied across studies because of methodologic deficiencies similar to those noted previously. Suggestions are offered for improving the internal and external validity of randomized PST trials in primary care settings.