Do haphazard reviews provide sound directions for dissemination efforts?

Comments on The dissemination and implementation of evidence-based psychological treatments: A review of current efforts (see record 2010-02208-010) by Kathryn R. McHugh and David H. Barlow. The lead article in the February–March issue by McHugh and Barlow (2010) emphasized the need for “dissemination and implementation of evidence-based psychological treatments.” The authors identified a number of intervention programs as evidence based and in need of dissemination. One is multisystemic therapy (MST). They claimed that this program is among “the most successful dissemination efforts...pursued by treatment developers” (p. 79). McHugh and Barlow’s (2010) discussion of the implementation of MST in Hawaii is troubling, because it neglected to mention concerns about the perceived lack of cultural sensitivity of the MST program in that state.     

Addressing the Global Burden of Mental Illness: Why Transdiagnostic and Common Elements Approaches to Evidence-Based Practice Might Be Our Best Bet

This paper provides a commentary of Murray et al. (2014--this issue), who discuss the need for greater treatment quality and availability globally, particularly in low- and middle-income countries, and present outcome data for a common elements treatment approach that was developed to address the staggering burden of mental illness. This commentary discusses barriers to the dissemination and implementation of evidence-based psychological treatments, with a particular emphasis on training initiatives. The utility of a transdiagnostic approach to evidence-based practice is also explored within the context of training initiatives and ease of dissemination.     

Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions

Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.     

When it comes to evaluating psychodynamic therapy, the devil is in the details

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). As Shedler noted, some researchers have reflexively and stridently dismissed psychodynamic therapy (PT) as ineffective without granting outcome studies on this modality a fair hearing. We applaud Shedler's efforts to bring PT into the scientific mainstream and hope that his article encourages investigators to evaluate claims regarding PT's efficacy with a more objective eye. Nevertheless, as Shedler also observed, one reason for the scientific community's premature dismissal of PT is traceable to some psychodynamic practitioners' historical antipathy toward controlled research and propensity to overstate PT's efficacy. Regrettably, Shedler falls prey to the latter error by glossing over key methodological details, ignoring crucial findings that run counter to his position, and overstating the quality and quantity of the evidence base for PT. Because of space constraints, we focus only on a handful of the more serious shortcomings of Shedler's analysis (a more complete review of these issues is available from the first author on request).     

Connecting Youth Violence Prevention, Positive Youth Development, and Community Mobilization

Several disconnects serve to weaken the use of evidence based programming in community settings. Communities face the need to address the challenges of multiple risk behaviors faced by adolescents in their communities, but must also work to support successful transitions to adulthood and the broader positive development of their youth. The stronger integration of positive youth development and prevention of youth risk at the community level may offer an opportunity to support the implementation and ongoing development of evidence-based practices (EBPs). This article provides an overview of the VCU Clark-Hill Institute for Positive Youth Development Institute's community mobilization effort in Richmond, Virginia and reports preliminary findings from our integrated mobilization efforts. First, we review the role of our Community Advisory Council in their collaborative work to support positive youth development and reduce risk for youth violence. Next, we present examples of institute efforts in providing technical assistance relevant to supporting the use and development of EBPs. We then discuss the adaptation of an evidence-based program to target positive youth development. We also present overviews from qualitative investigations examining barriers and supports that inform and are relevant to the implementation of EBPs. Finally, we consider ways in which community efforts inform and shape institute efforts to develop EPBs. Taken together, these activities provide examples of how community-based mobilization efforts can integrate and inform the implementation of EBPs and the role and use of prevention science as a tool in supporting effective programming to promote positive youth development and prevent youth violence.     

Methods and mechanisms in the efficacy of psychodynamic psychotherapy

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler summarized a large body of research that shows psychodynamic therapy to have a substantial effect size, comparable to that for many empirically supported treatments. This is an important finding, in part refuting the concerns raised by Bornstein (2001, 2002) regarding the future of psychodynamic approaches had there been no substantial changes in how practitioners and researchers approached the science to demonstrate efficacy. Further, Shedler showed that the efficacy of psychoanalytic psychotherapy is due to therapeutic methods commonly employed in cognitive behavior therapy (CBT), one of the most frequently cited empirically supported approaches for a wide range of psychological conditions. From a methodological perspective, there are some important limitations to the claim of psychodynamic psychotherapy's comparable efficacy to other empirically supported approaches.     

Nursing and psychological treatments

Presents a comment on "Psychological Treatments" by D. H. Barlow. In his article, Barlow pointed to the need "to solidify the identification of psychology as a health care profession" by changing the terminology of practice in the health care context from psychotherapy to psychological treatments and suggested that the only persons qualified to carry out such interventions are doctoral-level psychologists. Unfortunately, there was no discussion of the health care professionals who already provide psychological treatments in health care settings and their contribution to the evidence base supporting such treatment. The authors find several aspects of the article to be problematic. Overall, the authors feel that suggesting that psychology should claim treatment of psychological disorders and psychological components of physical disorders in health care settings as exclusively its own domain ignores the research and clinical contributions of others.     

Is there room for criticism of studies of psychodynamic psychotherapy?

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler declared unequivocally that "empirical evidence supports the efficacy of psychodynamic therapy" (p. 98). He did not mention any specific criticisms that have been made of evidence on psychodynamic psychotherapies or address possible distinctions between evidence for short-term versus long-term psychodynamic psychotherapies. Instead, he attributed dissenting views to biases in evidence dissemination and review, which he suggested are rooted in a "lingering distaste in the mental health professions professions for past psychoanalytic arrogance and authority" related to a "hierarchical medical establishment that denied training to non-MDs and adopted a dismissive stance toward research" (Shedler, 2010, p. 98). Shedler (2010) justified his blanket dismissal of criticisms of evidence supporting psychodynamic psychotherapy on the basis of several published meta-analyses. The validity of conclusions from metaanalyses depends on the quality of the evidence synthesized, the nature of the studies included, and the rigor of the statistical analyses employed. Many meta-analyses, however, are not performed rigorously, which can result in treatment efficacy estimates that obscure important intertrial differences and that are unlikely to be replicated in clinical practice.     

Psychological treatment of eating disorders

Significant progress has been achieved in the development and evaluation of evidence-based psychological treatments for eating disorders over the past 25 years. Cognitive behavioral therapy is currently the treatment of choice for bulimia nervosa and binge-eating disorder, and existing evidence supports the use of a specific form of family therapy for adolescents with anorexia nervosa. Important challenges remain. Even the most effective interventions for bulimia nervosa and binge-eating disorder fail to help a substantial number of patients. A priority must be the extension and adaptation of these treatments to a broader range of eating disorders (eating disorder not otherwise specified), to adolescents, who have been largely overlooked in clinical research, and to chronic, treatment-resistant cases of anorexia nervosa. The article highlights current conceptual and clinical innovations designed to improve on existing therapeutic efficacy. The problems of increasing the dissemination of evidence-based treatments that are unavailable in most clinical service settings are discussed.     

A New Unified Treatment Approach for Emotional Disorders Based on Emotion Science

ABSTRACT— Research on the nature of emotional disorders points toward a common set of diatheses (underlying psychological vulnerabilities) and functionally (but not superficially) similar expression of pathological emotional responding (e.g., Barlow, 2002 ). Successful drug treatments for different emotional disorders are very similar, with selective serotonin reuptake inhibitors or related compounds in wide use. Successful psychological treatments, on the other hand, are currently specifically targeted to each individual disorder. Distilling common principles among existing empirically supported psychological treatments, and giving attention to new findings on emotion regulation and dysregulation from emotion science, we propose and describe a new unified psychological treatment for emotional disorders.     

Trade-offs and individual differences in evolved traits

Comments on Evolutionary psychology: Controversies, questions, prospects, and limitations (see record 2010-02208-001) by Confer et al. We applaud Confer et al.'s (February-March 2010) clarifications of the many misconceptions surrounding the use of evolutionary analyses in psychology. As they noted, such misunderstandings are common and result in a curious tendency of some of our colleagues to criticize evolutionary psychology without a firm understanding of evolution itself. Confer et al. also did an admirable job acknowledging current unresolved issues among evolutionary psychologists (e.g., the relative importance of group selection on humans). The above said, we disagree with their view that a current limitation of evolutionary psychology is its inability to explain phenomena "that appear to reduce an individual's reproductive success, and cannot be explained by mismatches with, or hijacking of, our psychological mechanisms by modern-day novel inputs" (Confer et al., 2010, p. 122). Mismatches between modern environments and environments of evolutionary adaptedness are only one set of explanations for seemingly maladaptive traits (Nesse, 2005). Another set involves evolutionary trade-offs.     

Bridging the Gap Between Research and Practice in Mental Health Service Settings: An Overview of Developments in Implementation Theory and Research

Twenty years after Sobell’s (1996) influential call to integrate advances in behavior therapy into clinical settings, significant progress has been made in implementation science. In this narrative review, we provide an overview of implementation research findings and highlight recent findings that can inform efforts to bridge the gap between research and practice in mental health service settings. Key findings are summarized, organized according to levels of influence described in two implementation frameworks: The Exploration, Planning, Implementation, and Sustainment Framework (EPIS; Aarons et al., 2011) and the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009). Important levels of influence to consider when implementing new treatments include the outer context, inner context, characteristics of the individual, and characteristics of the innovation. Research on strategies to prepare clinicians to deliver evidence-based psychosocial treatments (EBPTs) and to address contextual barriers to implementation at each level is described, with discussion of implications for the implementation of EBPTs and next steps for research.     

Mind the gap: Improving the dissemination of CBT

Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.     

Knowing what we do not know about sexual orientation change efforts

Comments on the original article, "Guidelines for psychological practice with lesbian, gay, and bisexual clients," by the American Psychological Association (see record 2011-19419-001). The present authors notes that the APA has provided a very helpful document for those who do clinical work with individuals experiencing same-sex attractions. Psychologists no doubt need to be familiar with the literature described in these guidelines as a part of ethical practice. However, the present authors register concern regarding how the guidelines address sexual orientation change efforts (SOCE). They focus their critique on how the guidelines portray two issues pertaining to SOCE-effectiveness and harm-and conclude with a proposal to move the discussion forward via science. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Toward a Unified Treatment for Emotional Disorders: Update on the Science and Practice

Mental health professionals have long been concerned with describing and proscribing a structure around the myriad variations of psychological and emotional distress that are deemed to be disordered. This has frequently been characterized as a conflict between so-called “lumpers” and “splitters”—those who advocate broad categorizations based on overarching commonalities versus those who endeavor toward a highly refined structure emphasizing unique characteristics. Many would argue that with the era of the modern Diagnostic and Statistical Manual of Mental Disorders (DSM-III to DSM-5), a splitting ideology has been dominant despite re-emerging concerns that some groups of diagnoses, particularly disorders of anxiety and other emotions, may be more similar than different. As a result of such concerns, transdiagnostic or unified models of psychopathology have burgeoned. In this review, we describe the work of Barlow, Allen, and Choate (2004), whose invited paper “Toward a Unified Treatment for Emotional Disorders” reignited transdiagnostic perspectives of emotional disorders. We provide an update on the scientific models and evidence-based treatments that have followed in the wake of this 2004 publication, including key areas for future study in the advancement of transdiagnostic and unified treatment of emotional disorders.     

When Treatment as Usual Gives You Lemons,Count on EVBPs: Economic Arguments for Training Child Clinicians in Evidence-Based Practices

This article is a commentary advocating for dissemination and implementation workers to incentivize the adoption of evidence-based practices (EVBPs) with youth. Treatment-as-usual in community settings yields weak effectiveness results. EVBPs for youth exist but are not widely adopted. Consequently, “lemons” or poor treatments are added to the behavioral health care marketplace. The economic concept of lemon market theory is explained and its relevance to the behavioral health care marketplace is illustrated. Several recommendations based both on economic and learning theory are offered. The article argues for the increased use of incentives as behavior modifiers for clinicians’ practices. More specifically, proper branding and fidelity, quality improvement measures, and pay for performance initiatives are discussed.     

Science meets practice in determining effectiveness of sexual orientation change efforts

Comments on the original article, "Guidelines for psychological practice with lesbian, gay, and bisexual clients," by the American Psychological Association (see record 2011-19419-001). Guideline 3 of the acknowledges the diversity of human sexual orientation and that "efforts to change sexual orientation have not been shown to be effective or safe" (p. 14). As noted in the Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation (APA, 2009), "Current criteria for effective treatments and interventions are specific in stating that to be considered effective, an intervention has consistent positive effects without serious harmful side effects [emphasis added]" (p. 26). The present authors note that half a century of scientific research on a variety of sexual orientation change efforts (SOCE) has not demonstrated their effectiveness according to the criteria of consistent positive effects and absence of serious harmful effects. Guideline 3 (APA, 2012) therefore urges psychologists to closely assess the motivations of clients who seek SOCE in the context of stigma and internalized prejudice about their non-heterosexual orientation. In addition, the guideline also recommends that psychologists obtain truthful, thorough, and thoughtful informed consent and that they focus on personal integration instead of sexual orientation change. The burden of proof has been on advocates of SOCE, and the present authors assert that it has not been met. (PsycINFO Database Record (c) 2012 APA, all rights reserved).