Is the Divide a Chasm?: Bridging Affective Science with Clinical Practice

This special section endeavors to facilitate the integration of biologically-based assessments of emotion into the clinical setting. This goal is consistent with the Research Domain Criteria (RDoC) initiative, which aims to identify transdiagnostic biobehavioral mechanisms that underlie mental disorders. We focus on four challenges to applying biologically-informed research on emotion and emotion regulation to clinical contexts: (1) How do we assess emotion in an RDoC framework? (2) How do we integrate measures of emotion with other systems in a wider context? (3) What do physiological indices of emotion tell us about clinical phenomena? and (4) How do we integrate physiological assessments into clinical practice? Throughout this comment, we refer to the articles in this special section to make our points, and, when possible, offer suggestions for future work to continue to address these challenges.     

Clinical versus actuarial prediction: a review of the literature.

Decisions made by psychologists can have considerable consequences on people's lives. Their decisions could be based on clinical judgment or empirically derived formulas. These two alternatives created a controversy concerning clinical and actuarial prediction. This controversy has been in existence for almost 70 years. During this time hundreds of articles have been published on this topic. This paper contains a review of the findings and issues on clinical versus actuarial prediction. The main conclusions are that (1) linear models are superior to other mathematical models of human judgment, (2) actuarial methods are more accurate than clinical prediction in many situations, (3) human judgment is flawed, and (4) actuarial methods are rarely employed in practice for a variety of reasons.     

Clinical Expertise: A Preliminary Attempt to Clarify Its Core Elements

The recent emphasis on evidence-based practice revolves around an integration of three domains: client characteristics, relevant research, and clinical expertise. Unfortunately, most reports focus on the examination of current research, while few guidelines exist for clarifying or developing expertise in clinical psychology. Although expertise is more advanced than competence, basic clinical competence can set the foundation for the development of more sophisticated skills. It is best to strive for narrow domains of expertise instead of global ratings of a professional as an “expert”. Five criteria are proposed for evaluating, developing, and maintaining clinical expertise: (1) the professional must possess a terminal degree in the field, (2) the professional has accumulated multiple years of clinical experience in the direct provision of clinical assessment, psychological testing, or psychological treatment, (3) the professional has attained advanced credentials in a specific area of psychology, (4) the professional is visible in the professional community at a national level, and (5) the professional has demonstrated evidence of superior clinical skills in a specific application of psychology. Together, these five criteria help to objectify the evaluation and cultivation of clinical expertise in psychology. Because each criterion is weak and flawed if used alone, it is recommended that multiple criteria are used in combination to define clinical expertise.     

Professional liability (malpractice) coverage of humanist scholars functioning as clinical medical ethicists

In contrast to theoretical discussions about potential professional liability of clinical ethicists, this report gives the results of empirical data gathered in a national survey of clinical medical ethicists. The report assesses the types of activities of clinical ethicists, the extent and types of their professional liability coverage, and the influence that concerns about legal liability has on how they function as clinical ethicists. In addition demographic data on age, sex, educational background, etc. are reported. The results show that while nearly one third (28.9%) of the ethicists regularly make recommendations about patient care, only 10.8% of them regularly make entries in the medical record; only approximately half (53.0%) of them are covered by professional liability (malpractice) insurance; and the vast majority (84.3%) of them say that concerns about legal liability do not influence the way they function as clinical ethicists.     

Assessing risk of reoffending in adolescents who have committed a sexual offense: the accuracy of clinical judgments after completion of risk assessment instruments

As courts often rely on clinicians when differentiating between sexually abusive youth at a low versus high risk of reoffense, understanding factors that contribute to accuracy in assessment of risk is imperative. The present study built on existing research by examining (1) the accuracy of clinical judgments of risk made after completing risk assessment instruments, (2) whether instrument-informed clinical judgments made with a high degree of confidence are associated with greater accuracy, and (3) the risk assessment instruments and subscales most predictive of clinical judgments. Raters assessed each youth's (n = 166) risk of reoffending after completing the SAVRY and J-SOAP-II. Raters were not able to predict detected cases of either sexual recidivism or nonsexual violent recidivism above chance, and a high degree of rater confidence was not associated with higher levels of accuracy. Total scores on the J-SOAP-II were predictive of instrument-informed clinical judgments of sexual risk, and total scores on the SAVRY of nonsexual risk.     

Beyond a single standard: levels of evidence approach for evaluating marriage and family therapy research and practice

Randomized clinical trial (RCT) research has come to dominate the research landscape of marriage and family therapy (MFT). Despite becoming the ‘gold standard’ for evaluating clinical research and clinical practices, there is a growing debate regarding the reliance on RCTs as the primary basis for evaluating clinical intervention in MFT. Given the natural diversity of clients, settings and clinical problems faced by practitioners and the relational and recursive interactional process of MFT, one of the major challenges for the field of MFT will be to come to grips with the research–practice gap by moving beyond a single methodological standard through adopting a ‘levels of evidence’ approach as a framework that promotes diverse research methods, different methodological criteria (depending on the method), and evaluation based on the accumulated type of evidence needed to answer a specific policy, clinical practice choice, or within a model clinical decision.     

A model for clinical-quantitative classification. Generation I: Application to language-disordered preschool children

A model is presented for the integration of clinical-inferential and quantitative approaches to classification. In this, the first application of the proposed model, preschool children with developmental language disorders were classified on the basis of clinical interpretations of performance on psychometric subtests. Five hypothesized subgroups were validated on the basis of (a) consensus among five clinical neuropsychologists, (b) language pathologists' reports, (c) comparisons with subgroups defined by a cluster analytic approach, and (d) comparisons among subgroups on variables not used for classification. Results are discussed in terms of the feasibility of the integrated approach, commonalities with other typologies, and the implications of this work to issues of subtype stability, remediation, predictions of later reading achievement, brain-behavior relationships, and generalizability to other clinical groups.     

Clinical Cardiovascular Genetic Counselors Take a Leading Role in Team-based Variant Classification

We sought to delineate the genetic test review and interpretation practices of clinical cardiovascular genetic counselors. A one-time anonymous online survey was taken by 46 clinical cardiovascular genetic counselors recruited through the National Society of Genetic Counselors Cardiovascular Special Interest Group. Nearly all (95.7%) gather additional information on variants reported on clinical genetic test reports and most (81.4%) assess the classification of such variants. Clinical cardiovascular genetic counselors typically (81.0%) classify variants in collaboration with cardiologist and/or geneticist colleagues, with the genetic counselor as the team member who is primarily responsible. Variant classification is a relatively recent (mean 3.2 years) addition to practice. Most genetic counselors learned classification skills on the job from clinical and laboratory colleagues. Recent graduates were more likely to have learned this in graduate school (p?<?0.001). Genetic counselors are motivated to take responsibility for the classification of variants because of prior experiences with variant reclassification, inconsistencies between laboratories, and incomplete laboratory reports. They are also driven by a sense of professional duty and their proximity to the clinical context. This practice represents a broadening of the skill set of clinical cardiovascular genetic counselors and a unique expertise that they contribute to the interdisciplinary teams in which they work.     

Measuring Parental Treatment Adherence in a Multimodal Treatment Program for Children with ADHD: A Preliminary Investigation

This study evaluated the clinical significance of measuring between session parental adherence on child and parent outcomes for 51 children (age 4 to 8.5 years) with attention deficit/hyperactivity disorder (ADHD) in a multimodal group training program. Three group treatment conditions: (a) child-only treatment (C1), (c) child and parent training (C2), and (c) C2 + Parent Adherence Measure [PAM (C3)] were compared to assess the clinical significance of measuring parental adherence on child behavioral problems, socialization skills, and parental efficacy. Parents administered the PAM (C3) displayed, in general, better outcomes on child and parent measures than the other two conditions. Results suggest that a multimodal group training program for young children with ADHD is favorable to child group training only. This study offers preliminary support for the clinical utility of measuring parental adherence in a child ADHD multimodal group training program.     

Incorporating a developmental perspective in doctoral training: survey of clinical child psychology training programs and introduction to the special section

Examined the degree to which clinical child programs incorporate and integrate developmental theory into their training, and introduced the contributions of 6 leaders in the field to this special section. Fifty-one clinical child doctoral programs responded to the survey. Results indicate that 3 types of training programs are operating: (a) child emphasis (n = 7), which do not have a formal clinical child training program but do have a faculty member who has child research interests; (b) clinical child (n = 37), which have a group of faculty members with specific child research and clinical interests and a formalized program of study; and (c) developmental-clinical programs (n = 7), which are similar to clinical child programs but require a substantive amount of developmental psychology course work and endorse a developmental psychopathology perspective. Findings reveal that clinical child programs have become increasingly differentiated and specialized over the past 20 years, but, with the exception of developmental-clinical programs, most programs are still neglecting to incorporate developmental theory into training. This issue, as well as concerns about the future direction of clinical child doctoral training is addressed in this special section on the Importance of Incorporating Developmental Theory Into Clinical Child Training.     

Negotiating criteria and setting limits: The case of aids

The classification of clinical problems, such as AIDS, requires choices. Choices are made on epistemic (i.e., knowledge-based) and non-epistemic (i.e., action-based) grounds. That is, the ways in which we classify clinical problems, such as AIDS, involve a balancing of different understandings of clinical reality and of clinical values among participants of the clinical community. On this view, the interplay between epistemic and non-epistemic interests occurs within the embrace of particular clinical contexts.The ways in which we classify AIDS is the topic of this paper. We consider the extent to which we construct clinical reality; we examine a suggested classification of AIDS; and we conclude suggesting that the choice regarding how to classify AIDS is the result of negotiation among participants in the clinical community.     

The Initial Psychotherapy Interview with Adolescent Clients

Initial psychotherapy sessions with adolescents can be very challenging due to the need to balance assessment, relationship building, caretaker/parent management, and case formulation with a client population that sometimes has little motivation for psychotherapy. This article combines empirical evidence, theoretical knowledge, and clinical experience to describe strategies for how psychotherapists can prepare themselves for initial psychotherapy sessions and manage tasks associated with five stages of the clinical interview: (a) the introduction, (b) the opening, (c) the body, (d) the closing, and (e) termination. Using case vignettes and short examples, there is an emphasis on how psychotherapists can develop and maintain a strong therapeutic alliance while simultaneously helping adolescent clients focus on psychotherapy tasks and goals. The overall goal of this article is to help psychotherapists smoothly navigate the potentially stormy stages of the initial clinical interview with adolescents.     

Introduction to the special section on incremental validity and utility in clinical assessment

This special section focuses on the incremental validity and utility of clinical assessment data. The lack of replicated incremental validity research limits the ability of psychologists to establish their assessment practices on a solid empirical footing. The articles in this section deal with conceptual, methodological, and content issues in the development and use of clinical measures. The authors addressed several aspects of incremental validity research, including (a) the evaluation of the magnitude of validity increments, (b) the use of incremental validity data for test development and validation, (c) the costs of assessment, (d) the use of multi-informant and multimethod assessments, and (e) the treatment utility of assessment. Obstacles limiting the use of incremental validity research to inform and guide clinical practice are also emphasized.     

The clinical pain acceptance Q-sort: a tool for assessment and facilitation of pain acceptance

The topic of pain acceptance can be clinically difficult to raise in a respectful way. This article introduces a method of managing the topic of pain acceptance in daily clinical practice: The clinical pain acceptance Q-sort. The Q-sort procedure comprises 13 small cards with printed statements concerning pain acceptance on the one side, score numbers on the other side. The procedure involves the patient handling and prioritizing the statements in a personally meaningful order. Both quantitative and qualitative use of the tool is possible. The method has a three-fold outcome: (1) topics of pain acceptance are presented in a multi-faceted way for the chronic pain patient, (2) an approximate assessment of the level of pain acceptance issues is offered to the clinician, and (3) good opportunities for a therapeutic discussion on pain acceptance are made available. The clinical pain acceptance Q-sort procedure may positively contribute to daily clinical work with pain acceptance in a straightforward way. The method provides options for assessment of pain acceptance, for better understanding of the patient, and for clinical training in psychological pain management.     

Primitive Anxieties,Gender Madness,and Perversions of Agency in Eating Disordered Patients: Commentary on Paper by Tom Wooldridge

The following is a discussion of Tom Wooldridge’s (this issue) paper on primitive anxieties in anorexia and his metaphor of the “entropic body” as a false self “body-state” (Petrucelli, 2014) that functions to omnipotently deny dependency. The focus here is on how, for the eating disordered patient, primitive anxieties related to dependency and containment intertwine with the challenges of rapprochement, in which separation, agency, and awareness of sex difference emerge in a traumatic field. This response emphasizes the clinical utility of conceptualizing eating disorders as disorders of a gendered, agentic self. Wooldridge’s clinical material is discussed with a focus on (a) the salience of gendered enactments in work with eating disordered patients and (b) the relationship between experiences of “entropy” in the clinical dyad and the mutual disavowal of gender-inflected identifications and desires.     

Building an evidence base for DSM-5 conceptualizations of oppositional defiant disorder and conduct disorder: introduction to the special section

The DSM-5 ADHD and Disruptive Behavior Disorders Work Group recently outlined a research agenda designed to support possible revisions to the diagnostic criteria for oppositional defiant disorder (ODD) and conduct disorder (CD). Some of the areas in need of further investigation include (a) examining the clinical utility of the current diagnostic system in girls, (b) further clarifying the developmental progression from ODD to CD, (c) determining whether facets of ODD symptoms can help explain heterotypic continuity and enhance predictive validity, (d) evaluating the clinical utility of a new subtyping scheme for CD on the basis of the presence of callous-unemotional traits, and (e) comparing the clinical utility of dimensional versus categorical conceptualizations of ODD and CD. This special section was organized in an attempt to provide data on these issues using a diverse array of longitudinal data sets consisting of both epidemiological and clinic-based samples that collectively cover a large developmental span ranging from childhood through early adulthood.     

Macrocosm to microcosm: Toward a systemic model of personality

This paper attempts to: (1) provide a paradigm through which to understand the human self and, (2) bring some order out of the variety of theories of personality and strategies of change used in clinical practice today. Drawing on modern physics and general systems theory, a multi-leveled, systemic model incorporating physical, psychological, and spiritual dimensions is proposed and then applied to a representative clinical case. Implications of this model for clinical work and for a spiritual understanding of personality are elaborated.     

The paradox of quetiapine in obsessive-compulsive disorder

Schizophrenia and obsessive-compulsive disorder (OCD) have historical, clinical, and epidemiological links. The clinical use of atypical neuroleptics (ie, dual serotonin-dopamine antagonists) to treat both conditions sheds a new light on them. We report the first two cases of obsessive-compulsive symptoms (OCS) induced by quetiapine in schizophrenia patients. A case of successful augmentation by quetiapine in refractory OCD is also presented. A review of the literature on OCS induced by atypical neuroleptics follows. This paradoxically induced OCD symptomology in schizophrenia patients administered atypical neuroleptics is discussed from new pathophysiological and clinical perspectives. The discussion emphasizes the prognostic implications of OCS in schizophrenia and available therapies for this comorbidity.