Alternative Methodologies in Research Literature Review: Links Between Clinical Work and MFT Effectiveness

Traditionally, "good outcome research" has referred to laboratory-based, controlled studies that report the efficacy of a given treatment on a specific population. Although useful and needed in the struggle to establish MFTs as accepted mental health service providers, this type of research does not address whether MFT is effective in "real world" settings. In order to highlight the clinical and professional relevance of existing effectiveness research, this article reviews 15 years of clinical research in three major family therapy journals. The results suggest that 1) MFT effectiveness is under-represented in major review articles, 2) clinicians can use a variety of methodologies to establish the effectiveness of their work, and 3) more research is needed that investigates how and why MFT works in "real world" settings. Implications for practice and future research are discussed.     

Translating multiple assessment techniques into an intervention selection model for classrooms

Translating current research to school-based clinical practice highlights issues not often encountered in laboratory settings. With the assistance of a consultant, teachers conducted functional analyses, brief multielement treatment comparisons, and controlled treatment evaluations under naturalistic conditions in the classroom. Teachers also provided input on treatment selection. Treatment integrity data collected throughout the study suggested that teachers implemented analyses and treatments with high integrity. The functional analysis outcomes combined with effectiveness and acceptability data led to the selection of interventions that reduced problem behavior in the classrooms for each of 3 children.     

The REBT Competency Scale for Clinical and Research Applications

This paper presents the REBT Competency Scale which can be used in the evaluation of adherence to an REBT treatment model in clinical and research applications. The scale has been developed to map closely onto the REBT treatment protocol developed by Dryden et al. (A primer on rational emotive behaviour therapy, Research Press, Champaign, 2003). Based on this treatment protocol 21 core steps (tasks) were identified for effective REBT practice. Each step is operationally defined, the rater is reminded of how the step relates to REBT theory and practice and scoring criteria are established that enable a rating of the therapists performance of the task. The potential uses for and application of the scale in clinical and research settings are considered.     

Counselling Older Adults Living in Residential Aged Care Settings: Four Illustrative Case Studies

The role of psychologists and other mental health professionals in long‐term care settings is undefined in Australia. Graduate psychology students receive little training in clinical geropsychology, and residential aged care providers do not routinely employ psychologists within such settings. Further, despite high rates of depression, neurocognitive problems, and other mental health problems, residents are rarely referred for evidence‐based psychological treatment. This article presents four case studies showing how psychology services may be employed in such settings within the context of a postgraduate psychology placement programme. These case studies emphasise the importance of engagement, the use of flexible and individualised treatment approaches, and the involvement of family and professional carers in the provision of psychological services. Psychology services in residential settings can have a positive impact on the care of older adults and their families.     

Development and description of an empirically based ecobehavioral treatment program for child maltreatment

Victims of child maltreatment and their families evince a myriad of behavioral problems, including deficits in parenting skills, social skills, safety skills, anger, stress, and financial management, mood disorders, and abusive behavior. Controlled treatment outcome studies in child maltreated samples have indicated that many of these problems are responsive to clinical intervention strategies. However, empirically based practitioners who treat child maltreatment are faced with the inevitable task of effectively integrating these treatments into their clinical programs. Therefore, this paper describes the development of an ecobehavioral treatment program for child maltreatment that is founded on a comprehensive integration of previously validated procedures. The program's development, and methods of assessment and intervention, will be underscored, including therapist training strategies, and solutions to problems that sometimes occur. Data in support of the program is examined, but primarily as a means to demonstrate how evaluative components may be utilized in practice settings to guide intervention. Copyright © 1999 John Wiley & Sons, Ltd.     

The epidemiology of attention-deficit/hyperactivity disorder (ADHD): a public health view

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood. However, basic information about how the prevalence of ADHD varies by race/ethnicity, sex, age, and socio-economic status remains poorly described. One reason is that difficulties in the diagnosis of ADHD have translated into difficulties developing an adequate case definition for epidemiologic studies. Diagnosis depends heavily on parent and teacher reports; no laboratory tests reliably predict ADHD. Prevalence estimates of ADHD are sensitive to who is asked what, and how information is combined. Consequently, recent systematic reviews report ADHD prevalence estimates as wide as 2%-18%. The diagnosis of ADHD is complicated by the frequent occurrence of comorbid conditions such as learning disability, conduct disorder, and anxiety disorder. Symptoms of these conditions may also mimic ADHD. Nevertheless, we suggest that developing an adequate epidemiologic case definition based on current diagnostic criteria is possible and is a prerequisite for further developing the epidemiology of ADHD. The etiology of ADHD is not known but recent studies suggest both a strong genetic link as well as environmental factors such as history of preterm delivery and perhaps, maternal smoking during pregnancy. Children and teenagers with ADHD use health and mental health services more often than their peers and engage in more health threatening behaviors such as smoking, and alcohol and substance abuse. Better methods are needed for monitoring the prevalence and understanding the public health implications of ADHD. Stimulant medication is the treatment of choice for treating ADHD but psychosocial interventions may also be warranted if comordid disorders are present. The treatment of ADHD is controversial because of the high prevalence of medication treatment. Epidemiologic studies could clarify whether the patterns of ADHD diagnosis and treatment in community settings is appropriate. Population-based epidemiologic studies may shed important new light on how we understand ADHD, its natural history, its treatment and its consequences.     

Attention Deficit Hyperactivity Disorder in Adults: Implications for Theories of Diagnosis

The diagnosis of attention deficit hyperactivity disorder (ADHD) in adults has been a source of controversy, with some prominent researchers questioning its very existence and others suggesting it is an urgent clinical problem. This article reviews five domains of data addressing the validity of adult ADHD: clinical correlates, family history, treatment response, laboratory studies, and long-term outcome. It then shows how the debate over adult ADHD reflects a clash of theoretical paradigms and concludes by suggesting ways in which psychological science can collect the data needed to clarify the validity of adult ADHD.     

Capturing naturally occurring superior performance in the laboratory: translational research on expert performance

One of the central challenges to studying highly skilled performance in the laboratory is methodological. It is necessary to develop standardized methods that allow investigators to make experts repeatedly reproduce their superior performance in the laboratory. The recent increase in demand for translational research has raised related issues of how everyday phenomena, such as successful clinical treatments and expert achievement, can be reproduced in the laboratory and how laboratory studies of these phenomena can lead to successful interventions in everyday life. The expert-performance approach was developed as a framework for capturing, analyzing, and accounting for complex acquired skills and adaptations. Performance is initially captured and elicited in the laboratory using tasks representative of core activities in the domain. Process-tracing measures are employed to identify the mechanisms that mediate the reproducibly superior performance. Finally, the factors responsible for the development of the mediating mechanisms are studied by a retrospective analysis of training activities, such as deliberate practice, as well as genetic prerequisites. The principles and mechanisms discovered need then be validated using more traditional longitudinal and experimental designs.     

The effectiveness of therapeutic assessment with an adult client: a single-case study using a time-series design

This article presents the therapeutic assessment (TA; Finn, 2007) of a traumatized young woman named Claire. Claire reported feeling debilitated by academic demands and the expectations of her parents, and was finding it nearly impossible to progress in her studies. She was also finding it difficult to develop and sustain intimate relationships. The emotional aspects of close relationships were extremely difficult for her and she routinely blamed herself for her struggles in this arena. The assessor utilized the TA model for adults, with the exception of not including an optional intervention session. The steps of TA, particularly the extended inquiry and the discussion of test findings along the way, cultivated a supportive and empathic atmosphere with Claire. By employing the single-case time-series experimental design used in previous TA studies (e.g., Smith, Handler, & Nash, 2010; Smith, Wolf, Handler, & Nash, 2009), the authors demonstrated that Claire experienced statistically significant improvement correlated with the onset of TA. Results indicated that participation in TA coincided with a positive shift in the trajectory of her reported symptoms and with recognizing the affection she held for others in her life. This case illustrates the successful application of case-based time-series methodology in the evaluation of an adult TA. The potential implications for future study are discussed.     

Collaborative Empiricism in Culturally Sensitive Cognitive Behavior Therapy

Collaborative empiricism, one of the main tenets of cognitive behavior therapy, could encounter conceptual and practical problems when applied to culturally sensitive settings. This paper sets out to discuss issues in applying collaborative empiricism to Chinese patients, taking into account a number of cultural determinants such as collectivism, hierarchical perception, passivity, reticence, and superstition. These will be discussed in light of studies on the impact of Chinese culture on patient behavior. Evidence on the successful application of cognitive behavior therapy to Chinese patients will also be presented. There is a pressing need for culturally sensitive clinical procedures and skills adaptation. A case study is presented to illustrate how culturally mediated resistance in collaborative empiricism can be overcome by good clinical practice.     

Family-based treatment for adolescent substance abuse: controlled trials and new horizons in services research

This article provides an overview of controlled trials research on treatment processes and outcomes in family-based approaches for adolescent substance abuse. Outcome research on engagement and retention in therapy, clinical impacts in multiple domains of adolescent and family functioning, and durability and moderators of treatment effects is reviewed. Treatment process research on therapeutic alliance, treatment fidelity and core family therapy techniques, and change in family processes is described. Several important research issues are presented for the next generation of family-based treatment studies focusing on delivery of evidence-based treatments in routine practice settings.     

Implementing the Boulder Model of Training in a Psychology Training Clinic

The scientist–practitioner (S–P) model of training has guided professional psychology in the United States for nearly six decades. However, since its inception, the model has been hotly debated and implementation of the model has been chronically problematic. One counseling psychologist who is working as both a faculty member and psychology training clinic director describes how scientific principles can be retained in a practice setting. He overviews the Boulder model of training, provides a brief review of the psychology training clinic (PTC), describes his current work setting and unique faculty appointment, and outlines five strategies for integrating science and practice in applied clinical settings. He also highlights how embracing the Boulder model has promoted a strong professional identity and presents the PTC as a model professional home for S–Ps.     

A review of research on the prevalence,antecedents, consequences and prevention of workplace aggression in clinical medical practice

A broad-ranging review of the published research literature was undertaken on workplace aggression in clinical medical practice. Prevalence studies have found that 15–75% of survey respondents reported verbal aggression and 2–29% reported physical aggression in medical practice settings in the previous 6–24 months. In comparison, there was limited published research on the antecedents and consequences of clinician exposure to workplace aggression, and a dearth of published research on the prevention and minimization of workplace aggression in medical practice settings. Future research efforts need to investigate workplace aggression from all sources and across all medical clinician sub-populations in the diverse settings in which they work. Specific attention needs to be given to identifying key risk and protective factors for workplace aggression exposure, including in relation to clinician profiles, the settings and conditions of medical work, and the presence of key aggression prevention and minimization efforts, both individually and in combination. The impact of workplace aggression on clinician health, well-being, performance and work participation remains under-researched. Overall, a more extensive and robust evidence base is required to enable informed decision-making on reducing the likelihood and consequences of workplace aggression in clinical medical practice.     

Learning and teaching (briefly)

This paper was given as the Annual Ellen Noonan Counselling Lecture on July 2012 and retains some of the spoken style of the lecture. It uses examples of Ellen Noonan’s work to examine aspects of the process of teaching and learning psychodynamic practice. The difficulties of how to embed theoretical knowledge with its clinical application are discussed and the question of what are the key skills of the self-reflective practitioner is raised with reference to whether, and how, they can be taught or learnt. It is suggested that part of this process consists in helping students, and their teachers, to be more comfortable with not knowing, a concept that is both counter intuitive and counter cultural. From this aspects of contemporary therapeutic practice, with specific reference to psychodynamic short-term therapy, are addressed. The paper looks at the ambivalence felt by many psychodynamic clinicians towards working within a short-term paradigm in current workplace settings and how this might be addressed. The paper discusses the intrinsic qualities of a psychodynamic short-term approach and its relation to contemporary therapeutic modalities. It is suggested that the increasing managerial culture, leading to the ascendance of protocol driven, manualised and structured therapies, represents an attack on the relational and must be challenged.     

Issues associated with repeated neuropsychological assessments

Distinguishing practice effects from other factors in repeated neuropsychological assessments are discussed in the context of research studies and clinical/forensic assessments. Potential methodological procedures for reducing the impact of practice effects in research settings are outlined. In contrast, the potential clinical utility and interpretation of practice effects in clinical assessments and forensic evaluations are highlighted.     

The clinical representativeness of couple therapy outcome research

The clinical representativeness of outcome studies is defined as the generalizability of recruitment processes, assessment/diagnostic procedures, treatment protocols, and therapeutic results from research settings to naturalistic treatment settings. The main goal of the present study was to examine the clinical representativeness of couple therapy in outcome studies. The data set was formed by 50 published clinical trials, including 34 couple therapy outcome studies for marital distress (CTMD) and 16 couple therapy outcome studies for comorbid relational and mental disorders (CTMD + C). The present findings showed that, overall, the clinical representativeness of couple therapy outcome studies is only fair (i.e., the mean global score is slightly lower than the midpoint of the rating scale used to assess representativeness). CTMD + C studies fared better than CTMD studies on many dimensions of clinical relevance. Studies in which pretherapy training was less intensive (for CTMD studies only), treatment was less structured, and therapists were more experienced showed larger effect sizes than those in which such was not the case.     

Einfluss des Behandlungssettings auf den Gesundungsverlauf

Even though managed care systems research emerged as an important field in psychotherapy research in the last years, studies examining the effects of its psychotherapeutic measures on outcome are still rare, especially in Germany. Little is known about the effectiveness of psychotherapy in different treatment settings, i. e. whether and how patients in outpatient psychotherapy differ from inpatients in respect to initial impairment status and pace of improvement. Two longitudinal data sets—inpatient (N=759) and outpatient (N=521)—were used to scrutinize these questions. Results yielded no differences between treatment settings as to patients’ initial impairment. A linear model adequately represented the mean course of improvement in inpatient psychotherapy. For outpatient psychotherapy, a bipartite linear model for treatment and for the follow-up period proved more appropriate. During 1 year, patients in both settings attained a similar amount of improvement. However, pace of in-treatment improvement was 10 times faster in the inpatient setting. Initial impairment substantially predicted the course of psychological improvement in both treatment settings.     

Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain

Psychosocial treatments for chronic pain are effective. There is a need, however, to understand the processes involved in determining how these treatments contribute to behavior change. Control and acceptance strategies represent two potentially important processes involved in treatment, although they differ significantly in approach. Results from laboratory-based studies suggest that acceptance-oriented strategies significantly enhance pain tolerance and behavioral persistence, compared with control-oriented strategies. There is a need, however, to investigate processes of acceptance and control directly in clinical settings. The present study investigated the effects of three brief instructional sets (pain control, pain acceptance, continued practice) on demonstrated physical impairment in 74 individuals with chronic low back pain using an analogue experimental design. After controlling for baseline performance, the pain acceptance group demonstrated greater overall functioning on a set of 7 standardized physical tasks relative to the other two groups, which did not differ from one another. Further, the acceptance group exhibited a 16.3% improvement in impairment, whereas the pain control group worsened by 8.3% and the continued practice group improved by 2.5%. These results suggest that acceptance may be a key process involved in behavior change in individuals with chronic pain.     

“Don't think zebras”: Uncertainty,interpretation, and the place of paradox in clinical education

Working retrospectively in an uncertain field of knowledge, physicians are engaged in an interpretive practice that is guided by couterweighted, competing, sometimes paradoxical maxims. “When you hear hoofbeats, don't think zebras,” is the chief of these, the epitome of medicine's practical wisdom, its hermeneutic rule. The accumulated and contradictory wisdom distilled in clinical maxims arises necessarily from the case-based nature of medical practice and the narrative rationality that good practice requires. That these maxims all have their opposites enforces in students and physicians a practical skepticism that encourages them to question their expectations, interrupt patterns, and adjust to new developments as a case unfolds. Yet medicine resolutely ignores both the maxims and the tension between the practical reasoning they represent and the claim that medicine is a science. Indeed, resolute epistemological naivete is part of medicine's accommodation to uncertainty; counterweighted, competing, apparently paradoxical (but always situational) rules enable physicians simultaneously to express and to ignore the practical reason that characterizes their practice.