[Clin Psychol Sci Prac 18: 215–231, 2011]
The development of effective treatments for Asian Americans is important because treatment disparities continue to exist for this population. Because of their theoretical grounding in East Asian philosophies, mindfulness and acceptance-based psychotherapies appear to constitute promising ways to provide culturally responsive mental health care to Asian Americans. However, in practice, these approaches often reflect conceptions of mental health that are more consistent with Western worldviews. We review points of intersection and divergence between Western-based mindfulness and acceptance psychotherapies and Asian American cultural values. We then propose a culturally syntonic approach that accentuates certain components of mindfulness and acceptance psychotherapies and adapts other components of these approaches to be more consistent with Asian American cultural values.
The aim of this article is to highlight the importance of the sleep-wake cycle in children, adolescents, and adults with bipolar disorder. After reviewing the evidence that has accrued to date on the nature and severity of the sleep disturbance experienced, we document the importance of sleep for quality of life, risk for relapse, affective functioning, cognitive functioning, health (sleep disturbance is implicated in obesity, poor diet, and inadequate exercise), impulsivity, and risk taking. We argue that sleep may be critically important in the complex multifactorial cause of interepisode dysfunction, adverse health outcomes, and relapse. An agenda for future research is presented that includes improving the quality of sleep measures and controlling for the impact of bipolar medications.
Bipolar disorder has garnered increasing attention as many argue that rates of bipolar disorder are skyrocketing and the definition of the classic bipolar disorder phenotype should be expanded, especially among children and adolescents. Understanding the psychosocial etiologies of bipolar disorder across the lifespan is critically important, and Alloy and colleagues' (2009) scholarly review makes an important contribution. Given the debate and controversy surrounding the description, diagnosis, and phenotype of bipolar disorder, having an accurate, reliable, and valid classification for definition, diagnosis, and assessment is critical for explicating potential etiology. Likewise, advanced understanding of etiology, especially when grounded in basic psychological science as Alloy and colleagues' review is, can importantly inform clinical phenomenology, course, assessment, and intervention. In summary, there is an essential interplay among description, classification, assessment, etiology, and intervention, such that a deeper understanding of all these areas is necessary for advancing an empirically based practice of assessment and intervention.
[Clin Psychol Sci Prac 18: 238–241, 2011]
Psychotherapy is a Western method of treating mental illness. Culturally adapting psychotherapy to better meet the needs of ethnic minorities is an important endeavor. Hall, Hong, Zane, and Meyer. (2011) did an excellent job of reviewing the intersection and divergence between Asian culture and mindfulness and acceptance-based therapies. They also point out that some therapies can be naturally syntonic with Asian American cultural values and belief systems. This is especially important given cultural differences between the East and West. Later, I provide an overview of the complexities involved in adapting treatments for diverse clients. I also discuss the importance of deconstructing stereotypes and understanding the complex interplay between clinical and cultural issues. Individualization of treatment for diverse clients can be achieved through culturally formed practice.
The co-occurrence of schizophrenia and alcohol use disorders often leads to poor treatment retention and adherence. Both empirical research and statements of best practices suggest that interventions including motivational interviewing principles can enhance treatment engagement and improve outcomes. This article describes a set of exercises used within a motivational enhancement protocol for outpatients with schizophrenia-spectrum and alcohol use disorders. We describe how each exercise was tailored to the target population, and how it is designed to enhance motivation to change and treatment engagement. Examples from clinical transcripts are used to demonstrate how motivational interviewing is adapted to the cognitive, social, and environmental circumstances associated with schizophrenia.
[Clin Psychol Sci Prac 17: 350–359, 2010]
Published rates of comorbidity between pediatric bipolar disorder (PBD) and attention-deficit/hyperactivity disorder (ADHD) have been higher than would be expected if they were independent conditions, but also dramatically different across different studies. This review examines processes that could artificially create the appearance of comorbidity or substantially bias estimates of the PBD-ADHD comorbidity rate, including categorization of dimensional constructs, overlap among diagnostic criteria, over-splitting, developmental sequencing, and referral or surveillance biases. Evidence also suggests some mechanisms for “true” PBD-ADHD comorbidity, including shared risk factors, distinct subtypes, and weak causal relationships. Keys to differential diagnosis include focusing on episodic presentation and nonoverlapping symptoms unique to mania.
To extend the reach, transparency, and accountability for the implementation and outcomes of effective treatments in routine care, more clarity is needed about what happens in treatment. We attempt to (a) clarify terminology to describe and measure psychological treatment, and (b) consider what treatment adherence instruments can tell us about what happens in treatment. We reviewed the content of 11 adherence instruments for 14 evidence-based treatments for disruptive behavior problems in youth identified in an ongoing review of adherence measurement methods used in psychosocial treatment studies from 1980 - 2008. Item number, content, and level of detail varied widely. Implications are considered for the definition of effective treatments and design and testing of strategies to measure and monitor their delivery.
Increasingly, the telephone is being used to deliver psychotherapy for depression, in part as a means to reduce barriers to treatment. Twelve trials of telephone-administered psychotherapies, in which depressive symptoms were assessed, were included. There was a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to control conditions (d = 0.26, 95% confidence interval [CI] = 0.14-0.39, p < .0001). There was also a significant reduction in depressive symptoms in analyses of pretreatment to posttreatment change (d = 0.81, 95% CI = 0.50-1.13, p < .0001). The mean attrition rate was 7.56% (95% CI = 4.23-10.90). These findings suggest that telephone-administered psychotherapy can produce significant reductions in depressive symptoms. Attrition rates were considerably lower than rates reported in face-to-face psychotherapy.
This article reviews the current state of the literature on the assessment of bipolar disorder in adults. Research on reliable and valid measures for bipolar disorder has unfortunately lagged behind assessment research for other disorders, such as major depression. We review diagnostic tools, self-report measures to facilitate screening for bipolar diagnoses, and symptom severity measures. We briefly review other assessment domains, including measures designed to facilitate self-monitoring of symptoms. We highlight particular gaps in the field, including an absence of research on the reliable diagnosis of bipolar II and milder forms of disorder, a lack of empirical data on the best ways to integrate data from multiple domains, and a shortage of measures targeting a broader set of illness-related constructs relevant to bipolar disorder.
This special series focuses upon the ways in which research on treatment integrity, a multidimensional construct including assessment of the content and quality of a psychosocial treatment delivered to a client as well as relational elements, can inform dissemination and implementation science. The five articles for this special series illustrate how treatment integrity concepts and methods can be applied across different levels of the mental health service system to advance dissemination and implementation science. In this introductory article, we provide an overview of treatment integrity research and describe three broad conceptual models that are relevant to the articles in the series. We conclude with a brief description of each of the five articles in the series.
Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are prevalent and frequently co-occur. Comorbid PTSD/SUD is associated with a more complex and costly clinical course when compared with either disorder alone, including increased chronic physical health problems, poorer social functioning, higher rates of suicide attempts, more legal problems, increased risk of violence, worse treatment adherence, and less improvement during treatment. In response, psychosocial treatment options have increased substantially over the past decade and integrated approaches - treatments that address symptoms of both PTSD and SUD concurrently -are fast becoming the preferred model for treatment. This paper reviews the prevalence, etiology and assessment practices as well as advances in the behavioral and pharmacologic treatment of comorbid PTSD and SUDs.
The model of brief therapy developed by Fisch, Weakland, Watzlawick, and colleagues in Palo Alto is based on identifying and interrupting ironic processes that occur when repeated attempts to solve a problem keep the problem going or make it worse. Formulations of ironic problem-solution loops provide a template for assessment and strategic intervention, indicating where to look to understand what keeps a problem going (look for "more of the same" solution) and what needs to happen for the complaint to be resolved (someone must apply "less of the same" solution). Supporting research is preliminary but suggests this approach may be well suited for change-resistant clients.
[Clin Psychol Sci Prac 17: 293–306, 2010]
The high level of concurrent and sequential comorbidity between anxiety and depression in children and adolescents may result from (a) substantial overlap in both the symptoms and items used to assess these putatively different disorders, (b) common etiologic factors (e.g., familial risk, negative affectivity, information-processing biases, neural substrates) implicated in the development of each condition, and (c) negative sequelae of anxiety conferring increased risk for the development of depression. Basic research on their various common and unique etiologic mechanisms has guided the development of efficacious treatments for anxiety and depressive disorders in youth. Potential processes through which the successful treatment of childhood anxiety might prevent subsequent depression are described.
[Clin Psychol Sci Prac 17: 307–318, 2010]
Although oppositional defiant disorder (ODD) and anxiety disorders (ADs) often co-occur, the literature is mixed regarding the effects of such co-occurrence. For example, there is evidence that AD symptoms may mitigate ODD symptoms (buffer hypothesis) or exacerbate ODD symptoms (multiple problem hypothesis). A dual-pathway model incorporates previous research and addresses both hypotheses. We describe several possible etiological or risk processes that may underlie each of these ODD–AD pathways, including child temperament, aggression, limbic system processes, executive functioning abilities, and social information–processing biases, and suggest an integrated model. We conclude with implications for the model and directions for future research involving co-occurring ODD and ADs.
[Clin Psychol Sci Prac 18: 266–273, 2011]
Research on anxiety treatment with Black women reveals a need to develop interventions that address factors relevant to their lives. Such factors include feelings of isolation, multiple roles undertaken by Black women, and faith. A recurrent theme across treatment studies is the importance of having support from other Black women. Sister circles are support groups that build upon existing friendships, fictive kin networks, and the sense of community found among Black women. Sister circles appear to offer many of the components Black women desire in an anxiety intervention. In this article, we explore sister circles as an intervention for anxious Black women. Culturally infused aspects from our sister circle work with middle-class Black women are presented. Further research is needed.
[Clin Psychol Sci Prac 18: 305–310, 2011]
An exciting review in this issue (Forgeard et al., 2011) highlights a number of emerging themes in contemporary translational research. A primary challenge for the next generation of researchers reading this work will be how to carry out the grand charges levied by Forgeard et al. on the ground, that is, to lay the foundations for moving the emerging basic science of depression into the Depression Clinic of Tomorrow. Addressing these challenges could suggest changes in the nature of the basic science, and the questions that are being asked, and employed approaches in contemporary depression research. Preconditions for clinical adoption discussed in the review include (a) beginning to hold neuroscience-based measures of features of depression to the same standards held for other depression measures in the clinic, (b) attending to how the proposed methods might actually end up being feasibly imported into the clinic, and (c) what interventions targeted at mechanisms of depression might look like in the next decade.
[Clin Psychol Sci Prac 17: 72–81, 2010]
Research on substance use disorders has produced a slew of disappointments in studies designed to confirm basic principles of the technology approach to treatment dissemination. These setbacks should inspire addictions science to pursue complementary paths of inquiry that focus on evidence-based practices delivered under naturalistic conditions. This will require larger accommodations to, and closer partnerships with, the indigenous cultures of everyday care.
Psychosocial treatments for persons with severe mental illness (SMI) have been developing rapidly over the past decade. Despite the fact that people with SMI are often in the greatest need of care, clinical psychologists are not currently playing a major role in their treatment and are underrepresented compared to other disciplines in this area such as nursing, social work, and psychiatry. In this article, we present possible reasons for clinical psychologists' underrepresentation and discuss motivators, potential opportunities, and ways for clinical psychologists to take a greater role in the provision of services for persons with SMI. Implications for the training of clinical psychologists are discussed.
Research has emerged providing consistent support for the behavioral approach system (BAS) dysregulation theory of bipolar disorder. The objective of the current article is to examine the extent to which findings from the BAS dysregulation theory can inform psychosocial interventions for bipolar disorder. Towards this end, we first provide an overview of the BAS dysregulation theory. Second, we review extant research on psychosocial interventions for bipolar disorder. And, third, we discuss means by which research and theory in line with the BAS dysregulation model can inform psychosocial interventions for bipolar disorder. Particular attention is given to the clinical implications of research suggesting that bipolar disorder is characterized by high drive/incentive motivation, ambitious goal-setting, and perfectionism in the achievement domain.
We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal - distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.
Nusslock, Abramson, Harmon-Jones, Alloy, and Coan (this issue) propose that current psychosocial treatments for bipolar disorder be supplemented with interventions focused on altering goal dysregulation pathways. While innovations to existing treatment manuals are always welcome, there are several reasons why this suggestion may require further consideration. We highlight issues pertaining to the status of cognitive-behavioral therapy for bipolar disorder, the distinction between education and psychoeducation, the nature of familial expressed emotion, differences between clinical and analog samples, and the larger question of how to assess mechanisms in psychosocial treatment studies. We also raise the question of whether an optimistic goal orientation can be a protective factor in patients' long-term coping with bipolar disorder.
[Clin Psychol Sci Prac 17: 58–71, 2010]
The present study is a secondary analysis of a randomized trial of brief motivational interventions (BMIs) for 198 college students sanctioned for alcohol-related violations of school policy (Carey, Henson, Carey, & Maisto, 2009). Using multivariate latent growth curve models, we evaluated theoretically derived mediators of the observed BMI effect: motivation to change (readiness-to-change, costs and benefits of drinking) and drinking norms (injunctive norms for peers, and descriptive norms for friends, local peers, and national peers). Results provided partial support for mediation by changes in perceptions of descriptive but not injunctive norms, a pattern that varied by gender and norm type. We found no evidence of a mediating role for any of the motivational variables.
Measures of treatment integrity are needed to advance clinical research in general and are viewed as particularly relevant for dissemination and implementation research. Although some efforts to develop such measures are underway, a conceptual and methodological framework will help guide these efforts. The purpose of this article is to demonstrate how frameworks adapted from the psychosocial treatment, therapy process, healthcare, and business literatures can be used to address this gap. We propose that components of treatment integrity (i.e., adherence, differentiation, competence, alliance, client involvement) pulled from the treatment technology and process literatures can be used as quality indicators of treatment implementation and thereby guide quality improvement efforts in practice settings. Further, we discuss how treatment integrity indices can be used in feedback systems that utilize benchmarking to expedite the process of translating evidence-based practices to service settings.
[Clin Psychol Sci Prac 18: 67–83, 2011]
Multiple evidence-based treatments for adolescents with substance use disorders are available; however, the diffusion of these treatments in practice remains minimal. A dissemination and implementation model incorporating research-based training components for simultaneous implementation across 33 dispersed sites and over 200 clinical staff is described. Key elements for the diffusion of the Adolescent Community Reinforcement Approach and Assertive Continuing Care were as follows: (a) 3 years of funding to support local implementation; (b) comprehensive training, including a 3.5-day workshop, biweekly coaching calls, and ongoing performance feedback facilitated by a web tool; (c) a clinician certification process; (d) a supervisor certification process to promote long-term sustainability; and (e) random fidelity reviews after certification. Process data are summarized for 167 clinicians and 64 supervisors.
Maser et al. (2009) identify several problems with the categorical DSM, and suggest that a shift to a mixed categorical-dimensional system is warranted. Maser et al. support their argument by citing evidence related to mood and anxiety disorders, among other conditions. In this commentary, I consider the applicability of several issues raised by Maser et al. to two disruptive behavior disorders in youth, oppositional defiant disorder (ODD) and conduct disorder (CD). The issues include paradigm shifts concerning (a) the diagnostic threshold, (b) symptoms, and (c) distress/psychosocial impairment. Within each topic, several developmental psychopathology principles that parallel and extend the Maser et al. issues are presented and described. This commentary also provides examples of dimensions that could be useful for conceptualizing ODD and CD within a mixed categorical-dimensional classification system.
Drawing heavily from the nonhuman animal literature, understanding of tonic immobility (TI), a sustained and involuntary physical immobility, may yield clear clinical implications and strong future translational research. Clinically, for individuals who potentially have experienced TI, psychoeducation regarding its involuntary and defensive nature may help normalize trauma-related reactions. This must be balanced with the reactive nature of the information and the recognition of potentially more common survival strategies. The application of TI for research purposes may pose translational obstacles regarding construct definition and assessment. Issues include separating the construct from non-TI-related event or perpetrator characteristics, peritraumatic dissociation, and event severity. Furthermore, with its assessment, clinical status and time may inflate endorsement of the presence or severity of TI reactions.
The majority of men and women prison inmates are parents. Many lived with children prior to incarceration, and most have at least some contact with their children and families while serving their sentences. As prison populations have increased in the United States, there has been a renewed interest in finding ways not only to reduce recidivism, but also to prevent incarceration in the first place, particularly amongst the children of incarcerated parents. Positive family interaction is related to both issues. The ongoing development of a multisystemic intervention designed to increase positive family interaction for parents and families involved in the criminal justice system is described. The intervention package currently includes a prison-based parent management training program called Parenting Inside Out (PIO); a prison-based therapeutic visitation program; and complimentary versions of PIO designed for jail and probation and parole settings. Work on other components designed for justice-involved parents, children and for caregivers during reunification from prison is ongoing. Program development has occurred within the context of strong support from the state department of corrections and other key governmental and non-profit sector groups, and support systems have been established to help maintain the interventions as well as to develop complimentary interventions, policies and procedures.
To provide effective treatment for individuals with mental health needs, there is a movement to deploy evidence-based practices (EBPs) developed in research settings into community settings. Training clinicians in EBPs is often used as the primary implementation strategy in these efforts, despite evidence suggesting that training alone does not change therapist behavior. A promising implementation strategy that can be combined with training is consultation, or ongoing support. This paper reviews the literature on consultation following initial training. A model of consultation is presented as well as preliminary findings regarding effective consultation techniques. Future directions are offered.
[Clin Psychol Sci Prac 17: 1–30, 2010]
Evidence-based practice (EBP), a preferred psychological treatment approach, requires training of community providers. The systems-contextual (SC) perspective, a model for dissemination and implementation efforts, underscores the importance of the therapist, client, and organizational variables that influence training and consequent therapist uptake and adoption of EBP. This review critiques the extant research on training in EBP from an SC perspective. Findings suggest that therapist knowledge improves and attitudinal change occurs following training. However, change in therapist behaviors (e.g., adherence, competence, and skill) and client outcomes only occurs when training interventions address each level of the SC model and include active learning. Limitations as well as areas for future research are discussed.
The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/"micro" variables to services-level/"macro" variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs.
[Clin Psychol Sci Prac 17: 253–257, 2010]
Mazzucchelli and Sanders (2010) provide a thoughtful, detailed, and complex description of how to encourage flexible fidelity to one well-established, evidence-based treatment, the Triple P-Positive Parenting Program. As the authors highlight, many of the “lessons learned” from this wealth of treatment, research, and implementation experience were developed over decades and can be applied to other evidence-based treatments. Underlying many of the recommendations provided by Mazzucchelli and Sanders (2010) is a well-refined infrastructure to support implementation and the need to refine the measurement of fidelity in the field. This commentary will discuss each of those topics. It seems that we have many lessons to learn and hurdles to clear in this emerging area of science, which will be hastened by pioneers like Mazzucchelli and Sanders.
[Clin Psychol Sci Prac 17: 272–280, 2010]
Recent years have evidenced a tremendous increase in research using a developmental psychopathology framework to examine clinical diagnoses among youth. Despite this increase, a relative dearth of literature systematically examines the development of co-occurring conditions among youth. In this introduction to the Special Issue on comorbidity among youth, we suggest that a developmental psychopathology perspective can provide an important foundation for the diagnosis of mental health problems among youth. As a potential framework for future investigations, we consider several developmental psychopathology principles that can inform assessment and diagnosis among youth psychological disorders. We use these principles as a foundation for considering co-occurring psychological disorders and provide potential explanations for comorbidity that can be addressed in future research that uses a developmental psychopathology perspective.
The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.
[Clin Psychol Sci Prac 18: 41–46, 2011]
Combining intervention diffusion with change in clinical practice and public policy is an ambitious agenda. The impressive effort in Hawaii can be instructive, highlighting questions for a science of treatment dissemination. Among these questions, some of the most important are the following: (a) Who should be targeted for change? (e.g., “downstream” clinicians in practice, “upstream” clinicians in training, consumers, “brokers,” policy makers, or payers?); (b) What should be disseminated? (e.g., full evidence-based protocols, specific treatment elements or “kernels”?); and (c) Which procedures maximize change? (e.g., what combination and duration of teaching, supervision, consultation, and other support?). Ultimately, change efforts need to assess what aspects of practice were actually altered, what measurable impact the changes had on clinical outcomes, and what changes in practices and outcomes can be sustained over time.
This Special Issue of Clinical Psychology: Science and Practice provides a series of articles detailing efforts to consider the concepts of emotion and emotion regulation in relation to clinical assessment and psychopathology intervention efforts across the lifespan. In our commentary, we review some common themes and challenges presented in these articles to move forward the discussion of emotion's role in psychological therapy. We discuss efforts to conceptualize the role of context in defining emotion concepts and maximizing the relevancy of such concepts to treatment. We review the importance of imbuing efforts to develop emotion-focused treatments with emphases on positive, as well as negative, emotions and flexibility in the expression of these emotions. We also highlight the relevance of a lifespan developmental approach to the accurate use of emotion and emotion regulation concepts within treatment. Finally, we discuss the application of these issues to our own treatment development and evaluation efforts regarding a unified approach to the treatment of emotional disorders in adults and adolescents.
[Clin Psychol Sci Prac 18: 36–40, 2011]
The last decade has witnessed increased interest in the implementation and dissemination of evidence-based treatments (EBTs) for youth. Nakamura et al. (2011) detail lessons learned over the past decade from the large-scale implementation of EBTs for children in Hawaii. This commentary discusses how lessons from Hawaii’s initiative can help inform the next generation of implementation research. Specifically, we focus on how treatment integrity models and methods designed to characterize core aspects of treatment delivery can be used to study the implementation process. Using the new interactive online reporting systems developed by Nakamura et al. to collect treatment integrity data offers researchers a way to determine how best to implement EBTs in community-based service settings with integrity and skill.
[Clin Psychol Sci Prac 18: 148–153, 2011]
Treatment integrity, also known as treatment fidelity, is integral for empirical testing of intervention efficacy, as it allows for unambiguous interpretations of the obtained results. Ensuring treatment integrity is also important for dissemination of evidence-based practices and quality improvement of services. However, in the examination of the relationship between treatment integrity and treatment outcome, it is important to consider that treatment integrity may be a proxy variable for other variables impacting therapeutic change (e.g., characteristics of intervention, clients, setting, and therapist). Considerations on examining the association between integrity and outcome are discussed. Further, recommendations on the level to which treatment integrity needs to be addressed in psychotherapy research and clinical practice are provided.
Although the efficacy of numerous psychosocial interventions for social phobia has been clearly demonstrated, little is known about the mediators and moderators of treatment change. Three potential mediators are discussed that are derived from prominent psychological theories: negative cognitive appraisal (estimated social costs), perceived self-efficacy (perceived social skills), and perceived emotional control. Furthermore, the generalized subtype of social phobia and the additional diagnosis of avoidant personality disorder are considered as potential treatment moderators.
This reaction to Weinberger's article (this issue) about common factors in therapy focuses on two issues: (a) to be useful, the common factors need to be defined in more concrete terms, so they can be measured separately from other aspects of therapy process; and (b) rather than just measuring the common factors, we need to study the mechanisms of change, or how the common factors interact with other variables to result in change. Finally, I suggest that we consider the concept of equifinality, that is, that even though different factors have different mechanisms of change, they may all produce the same outcome.
Weinberger presents a number of reasoned arguments to explore the nature of common factors in psychotherapy among different theoretical approaches. While it is apparent that common factors are both inconsistently described and often ignored as one looks at various approaches, I contend that there are some unrecognized common elements. The attempt to derive a common list ignores both the different ways that these factors may develop and the variable interaction that may characterize each factor's impact across different theories. Moreover, Weinberger's suggestion that the technical eclectic movement lacks a theoretical base is erroneous. Rather than being a weakness, the absence of a single theory of pathology and change is the strength of technical eclectic approaches.
Lenzenweger (2003, this issue) objected to my suggestion that Lenzenweger and Korfine (1992) interpreted their taxometric study as support for Meehl's (1962, 1990) single major gene model of schizophrenia. I suggest in this brief response that my representation of Lenzenweger and Korfine was consistent with the statements they had made. However, I do welcome the clarification that there are alternative explanations for the manifest class taxon identified by Lenzenweger and Korfine (e.g., see Widiger, 2001) and I would encourage future taxometric studies to explore these alternatives.
We respond to comments by Pope regarding research by Poole, Lindsay, Memon, and Bull. Pope called on psychologists to “scrutinize the assumptions” underlying our research on the grounds that the findings were reported inappropriately, there was no plan to control for Type I errors, and the sample was too small. We rebut each of these criticisms and clarify the findings and conclusions offered by Poole et al.
In a recent commentary on taxometric methods (Meehl, 1973; Waller & Meehl, 1998), Widiger (2001) takes issue with the value of the taxometric approach and offers his views on the use of taxometric methods and the interpretation of taxometric findings. A principal concern of Widiger's is what he terms the “exaggerated implications” (p. 529) that he believes have been offered by investigators who have interpreted taxometric findings. He misrepresents the findings and conclusions of a well-known taxometric study of schizotypy (Lenzenweger & Korfine, 1992) in order to substantiate the claim of “exaggerated implications” and ascribes to the authors of the original study a conclusion not drawn by them. The possible nature of a critical logical error in Widiger's assessment of the Lenzenweger and Korfine study is explored with special reference to the theoretical context of the original schizotypy study.
Ruscio and Holohan (2006) address the challenges of applying empirically supported treatments (ESTs) with complex patients (e.g., those with comorbid conditions). Many clinicians, in such instances, abandon ESTs on the assumption that treatment manuals do not apply. In the present commentary I argue that although ESTs provide the best available guidance for how to treat many psychological disorders, effective treatment does not require rigid adherence to treatment manuals if the clinician is able to develop a case formulation on the basis of a functional analysis of behavior and apply empirically supported treatment procedures accordingly. The development of exposure and response prevention for obsessive-compulsive disorder is presented as an example of how knowledge of basic cognitive and behavioral processes transcends ESTs and their manuals. I conclude that it is important for beginning therapists to learn to apply principles based on these processes rather than to rely exclusively on treatment manuals.
After a decrease in publication rates on the topic through the 1990s, the article by Chorney and Morris (2008) represents a renewed interest in the construct of dating anxiety fueled by both clinical and developmental researchers. This commentary discusses the importance of the article by placing it in historical context while adding to the call for the assessment of dating anxiety and related constructs in diverse populations. The possible relation between dating anxiety and heterosocial competence during adolescence and young adulthood is also considered. Moreover, researchers are encouraged to look at the broader spectrum of problematic heterosocial situations in addition to dating anxiety. Finally, recommendations for directions of future research are detailed.
Wilson (this issue) raises several thought-provoking issues pertaining to the use of manual-based treatments (MBTs) in clinical practice. Based on my experiences as a researcher of manual-based treatments for social phobia and as a clinical psychologist in independent practice, I share my perspective on several of Wilson's points. Comorbid conditions do not appear to hinder the outcomes of MBTs for social phobia, and participants in controlled clinical trials do not appear very different from persons who refuse or are excluded from participation. Manuals can be written in a manner that retains a great deal of flexibility for the clinician, and these manuals may be productively employed in clinical settings. Proper implementation of MBTs requires experience with the disorder of interest and a strong background in theories of psychopathology and therapy technique.
Speer and Schneider's review (2003; this issue) illustrates a number of problems in psychologists’ understanding of elderly primary care (PC) patients and their providers, as well as the context of PC. Claims that elderly patients overutilize health services and do so primarily because of mental health problems are not well founded. Older PC patients also face practical and preference barriers to accepting conventional psychological treatment The evidence that psychological services provide cost offset is questionable, and cost offset is not the best way of evaluating the value of psychological services. Rather than as frontline providers, psychologists’ best prospects for an expanded role in PC is in the design, supervision, and evaluation of augmented services in this setting.
The “hypervigilance, escape, struggle, tonic immobility” evolutionarily hardwired acute peritraumatic response sequence is important for clinicians to understand. Our commentary supplements the useful article on human tonic immobility (TI) by Marx, Forsyth, Gallup, Fusé, and Lexington (2008). A hallmark sign of TI is peritraumatic tachycardia, which others have documented as a major risk factor for subsequent posttraumatic stress disorder (PTSD). TI is evolutionarily highly conserved (uniform across species) and underscores the need for DSM‐V planners to consider the inclusion of evolution theory in the reconceptualization of anxiety and PTSD. We discuss the relevance of evolution theory to the DSM‐V reconceptualization of acute dissociative‐conversion symptoms and of epidemic sociogenic disorder (epidemic “hysteria”). Both are especially in need of attention in light of the increasing threat of terrorism against civilians. We provide other pertinent examples. Finally, evolution theory is not ideology driven (and makes testable predictions regarding etiology in “both directions”). For instance, it predicted the unexpected finding that some disorders conceptualized in DSM‐IV‐TR as innate phobias are conditioned responses and thus better conceptualized as mild forms of PTSD. Evolution theory may offer a conceptual framework in DSM‐V both for treatment and for research on psychopathology.
NOTE: In this commentary, we will interchangeably use “innate,”“hardwired,”“evolutionarily conserved,”“evolved,” and “prepotentiated” fears for the nonassociative mode‐of‐acquisition‐based fears traditionally termed “unconditioned,”“primary,”“instinctual,”“prepared,”“ancestral,”“anachronistic,”“primeval,” or “atavistic.” Additionally, we will mostly use the neurobiological research‐based etiological terms “memory‐trace‐overconsolidation‐based disorders,”“overconsolidated‐fear disorders,” or “overconsolidational anxiety disorders” ( Bracha, 2006; Pitman & Delahanty, 2005). These are newly proposed terms for the associative‐mode‐of‐acquisition‐based, PTSD‐like disorders traditionally termed “secondary,”“learned,”“conditioned,”“posttraumatic,” or “acquired.”
Somatic interventions such as antidepressant medication and electroconvulsive therapy (ECT) have the potential to produce dramatic, potentially life-saving, responses in elderly patients suffering from depression. At the same time, the body of systematically collected evidence supporting the use of such interventions in geriatric populations is not robust and may not be sufficient to adequately guide clinicians regarding their use. In light of the greater risks associated with somatic treatments in the elderly vis-à-vis younger populations, clinicians suggesting the application of somatic interventions for late-life depression should be aware of the limitations to the data and should recommend these interventions with caution. To maximize effectiveness, somatic interventions should be incorporated into a comprehensive psychosocial treatment plan.
This commentary on the article by Sbraga and O'Donohue (2003, this issue) discusses the proper role of expert testimony in relation to child sexual abuse in criminal and civil proceedings, the use of opinion evidence in court, and the specific role of mental health experts. We argue that, due to faulty assumptions about the role of mental health experts in the courtroom, much of the information in the article is misleading. Mental health experts would not, ethically or legally, be permitted to offer an opinion (post hoc or otherwise) as to whether or not someone had been sexually abused. Rather, their appropriate role is to offer sound scientific and clinical opinion on the consistency and/or inconsistency of presenting symptoms, complaints, and/or behavior patterns relating to child sexual abuse in order to educate or inform the court. Expert witnesses are distinct from other witnesses (e.g., victim advocates, therapists) and must offer unbiased and objective information that does not usurp the role of the trier of facts.