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Behind the scenes of clinical research: Lessons from a mindfulness intervention with student-athletes

January 2015

Authors:

Fallon Goodman

George Washington University

Todd B Kashdan

George Mason University

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September •2015 141

the Behavior Therapist

ISSN 0278-8403

VOLUME 38, NO.6•SEPTEMBER 2015

Contents

President’sMessage

Jonathan S. Abramowitz

Walgreens,AutoMechanics,and the Arc of aLife •141

Science Forum

ToddE. Brown, MichaelE. J. Reding, Bruce F. Chorpita

The Uncertain Stepson the Certain Pathto Progress:

SomeGuesses About the Future of Cognitive and

BehaviorTherapies •144

Access&Equity

Annette Miller, Monnica T. Williams, ChadT. Wetterneck,

Jonathan Kanter, Mavis Tsai

Using Functional AnalyticPsychotherapyto Improve

Awareness and Connection in Racially Diverse Client-

Therapist Dyads •150

Science Forum

Fallon R. Goodmanand ToddB. Kashdan

Behind the Scenes of Clinical Research: LessonsFromaMind-

fulness Intervention WithStudent-Athletes •157

Clinical Tr aining Update

David W. Pantalone, Sarah M. Bankoff,Sarah E. Valentine

CreatingPublishable WritingAssignments in Clinical Psychol-

ogy Graduate Courses:ADBTSeminar Reviewsthe Treatment

OutcomeLiterature •159

Professional &Legislative Issues

Marsha M. Linehan

Howto EstablishYourselfas aBurgeoningPsychological

Practitioner, Researcher,and Teacherin Today’s Political

World •163

At ABCT

Danielle Maack

ABCT StudentBuddy Program•165

Calls for Editors •167

ASSOCIATION FOR BEHAVIORAL

AND COGNITIVE THERAPIES

[continued on p. 143]

PRESIDENT’SMESSAGE

Walgreens, Auto

Mechanics, and the Arc

of aLife

Jonathan S. Abramowitz, University

of North Carolina–Chapel Hill

ALONG WITH MY (often

feeble) attempt to keep up

with the psychological litera-

ture, Itry to read one popular

press book each season. Last

winter’s reading was A

Chance in the World: An

Orphan Boy, a Mysterious

Past, and How He Found a

Place Called Home, by Steve Pemberton, the

Chief Diversity Officer at Walgreens. The book

chronicles Pemberton’s upbringing in New

Bedford, Massachusetts. Removed from an

alcoholic mother at age 3, he bounced between

foster families, survived dreadful physical abuse

and neglect, and ultimately sought out and

found his biological kinfolk.

At one point in his journey, Pemberton met

awoman who appreciated both his plight and

his promise, took him under her wing, and

became a fixture in his life. She nurtured him

and helped him uncover an inner strength and

build self-assurance. Looking back, Pemberton

reflected that “small acts of kindness can change

the arc of alife.”

Those eleven words have been swirling

around in my head for several months now. The

start of this new academic year, however, makes

Pemberton’s message especially pertinent for

me as Ireflect on the late Professor Silas White,

who taught the first psychology class I ever

attended at Muhlenberg College.

Introduction to Psychology had 40 to 45 stu-

dents, which made it one of the larger classes at

ABCT’s 49th Annual Convention i–xix

➞

142

the Behavior Therapist

Published by the Association for

Behavioral and Cognitive Therapies

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EDITOR ···················Brett Deacon

Editorial Assistant .......... Melissa Them

Access and Equity ......Monnica Williams

Behavior Assessment ........Matthew Tull

Book Reviews ···············C. Alix Timko

Clinical Forum ·················Kim Gratz

Clinical Training Update ... Steven E. Bruce

Institutional Settings. ....... Dennis Combs

Lighter Side···············Elizabeth Moore

Medical and Health Care

Settings ...................Laura E. Dreer

News and Notes. ......... Nicholas Forand

Nathaniel Herr

James W. Sturges

Shannon Wiltsey-Stirman

Professional

and Legislative Issues ........ Susan Wenze

Public Health Issues. ...........Giao Tran

Research-Practice

Links ···················David J. Hansen

Research-Training

Links·······················Stephen Hupp

Science Forum ·············Jeffrey M. Lohr

Michael Anestis

Student Forum ··············David DiLillo

Shannon Blakey

Technology Update ....... Steve Whiteside

ABCT President .....Jonathan Abramowitz

Executive Director········Mary Jane Eimer

Director of Education &

Meeting Services ············Linda M. Still

Director of Communications David Teisler

Director of Outreach

&Partnerships ············Tammy Schuler

Managing Editor ...... Stephanie Schwartz

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September •2015 143

’Berg. Yet Dr. White got to know each of us

by name. Actually, he seemed to know

everyone. He was a fixture on campus,

having been teaching there for close to 20

years by the time I arrived in the fall of

1987. Unconventional and distinguished in

his own way, he had quite acheeky sense of

humor—which I would later learn made

him arather controversial figure among his

faculty peers. I’d often see him outside

reading in the crisp fall sunlight or

befriending and feeding the many squirrels

that inhabit Muhlenberg’s grounds in

northeastern Pennsylvania. “Good morn-

ing, Mr. Abramowitz!” he would abruptly

proclaim as Ipassed by (see Figure 1).

One late afternoon during my first

semester Iwas in the psychology building

and happened to commentto afriend that

my car,acast-off of my father’s, was growl-

ing in misery and hiccupping smoke. Dr.

White overheard this and immediately

insisted that I trail him to a mechanic

around the corner—a guy he knew person-

ally. Once we got to the shop, Ilistened as

he bargained on my behalf, insisting on the

“friends and family” rate. Then he gave me

alift back to my dorm in his truck—but not

before treating me to asandwich and soda

at his favorite delicatessen. Afew days later

my car was repaired, my credit card (well,

my parents’ card)was unscathed, and Ihad

alife-lesson in human kindness.

At the time, that day hardly seemed

life-altering. But looking back, it’s fair to

say that it indeed had an influence on my

own “arc.” Dr. White’s interest in me led to

my taking another psychology course with

him. Before long, Iwas part of the psychol-

ogy department family and Ideclared it as

my major. During my 4years at Muhlen-

berg I had my first experiences as a

research assistant (I did social psychology

and perception research) and as ateaching

assistant for psychological statistics. I

learned from amazing professors who

piqued my interest in graduate school and

gave me the nurturance and tools to suc-

ceed there and beyond. Thanks in no small

part to Dr. White, Iwas off to the races!

Have small acts of kindness changed

the arc of your life? This question, Ibelieve,

deserves reflection from all of us. And how

do we recognize and appreciate the kind

acts that we have been fortunate enough to

receive? Sometimes, we get to acknowledge

them immediately; in Pemberton’s case, he

was able to thank his surrogate mother,

bringing her into his family and paying

tribute to her in print as he shares his story.

Often, though, we don’t catch the magni-

tude of such acts in themoment,andit’s

only in retrospect that we’refullyable to

appreciate theirsignificance.In my case,

the acknowledgment and gratitude comes

after Dr. White’s death. As recipients of

small but essential kindnesses, Ibelieve we

can honor the gifts we have received by

extending the same to others—as clini-

cians, as teachers, as mentors, and as

human beings. For one never knows when

an arc will be changed.

...

Correspondence to Jonathan S.

Abramowitz, Ph.D., University of North

Carolina-Chapel Hill, Department of

Psychology, Campus Box 3270, Chapel

Hill, NC 27599; jabramowitz@unc.edu

Figure 1.Me with Dr. White sometime

between 1987 and 1991.

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144 the Behavior Therapist

WE WERE RECENTLY INVITED to share our

thoughts on emerging issues facing cogni-

tive and behavior therapies for this issue of

the Behavior Therapist. Ironically, a pri-

mary theme in our laboratory research for

almost two decades has involved the very

notion that many critical issues cannot be

known in advance; hence our emphasis on

collaborative design, structured flexibility,

and real-time (vs. design time) control

(e.g., Chorpita &Daleiden, 2014). Further-

more, an honest look back reminds us to be

humble—one of us was old enough in the

late 1990s to wager guesses about whether

and how evidence-based practices would

become the new norm. These guesses did

not seem farfetched at the time but are now

too embarrassingly wrong to revisithere.

That said, we nevertheless feel that there

is at least some certainty that more big

advances are in store, and even our hum-

bling look backward reassures us of that. It

is with that sentiment that we contemplate

afew ideas that we feel could become ever

more central to our collective conversation

as members of ABCT. The following set of

topics is not comprehensive, but rather a

partial list of the issues our laboratory con-

tinues to believe represent the new fron-

tiers we must continue to explore.

Some Developing Ideas

Design

For the past 20 years, an increasingly

dominant theme in the field of cognitive

and behavior therapies, and of health care

practice in general, is that service providers

must increasingly adopt and sustain the use

of the best-supported interventions. This is

particularly true in real-world settings

where evidence-based practices (EBPs) are

typically underutilized, undersupported, or

underpowered even when delivered (e.g.,

Garland, Bickman, & Chorpita, 2010).

Although systemic, organizational, and

provider-level factors have been shown to

influence the adoption of behavioralthera-

pies(i.e., how to workwiththe perceptions

and practices of providers and organiza-

tions to improve uptake of evidence-based

approaches), we feel an emphasis on the

design side of the equation is due. That is,

treatment developers can play acritical role

influencing the subsequent dissemination

and implementation process through

designs that a priori address many of

providers’ primary concerns and better

match the challenging clinical and business

contexts in which practice is expected to

occur. For example, providers attempting

to implement EBP have historically

expressed concern that the available inno-

vations are insufficient in meeting the

needs of complex cases or diverse commu-

nities (e.g., Addis & Krasnow, 2000). To

address such concerns, developers may

need to increase focus on designing treat-

ment (and training) models whose struc-

ture or content can be (a) adapted in real

time during a treatment (or training)

episode, and (b) updated to incorporate

emerging empirical findings without

lengthy development cycles.

Design-centered solutions. Design-cen-

tered solutions—including, but not limited

to, instructional design, protocol design,

and service system design—have been

increasingly utilized to improve the process

of dissemination and implementation. One

example of a design-centered strategy in

implementation is Weingardt’s (2004)

instructional design and technology (IDT)

approach to training in manual-based ther-

apies, which proposes user-friendly, web-

based formats to actively engage providers

in the learning process. Relatedly, Just in

Time Teaching (JiTT; Novak, Patterson,

Gavrin, Christian, &Forinash, 1999) is an

instructional design approach that engages

learners by allowing them to apply their

existing knowledge of atopic just prior to

formal instruction, simultaneously provid-

ing the instructor with an assessment of

learners’ incoming understanding of the

material so that lessons can be targeted to

address knowledge gaps. Such instruc-

tional approaches take advantage of recent

advances in technology and can potentially

enhance the EBP training process through

improving the efficiency and utility of

teaching as well as bolstering provider

engagement during the learning process.

Modular treatment design (e.g., Chor-

pita, Daleiden, &Weisz, 2005) represents a

similar effort to address stakeholder con-

cerns about the flexibility of existing inter-

ventions by creating aframework to adjust

the flexibility of practice content and

sequencing to fit aparticular context, with

the idea that an intermediate level of flexi-

bility can be identified that balances the

application of the structured knowledge

base with the reality of clinical uncertainty

(e.g., emergent comorbidity; engagement

challenges). As has been said elsewhere,

these innovations are less about aspecific

new treatment than about the broader

implications of designs that create acollab-

orative workspace that contains the struc-

tured guidance offered by the treatment

developer while allowing substantial room

for real-time decisions and adaptation in

the face of local case-based evidence.

Design approaches can also be used to

support the successful adoption and sus-

tainment of existing treatment protocols.

For example, Multisystemic therapy (MST;

Henggeler&Borduin, 1990)uses amanu-

alized consultation protocol (Schoenwald,

1998) and demonstrated that structured

consultation positively impacts both

provider adherence and youth treatment

outcomes (Schoenwald, Sheidow, &Chap-

man, 2009). Similar to modular treatment

protocols, modular supervision protocols

can also be designed based on knowledge

distilled from the literature on supervision

and offered as resources for addressing

provider concerns. For example, a lack of

provider engagement in supervision could

be addressed with supervisor guides on

topics such as motivation and preparation

of supervisees.

Treatments informed by feedback.Self-

organizing, reflective systems and continu-

ous quality improvement (CQI) infrastruc-

tures (e.g., Higa-McMillan, Powell,

Daleiden, &Mueller, 2011) represent ser-

vice system design approaches that pro-

mote an increasingly collaborative and self-

correcting EBP implementation process.

For example, the Contextualized Feedback

Intervention and Training (CFIT; Bick-

man, Riemer, Breda, &Kelley, 2006) pro-

gram is an evidence-based CQI system that

SCIENCE FORUM

The Uncertain Steps on the Certain Path to

Progress: Some Guesses About the Future of

Cognitive and Behavior Therapies

Todd E. Brown, Michael E. J. Reding, Bruce F. Chorpita,

University of California, Los Angeles

September •2015 145

utilizes ongoing client progress to indicate

opportunities for provider learning. Its

common practice elements configuration

allows the system to suggest individualized

evidence-based interventions that are regu-

larly updated to reflect the evolving evi-

dence base. Such infrastructures provide

alternatives to more traditional service

arrays composed of set EBT menus, which

can be costly, redundant, and/or limited in

their coverage of client problems and char-

acteristics (Chorpita, Bernstein, & Dalei-

den, 2011).

In addition to reflective system design,

developers of cognitive and behavioral

therapies also stand to benefit considerably

from utilizing qualitative research to

improve the quality of current innovations

offered. Consistent with aCQI framework,

qualitative research enacts a direct feed-

back loop between user and developer to

identify chief provider concerns regarding

EBP implementation and illuminate new

pathways to improve existing innovations

(e.g., Kazdin, 2008; Southam-Gerow &

Dorsey, 2014). The rich, contextually laden

data gathered from qualitative approaches

allow for amore nuanced understanding of

provider experiences, which should be of

central concern to us as behavioral treat-

ment developers seeking to maximize the

applicability and impact of the interven-

tions we create since their real-world

impact is only as great as aprovider’s will-

ingness to utilize it. The Revised Technol-

ogy Acceptance Model (Wu & Wang,

2005) suggests that perceived usefulness,

perceived ease of use, and compatibility

with current practices are principal deter-

minants of new technology adoption. As

such, treatment developers must take the

necessary steps to ensure that their innova-

tions are optimized in terms of these fac-

tors. Simply designing, testing, and dissem-

inating treatments is not enough; we may

need to take the significant extra steps of

engaging with providers to determine how

to best facilitate their use of our treatments,

and then redesign our treatments to

address their concerns. Better yet, we

should engage them initially and through-

out the treatment development process

rather than at simply its terminal stages.

Although promising attempts to facilitate

ongoing communication between pro-

viders and developers are well under way

(e.g., practice research networks; Cas-

tonguay et al., 2010), we believe this objec-

tive is worthy of increased attention by the

ABCT and broader evidence-based therapy

communities.

Agility in treatment refinement.

Although regular communication between

providers and developers seems necessary

for improved treatments, it may not be suf-

ficient because we are currently hampered

by an arduous development-testing-pub-

lishing-retesting cycle as we develop treat-

ments. Although thesedecade-longcycles

have always produced the most reliable

knowledge, this pace has threatened the

relevance of that knowledge in an era

where we have instant access to new

research and community practice data that

wouldallowus to refine our treatments at a

much faster rate. A shift towards a more

rapid development cycle would allow us to

reference these manuals as astarting point

while allowing possible refinement to

reflect the best information available to us.

We can harness the strategies used in other

fields to implement this approach. For

instance, looking to the information tech-

nology field, theagilesoftware development

approach promotes fast turnaround time

for the creation of new software products

Introducing

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Finally, the App that delivers YOUR homework.

Displays any question, or series of questions, and

prompts the user for written or dictated answers.

Saves responses with date and time stamps so user

can email them to therapist or researcher.

User can initiate prompting immediately, as they

would with a coping card or worksheet. Researchers

and therapists can set prompting to occur at

random time intervals, for truly random time

sampling.

All prompts are 100% customizable, and can be

presented singly or in sequential or random order.

Researcher or therapist can install a security

password to prevent alteration by the user.

Capable of virtually any non-branching Ecological

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146 the Behavior Therapist

by utilizing an evolutionary approach that

allows for continuous improvement in a

rapid and flexible manner. A similar

approach could be implemented for the

development and refinement of mental

health treatments. This shift would

undoubtedly be a considerable one, and

careful considerations would be necessary

to ensure that this process could produce

results on par with those found from the

traditional development cycle, but the abil-

ity to implement rapid refinements could

quickly lead to treatments better suited for

many. As acomparison, we can look to the

shift from the use of encyclopedias to

Wikipedia. Although Wikipedia is

maligned for not having years of authorita-

tive research behind its entries, its accessi-

bility and ability to be readily modified and

refined as new information comes to light

has provided greater benefits to more

people than encyclopedias ever had.

Technology

Technology continues to evolve and

permeate our lives at abreathtaking pace,

yet the possibilities enabled by such

advances remain largely untapped in the

behavioral health field. We owe it to our-

selves and the community at large to

embrace technology as a means to better

the mental health landscape. Although

some reluctance or resistance may arise

around the use of modern technology as

cold, impersonal, or dehumanizing, it can

in fact elevate our abilities to explore and

interact with others, just as the printed

word enabled knowledge dissemination far

beyond the reach of oral tradition. Techno-

logical tools and strategies are not meant to

act as replacements or complements to our

approach to behavior therapy; rather, the

new technologies and the enduring ones

should work synergistically, improving the

utility of the technology and improving our

abilities to perform. Several approaches

towards this goal have begun to take shape,

but these efforts must charge past proofs of

concept and into full implementations if

we are to remain committed to producing

the greatest improvements in mental

health.

Clinical dashboards. Clinical dash-

boards, or measurement feedback systems

(MFSs), are tools used alongside clinical

treatments in order to organize critical

information, monitor progress, identify

problems, and assist in the selection of

treatment strategies (Bickman, 2008; Chor-

pita, Bernstein, Daleiden, &The Research

Network on Youth Mental Health, 2008).

Use of dashboards throughout treatment

has been found to improve outcomes in

both adult (Reese, Norsworthy, & Row-

lands, 2009) and youth populations (Bick-

man, Kelley, Breda, de Andrade, &Riemer,

2011); however, after nearly 15 years of

research on these approaches, many of the

substantive developments may still lie

ahead. For example, although nearly all

dashboards provide means to track current

treatment progress, few provide context

around how that data should be inter-

preted. Dashboards may need to move

towards integrating benchmarks and

expected values derived from existing

knowledge bases, including client and

health-care-population based, as well as the

research literature. Including such infor-

mation alongside observed treatment

progress would help contextualize clinical

decisions by providing additional informa-

tion with whichto make judgments.

Looking beyond the evidence bases,

dashboards have room for ample improve-

ments beyond mere benchmarks.

Although simply highlighting “not on

track” has been shown to improve out-

comes (Lambert, Harmon, Slade, Whipple,

&Hawkins, 2005), cliniciansgiven specific

feedback might have even greater abilities

to better their clients’ outcomes. In other

words, dashboards could provide sugges-

tions rather than simply providing an alert.

Conversely and so as not to remove all

sense of agency from aclinician’s treatment

planning, dashboards could provide more

streamlined means for users to explore the

data themselves, such as tapping into data-

bases such as the PracticeWise Evidence

Based Services database (PWEBS; see

Chorpita et al., 2011). However, these fea-

tures alone will provide only limited bene-

fits unless paired with an increased focus

on acritical but largely ignored feature of

all dashboards: the user interface and user

experience (UI/UX).

The realm of UI/UX has continued to

make strides forward via studies in human-

computer interaction and design, but dash-

boardandfeedback system developmentin

behavioral health has not placed a heavy

focus on these aspects. Dashboards provide

many opportunities for the betterment of

behavior therapy outcomes and, indeed,

real-time measurement. Observation is a

core practice of behavioral and cognitive

therapies, predating evidence-based man-

ualized treatments by decades, and this

technology thus is an opportunity for an

efficient manifestation of the core values of

CBT practice. However, unwieldy and dis-

parate systems, potentially made even

more complicated with the introduction of

the previously discussed elements, may

have limited uptake until atrue dedication

to UI/UX is introduced.

Literature mining. The multiple evi-

dence bases discussed by Daleiden and

Chorpita (2005) have their own unique

challenges around the collection and even-

tual display of the associated data, but the

empirical research evidence is an area of

particular interest due to its peer-reviewed

and vetted nature. Despite the relatively

slow speed at which such evidence is intro-

duced into the field, avast amount of infor-

mation is contained across these published

manuscripts. However, for all intents and

purposes, this information often remains

invisible to our membership unless indi-

viduals encounter that specific article or

discover it by utilizing just the right key-

word search, discoveries that are often not

temporally aligned with when we might

actually need that information to guide a

decision.

The process of consolidating and

extracting data from published research

may need to be improved if we are to

increase the impact of cognitive and behav-

ioral research. Meta-analysis and commis-

sioned reviews can be used to chip away at

this task, but automated approaches may

soon outperform those traditions and may

be necessary to make significant headway

with an ever-expanding literature. Onto-

logical translation efforts should begin in

earnest to map disparate terminologies

across studies (e.g., behavioral targets,

DSM-5, Research Domain Criteria). These

mappings may be obtained via qualitative

tools and artificial intelligence strategies

that can process full datastores of manu-

scripts and their associated data, leading to

acommon metadata structure that can be

used to streamline the data exploration

required for evidence-based practice and

made easier via dashboards. These tools

and strategies will require considerable

effort to develop, but the undertaking can

be made considerably less daunting via the

use of interdisciplinary resources and

teams, where artificial intelligence and “big

data” experts from IT industries can be

called upon to offer skills in areas where we

have little-to-none. In the perfect world,

the publication process would also entail

placing astudy’s results into acentral stan-

dardized database for all to explore, but

absent that (and given the already large

number of extant published manuscripts),

an automated approach to processing the

evidence may be of significant value if we

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148 the Behavior Therapist

are to maintain and expand the link

between research and practice.

Industriesand Workforce

Another consideration involves not

what is coming next, but who. Who will be

themajorpartiesinvolved in thecollabora-

tive enterprise of research, policy, and

practice? For the past 20 years, the domi-

nant practice information management

strategy has been served by publishers,

accelerated by a20-year emphasis on man-

ualized treatments. Training in best-sup-

ported practices has largely been per-

formed by universities, or more

specifically, by those researchers who have

developed effective treatment approaches,

often through conferences and workshops.

More recently, there has been an emphasis

on graduate training (Shoham et al., 2014),

with an increasing number of graduate

programs training in evidence-based

approaches (e.g., Bertram, Charnin, Kerns,

&Long, 2014)

One wonders whether that is sufficient

to keep pace with the way treatment deliv-

ery may change as the field continues to

industrialize. As astandard of comparison,

few of us now purchase food from farmers

or clothing from tailors, and yet the

research-practice exchange often still

necessitates direct encounters between

those who produce and those who con-

sume the research evidence base. It may be

possible that industries will emerge that

coordinate and deliver new discoveries

about treatment can make this collabora-

tion more efficient, much as online shop-

ping (e.g., Amazon) has revolutionized

retail, search engines (e.g., Google) have

revolutionized discrete information

retrieval, and digital media services (e.g.,

Netflix, iTunes) have revolutionized enter-

tainment. Whether those functions are ful-

filled by the current institutions adapting

(e.g., universities, government) or new

institutions emerging is an open question,

but a massive increase in efficiency and

scalability of knowledge application and

management almost certainly will require

an industrial leap of some kind.

The concerns around psychological

workforce capacity represent one area

where this leap seems necessary. The

Patient Protection and Affordable Care Act

(Patient Protection and Affordable Care

Act [ACA], 2010) has significantly

expanded insurance coverage to millions

with behavioral health concerns but has

done less to address the demand for receiv-

ing services. Indeed, regardless of the

ACA’s ultimate political fate, there is a

large, unmet demand for additional

providers to deliver treatment. This need

could be met via the creation of a new

training infrastructure built to harness psy-

chology bachelor degree holders, who

number 100,000 new graduates per year

but who find apsychology-related job less

than 7% of the time, partially due to the

lack of career paths available to them

(Becker, Chorpita, & Daleiden, 2014). By

providing these graduates with greater

behavioral and cognitive backgrounds

along with the opportunities to apply such

solutions, the mental health landscape may

be better equipped to tackle the demand for

its services.

Conclusion

It is only fitting that dissemination is

this year’s ABCT convention theme. Just as

ABCThas beencoming intoits own with a

focus shifting away from dysfunction and

towardspositive behavior, the association

will no doubt also come into its own across

the many opportunities discussed here. We

sit in agolden age of acquisition and appli-

cation of knowledge, and nothing but

opportunity awaits us. Just as we ask

“what’s next,” we can also answer and

achieve. The future is what we make it.

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September •2015 149

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Women and Drinking:

Preventing Alcohol-Exposed Pregnancies

Volume 34

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An essential resourcefor targeting behavior change in women at riskfor alcohol-

exposedpregnancies

Drinking during pregnancy cancausearange of disabilities that have lifelong eects yet are 100%

preventable. A variety of brief motivational behavioralinterventionsdeveloped for nonpregnant women

of childbearing agecaneectively preventalcohol-exposedpregnancies (AEP). This bookoutlines clinical

deﬁnitionsandthe historyof FetalAlcohol Spectrum Disorders (FASD); epidemiology,andeects across

the lifespan;evidence-based prevention practices such as CHOICES andCHOICES-like interventions; and

opportunitiesfor dissemination.Basedon decadesof scientiﬁc research andclinical reﬁnement, this vol-

umeis packed with helpful illustrativecase vignettes, therapist–patientdialogues, sample forms, and

handouts.Theinformation andresourcespresented will help a wide variety of practitionersin diverse

settings,ranging fromhigh-risksettings such as mental healthandsubstance abuse treatment centers, to

primarycare clinics anduniversities, deliverinterventionstargeting behavior change.

New!

“Thisbook is an excellent overview of newlydeveloped interventions for preventing alcohol-exposedpregnan-

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drinking,thebook includes acomprehensive descriptionof theaward-winning project CHOICES and its adap-

tations. This is an encouraging and useful resource foranyhealthprofessional who workswith women.”

Tatiana Balachova, PhD, AssociateProfessor,Department of Pediatrics, University of OklahomaHealth Sciences

Center, OklahomaCity,OK

Praisefor the book:

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Binge Drinking and Alcohol Misuse

Among College Students and Young Adults

Volume 32

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This book provides clear guidanceabout

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alcohol misuse in young adults.

Stephen A. Maisto, Gerald J. Connors, Ronda L. Dearing

Alcohol Use Disorders

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Practice-oriented, evidence-based guidance on

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...

Correspondence to Todd E. Brown, M.A.,

University of California, Los Angeles,

Department of Psychology, 1285 Franz

Hall, Box 951563, Los Angeles, CA 90095

toddbrown@ucla.edu

AS OF 2010, NON-HISPANIC WHITES com-

prised 63% of the U.S. population, yet the

number of minority psychologists lingers

under 25% (American Psychological Asso-

ciation [APA], 2010; U.S. Census Bureau,

2011). The limited data available on psy-

chologist demographics is encouraging

insofar as APA membership is shifting to

include greater numbers of ethnic and

racial minorities in its various membership

categories. Even so, the rate at which eth-

noracially diverse populations seek mental

health services is outpacing the availability

of minority psychologists. Ethnic and racial

minorities are projected to exceed 57% of

the population by 2060 as non-Hispanic

White Americans become aminority over

the next three decades (U.S. Census

Bureau, 2012). As a result, ethnoracially

diverse therapy dyads are increasingly

common. This growth in diversity acceler-

ates the need for ongoing scholarship,

informed attitudes, and clinician compe-

tency for multicultural clinical training at

parity with other important therapeutic

skills.

Discrimination resulting from stigma-

tized minority status is associated with neg-

ative mental health outcomes, such as

depression, anxiety, substance use, post-

traumatic stress disorder, and overall psy-

chological distress (Banks &Kohn-Wood,

2007; Blume, Lovato, Thyken, & Denny,

2012; Chae, Lincoln, & Jackson, 2011;

Pieterse, Todd, Neville, &Carter, 2012). As

a result, such experiences and the related

psychological sequelae may require

focused clinical attention (e.g., Williams,

Gooden, & Davis, 2014). Additionally,

research indicates that the adaptation of

cognitive-behavioral therapies (CBT) for

cultural competency may be superior to

nonadapted CBT (Kohn, Oden, Munoz,

Robinson, &Leavitt, 2002; Miranda et al.,

2003). Thus, the mental health community

is ethicallyboundto cultivatemulticultural

competency and continue investigating

empirically supported treatments for

diverse populations (Constantine, Miville,

&Kindaichi, 2008; Ridley, 1985; Sue, Zane,

Hall, &Berger, 2009).

This need is met with a host of chal-

lenges as many therapists are unprepared

to address cultural issues due to inadequate

multicultural education and/or social

taboos surrounding racism, discrimina-

tion, and White privilege (Neville, Wor-

thington, &Spanierman, 2001; Terwilliger,

ACCESS&EQUITY

Using Functional Analytic Psychotherapy to

Improve Awareness and Connection in Racially

Diverse Client-Therapist Dyads

Annette Miller and Monnica T. Williams, University of Louisville

Chad T. Wetterneck, Rogers Memorial Hospital

Jonathan Kanter and Mavis Tsai, University of Washington, Seattle

September •2015 151

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Bach, Bryan, & Williams, 2013). There is

currently no standardized training model

for multicultural competency. Although a

handful of scholars have devoted signifi-

cant energy to measuring multicultural

competency, training for therapists to

engage clients of diverse racial, ethnic, and

cultural backgrounds may remain inade-

quate (Worthington, Soth-McNett, &

Moreno, 2007). One systematic review

found that although multicultural training

made clinicians feel more knowledgeable,

there was poor evidence that patient out-

comes were improved; furthermore, the

vast majority of programs omitted the con-

cepts of racism, bias, or discrimination

from their content (Price et al., 2005).

Matching by racial group has been one

approach used to serveethnoracialminori-

ties seeking mental health services. Propo-

nents of matching point to an elevated per-

ception of multicultural awareness,

treatment retention, and client preference

(Lee, Sutton, France, & Uhlemann, 1983;

Meyer &Zane, 2013). However, matching

may oversimplify both the client’s and clin-

ician’s experience as it assumes a high

degree of similarity in backgrounds, values,

level of assimilation, religion, and language

(Williams, Chasson, &Davis, 2015). It may

also remove acritical opportunity for client

and clinician to grow and connect as they

learn to appreciate differences in cultural

values and experiences. Although match-

ing is preferred by most clients, alliance,

skill, knowledge of client culture, ethnicity,

and race appear to have agreater impact on

positive therapeutic outcomes (Cabral &

Smith, 2011). Most recently, Ibaraki and

Hall (2014) examined ethnic matching,

finding it functions as a proxy for shared

culture, where common values and closely

held beliefs influence the content minority

clients discuss in therapy. This suggests

therapeutic outcomes are linked to the clin-

ician’s ability to understand the client’s

perspective and cultural background

(Flicker, Waldron, Turner, Brody, &Hops,

2008).

One risk in diverse dyads is uninten-

tionally stigmatizing the client. Lack of

insight about the client’s cultural, racial, or

ethnic identity might result in inadvertent

microaggressions or other expressions of

bias; this may alienate the client, threaten

the therapeutic relationship, impede treat-

ment progress, and increase risk of early

dropout (Constantine, 2007; Sue,

Capodilupo, Torino, & Bucceri, 2007).

Additionally, when culturally normative

behaviors are not considered in treatment,

therapists risk misdiagnosing minority

clients (Chapman, DeLapp, & Williams,

2014). Rather than adopting acolor blind

approach, which discourages the client

from expressing their experiences as a

racialized minority and exploring protec-

tive factors (Terwilliger et al., 2013), thera-

pists can benefit the relationship by bring-

ing this part of the client’s experience into

therapy. To do this effectively, therapists

must first understand their own relation-

ship to diverse groups and acknowledge

race as asocial power construct (Cardemill

&Battle, 2003). By building on this attune-

ment to social power and privilege, thera-

pists can benefit from experiential learning

to explore their own feelings, beliefs, and

attitudes about race, ethnicity, and culture,

to gain greater cross-racial understanding

(Devereaux, 1991; Okech & Champe,

2008). In describing the experiential

process of growth and change, McKinney

(2006) found that “most of the turning

152 the Behavior Therapist

point experiences involved aWhite person

first coming into sustained contact with

persons of color.” Similarly, cross-racial

friendships have been found to enhance

cross-racial therapeutic relationships

(Okech & Champe). Taken together, this

suggests experiential contact and closeness

with diverse populations may expand clin-

ical awareness.

Functional Analytic Psychotherapy

Functional analytic psychotherapy

(FAP), an approach rooted in the contex-

tual behavioral tradition (Hayes et al.,

2012), focuses on the therapeutic relation-

ship as the agent of change to improve the

client’s outside relationships (Tsai et al.,

2009). It is similar to many CBT interven-

tions because it focuses on concrete behav-

ioral change and includes homework

assignments, but it differs with respect to

the amount of time and attention given to

building astrong therapeutic relationship

that serves as the primary vehicle for client

change. Abasic position of FAP is that the

therapeutic relationship is a genuine

human relationship. This relationship is

powerful in promoting learning and

change, fostering motivation, and keeping

clients engaged in treatment and adherent

to treatment plans.

FAP promotes increased awareness

both in the client and the therapist. FAP

therapists take interpersonal risks by expe-

riencing, processing, and disclosing reac-

tions to the client immediately as they

occur in-session in the service of client

growth and, in turn, encourage their clients

to do the same. When the client engages in

courageous self-expression in session, the

therapist responds withgenuinefeedback

to increase theconnection throughthe

exchange. This vulnerability and immedi-

acy serves as a model to help the client

improve connections with others, which is

an important transdiagnostic outcome

(Wetterneck & Hart, 2012). In this way,

FAP provides a complement to peer sys-

tems’ techniques such as psychoeducation,

cognitive restructuring, behavioral experi-

ments, and exposure.

FAP leverages five core principles, or

rules, to conceptualize client behaviors,

evaluate their functions, and conditionally

change or reinforce behaviors through the

interpersonal dynamics in the dyadic rela-

tionship (Tsai, Callaghan, & Kohlenberg,

2013; Tsai, McKelvie, Kohlenberg, &

Kanter, 2014). These client behaviors are

identified as clinically relevant behaviors,

or CRBs (see Figure 1). Maladaptive CRBs

(CRB1s) and adaptive CRBs (CRB2s) are

identified collaboratively by both the ther-

apist and client and analyzed for function

at both the micro and macro level to

broadly understand and effect change in

the client (Tsai, Kohlenberg, Kanter,

Holman, &Plummer Loudon, 2012). Sim-

ilarly, therapist-relevant behaviors (TRBs)

have a clinically relevant impact in treat-

ment as well.

Recent FAP writings have discussed

how the implementation of FAP’s five

behavioral rules may be supplemented

with an understanding of awareness,

courage, and therapeutic love towards

clients (Tsai et al., 2009; Tsai et al., 2012).

The first rule of FAP centers on awareness

of how a client’s CRBs appear in session

and promotes self-awareness as well,

including awareness of one’s attitudes,

biases, and assumptions about the client.

The second rule is that clinicians evoke

CRBs in therapy, and this may at times

involve being courageous and vulnerable

with clients. The third rule centers on being

therapeutically loving to reinforce positive

CRBs while challenging maladaptive CRBs.

As behaviors are exhibited in-session, the

fourth rule calls for the therapist to be

aware of their impact on clients, both as a

clinician and as aperson. Finally, the fifth

rule calls on the therapist to facilitate gen-

eralization of in-session client behavior

changes to promote sustainable change in

the client’s life. FAP is particularly well-

suited for culturally sensitive CBT and clin-

ician growth because of its focus on the

relationship as a primary change mecha-

nism, and FAP is flexible enough to be used

for analyzing the functions of behaviors in

client-specific content across cultures and

ethnicities (Vanderburghe, 2008).

Common TherapistProblem

Behaviors

All therapists stand to gain increased

competency across treatment approaches,

settings, goals, and client backgrounds

using an authentic and culturally sensitive

approach. Below we describe examples of

common challenges therapists experience

when working in racially and ethnically

diverse therapist-client dyads and how they

might be addressed using FAP interven-

tions.

Discomfort AddressingRacial

Differences With Clients

Race is one of the first features per-

ceived when encountering a new person,

yet despite the obvious differences in an

unmatched dyad, many therapists are

uncomfortable discussing race (Knox,

2007). FAP emphasizes the unique history

of each client, and, for minority clients,

ethnic and racial identity are an important

part of this history that should be addressed

early in treatment. Therapeutic awareness,

acceptance, and exploration of discomfort

related to racial differences in the service of

client growth can be an important shift

toward therapist growth that ultimately

bolsters trust and connection with the

client. Although it may be anxiety-provok-

ing for therapists who have previously

avoided such discussions to address racial

differences, acknowledging diversity in the

therapeutic relationship is likely to result in

greater satisfaction and connection with

minority clients, as it demonstrates cultural

sensitivity (Neville, Tynes, &Utsey, 2009).

Working to understand aclient’s potential

struggles with identity, self-concept, and

intersectionality may mediate feelings of

Figure 1. Clinically relevant behaviors

September •2015 153

invisibility often reported by racial and

ethnic minorities, and correspondingly,

acknowledging cultural strengths, such as

collectivism and racial pride, can promote

resilience in the face of challenge (Franklin,

1999; Hays, 2009).

Failure to UnderstandWhite Privilege

As a culture, we are socialized not to

acknowledge Whiteness and the power and

unearned privilege it affords (Neville et al.,

2001). As aresult, therapists are often con-

fused and uncomfortable with related

topics, such as discrimination, racism, and

stigmatized minority status. Acknowledg-

ing unearned privilege may provoke guilt,

shame, and defensiveness. FAP, because it

locates the source of this problem in our

social context and not in the individual,

allows therapists to increase awareness and

exploration of White privilege and differ-

ential access to important reinforcers (e.g.,

money, education, promotions) as aresult

of differences in power and privilege.

Deliberate self-disclosure of this status,

when used in the service of client growth,

may be linked to higher levels of trust and

perceived sensitivity in ethnic minority

clients and improvements in the quality of

the therapeutic relationship (Constantine

& Kwan, 2003; Tsai et al., 2009). Indeed,

privilege and social group membership are

inseparable components of the emergent

therapeutic context (Terry, Bolling, Ruiz, &

Brown, 2010). For a White therapist,

admitting to astigmatized minority client

that the therapist has benefited from race in

away that the client has not, and to exhibit

a willingness to change behaviors that

maintain power and privilege (e.g., have a

sliding fee scale, being open to learning

more about indigenous therapies such as

soul retrieval for Native Americans) exem-

plify a commitment to genuineness that

can promote authenticity, growth, and

connection.

Endorsing StereotypicalBeliefs About

Clients

Because of pervasive negative social

messages about ethnic and racial minori-

ties, we tend to make automatic and inac-

curate judgments about others based on

pathological stereotypes, which in turn lead

to microaggressions (Blair, Judd, & Fall-

man, 2004; Williams et al., 2012). Microag-

gressions committed by therapists have

been demonstrated to be asignificant pre-

dictor of dissatisfaction with the therapeu-

tic experience (Constantine, 2007) and pre-

sent significant barriers to FAP’s

fundamental and necessary intimate, trust-

ing, andsafe transactions that celebratethe

client’s expression of his/herfull self as an

ethnic and cultural being. It is helpful for

therapists to acknowledge their own ten-

dency to make unfair judgments and

demonstrate awillingness to reject stereo-

types. By being courageous enough to

admit alack of accurate knowledge about

important cultural, racial, or ethnic topics,

therapists can exhibit vulnerability and

seek understanding with clients in a

manner that will facilitate an open

exchange of information. FAP’s behavioral

and interpersonal techniques allow thera-

pists to admit they are not the authority on

all topics, such as the minority experience.

In this way, clinicians can begin to under-

stand the client’s daily life without relying

on stereotypes and subsequently reducing

the likelihood of committing harmful

microaggressions.

It is not enough, however, just to admit

alack of cultural knowledge. It is important

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to remediate these deficits by seeking infor-

mation from sources other than clients, as

ethnic minorities often report feeling weary

of bearing the burden of educating others.

Furthermore, in order to minimize stereo-

typing clients, it is important to maintain

relentless emphasis on understanding the

cultural context of CRBs and the adaptive

functions of “problem” behaviors. For

example, what may be seen as “depen-

dence” and “enmeshment” by young Asian

clients with their families can be under-

stood within acultural context of emphasis

on interdependence and prioritizing family

needs over individual needs (Sue & Sue,

2008).

Failure of Therapistto Continually

Develop as an Instrumentof Change

FAP emphasizes that a therapist’s

potency as achange agent can be increased

by continually cultivating awareness of the

impact of one’s own history on potential

biases. It may be helpful to explore individ-

ually or in consultation group questions

such as the following:

What were your first experiences with

feeling different?

What were you told about others who

were ethnoracially different?

What were your earliest memories of

race or color?

What stereotypes do you hold of

pluralistic populations?

What are your experiences as aperson

having or not having power in relation

to race or class?

What steps can you take to learn more

about your clients’ cultural back-

grounds?

What are your preferred therapeutic

methods that may not be culturally

attuned or adequate?

How might you be inadvertently repeat-

ing negative or oppressive interactions

representing the dominant culture with

clients?

How can you make use of therapeutic

“mistakes” or microaggressions in ways

that increase therapeutic alliance?

What is difficult for you to address

regarding race, culture, or other differ-

ences you have with your clients?

Table 1lists afew examples of common

therapist issues surrounding race, ethnic-

ity, and culture (Daily Life Problems), how

the problem might look in a therapeutic

relationship (TRB1), and one way that a

therapist might overcome the problem

from aFAP perspective (TRB2).

Conclusion

As the scholar-clinician community

seeks to improve quality of care for every-

one, it is imperative that we acknowledge

the importance of multicultural knowledge

and skills. This includes an appreciation of

other psychological perspectives, such as

Afrocentric research, which is often viewed

critically rather than with respect (Delapp

& Williams, 2015). Future scholarship

should build on preliminary work to

enhance and measure therapist compe-

tence in diverse dyads (Constantine, 2008;

Daily Life Therapist Problem

Table 1. Therapist-Relevant Behaviors

Problem Behavior (TRB1) Goal Behavior (TRB2)

White therapist experiences

anxiety, agitation, and confu-

sion in response to racially

provocative material.

Referring a minority client

to another therapist of their

same ethnic background.

Expressing the feelings open-

ly with client and also recog-

nizing own potential bias or

lack of understanding.

Belief that discussing racial

issues beyond a superficial

level is a taboo.

Avoiding topics about race

or culture and redirecting

to a different topic when it

is culturally sensitive.

Asking the client if the dif-

ference in race is something

they would like to discuss,

while recognizing that it

might be uncomfortable.

White therapist denying

benefits experienced from

Whiteness because therapist

has not previously consid-

ered this.

Denying or invalidating

client when this topic or

problem arises.

Acknowledging the unfair

and unearned benefits of

being White and validating

client if the topic arises.

White therapist ashamed of

his/her own ignorance on

cultural topics.

Avoiding topics related to

race in order to hide own

shame.

Expressing feelings openly

and asking the client if/how

they would like to address

the topic.

Taking steps to learn more

about applicable cultural

topics.

Therapist generalizing norms

of racial minorities based

upon assumptions and

research/statistics.

Making assumptions in

session about problems

and not allowing client to

explain problems in his

or her own words.

Exploring problems with an

open mind and allowing

client to express how he or

she faces problems associated

with race.

Latino male therapist feeling

shame about his cultural

heritage.

Being too deferential to

White clients due to

feelings of inferiority.

Acknowledging therapist

may have biases due to

learning history and being

aware and appropriately

assertive in session.

Black female therapist with

dark skin believes that fairer

skinned Black women are

arrogant and want to be

White.

Hostility toward fair-

skinned Black female

clients.

Asking client about her expe-

riences as a fair-skinned

Black woman, and recogniz-

ing her own biases.

154 the Behavior Therapist

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Drinane, Owen, Adelson, & Rodolfa,

2014). Such investigations may reveal

where cultural competency constructs

diverge from general clinician compe-

tency, allowing training to better prepare

clinicians to work with diverse popula-

tions.

Furthermore, many training programs

may benefit from aformat that is curricu-

lum-integrated and experiential. To

answer the need for culturally adapted

CBT, we propose FAP for its integrative

principles of awareness, courage, and love.

Future research should investigate the use

of such skills, including clinician self-

awareness, immediacy, and connection

relative to therapeutic outcomes within

mismatched racial dyads. Remembering

that training is alifelong exercise for ther-

apists, FAP provides the additional benefit

of ongoing therapist self-discovery and

growth (Tsai et al., 2009). In anation built

on fused genealogies and cultures, it is

imperative that we advance an under-

standing and application of skills to

enhance treatment utilization, reduce pre-

mature dropout, and promote culturally

informed change. Every client is amicro-

culture, carrying deeply rooted cultural,

social, generational, and reinforcement

histories. The building blocks of inclusion,

racial equity, social justice and prosocial

change can begin within the therapeutic

alliance (Vandenberghe et al., 2010).

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...

Correspondence to Monnica Williams,

Ph.D., Center for Mental Health Dispari-

ties, University of Louisville, Department

of Psychological &Brain Sciences, 2301

South Third St., Louisville, KY 40292;

m.williams@louisville.edu

www.abct.org

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September •2015 157

INTERVENTION STUDIES ARE IN NO SHORT

supply. Researchers are routinely piloting

new ideas, applying existing protocols to

understudied or unique populations, and

working to amass evidence for (or against)

a given theoretical orientation. Several

frameworks offer guidelines for developing

interventions, which include identifying or

developing atheoretical framework, deter-

mining sample size, creating recruiting

strategies, estimating cost, and piloting the

intervention (e.g., Craig et al., 2008). But

what makes an intervention successful

beyond achieving the desired change in

human behavior? What details increase

participant engagement, reduce attrition,

and maximize adherence to aprotocol? In

this paper, we critically examine amindful-

ness intervention study that we conducted

with student-athletes. Our hope is that dis-

seminating this information will encourage

best practices to maximize intervention

implementation.

StudyOverview

To orient the reader, we first provide an

overview of the study (for full paper, see

Goodman, Kashdan, Mallard, & Schu-

mann, 2014). One men’s and one women’s

NCAA Division I athletic team from the

same sport participated in abrief mindful-

ness intervention.1The teams separately

attended eight 90-minute group sessions

over aspan of 5weeks. Two practitioners

administered the Mindfulness-Accep-

tance-Commitment (MAC; Gardner &

Moore, 2007), a mindfulness-based pro-

gram designed for athletes. This interven-

tion is rooted in Acceptance and Commit-

ment Therapy (ACT; Hayes, Strosahl, &

Wilson, 1999), in which the central aim is

to help people observe their thoughts, feel-

ings, sensations, and memories as they

exist (without unhelpful attachments),

while engaged in value-congruent behav-

ior. Participants are taught foundational

principles through lecture, discussion in

pairs and larger groups, and experiential

exercises. The goal is for athletes to learn

how to flexibly attend to, react to, and

accept internal and external experiences as

they unfold. Athletes are shown how to

draw connections between how they

respond to stimuli and their athletic per-

formance. Below, we critically examine

what worked well and what fell short in our

intervention. To improve the design and

implementation of interventions, we offer

three specific suggestions for researchers

and practitioners.

1. Know Your Participants

Before diving into an intervention, get

to know thegroupor groups that will be

participating. In our study, the groups were

two teams of student-athletes at a large,

athletically competitive Division Iuniver-

sity. This population was unique in several

ways. For one, research suggests that stu-

dent-athletes tend to be more stressed and

at greater risk for emotional and behavioral

difficulties than their nonathlete peers

(Proctor & Boan-Lenzo, 2010). Student-

athletes are typically on tight schedules

packed with athletic practice and training,

games, schoolwork, romantic relation-

ships, social lives, and, for some, parenting.

On top of juggling these obligations, par-

ticipation in the intervention required an

additional 90 minutes twice per week to

learn complex material. We were given the

task of engaging busy, often exhausted stu-

dent-athletes with unfamiliar psychologi-

cal concepts to approach their lives differ-

ently. We strategically chose student-

athletes for these reasons, as they are an

ideal group that could benefit from this

type of intervention. It is worth noting that

although team coaches and athletic staff

did not require student attendance, and the

frequency and quality of student participa-

tion was kept confidential, most athletes

attended every session.

Another unique feature of working with

athletes is that they are accustomed to

intense physical exercise. Student athletes

may prefer to learn through active experi-

ential exercises rather than passive, lecture-

based instruction (Groves, Bowd, &Smith,

2010). In our study, the most commonly

cited feedback was boredom. For example,

one participant suggested, “More hands-on

activities for the players to do so we can

stay engaged.”2Concepts introduced in

mental health interventions can be difficult

to understand,particularly forpeople with

little to no prior familiarity. Ideas need to

be broken down concisely, slowly, and in a

way that is interesting to the audience.This

includes areliance on storytelling and the

intentional collection of examples from

their lives to help illustrate points. The stu-

dent-athletes we worked with wanted more

experiential exercises to apply the concepts,

especially in relation to their sport. When

working with athletes, practitioners should

tailor intervention-related stories,

metaphors, and exercises to athletes’

propensity towards physical movement.

In addition to the qualities of partici-

pants, the arrangement of the group can

also impact the effects of an intervention.

Participating as an entire group (e.g., team,

organization, company) will yield adiffer-

ent environment than participating indi-

vidually or with asubset of others. Team-

work and group cohesiveness can be

facilitated by learning, discussing, and

practicing new concepts as a team. The

MAC intervention protocol we used builds

in discussions about individual and team

values. These discussions encourage self-

disclosure, which can increase feelings of

closeness and strengthen teammate rela-

tionships. In the written feedback follow-