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



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September 2015 141
the Behavior Therapist
ISSN 0278-8403
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
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
Danielle Maack
ABCT StudentBuddy Program165
Calls for Editors 167
[continued on p. 143]
Walgreens, Auto
Mechanics, and the Arc
of aLife
Jonathan S. Abramowitz, University
of North Carolina–Chapel Hill
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
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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
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and Legislative Issues ........ Susan Wenze
Public Health Issues. ...........Giao Tran
Links ···················David J. Hansen
Links·······················Stephen Hupp
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Student Forum ··············David DiLillo
Shannon Blakey
Technology Update ....... Steve Whiteside
ABCT President .....Jonathan Abramowitz
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Meeting Services ············Linda M. Still
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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;
Figure 1.Me with Dr. White sometime
between 1987 and 1991.
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What happens
144 the Behavior Therapist
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
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
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
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
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User can initiate prompting immediately, as they
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Researcher or therapist can install a security
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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 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
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
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
September 2015 147
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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.
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.
Addis, M. E., &Krasnow, A. D. (2000). A
national survey of practicing psycholo-
gists'attitudestoward psychotherapy
treatmentmanuals. Journal of Consulting
and Clinical Psychology,68(2),331.
Becker, K. D., Chorpita, B. F., &Daleiden,
E. L. (2014). Coordinating people and
knowledge: Efficiency in the context of
the Patient Protection and Affordable
Care Act. Clinical Psychology: Science and
Practice, 21,106-112.
Bertram, R. M., Charnin, L. A., Kerns, S. E.
U., &Long,A. C. J. (2014). Evidence-
basedpracticesin North American MSW
curricula.Research on Social Work Prac-
tice. Advance online publication.
Bickman, L. (2008). Ameasurement feed-
back system (MFS)is necessaryto
improve mental healthoutcomes.Jour-
nal of the American Academy of Child
and AdolescentPsychiatry,47,1114
1119. doi:10.1097/CHI.0b013e3181825af8
Bickman, L., Kelley, S. D., Breda, C., de
Andrade, A. R., &Riemer, M. (2011).
Effects of routine feedback to clinicians
on mental healthoutcomes of youths:
Results of arandomizedtrial. Psychiatric
Services,62(12), 1423–1429.
Bickman, L., Riemer, M., Breda,C., &
Kelley, S. D. (2006). CFIT:Asystem to
provide acontinuous quality improve-
ment infrastructure through organiza-
tional responsiveness, measurement,
training,and feedback.Report on Emo-
tional and BehavioralDisordersin Youth,
6(4), 86-87.
Castonguay, L. G., Nelson, D. L., Boutselis,
M. A., Chiswick, N. R., Damer, D. D.,
Hemmelstein, N. A., ... Borkovec,T. D.
(2010). Psychotherapists, researchers, or
both? Aqualitative analysis of psy-
chotherapists'experiences in apractice
research network. Psychotherapy:Theory,
Research, Practice,Training,47(3), 345.
Chorpita, B. F., Bernstein, A., &Daleiden,
E. L. (2011). Empirically guidedcoordi-
nation of multiple evidence-based treat-
ments: An illustration of relevancemap-
ping in children'smental health services.
Journal of Consulting and Clinical Psy-
chology, 79(4),470. doi:
Chorpita, B. F., Bernstein, A., Daleiden, E.
L., &The Research Network on Youth
Mental Health. (2008). Driving with
roadmaps and dashboards: Usinginfor-
mation resourcesto structurethe deci-
sion models in service organizations.
Administration and Policy in Mental
Health, 35,114–123. doi:10.1007/s10488-
Chorpita, B. F., &Daleiden,E. L. (2014).
Structuring the collaborationof science
and service in pursuit of ashared vision.
Journal of Clinical Child and Adolescent
Psychology, 43(2),323–338.
Chorpita, B. F., Daleiden,E. L., Ebesutani,
C., Young, J., Becker, K. D., Nakamura,
B. J., Starace, N. (2011). Evidence-
basedtreatments for children and adoles-
cents: An updated review of indicatorsof
efficacy and effectiveness. Clinical Psy-
chology: Science and Practice, 18,153-
Chorpita, B. F., Daleiden,E. L., &Weisz,J.
R. (2005). Modularity in the designand
application of therapeutic interventions.
Applied and PreventivePsychology, 11,
141-156. doi:10.1016/j.appsy.2005.05.002
Daleiden,E. L., &Chorpita, B. F. (2005).
From data to wisdom: Quality improve-
ment strategies supporting large-scale
implementation of evidence basedser-
vices. Child and Adolescent Psychiatric
Clinics of NorthAmerica, 14,329-349.
Garland, A. F., Bickman, L., &Chorpita,B.
F. (2010). Changewhat? Identifying
quality improvement targets by investi-
September 2015 149
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Advances in Psychotherapy
Evidence-Based Practice
Book series developed and edited with the support of the Society of Clinical Psychology (APA Division12)
See more titles at
Mary Marden Velasquez, KarenS. Ingersoll,
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Women and Drinking:
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This book provides clear guidanceabout
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Alcohol Use Disorders
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Practice-oriented, evidence-based guidance on
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150 the Behavior Therapist
gating usual mental health care. Adminis-
tration and Policy in Mental Health, 37,
15-26. doi:10.1007/s10488-010-0279-y
Henggeler, S. W., &Borduin, C. M. (1990).
Family therapy and beyond: Amultisys-
temic approach to treating the behavior
problems of children and adolescents.
Pacific Grove, CA: Brooks/Cole.
Higa-McMillan, C. K., Powell, C., Dalei-
den, E. L., &Mueller, C. W. (2011). Pur-
suing an evidence-based culture through
contextualized feedback: Aligning youth
outcomes and practices. Professional Psy-
chology: Research and Practice, 42(2),
137. doi:10.1037/a0022139
Kazdin, A. E. (2008). Evidence-based
treatment and practice: New opportuni-
ties to bridge clinical research and prac-
tice, enhance the knowledge base, and
improve patient care. American Psycholo-
gist, 63(3), 146-159. doi:10.1037/0003-
Lambert, M. J., Harmon, C., Slade, K.,
Whipple, J. L., &Hawkins, E. J. (2005).
Providing feedback to psychotherapists
on their patients’ progress: Clinical
results and practice suggestions. Journal
of Clinical Psychology, 61(2), 165–174.
Novak, G. M., Patterson, E. T., Gavrin, A.
D., Christian, W., &Forinash, K. (1999).
Just in time teaching. American Journal
of Physics, 67(10), 937-938. doi:
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Act, Pub. L. No. 111 148, §2702, 124
Stat. 119, 318-319 (2010).
Reese, R. J., Norsworthy, L. A., &Row-
lands, S. R. (2009). Does acontinuous
feedback system improve psychotherapy
outcome? Psychotherapy Theory,
Research, Practice, Training, 46(4), 418–
431. doi:10.1037/a0017901
Schoenwald, S. K. (1998). Multisystemic
therapy consultation manual.Charleston,
SC: The MST Institute.
Schoenwald, S. K., Sheidow, A. J., &Chap-
man, J. E. (2009). Clinical supervision in
treatment transport: Effects on adher-
ence and outcomes. Journal of Consulting
and Clinical Psychology, 77(3), 410–421.
Shoham, V., Rohrbaugh, M. J., Onken, L.
S., Cuthbert, B. N., Beveridge, R. M., &
Fowles, T. R. (2014). Redefining clinical
science training: Purpose and products of
the Delaware Project. Clinical Psychologi-
cal Science, 2(1), 8-21. doi:10.1177/
Southam-Gerow, M. A., &Dorsey, S.
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Weingardt, K. R. (2004). The role of
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Wu, J. H., &Wang, S. C. (2005). What
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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
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
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,
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,
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
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-
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
Endorsing StereotypicalBeliefs About
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
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,
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-
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
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).
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
Expressing feelings openly
and asking the client if/how
they would like to address
the topic.
Taking steps to learn more
about applicable cultural
Therapist generalizing norms
of racial minorities based
upon assumptions and
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
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
Hostility toward fair-
skinned Black female
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-
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
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teaching resources |research resources |clinical resources
September 2015 157
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
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-
ing our intervention, some players wrote
the presence of the “team” or “teammates”
in their response to what they found most
In this intervention, we quickly learned
that the men’s and women’s teams had
starkly different team dynamics; it would
be amistake to conclude that athletes from
the same sport are a homogeneous group
that should be treated in a homogeneous
manner. The women’s team consisted of
primarily freshmen and sophomores and
had just hired anew coach 2months prior
to the intervention, whereas the men’s
team consisted of primarily juniors and
seniors. Thus, players on the men’s team
Behind the Scenes of Clinical Research: Lessons
From aMindfulness Intervention With Student-
Fallon R. Goodman and Todd B. Kashdan, George Mason University
1For confidentiality reasons, we chose to not
identify which sport the teams played.
2All quotations provided in this paper are direct
quotes from intervention participants.
158 the Behavior Therapist
had more time (and more athletic seasons)
to connect and get to know one another.
These objective differences were indicators
of more important subjective differences—
the men’s team displayed more team
chemistry and trust in one another than
the women’s team. We want to highlight
these discoveries about our sample as these
characteristics run counter to the “average
scores” in prior studies on sex differences
(e.g., Haselhuhn et al., 2015) and existing
psychological theories (e.g., Cross &
Mason, 1997). Unfortunately, our assess-
ment of group characteristics is based on
subjective observations that were not mea-
sured, which speaks to our next point—
measure what matters.
2. Measure What Matters
It was clear to the practitioners at the
start of the intervention that the men’s and
women’s teams had different group
dynamics, but we (the researchers) did not
capture this in our measurements. Our
assessment protocol was limited to indi-
vidual functioning, independent of team
dynamics and functioning. To offer anec-
dotal evidence, the practitioners described
the men’s team as full of vitality.3They said
male athletes would arrive at each session
talking, laughing, and displaying a light-
hearted attitude towards one another. In
contrast, the women often came in silent,
alone despite proximity to teammates.
During group exercises, practitioners said
that athletes from the men’s team actively
engaged in group discussions and seemed
more willing to trust one another by shar-
ing personal experiences. Players from the
women’s team, in contrast, were hesitant
to share information and often disengaged
during group discussions. These dynamics
likely impacted the effectiveness of the
intervention, but because we did not mea-
sure the constructs being mentioned here,
we cannot pronounce this with any degree
of certainty. This does offer an opportunity
for the next set of researchers and practi-
tioners to test the validity of these research
Following the intervention, players
from the men’s team reported greater
mindfulness, greater goal-directed energy,
and less perceived stress following the
intervention. Players from the women’s
team, in contrast, reported no significant
increases on any measured areas. We real-
ize that the general response to null find-