Enhancing clinical practice: The role of practice guidelines.

Health service researchers believe that significant practice variations occur, in part, because there is no strong consensus on best practices for managing a specific condition. The Agency for Health Care Policy and Research supports the development of science-based clinical guidelines, performance measures, and standards of quality. Since 1992, it has published 6 clinical guidelines and is supporting development of more than 20 others. Each has a consumer version, in English and Spanish, to educate patients and describe care options. Widespread use of these guidelines will improve the quality of health care by assisting providers in making more informed decisions, thereby reducing unnecessary health care practices; will reduce some costs; and will provide feedback on knowledge gaps that merit the attention and support of researchers and policymakers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the Psychopathy Checklist: Screening Version.

This study examined the predictive validity of the HCR–20 (Historical, Clinical, and Risk Management) violence risk assessment scheme and the Psychopathy Checklist: Screening Version (PCL:SV). Files of 193 civilly committed patients were coded. Patients were followed up in the community for an average of 626 days. Receiver operating characteristic analyses with the HCR–20 yielded strong associations with violence (areas under curve [AUCs?=?.76–.80). Persons scoring above the HCR–20 median were 6 to 13 times more likely to be violent than those scoring below the median. PCL:SV AUCs were more variable (.68–.79). Regression analyses revealed that the HCR–20 added incremental validity to the PCL:SV and that only HCR–20 subscales predicted violence. Implications for risk assessment research, and the clinical assessment and management of violence, are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The psychological assessment of risk for crime and violence.

This article provides an overview of the current practices and challenges in psychological risk assessment for crime and violence. Risk assessments have improved considerably during the past 20 years. The dismal predictive accuracy of unstructured professional opinion has largely been replaced by more accurate, structured risk assessment methods. Consensus has not been achieved, however, on the constructs assessed by the various risk tools, nor the best method of combining factors into an overall evaluation of risk. Advancing risk assessment for crime and violence requires psychometrically sound evaluations of psychologically meaningful causal risk factors described using nonarbitrary metrics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relevance of interrater agreement to violence risk assessment.

This study considered whether assessments of violence risk in which 2 clinicians reach similar conclusions are more accurate than the conclusions of either clinician alone when their assessments disagree. One hundred ten physicians and 44 nurses estimated the probability of physical assault of 478 patients admitted to a short-term locked psychiatric inpatient unit. The level of assessed risk showed a substantial correspondence with the likelihood of later violence when the physician and nurse ratings were highly concordant. As the extent of agreement between the physician and nurse ratings decreased, the strength of the association between the risk assessments and the occurrence of violence decreased accordingly. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conducting risk evaluations for future violence: Ethical practice is possible.

Psychologists frequently testify in court about an individual's risk for future violence. Decades ago, the basis for such testimony was problematic, but the field has made significant progress. However, recent criticisms raise ethical concerns about risk evaluations and state that current methods do not meet admissibility standards. Responding to such criticisms is important for expert witness involvement in these evaluations. We note that it is feasible to conduct thorough ethical evaluations that will aid judicial and clinical decision making. We argue that the courts find this information necessary, and well-informed professionals can make valid and important contributions in these proceedings. To leave the courts without access to the best science available could cause more harm than good. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improving the relationship between the randomized clinical trial and real-world clinical practice.

I comment on the article by Krause (see record 2011-19228-002), which discusses a number of ways for clinical psychotherapy outcome researchers to make the results of randomized controlled trials (RCT) more useful to practicing psychotherapists primarily by making the distributions of raw data from those studies available to the public. In this way, it would be possible for psychotherapists to determine which treatment of an RCT (experimental or control) would be best for a specific patient. Problems with this proposal are discussed and an alternative model that integrates psychotherapy outcome data from group means and clinical case studies is offered. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The validity and reliability of the Violence Risk Scale: A treatment-friendly violence risk assessment tool.

The development of risk assessment tools that use dynamic variables to predict recidivism and to inform and facilitate violence reduction interventions is the next major challenge in the field of risk assessment and management. This study is the first in a 2-step process to validate the Violence Risk Scale (VRS), a risk assessment tool that integrates violence assessment, prediction, and treatment. Ratings of the 6 static and 20 dynamic VRS variables assess the client's level of risk. Ratings of the dynamic variables identify treatment targets linked to violence, and ratings of the stages of change of the treatment targets assess the client's treatment readiness and change. The VRS scores of 918 male offenders showed good interrater reliability and internal consistency and could predict violent and nonviolent recidivism over both short- and longer term (4.4-year) follow-up. The probability of violent and nonviolent recidivism varied linearly with VRS scores. Dynamic and static variables performed equally well. The results support the contention that the VRS can be used to assess violent risk and to guide violence reduction treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The legal implications of clinical practice guidelines

In the past several years, considerable attention has been focused on clinical practice guidelines. They are developed to foster improved clinical care and to increase clinical efficiency. The legal implications of developing and following guidelines are not yet clear. The author argues that properly formulated guidelines could reduce the burdens of preventing and resolving malpractice claims.     

The efficacy of violence prediction: A meta-analytic comparison of nine risk assessment tools.

Actuarial risk assessment tools are used extensively to predict future violence, but previous studies comparing their predictive accuracies have produced inconsistent findings as a result of various methodological issues. We conducted meta-analyses of the effect sizes of 9 commonly used risk assessment tools and their subscales to compare their predictive efficacies for violence. The effect sizes were extracted from 28 original reports published between 1999 and 2008, which assessed the predictive accuracy of more than one tool. We used a within-subject design to improve statistical power and multilevel regression models to disentangle random effects of variation between studies and tools and to adjust for study features. All 9 tools and their subscales predicted violence at about the same moderate level of predictive efficacy with the exception of Psychopathy Checklist—Revised (PCL-R) Factor 1, which predicted violence only at chance level among men. Approximately 25% of the total variance was due to differences between tools, whereas approximately 85% of heterogeneity between studies was explained by methodological features (age, length of follow-up, different types of violent outcome, sex, and sex-related interactions). Sex-differentiated efficacy was found for a small number of the tools. If the intention is only to predict future violence, then the 9 tools are essentially interchangeable; the selection of which tool to use in practice should depend on what other functions the tool can perform rather than on its efficacy in predicting violence. The moderate level of predictive accuracy of these tools suggests that they should not be used solely for some criminal justice decision making that requires a very high level of accuracy such as preventive detention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Domestic violence: legal, practice, and educational issues

Domestic violence is a recognized and growing public health concern in the United States. Health care professionals have a duty to improve the identification of victims of domestic violence, intervene effectively, and advocate for better education to break the cycle of abuse.     

Linking psychology and public health: A predoctoral clinical training program in youth violence prevention.

Although clinical psychology has made strides in developing prevention and intervention strategies to reduce youth violence, there has been little attention to skills-oriented preprofessional training to prepare graduate students for practice roles in this emerging area of public health concern. This article describes a practicum training experience that prepares doctoral-level clinical psychology trainees to serve as youth violence prevention service providers, trainers, and consultants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internship opportunities in clinical neuropsychology emphasizing recent INS training guidelines.

Surveyed the directors of 230 predoctoral internship programs in clinical and counseling psychology about the nature of clinical neuropsychological experiences provided at the internship site, training in neuropsychological batteries, information about providers, and availability of formal postdoctoral training. Of the 170 programs responding, 117 indicated that they offered some form of training in clinical neuropsychology. The most common format for this training was the seminar. Findings show that while there is continued demand for clinical neuropsychology training opportunities, the programs' present structure and limited training opportunities are not likely to produce competent practitioners. Although formal postdoctoral experiences were a major recommendation of the International Neuropsychological Association (INS) training guidelines, positions were limited. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attributes of clinical guidelines that influence use of guidelines in general practice: observational study

OBJECTIVE: To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice. DESIGN: Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelines-for example, evidence based, controversial, concrete. SETTING: General practice in the Netherlands. SUBJECTS: 61 general practitioners who made 12 880 decisions in their contacts with patients. MAIN OUTCOME MEASURES: Compliance of decisions with clinical guidelines according to the attribute of the guideline. RESULTS: Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)). CONCLUSIONS: People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.     

Internship training in behavioral medicine: Program description, issues, and guidelines.

Describes an experimental, behavioral medicine training program in the clinical psychology internship of the Palo Alto VA Medical Center. Aspects of program development, clinical and research training experiences, and issues for training are discussed. Guidelines for future training are presented. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Stress management training in health psychology practice: Critical clinical issues.

Stress management training interventions have become one of the most popular treatment programs in health psychology practice. Although numerous clinical approaches are available, limited attention is given to the matching of intervention with the clinical needs of individuals. As a result, stress management programs are more frequently marketed in clinical and community settings as palliative techniques without sufficient exploration of the causes of stress. We review these concerns and highlight critical assessment and treatment variables that moderate the efficacy of specific stress management interventions. Suggestions for further research and guidelines for clinical practice are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Biofeedback: Research, training, and clinical roles.

Reviews the origins of biofeedback research in studies of altered states of consciousness and of the possibility of the operant conditioning of the autonomous nervous systems. Criticisms of biofeedback research are also discussed. It is concluded that there is little relationship between research findings and the clinical practice of biofeedback and that it is the responsibility of graduate training programs to select and train students who can think critically about this relationship. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Facilitative training: Acquisition, retention, and modes of assessment.

Examined 10 hr. of didactic-experiential training in facilitative functioning for acquisition, retention, and equivalence of modes of assessing levels of facilitative functioning. 20 prerated moderate-level and 20 low-level functioning counselors-in-training were assigned to treatment and control groups according to a randomized block design. Results confirm previous research indicating that levels of facilitation can be increased, whether assessed from written or oral modes of responding. Prerated moderate Ss appeared more able to use the training for formulating higher facilitative oral responses in a counseling interview than low-level Ss. Posttraining levels of functioning were maintained throughout the 4-wk latency period by both prerated moderate- and low-level Ss. Equivalence in levels of facilitative functioning between written and oral modes of responding was not found for any of the prerated subgroups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)