Posttraumatic Stress Disorder in Youth: A Critical Review of the Cognitive and Behavioral Treatment Outcome Literature.

What treatments work for children who have posttraumatic stress disorder (PTSD)? Perhaps more important, what else do clinicians need to learn? In this article, the authors focus on treatment research in the area of trauma and PTSD in youth, in an attempt to highlight the clinical implications of such work and to identify the areas in which additional research is needed. Overall, there is emerging evidence that a variety of cognitive and behavioral programs are effective in treating youth with PTSD. In spite of such evidence, additional research is needed to shore up the scientific base for effective clinical practice with these youth. Psychologists working with traumatized youth will find this article a useful update on the state of evidence for cognitive-behavioral interventions in the treatment of PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A practical, evidence-based approach for means-restriction counseling with suicidal patients.

Assessing a patient's access to potentially lethal means for suicide and taking steps to restrict access to means are common expectations for reasonable outpatient management of suicidal patients. Although scientific evidence supports means restriction as a suicide prevention strategy, means restriction continues to be infrequently utilized by clinicians, in large part because of the general lack of available training and guidance. The present article reviews the conceptual basis and empirical evidence for means restriction, discusses common barriers to means-restriction counseling, and provides practical procedures and tools (e.g., the means receipt, the crisis support plan) for accomplishing means-restriction counseling in routine clinical practice. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

On the relation of clinical research to clinical practice: Current issues, new directions.

Recent trends in clinical psychology training have institutionalized the scientist–practitioner split after observations that clinicians are unlikely to engage in research of any kind. But a more serious development is the realization that many clinicians are not even influenced by clinical research findings, resorting instead to a trial-and-error eclecticism in their clinical practice. This is due more to limitations in traditional research strategies than to inadequate training. Practical and philosophical differences between traditional research and clinical practice make it impossible for clinicians to do research and make research findings of limited relevance to clinicians. L. J. Cronbach's (1975) method of intensive local observation provides a meaningful and necessary role in the research process for practicing clinicians. It provides answers to questions that have not been forthcoming from clinical research, specifically, the effectiveness of treatments with individual clients and its generality. This would not require radical changes in clinical practice but would increase accountability and ensure the influence of research findings on practice. (54 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical research, practice, and the crisis of confidence.

Contends that the complaint that clinical research has had little influence on clinical practice is largely a pseudoproblem. Since research in psychotherapy has become highly specialized, it is unrealistic to expect that clinicians can also become productive researchers. First-rate clinicians and therapists have not been trained, nor has the profession succeeded in defining and communicating clearly what psychotherapy is intended to do, what it can (and cannot) do, with whom, and under what circumstances. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Negative treatment effects: Is it time for a black box warning?

Comments on Negative effects from psychological treatments: A perspective by David Barlow (see record 2009-24989-002). The author addresses negative treatment effects in the psychotherapy field by stating that Barlow provided a historical perspective of clinical psychology’s long-standing interest in studying the positive effects of psychotherapy, and he indicated that although negative treatment effects have long been identified, little attention has been paid to them. Barlow also recommended a greater emphasis on more idiographic approaches to studying negative effects. He further added that “this would be best carried out in the context of a strong collaboration among frontline clinicians and clinical scientists”. I would argue that this may best be carried out between frontline clinicians and their clients. So the science that we use may not be clinical mandates prohibiting, for example, certain treatments but may simply be the sharing of our scientific knowledge about clinical possibilities so as to better inform clients about the treatment they are considering. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

EBP ≠ EST: Reply to Crits-Christoph et al. (2005) and Weisz et al. (2005).

Replies to Crits-Christoph et al. (see record 2005-04167-007) and Weisz et al (see record 2005-04167-008). Evidence-based practice (EBP) is not a synonym of empirically supported therapies (ESTs). ESTs reflect 1 kind of evidence that should guide EBP. The authors focus in this response on 4 issues: the distinction between 2 functions of randomized clinical trials (RCTs) with very different methodological and clinical implications, problems with the experimental designs used to test ESTs that have unnecessarily limited their clinical and scientific utility, the question of how to integrate findings from RCTs with findings from other empirical methods to guide evidence-based interventions, and what one means by clinicians (i.e., whether clinicians should be paraprofessionals who implement procedures developed by researchers or full-fledged partners in the development and implementation of evidence-based psychological practice). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the Merits of Clinical Judgment: Comment.

Comments on the article by D. Westen and J. Weinberger (see record 2004-19091-002), which criticized academic clinical psychologists for being cynical about clinical judgment and clinical practice. In our view, it seems unlikely that more than a few academic clinical psychologists believe that they have little to learn from clinical practice or experience. In this comment, we examine the arguments about clinical judgment made by Westen and Weinberger (2004). Westen and Weinberger (2004) conflate the effect of training with the effect of experience. Westen and Weinberger (2004) do not mention that the value of training in psychology has been well-supported by research. While Westen and Weinberger (2004) make positive comments about the types of feedback that clinicians receive, for a number of reasons, including the Barnum effect, psychologists can be misled by feedback. Westen and Weinberger (2004) also argue that "psychotherapists tend to have much more direct and immediate feedback than most other medical practitioners, who may prescribe a medication or perform a procedure and not see the patient again for a year" (p. 603). But when psychologists make a diagnosis or describe a personality trait, they frequently do not receive "direct and immediate feedback" on whether they are right or wrong. In contrast, physicians often receive highly valid feedback. Finally, in discussing the value of ratings made by clinicians, Westen and Weinberger (2004) observe that "empirically, we have found surprisingly little evidence of theory-driven observational bias in using clinician-report methods" (p. 601). The issue is important because Westen and Weinberger argue in favor of using clinician ratings to construct diagnostic criteria. If clinicians' ratings are biased, then the criteria will be biased. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Understanding and treating the pathological gambler: Book review.

This book represents an introduction to basic cognitive and behavioral treatment principles and strategies that guide the authors' clinical research on pathological gambling. While this book is primarily presented as a clinical tool and will be highly useful to clinicians already well-versed in cognitive-behavioral therapy for pathological gambling, those new to the field will find the absence of supporting references a frustrating aspect of this otherwise helpful text. At minimum, a bibliography of key books and articles would have greatly enhanced the value of this work. In addition, the authors do not present any empirical evidence for their clinical approach, leaving the reader without any sense of how effective this approach has been shown to be or why it is superior to any other clinical approach to excessive gambling. Although the intention of this book was primarily to outline a clinical approach to excessive gambling, the definitive evaluation of the approach presented in this text will rest on its demonstrated empirical efficacy. Until then, this book will be of great use to clinicians who treat problem gambling and who wish to employ an approach that has been found to be effective with other addictions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Paradox or contradiction?

Notes that in the April, 1955 issue of the American Psychologist, two young psychologists note the discrepancy between theory and practice in the clinical field, particularly during training, and a veteran says that he itches too but offers no suggestions for relief. It seems clear that our society can use many clinicians, a few experimentalists, and fewer who are half-and-half. On the other hand, scholarly tradition requires publication and the age requires it to seem scientific. Training is institutional for ends that are individual. Such observations could be compounded and argue for much franker facing of the sociology and economics of clinical psychology than has been given them. The author concludes that no one should be certified for the use of a clinical technique unless and until he can prove competence through results in the judgment of a group of his peers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The evidence missing from evidence-based practice.

Comments on the report by the APA Presidential Task Force on Evidence-Based Practice (see record 2006-05893-001) entitled Evidence-based practice in psychology. Regrettably, the task force report was largely silent on three critical issues. As a consequence, it omitted much of the evidence necessary for a complete picture of evidence-based practice. First, the task force report did not operationalize "evidence." Second, the task force report did not address the crucial problem of iatrogenic treatments. Third, the task force report said little about the necessity for ongoing objective evaluation of clinical cases, which is critical to ethically responsible services. Current debate centers on how research findings should be factored into interventions, not on whether it is necessary to do so. Rather than waiting for the resolution of competing views on the matter, psychologists bear an ethical obligation to offer evidence-informed services. Three critical steps that were largely neglected by the task force report can go far toward helping psychologists honor that commitment: (a) providing a clearer operationalization of scientific evidence, (b) using current research to rule out the use of potentially harmful methods, and (c) using objective criteria to evaluate all of their cases on an ongoing basis. These steps, in turn, clarify the menu of options available to therapists, help protect clients from harm, and offer the advantage of allowing clinicians to contribute to the growing body of knowledge about what does and does not work in psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comment: Can clinical judgment hold its own against scientific knowledge? Comment on Zeldow (2009).

P. B. Zeldow (2009) presents a series of vignettes that make a compelling case for the role of clinical judgment and for the claim that the knowledge of a credentialed practitioner stand up against the credentialed knowledge of scientific research. This comment discusses how the dispute between scientific knowledge and clinical judgment is not unique to psychotherapy but has been extensively discussed in other disciplines, especially medicine and education. Two models of science and practice are presented: a model based on Aristotle's (1999) distinction between techne and phronesis and H. L. Dreyfus and S. E. Dreyfus's (1986) five-stage model of skill acquisition. Both a scientific knowledge base and a model of clinical practice that value the judgment of the expert practitioner are necessary for psychology to be a learned profession. Nevertheless, the gap between science and practice may never be fully closed but will always have irresolvable conflicts that can only be contained. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Addressing key challenges in evidence-based practice in psychology.

With its promise of enhancing the effectiveness of services, evidence-based practice in psychology (EBPP) appears to offer much to psychologists, patients, and policymakers. The purpose of this article is to examine some of the key challenges facing psychologists who wish to provide evidence-based treatment services, including how research evidence is used in EBPP, whether the results of the treatment research literature can be generalized to typical clinical practice, and how effective evidence-based treatments are in clinical practice. On the basis of recent evidence-based initiatives and treatment research, there is a solid scientific basis for EBPP, although much more research is necessary on the treatment of relatively mild, but common, clinical conditions and on the transporting of evidence-based treatments into clinical practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical Decision Making About Psychopathy and Violence Risk Assessment in Public Sector Mental Health Settings.

Although there has been extensive research on psychopathy, it is unknown how, or whether, clinicians in public sector mental health settings consider the Psychopathy Checklist (PCL) for assessing violence risk. Mental health clinicians (N = 135) from 4 facilities were interviewed by using multiple methods for collecting data on decision making. Participants considered clinical information most often when assessing violence risk, indicating that these data were most readily available. Clinicians perceived formal testing results (e.g., PCL) to be least available and considered testing least often, especially if clinicians had less clinical experience. Participants did not explicitly report using the PCL but did implicitly rely on psychopathy factors when assessing violence risk. Clinicians in crisis settings reported less availability of historical data typically needed for the PCL. The data point to specific ways to improve the clinical practice of violence risk assessment in public mental health settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Can biological activity be maintained at ultra-high dilution? An overview of homeopathy, evidence, and Bayesian philosophy

Forty percent of general practitioners in the Netherlands practice homeopathy. With over 100 homeopathic medical schools, homeopathy is practiced in India along with conventional Western medicine in government clinics. In Britain, 42% of general practitioners refer patients to homeopaths. Two recent meta-analyses of homeopathy both indicate that there is enough evidence to show that homeopathy has added effects over placebo. Against this evidence is a backdrop of considerable scientific scepticism. Homeopathic remedies are diluted substances--some are so diluted that statistically there are no molecules present to explain their proposed biological effects (ultra-high dilutions or UHDs). Without knowledge of the evidence, most scientists would reject UHD effects because of their intrinsic implausibility in the light of our current scientific understanding. The objective of this article is to critically review the major pieces of evidence on UHD effects and suggest how the scientific community should respond to its challenge. Such evidence has been conducted on a diverse range of assays--immunologic, physiological, behavioral, biochemical, and clinical in the form of trials of homeopathic remedies. Evidence of UHD effects has attracted the attention of physicists who have speculated on their physical mechanisms. Included is a critique of several experiments that form the Benveniste affair which was sparked by a publication in Nature that advocated the existence of UHD effects of anti-immunoglobulin E (IgE) on human basophils, and is the paradigm example of how a controversial phenomenon can split the scientific community. It is argued that if the phenomenon was uncontroversial, the evidence suffices to show that UHD effects exist. However, given that the observations contradict well-established theory, normal science has to be abandoned and scientists need to decide for themselves what the likelihood of UHD effects are. Bayesian analysis describes how scientists ought rationally to change their prior beliefs in the light of evidence. Theories by Kuhn and Lakatos indicate that whether UHD effects are proved or not depends on the beliefs and behaviors of scientists in their communities. This article argues that there is as yet insufficient evidence to drive rational scientists to a consensus over UHD effects, even if they possessed knowledge of all the evidence. The difficulty in publishing high-quality UHD research in conventional journals prevents a fair assessment of UHD effects. Given that the existence of UHD effects would revolutionize science and medicine, and given the considerable empirical evidence of them, the philosophies of science tell us that possible UHD effects warrant serious investigation by conventional scientists and serious attention by scientific journals.     

Clinical Judgment in Science: Reply.

Replies to comments published by M. S. Schulz and R. J. Waldinger (see record 2005-11115-010), J. M. Wood and M. T. Nezworski (see record 2005-11115-011), and H. N. Garb and W. M. Grove (see record 2005-11115-012) on the original article by D. Westen and J. Weinberger (see record 2004-19091-002). Schulz and Waldinger (2005) make the important point that just as researchers can capitalize on the knowledge of experienced clinical observers through aggregation, they can aggregate the judgment of lay observers in assessing phenomena such as emotion. The reason, as they articulate, is that skills such as "reading" emotion from facial expression, tone of voice, posture, and the constellation of cues provided in everyday life are an area of expertise for most people, one that is now often called social or emotional intelligence. As psychometricians have known for years, one can increase reliability in many different ways. The comments by Wood and Nezworski (2005) and Garb and Grove (2005) do not address our central thesis--namely, the importance of distinguishing two meanings of clinical. The point of the sentence around which Wood and Nezworski (2005) build their comment was simply that the same biases widely attributed to clinicians are common in scientists as well--a point for which we would be delighted to take credit, but it is one that was actually made much more elegantly by the historian and philosopher of science Thomas Kuhn (1962). The authors respond to Wood and Nezworski's (2005) specific concerns about misrepresentation. In their comment, Garb and Grove (2005) challenge us to document our view that anticlinician prejudice is widespread among many academic clinical psychologists. As research on implicit prejudice suggests, surveys of academic clinical psychologists might indicate little about their implicit attitudes, as evident in Garb and Grove's apparent lack of recognition of the offensive nature of comparing a clinician's attempt to revise his or her understanding when the patient says "I don't think what you just said is right" to astrology and Barnum effects. We appreciate Garb and Grove's (2005) point about potential differential effects of training and experience on reliability and validity of clinical judgment. The data they cite are important and bear consideration. We would offer two caveats, however. Finally, we cannot help but note that this series of comments and our reply to them provide a prototypical example of "clinical" judgment in science--that is, subjective, informal aggregation of data, often leading to a "gestalt" judgment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing Religious/Spiritual Functioning: A Neglected Domain in Clinical Practice?

Is client religious or spiritual functioning adequately addressed in clinical practice? Two studies are presented that address this issue. Each study was informed by an endogenous view of spirituality as a clinically relevant functional domain. The first study surveyed clinicians at 4 exemplar clinics. The second study was a national survey of 1,000 clinical psychologists. Both studies found that psychologists believe client religiousness/spirituality to be an important area of functioning. Yet most do not routinely assess the domain or address it in treatment planning. The article concludes by examining the clinical implications of an endogenous perspective on client spirituality and religiousness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What Works in Psychotherapy and How Do We Know?: What Evidence-Based Practice Has to Offer.

Evidence-based practice may be insufficiently understood by dynamically oriented therapists and analysts. It includes the integration of the best available research evidence, clinical expertise, and considered attention to a patient's personal attributes, sociocultural characteristics, and unique dynamics. These 3 streams of knowledge inform clinical practice. Advocates of a manual approach to treatment have challenged clinicians to rethink the importance of what they consider salient in their therapeutic endeavors. This article demonstrates the relevance of an evidence-based practice perspective for dynamically oriented clinicians. An American Psychological Association task force has been established to develop and elaborate the view of current clinical practice so that it can be disseminated to clinicians and to the public as a policy statement that governs clinicians' thinking and work. The goal is to provide knowledgeable, reasonable, and responsible high-quality health care to those who need it based on these developed practice principles. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Daubert v. Merrell Dow and expert testimony by clinical psychologists: Implications and recommendations for practice.

The role and practice of clinical psychologists as expert witnesses is discussed in light of the United States Supreme Court decision in Daubert v. Merrell Dow Pharmaceuticals (1993). Daubert v. Merrell Dow is reviewed, and its implications for clinicians who testify as expert witnesses are presented. A distinction is made between expert testimony in a generic sense, and scientific expert testimony. By virtue of clinical psychology's adoption of the mantle of science, clinical psychologists should adhere to scientific standards of data gathering in order to qualify as scientific experts. Guidelines are provided to assist clinicians in assessing the confidence with which conclusions can be termed scientific, and ethical concerns are reviewed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)