Integrating Interventions and Services Research: Progress and Prospects

Although interventions and services research paradigms have distinct historical roots and methodologic traditions, both aim to improve mental health services for adults and youth. This article introduces a series of articles that represent examples of innovative and integrative (i.e., integration of services and interventions research) research efforts. This work involves an integration of the interventions and services research paradigms to address the difficult questions related to improving mental health services in diverse settings. Each of the four articles takes a distinctly different path in bringing together the interventions and services research traditions, with foci ranging from (a) using psychotherapy measurement tools to assess the content of usual care practice in collaboration with providers, (b) adapting randomized clinical trial design to fit nonmental healthcare settings while addressing relevant outcomes, (c) understanding and incorporating patient preferences into treatment research, and (d) identifying organization-level variables relevant to interventions development and implementation. In the introductory article, we provide a brief précis concerning the interventions and services research traditions, highlight how each of the four articles illustrates an innovative integration of interventions and services research, and discuss additional future directions beyond the work introduced in this series.     

The meaning of community in community mental health.

This article critically reviews the development of community mental health in both theory and practice and explores new directions and dilemmas for future policy and programs. First, we trace the dialectical development of the ideology of community mental health and the rediscovery of community. Second, we outline the two key transitions: (a) from professionals to natural helpers and (b) from catchment areas to natural networks. Third, we offer alternative conceptions of community from the sociological literature and suggest ways that these can benefit new program planning. We conclude with a series of policy questions that legitimate the expansion of community mental health beyond the parochial confines of the local community.     

Enhancing Mental Health Service Delivery to Ethnically Diverse Populations: Introduction to the Special Series

The American Psychological Association's adoption of guidelines for providing psychological services to diverse populations and the enactment by the National Institutes of Health (NIH) of regulations that required the representation of women and ethnic minorities in NIH-funded research projects called attention to the need to improve mental health services for ethnically diverse populations. This special series illustrates the relevance of cultural and ethnic factors in addressing contemporary mental health needs and the role of these factors in the work of clinicians who serve ethnically diverse clinical populations. The articles comprising the series examine the mental health dimensions of five contemporary clinical practice issues: HIV/AIDS, eating disorders, hate crimes, folk healing, and youth at high risk for drug abuse.     

Ethical Challenges in Community-Based Research: Introduction to the Series

We describe the inspiration for this series of articles and articulate several themes that run throughout the four articles that follow. Particular ethical challenges in community-based mental health research are identified, as is the tension between existing ethical codes and policies and the requirements of more collaborative, community-based research. We edited this special series with an eye toward promoting greater discussion of ethical issues in this realm and the eventual development and promotion of guidelines for ethical decision-making in community-based research.     

Social Contexts of Mental Weil-Being in Later Life

Extending the preceding review, this commentary argues for serious attention to the social contexts of mental health of older adults in research and practice. Social gerontology research focuses primarily on summative or aggregate variables with little focus on mechanism, despite growing evidence that mechanisms as diverse as immunosuppression and expressed emotion influence mental health. Increased linkages between the macro-level and microlevel data are required to provide the theoretical models needed to shape practice. Current evidence is deemed sufficient, however, to alter the frameworks we use for both diagnosis and treatment.     

Theory and concepts of prevention science as applied to clinical psychology.

This article provides an overview for this special issue on prevention science in clinical psychology. A brief historical perspective on prevention in clinical psychology is presented. An even greater emphasis on prevention in the future is related to changes in the current health-care system and their likely impact on psychological practice as we move into the next century. Conceptual and theoretical models of the prevention enterprise are addressed with a distinction drawn between health promotion and disease prevention in the areas of mental disorders and general physical health. The classification of preventive interventions is discussed and methodological challenges to outcomes research are outlined. The article concludes with a discussion of training and public policy implications and a brief overview of the other articles included in this special issue on prevention science.     

Future Directions for Dissemination and Implementation Science: Aligning Ecological Theory and Public Health to Close the Research to Practice Gap

Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.     

Development of clinical guidelines for inborn errors of metabolism: Commentary

This is one of an occasional series of articles commenting on trends, advances, and challenges in understanding and treating inborn errors of metabolism (IEMs). Previously, we have called attention to the critical lack of a clinical trial infrastructure to routinely evaluate new therapies for IEMs and the adverse effect of this deficit (Vockley and Vockley, 2010 [1]). In this article, we highlight the role of therapeutic guidelines in implementing best practice for IEMs and the processes used to generate them. Current conventions for evidence-based guidelines are best applied to studies involving significantly more subjects than is feasible for IEMs, and can lead to relative weak-appearing recommendations when applied to rare disorders. We propose a guideline development process that maintains the use of conventional methodologies but adapts to unique features and inherent difficulties dealing with rare conditions such as IEMs. Such guidelines will consist of a hybrid between evidence and consensus based processes. Implementation of these recommendations and subsequent therapeutic guidelines for IEMs provides an opportunity to define current knowledge as well as starting points for future clinical trials.     

Examining Psychotherapy Processes in a Services Research Context

Interdisciplinary research efforts integrating services and interventions research methodologies are needed to improve the "real-world" clinical utility and impact of youth mental health research. "Hybrid" services and interventions research efforts can capitalize on the methodologic strengths of each research tradition in order to more rigorously examine and affect therapy processes in usual care youth mental health service settings. The goals of this article are to (a) identify the need for hybrid practice research on youth mental health care; (b) present a "case example" of a hybrid study, where child and family therapy processes are being examined in a usual care, practice-based context by a team of services researchers; (c) address the potential advantages and challenges of hybrid research; and (d) suggest promising areas for future hybrid research in youth mental health care.     

Commentary: A Practical Guide for Translating Basic Research on Affective Science to Implementing Physiology in Clinical Child and Adolescent Assessments

The National Institute of Mental Health recently launched the Research Domain Criteria (RDoC). RDoC is a framework that facilitates the dimensional assessment and classification of processes relevant to mental health (e.g., affect, regulation, cognition, social affiliation), as reflected in measurements across multiple units of analysis (e.g., physiology, circuitry, genes, self-reports). A key focus of RDoC involves opening new lines of research examining patients’ responses on biological measures, with the key goal of developing new therapeutic techniques that effectively target mechanisms of mental disorders. Yet applied researchers and practitioners rarely use biological measures within mental health assessments, which may present challenges in translating RDoC-guided research into improvements in patient care. Thus, if RDoC is to result in research that yields clinical tools that reduce the burden of mental illness and improve public health, we ought to develop strategies for effectively implementing biological measures in the context of clinical assessments. In this special issue, we sought to provide an initial step in this direction by assembling a collection of articles from leading research teams carrying out pioneering work on implementing multimodal assessments (biological, subjective, behavioral) of affective processes in applied settings. In this commentary, we expand upon the work presented in this special issue by making a series of suggestions for how to most parsimoniously conduct multimodal assessments of affective processes in applied research and clinical settings. We hope that this approach will facilitate translations of the RDoC framework into applied research and clinic settings.     

New directions and resources in group psychotherapy: introduction to the issue

Establishing an evidence-based practice (EBP) is a central byproduct of the ever-increasing emphasis on accountability in mental health services. Though much has been written and developed for individual psychotherapists who wish to develop EBPs, there are far fewer resources for group psychotherapists. This article introduces a series of articles designed to provide EBPs and resources for group psychotherapists. We discuss how therapists can develop and apply the following aspects of EBPs: research-supported treatments (RSTs), practice guidelines, practice-based evidence, and multicultural competence.     

Paradigms in aging research: a critical review and assessment

This is the first in a series of articles in which we intend to critically review some of the currently used models in gerontology research and evaluate their contribution to advancing our understanding of the phenomenon of senescence. The major theories of aging are considered. We discuss what makes a model useful in general and for aging research in particular. We suggest criteria for the selection of paradigms for the study of aging. The criteria we suggest for identifying underlying mechanisms that lead to age related changes are: intraspecies universality, intrinsicality, progressiveness, and interspecies universality. The subsequent articles of this series shall consider the merits and possible drawbacks of some of the most commonly used models of the biology of aging: (a) the yeast Saccharomyces cerevisiae; (b) the nematode, Caenorhabditis elegans and the fruitfly, Drosophila melanogaster; (c) mammalian cells in culture and telomerase model; (d) mitochondria and aging; (e) progeroid syndromes; (f) in vivo studies with laboratory rodent strains; and (g) plant senescence.     

Pilot test of cooperative learning format for training mental health researchers and black community leaders in partnership skills

To support reduction of racial disparities in mental health diagnosis and treatment, mental health researchers and black community-based organization (CBO) leaders need training on how to engage in collaborative research partnerships. In this study, we pilot tested a series of partnership skills training modules for researchers and CBO leaders in a collaborative learning format. Two different sets of three modules, designed for separate training of researchers and CBO leaders, covered considering, establishing and managing mental health research partnerships and included instructions for self-directed activities and discussions. Eight CBO leaders participated in 10 sessions, and six researchers participated in eight sessions. The effectiveness of the training content and format was evaluated through standardized observations, focus group discussions, participant evaluation forms and retrospective pre-/posttests to measure perceived gains in knowledge. Participants generally were satisfied with the training experience and gained new partnership knowledge and skills. Although the CBO leaders were more engaged in the cooperative learning process, this training format appealed to both audiences. Pilot testing demonstrated that: 1) our modules can equip researchers and CBO leaders with new partnership knowledge and skills and 2) the cooperative learning format is a well-received and suitable option for mental health research partnership training.     

Assessment and the Journal of Clinical Child and Adolescent Psychology’s Evidence Base Updates Series: Evaluating the Tools for Gathering Evidence

In 2014, Michael Southam-Gerow and Mitch Prinstein launched the Evidence Base Updates series. As invited contributors, authors of Evidence Base Updates articles offer the field an invaluable resource: regular evaluations of the latest data on tools for addressing the mental health needs of children and adolescents. Until now, authors of Evidence Base Updates articles have focused exclusively on evaluating treatment techniques. In this article, we outline how the Evidence Base Updates series will evolve to also include evaluations of assessment techniques. In our treatment-focused updates, contributors follow strict criteria when evaluating the evidence. Following these criteria allows authors of Evidence Base Updates articles to provide mental health professionals with clear “take-home messages” about the evidence underlying the treatments evaluated. Similarly, we outline the criteria that authors will follow when preparing Evidence Base Updates articles that evaluate assessments. We also highlight the formats of these articles, which will include evaluations of condition-focused measures (e.g., anxiety, conduct problems); transdiagnostic constructs (e.g., parenting, rumination); specific, widely used measures that cut across conditions; and updates on field-wide considerations regarding measurement (e.g., clinical utility, incremental validity).     

The evidence-based practice of psychotherapy: Facing the challenges that lie ahead

What does the future hold for psychotherapy research and practice? We review some key influences, including declining psychotherapy utilization, increasing impact of evidence-based medical practices, over-medicalizing of mental health problems, and changing priorities from grant funding agencies. These factors hold potential opportunities but also major pitfalls that will need to be carefully navigated related to implementation/dissemination issues, interdisciplinary collaborations, and psychosocial versus biomedical perspectives related to the nature and treatment of psychopathology. In addition, we review and comment on the other articles contained in this special issue pertaining to the future of evidence-based psychotherapy.     

Cultural diversity and mental health. Towards integrative practice

Adopting an integrative approach to mental health is especially important when working with people from diverse cultural backgrounds. In order to render culturally sensitive practice, we need to be immersed in the philosophical, contextual, and experiential considerations of the cultural group with whom we work. Comprehensive assessment and intervention involves bridging disciplines to gain a more holistic appreciation for the group's situation and experience. Thus, we have taken a transdisciplinary approach (a) to provide a framework for understanding and improving mental health in the context of cultural diversity and (b) to promote legitimate practice, or the unity of reflection, research, and action, in mental health in different cultures. We provide an example of how we use this framework in our work with the Portuguese immigrant community. The framework is not only limited to assessing the needs of individuals but draws on anthropology, philosophy, political science, and religious studies to understand the social, cultural, moral, and religious domains. In addition, community psychologists and social activists provide models of how to intervene at community or societal levels. The unique contribution of the integrative practice framework is that merges considerations that are typically studied in isolation. Needs, norms, context, values, and social change are not always studied in an integrative fashion. Thus, the article offers a way of considering seemingly disparate but highly complementary practice deliberations.     

‘As above,so below’ examining the interplay between emotion and the immune system

While the concept of a palpable relationship between our mental and physical well‐being is certainly not new, it is only in the light of modern scientific research that we have begun to realize how deeply connected our emotional and immune states may be. We begin this review with a series of studies demonstrating how four fundamental emotional responses: anger, anxiety, mirth and relaxation are able modulate cytokine production and cellular responses to a variety of immune stimuli. These modulations are shown to be either detrimental or beneficial to a patient's health dependent on the context and duration of the emotion. We also discuss the reverse, highlighting research demonstrating how the loss of key immune cells such as T lymphocytes in clinical and animal studies can negatively impact both emotional well‐being and cognition. Additionally, to give a more complete picture of the manifold pathways that link emotion and the immune system, we give a brief overview of the influence the digestive system has upon mental and immunological health. Finally, throughout this review we attempt to highlight the therapeutic potential of this burgeoning field of research in both the diagnosis and treatment of immune and disorders. As well as identifying some of the key obstacles the field must address in order to put this potential into practice.     

A community psychology framework for participating in mental health policy making

Psychologists are becoming more and more sensitized to the influence of mental health policy on the delivery of psychological services and, simultaneously, to the role they can or ought to play in the mental health policy-making process. Traditional and potential roles for psychologists in this process are identified and classified by means of a community psychology framework. The centrality of values in these roles is identified, and conceptual tools are presented for understanding the relationship between psychologists and policy makers. Implications for research, training, and practice are drawn.     

Illness and symptom perception: a theoretical approach towards an integrative measurement model

Several models have been proposed to conceptualize psychological representations of health, illness, and bodily sensations. These models differ as to the cognitive and affective components they include, whether they study the interaction of these components, and whether associations between psychological representations of bodily states and affective and behavioral reactions to these representations are considered conditional. These different conceptualizations and corresponding measurement approaches exist in parallel without resulting in synergistic effects or theoretical advancements within the field. In this paper, we review theoretical models on perception and attitudes and construct an integrative theoretical framework on psychological representation of bodily symptoms as well as more abstract representations of health and disease. The aim of this combination of approaches is to unify the strengths of different research domains in the conceptualization and measurement of mental representations of bodily states. Furthermore, the aim is to specify new, testable predictions and implications about the (conditional) relationship of these mental representations and affective and behavioral consequences. A core element in this integrative model is comparison. We review how comparison processes can change the cognitive and affective reference frame for illness and symptom perception and in turn affective and behavioral reactions. We discuss implications for measurement of illness and symptom representations as well as implications for clinical practice. Finally, we make suggestions for a research agenda to validate the proposed model as well as to address new questions derived from it.