A clinician's take on evidence-based group psychotherapy: a commentary

Each of the articles in this issue of the Journal of Clinical Psychology: In Session provides valuable resources to group psychotherapists looking to develop an evidence-based practice. This article provides a summary of and commentary on this information from a clinician's point of view. I discuss the clinical utility of these resources, while acknowledging and addressing the practitioner concerns associated with them.     

Evidence-based group psychotherapy: using AGPA's practice guidelines to enhance clinical effectiveness

Practice guidelines represent a useful approach to facilitate the delivery of evidence-based mental health care. In this article, we detail group psychotherapy practice guidelines developed by the American Group Psychotherapy Association (AGPA). Combining the research literature with expert consensus, the AGPA has created a resource that should prove useful for psychotherapists, administrators, and patients. We illustrate the guidelines through a series of clinical dilemmas and challenges.     

Evidence‐based implementation practices applied to the intensive treatment of eating disorders: Summary of research and illustration of principles using a case example

Implementation of evidence‐based practices (EBPs) in intensive treatment settings poses a major challenge in the field of psychology. This is particularly true for eating disorder (ED) treatment, where multidisciplinary care is provided to a severe and complex patient population; almost no data exist concerning best practices in these settings. We summarize the research on EBP implementation science organized by existing frameworks and illustrate how these practices may be applied using a case example. We describe the recent successful implementation of EBPs in a community‐based intensive ED treatment network, which recently adapted and implemented transdiagnostic, empirically supported treatment for emotional disorders across its system of residential and day‐hospital programs. The research summary, implementation frameworks, and case example may inform future efforts to implement evidence‐based practice in intensive treatment settings.     

Using research-supported group treatments

Resources that summarize research-supported treatments (RSTs) are useful tools in clinical decision making. These resources can be particularly helpful when clinicians are uncertain about which treatment direction to take, when treatment does not seem to be working, when clinicians need to justify their approach to others, and when clinicians do not have time to review recent research on a particular clinical issue. This article describes resources for finding short, user-friendly summaries of research-supported group treatments, briefly describes several research-supported group treatments that are not well described in existing resources, and recommends several ways in which these research summaries can be used to improve group practice.     

Making Fidelity an Intramural Game: Localizing Quality Assurance Procedures to Promote Sustainability of Evidence‐Based Practices in Usual Care

Although the science of disseminating empirically supported behavioral treatments has made remarkable advances, the ultimate goal of dissemination—sustaining the implementation of evidence‐based practices (EBPs) in usual care with a high degree of fidelity—remains challenging. This article presents a rationale and guidelines for transitioning from conventional purveyor‐driven dissemination methods to intramural quality assurance procedures that can be maintained with routine agency resources. Three innovations for localizing EBP quality assurance are described: adaptation of observational fidelity methods for therapist self‐report and supervisor observation of EBPs, process control benchmarking methods for continuous tracking of EBP fidelity strength and consistency, and development of intramural clinical expertise grounded in local management of EBP implementation and outcome data. These innovations exemplify a fundamentally empirical approach to sustaining quality EBP implementation in frontline settings.     

Using Blended Learning to Implement Evidence‐Based Psychotherapies

Historically, clinicians have learned about evidence‐based psychotherapies (EBPs) by reading therapy manuals and/or attending clinical training workshops. However, researchers agree that such methods alone are insufficient to support the implementation of EBPs. This article explores the concept of blended learning (BL) and its potential for facilitating the implementation of EBPs. Blended learning refers to integration of multiple methods of information delivery into a single learning system. Implementation of EBPs describes a specific set of activities that are designed to promote the uptake and sustained adoption of a psychotherapeutic approach, strategy, or technique that has demonstrable empirical support. This article reviews the most common methods by which EBPs are currently disseminated and implemented, defines the concept of BL, and presents some examples of different elements that can be combined into a BL system. Three models of BL are presented and illustrations of these BL formulations are provided using examples from the extant literature. This article concludes with a summary and recommendations for future research.     

Overcoming our resistances to "doing" evidence-based group practice: a commentary

This commentary focuses on how the articles in the group therapy issue of the Journal of Clinical Psychology: In Session can address the resistances that many group practitioners exhibit to "doing" evidence-based practice (EBP). The articles attempt to overcome the resistances to practicing evidence-based group therapy through a process of education and skills training. A major issue cutting across the articles is the narrow focus of incorporating empirical findings only from studies specifically examining psychotherapy groups. The author argues that incorporating research from the whole field of group dynamics research can increase the empirical basis for evidence-based practice.     

心理咨询师/治疗师与来访者对职业伦理的态度比较

目的:考察我国当前心理咨询或治疗师与来访者在心理咨询与治疗领域职业伦理上的态度和意识,以帮助专业人员更好地理解和解决职业伦理困境,并为制定我国在该领域的职业伦理规范提供参考。方法:采用自编心理咨询与治疗职业伦理意识和态度问卷对48名专业人员(咨询师/治疗师)和48名来访者进行调查,比较两组人群在职业伦理意识和态度上的差异,以及一些重要人口学变量的可能影响。结果:两组人群在自编问卷的12个条目评判上有显著差异,其中涉及咨询关系原则4条(如47.9%的来访者认为专业人员可以和来访者发展私人关系,专业人员持同样看法的为4.2%,P<0.01);保密性原则1条;职业责任原则2条;评估、测量和解释原则2条;督导、培训和教学原则2条,另有一条为询问被调查者是否听闻过有违伦理的行为,发现来访者知晓的违反伦理行为(35.4%)显著少于专业人员(97.9%)(P<0.001);专业人员群体在17个条目上评判一致,仅在涉及咨询关系原则的1条目有争议,即48.3%的专业人员认为在来访者和咨询师价值观冲突时应转介来访者,51.7%的专业人员认为不应转介;来访者群体则在11个条目上评判一致,有4个争议条目,其中涉及咨询关系原则的条目3条(即在咨询师可否和来访者发生私人关系,咨询可否给来访者带来伤害,咨询师可否接受来访者的礼物问题上持肯定或否定意见的来访者都在40%以上);职业责任原则的条目1条,即56.3%的来访者认为咨询师可以按照自己的喜好选择病人,46.7%的来访者则持反对意见。结论:专业人员总体上表现出较强的伦理意识和较为一致的伦理态度,而来访者的伦理态度更不一致,两组人群在保密原则和咨询关系方面的态度差异尤其明显。     

Assessment and treatment of sleep problems in bipolar disorder—A guide for psychologists and clinically focused review

Sleep problems are highly prevalent in bipolar disorder (BD) and constitute an important therapeutic focus in this population: They are highly impairing and distressing, are an area of subjective importance to consumers, and likely play a role in predicting/triggering mood episodes. The aim of this review is to orient psychologists and psychotherapists to current research relevant to their clinical practice with people with BD, including (a) the prevalence and presentation of sleep problems, (b) the impacts and correlates of impaired sleep, and (c) the relationship between sleep problems and mood symptoms (including the predictive/triggering role of sleep in BD mood relapses). Detailed recommendations for assessment and cognitive–behavioural intervention strategies for use in BD are described. It will be concluded that although some sleep problems and comorbidities require interdisciplinary collaboration, a range of evidence‐informed strategies can be effectively and appropriately applied by clinical psychologists and psychotherapists.     

Treatment Effects of Parent–Child Focused Evidence-Based Programs on Problem Severity and Functioning among Children and Adolescents with Disruptive Behavior

This study examined the treatment effects of manualized parent–child focused evidence-based programs (EBPs), characterized by an emphasis on parental involvement and engagement, on functioning and problem severity among a statewide sample of children and adolescents referred to outpatient psychiatric clinic for serious and persistent disruptive behavior. Propensity score matching was employed to account for baseline differences between children and adolescents (M_age = 8.4 years; 26% girls; 42% White, 10% Black, 42% Hispanic, 5% other) who received parent–child focused EBPs (treatment group; n = 220) and treatment-as-usual (comparison group; n = 2,543). Children and adolescents who received parent–child focused EBPs showed significantly greater reduction in problem severity compared to the comparison group, indicative of a drop below the clinical threshold for problem behavior. However, the pattern of improvement in problem severity was not paralleled by differential improvement in ratings of child functioning across treatment and comparison conditions. Finally, there were significant differences between the treatment and comparison groups pertaining to certain child and case characteristics that have potential implications for reaching high-risk populations of children and families. These findings support the potential of taking parent–child focused EBPs into scale to promote positive behavioral changes among children and adolescents. Parent–child focused EBPs may serve as an effective remedy that is less restrictive and more conducive to the healthy development of children and adolescents.     

Clinical practice guidelines in clinical psychology and psychotherapy

Evidence‐based clinical practice guidelines have proliferated over the past two decades. Few are limited to psychological therapies or are targeted at clinical psychologists and psychotherapists – the UK guideline Treatment Choice in Psychotherapy and Counselling is a major exception. However, psychological therapies will increasingly be considered alongside medical treatments in diagnosis‐specific guidelines. There has been interest and debate about the place of guidelines in the psychological therapies, with views ranging from scepticism to enthusiasm. This paper defines clinical practice guidelines, describes major guideline programmes internationally, examines guidelines of specific interest to psychologists and psychotherapists, explores issues in their implementation, reviews evidence for their effectiveness in changing practice and improving therapy outcomes and draws out implications for practice. Guidelines are only one aspect of informing psychologists and psychotherapists about best practice. They need to be supplemented by other clinical support methods and with methods of monitoring what is actually done in practice. Copyright © 2003 John Wiley & Sons, Ltd.     

Multicultural competence and evidence-based practice in group therapy

The multicultural competence (MC) and evidence-based practice (EBP) initiatives have each generated healthy debates in the mental health field, with ample implications for clinical training and practice. Using two case illustrations, we highlight practical challenges and prospects in the intersection of MC and EBP. To facilitate complementary practice of MC and EBP, we offer strategies for the group therapist as a "local clinical scientist" to deliver culturally responsive treatments. We stress the importance of cultural adaptation of EBP models, namely, modifying evidence-based interventions that involve changes in service delivery, in the nature of the therapeutic relationship, or in components of the treatment itself to accommodate the cultural beliefs and behaviors of racial-cultural minority clients. Cultural adaptation of EBP in group therapy needs to be grounded in developmental contextualism and social justice. We discuss the two cases with an eye toward advancing multicultural competence in group therapy.     

Dissemination and Implementation of Evidence–Based Practices: Training and Consultation as Implementation Strategies

To provide effective treatment for individuals with mental health needs, there is a movement to deploy evidence‐based practices (EBPs) developed in research settings into community settings. Training clinicians in EBPs is often used as the primary implementation strategy in these efforts, despite evidence suggesting that training alone does not change therapist behavior. A promising implementation strategy that can be combined with training is consultation, or ongoing support. This article reviews the literature on consultation following initial training. A model of consultation is presented as well as preliminary findings regarding effective consultation techniques. Future directions are offered.     

Community–academic partnerships in implementation research

Community–academic partnerships(CAPs) are a critical component of implementing and sustaining evidence‐based practices (EBPs) in community settings; however, the approaches used and mechanisms of change within CAPs have not been rigorously studied. The first step to advancing the science of CAP is to operationally define and contextualize the approaches used in CAP as part of the implementation process. Our research group has gleaned valuable lessons about the best ways to develop, support, and nurture community partnerships within the context of implementation. In this article, we share these lessons learned and relate them to implementation strategies that are most relevant to community‐partnered implementation endeavors. The implementation strategies most relevant to CAPs are as follows: (a) building a coalition, (b) conducting local consensus discussions, (c) identifying barriers and facilitators to implementation, (d) facilitating interactive problem solving, (e) using an advisory board or workgroup, (f) tailoring strategies, (g) promoting adaptability, and (h) auditing and providing feedback. We offer suggestions for future research to systematically evaluate these strategies, with an eye toward advancing the science of CAP and implementation science and the goal of guiding future research and improving the implementation of EBPs in community settings.     

Is Psychotherapy More Than Manual Labor?

Stimulated by Wilson's (this issue) elegant efforts to reassure researchers and practitioners of the soundness of using treatment manuals for purposes of training and practice, I have elected to discuss some likely responses of expert but non-manual-initiated psychotherapists to the following invitations: (a) to collaborate with researchers in efforts to improve treatment manuals and (b) to adopt manuals in their own clinical practice. I review the recent history of problematic outcome research findings and the researchers' clear denigration of the therapists' valued clinical judgment. The likely differential responses of novice and expert psychotherapists are discussed, as is the condition that is most likely to reduce the researchers' and practitioners' continuing state of "assault and nattery."     

Advancing Telecommunication Technology and its Impact on Psychotherapy in Private Practice

This paper is a report on an informal study by a small group of psychotherapists interested in exploring the impact of recent technological innovations on their work as independent clinicians in private practice. The range of technologies studied included websites, email, mobile phones, and internet‐based banking services for payment and receipt of fees. Some of the group had experience of using internet‐based video software (or Voice Over Internet Protocol/VOIP software) for providing therapy and/or establishing supervisory and training links. The study found that these technologies have had both positive and negative impacts on professional practice and, in particular, records how practitioners have managed these changes within their clinical practice. The study notes the lack of professional training about these matters and highlights some of the issues that need to be addressed in redressing this situation.     

Health behaviors of psychotherapists

Examined the health behaviors practiced by psychotherapists (N = 86) themselves and the extent to which they focus on these behaviors with their clients during the course of psychotherapy. The specific health behaviors investigated were dietary habits, physical exercise, relaxation practices, sleeping, alcohol consumption, and smoking. Results indicate that psychotherapists are at this time actively engaged in both evaluating and making recommendations to their clients in the areas of diet, physical exercise, and relaxation practice. In addition, 51% of those who participated in this study evaluate health practices of their clients and make recommendations with regard to their physical health. While only 47% agreed that it is important for the psychotherapist to assess the typical client's physical health status, 72% of this group frequently inquire about chronic illness during an intake session.     

The ethics of advertising, billing, and finances in psychotherapy

Psychotherapists must deal with practical business matters such as advertising, billing, collecting fees, and other practice management topics. We review the enforceable standards of the American Psychological Association's (2002) Ethics Code that deal with advertising, fees, billing, and related business matters in psychotherapy. Using a principle-based perspective, we link each of the standards to overarching ethical values and illustrate the concerns with case vignettes. We argue that understanding the moral foundations of ethical standards helps psychotherapists to implement with greater integrity the spirit and the letter of the standards with regard to advertising and business practices.     

THE BODY SPEAKS: BION'S PROTOMENTAL SYSTEM AT WORK1

Psychoanalysis has primarily explored somatic experience in relation to love and intimacy. This paper focuses on the body in relation to work. It explores the experience that what patients increasingly present for analysis are the traumas and pleasures of being caught up with and belonging to a body larger than their own, whether in a couple, a group, a work organization or the body politic. It begins with an exploration of Bion's idea of a relationship between protomentality and group disease. It goes on to consider what can be conceived of as his ecological methodology, which enables movement between different ‘fields of study’ ( Bion 1962 ). These are applied to the health risks encountered by psychotherapists and the profession as a whole. Finally, there is a proposal for mentoring to address professional health, as an under‐developed element in the profession.     

Psychoanalytic Psychotherapy with Deaf Patients: A Qualitative Study of Characteristics and Technical Adaptations in Clinical Practice

How do deaf patients treat their psychological conflicts? Is psychoanalytic psychotherapy possible for this population? Should adaptations be made in the psychotherapeutic setting? Many deaf people have come to psychotherapists’ offices in search of care for their emotional suffering only to encounter professionals who are unprepared, at least technically, to work with these patients and their differences. Due to the scarcity of publications or because very few professionals work with this population, many psychoanalysts are obliged to develop treatment in a basically intuitive way. The main objective of this study is to describe characteristics and technical adaptations carried out when treating this group through psychoanalytic psychotherapy as exercised by professionals who are familiar with the area. This article is the result of qualitative research backed up by very diverse reading. Content analysis was carried out according to Bardin's widely accepted method, and resulted in three final categories that are discussed. The categories are: (1) professional experience in the field of deafness: preparation and initial difficulties; (2) contextualization and subjectivity of deaf patients; (3) a psychoanalytic approach with deaf patients: characteristics and technical adaptations of clinical practice.