By way of introducing ourselves as the co-authors of this article and providing a little context for what follows, John Donahue is a clinical psychologist, an assistant professor at the University of Baltimore, and a practicing psychotherapist. Boyd Eustace is a licensed counselor and a lead therapist at a hospital-based outpatient mental health clinic in Baltimore, in addition to maintaining a private counseling practice in the city. The University of Baltimore’s graduate program in counseling psychology and the outpatient clinic in which Boyd works partner in the training and professional development of the university’s graduate students. Colleagues on both sides of this partnership share an interest in fostering collaboration between graduate-level training programs and clinicians in practice settings. A primary focus of the partnership is bridging the gap between academia and clinical practice.
At this point, it has been well-established that a science–practice gap exists in the field of mental health. In 1996, in an article for BMJ, David L. Sackett and colleagues suggested that evidence-based practice reflects clinical decision-making on the basis of three components:
1) Research evidence
2) Clinical expertise and judgment
3) Client values, preferences and characteristics
Later, the American Psychological Association adopted this “three-legged stool” approach when it defined evidence-based practice in psychology as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”
One way the separation between science and practice can be witnessed is in the varying weights that mental health practitioners tend to apply to the different legs of the evidence-based practice stool. For example, research has found that prior clinical experiences exert the strongest influence on treatment decisions. Additionally, mental health practitioners almost universally report incorporating client expectations and values into treatment planning and strive to establish strong working alliances with their clients. However, when it comes to the first leg of the stool, clinicians have frequently reported hesitancies about factoring in empirical research findings when assessing and treating their clients. This contrast may in part stem from negative perceptions toward empirically supported treatments (ESTs) (see Michael E. Addis et al., 1999) and from confusion among community mental health providers concerning the differences between ESTs and evidence-based practice (see Michelle A. DiMeo et al., 2012).
The EST movement has expanded our understanding of many psychotherapy protocols that are efficacious in the treatment of specific diagnostic categories. With that said, ESTs certainly have not become a panacea for treating distinct disorders, and a few serious issues have hampered widespread dissemination of research-backed treatments to community-based clinics. Among these issues are concerns that:
- Efficacy studies generally include samples that are not representative of the modal, multiproblem patient/client with several comorbidities
- Treatment manuals result in rigid and mechanistic applications of psychotherapy
- Studies often fail to attend to mechanisms of change that underlie variance in outcomes
- Primary outcomes of randomized controlled trials (i.e., symptom reduction) are not necessarily the primary outcomes of interest for patients/clients in the community
In addition to these stated concerns about treatment protocols, there is substantial evidence that the targets of ESTs — individual Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses — are themselves invalid. Since the DSM introduced the categorical model of psychopathology in 1980, research has generally supported the conclusion that the diagnostic system is plagued by comorbidity, heterogeneity of symptoms within diagnoses, lack of adequate symptom coverage (resulting in excessive “not otherwise specified” diagnoses), and diagnostic thresholds that appear quite arbitrary.
Given these findings, the National Institute of Mental Health has stated that it is moving away from DSM-based diagnoses as its outcome of interest and has instead introduced the Research Domain Criteria (RDoC) initiative, which articulates a group of putative mechanisms of psychopathology that can be studied at varying levels of analysis. However, the RDoC approach, which is still in its nascent stages, has been critiqued for its emphasis on the biological level of analysis. It is currently a framework for research rather than a classification system that demonstrates clinical utility.
Fostering evidence-based care in light of obstacles
Although ESTs have been helpful in furthering scientifically informed mental health practice, the preceding section demonstrates that they possess numerous limitations and do not represent the compendium of effective counseling methods or stand for our full understanding of evidence-based practice in clinical settings. They have also too often contributed to the proliferation and endorsement of brand-name treatment approaches and trademark interventions, creating further divisions between orientations and increasing resistance to evidence-based practice. Moving beyond the era of prescriptive treatment protocols for specific disorders may therefore be helpful in expanding the use of evidence-based practice in the clinic.
In this spirit, we embraced a recent book by Steven Hayes and Stefan Hofmann titled Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy. Rather than outline yet another protocol, or describe the techniques important for x disorder, the purpose of this text is to describe the “core processes that are common to many empirically supported treatments,” regardless of tribal theoretical identities and disregarding the confines of illusory diagnostic boundaries. Because of this approach, we thought it might be a particularly valuable vehicle in disseminating evidence-based practice into the community clinic.
As a lead therapist at this particular outpatient clinic, Boyd organized five monthly seminars focused on evidence-based practice and process-based cognitive behavior therapy (CBT) during the summer and fall of 2018 with the hospital’s mental health staff. We (John and Boyd) collaborated on curriculum content and co-led the seminars. The goals of these meetings were to increase the participants’ overall knowledge related to clinical research, broaden their understanding of evidence-based decision-making, and help identify various ways for them to incorporate science into their everyday practice. Participants included licensed practitioners, students-in-training and clinical supervisors.
Each monthly seminar was approximately 90 minutes in length, was offered around midday during a period that would conflict less with client sessions, and focused on specific chapters and topics from Process-Based CBT. Specifically, topics included:
1) The history of ESTs and problems with the “protocols for syndromes” approach
2) Evidence-based practice and some drawbacks with over-reliance on clinical judgment
3) Benefits and obstacles implementing ESTs in the clinic
4) Core cognitive, behavioral and emotion regulatory processes
5) Cognitive restructuring, cognitive defusion, exposure and psychological acceptance
Each seminar included brief didactic presentations on agenda items followed by group discussion. In essence, we did not want to teach another protocol. Instead, we sought to engage the mental health team in a discussion about specific processes and techniques that are empirically validated.
What did we learn?
At the conclusion of the seminar series, team members were offered an opportunity to complete a questionnaire designed to provide feedback concerning the pertinence and usefulness of the information presented in the educational workshops. The questionnaire included three items rated on a Likert scale ranging from strongly disagree to strongly agree, plus one open-ended question. Eight of 12 practitioners chose to complete the questionnaire. All of these practitioners were either licensed clinical social workers or licensed professional counselors with prior clinical experience ranging from four to 18 years. General outcomes were as follows:
- All practitioners either agreed or strongly agreed that the seminars provided information that might help them integrate science into their everyday practice in the clinic.
- Most practitioners either agreed or strongly agreed that the seminars broadened their understanding of counseling outcome studies, ESTs, randomized controlled trials, and some of the problems related to treatment-construct validity and generalizing findings to practice settings. (Two participants responded that they were undecided.)
- All practitioners either agreed or strongly agreed that the seminars delineated the advantages and challenges of using evidence base to inform
Additionally, practitioners were asked about the ways in which the seminar modified their views on evidence-based practice. Illustrative of the possible benefits of this program, several practitioners noted that evidence-based practice is beneficial because it helps clinicians select interventions that have been proved to work. One respondent wrote, “The seminar made me aware of the disconnect between research and practice … that we are still trying to find ways to connect research and practice.” Another wrote, “It is important to also consider clients’ preferences and values along with research.”
In conducting this seminar, we also arrived at some revelations. One is that, sometimes, clinicians are regularly using evidence-based techniques but are unaware that they are doing so. For example, in our discussion on exposure procedures, one clinician noted that she did not conduct exposure therapy, and this statement was then endorsed by several other members of the group. However, when the clinicians were prompted to consider ways in which their work with clients facilitated emotional willingness and tolerance of difficult experiences, it became clear that this procedure was a significant part of their practice. When the emphasis is on protocols, we may be more inclined to say, “I don’t do that.” But when the conversation shifts to processes, we can more easily notice the instances in which specific empirically supported procedures are useful, thus bringing additional intentionality to the use of these techniques.
In connection to our own work, this seminar series has reminded us of the importance of assessing and monitoring changes in processes, not just changes in outcomes. When we track a process in session and use procedures in the service of modifying that process, we should also close the loop and assess this change (or lack thereof). This can be done in a variety of ways, including self-report, behavioral tests and self-monitoring. It is important that we share these findings with our peers and continue to test and refine our practices.
This seminar series also helped solidify our view that practice-based research may be critical in reducing the science–practice gap. Information must flow in both directions — from the laboratory to the clinic, and from the clinic back to the laboratory. We hope that our discussions over these five months have helped lay the groundwork for practice-based research that will contribute to this noble task.
We (John and Boyd) practice acceptance and commitment therapy and rational emotive behavior therapy, respectively. Both of these evidence-based models are theoretically grounded in the CBT tradition and are transdiagnostic, and they overlap substantially in their approaches. Our view of counseling is aligned with the process-based approach advocated by Hayes and Hofmann, which highlights the advantages of therapists using testable models to employ a versatile range of evidence-based interventions. This approach reflects the complexity and situational specificity of presenting problems and implies a nondogmatic, nuanced, multimodal strategy.
The process-based approach takes to heart Abraham Maslow’s cautionary observation: “I suppose that it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” In other words, with a predetermined armamentarium in hand, we might be tempted to rigidly and reductively treat diagnostic labels instead of treating our individual clients/patients and their idiosyncratic problems.
Similarly, Arnold Lazarus, cognitive therapist and founder of multimodal therapy, advised therapists to have a variety of tools in their toolbox so that they could “offer a broad-spectrum versus narrow-band treatment approach.” Taking this broad-spectrum approach improves outcomes and prevents future behavioral and emotional problems for our clients.
In keeping with the aforementioned frame of reference, our goals in this seminar series were to:
- Use Hayes and Hofmann’s influential text as a method of engaging an eclectic group of mental health practitioners on the topic of evidence-based practice
- Begin to move away from the specific protocols and techniques linked to brand-name therapies for diagnostic syndromes
- Initiate a conversation about how to effectively target the precise processes that appear to be important across different psychotherapy orientations
Given the overall good receptivity to the seminar series across clinicians, we believe we took steps toward those goals.
Furthermore, we think that this approach is one that is transportable to other clinics. Reflecting on the successful aspects of this seminar series, we recommend:
- Organizing sessions at a time that is minimally disruptive to the busy schedules of mental health practitioners (for us, that was around lunchtime, but this will vary across settings)
- Tailoring each session to a specific topic or set of topics
- Including out-of-session readings that participants can review prior to
We also hope to extend this work with further trainings, which then may stimulate research questions and encourage practice-based research relevant to the process of therapy. In this effort, we may plant the seeds for the upward dissemination of evidence that will help to answer Gordon Paul’s great question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?” Or, as is stated in the Process-Based CBT text, “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?”
Boyd Eustace, a licensed clinical professional counselor and clinical supervisor, sees clients and supervises therapists in a hospital-based mental health clinic and in his private counseling practice in Baltimore. He received training in rational emotive-cognitive behavior therapy at the Albert Ellis Institute and specializes in brief solution-focused individual and couple counseling at LB Counseling Services. Contact him at firstname.lastname@example.org or via his website at pcc-mentalhealth.com.
John Donahue is a licensed clinical psychologist and assistant professor of psychology at the University of Baltimore. His clinical and research interests involve mechanisms underlying psychopathology that cut across traditional diagnostic boundaries and the application of mindfulness and acceptance-based approaches to psychotherapy. Contact him at email@example.com.
Letters to the editor: firstname.lastname@example.org
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