HANDBOOK OF EVIDENCE-BASEDPRACTICE IN CLINICAL PSYCHOLOGYVOLUME 2

HANDBOOK OF EVIDENCE-BASEDPRACTICE IN CLINICALPSYCHOLOGYVOLUME 2Adult Disorders

Edited by

PETER STURMEYANDMICHEL HERSEN

John Wiley & Sons, Inc.

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Library of Congress Cataloging-in-Publication Data:

Handbook of evidence-based practice in clinical psychology / edited by Peter Sturmey and Michel Hersen.v. ; cm.

Includes bibliographical references and index.Contents: v. 1. Child and adolescent disorders – v. 2. Adult disorders.ISBNs for Vol. 1: 978-0-470-33544-4 (cloth: alk. paper); 978-1-118-14471-8 (ebk); 978-1-118-14472-5 (ebk);978-1-118-14470-1 (ebk)

ISBNs for Vol. 2: 978-0-47033546-8 (cloth: alk. paper); 978-1-118-14476-3 (ebk); 978-1-118-14475-6 (ebk);978-1-118-14474-9 (ebk)

ISBN 978-1-118-15639-1 (eMRW)ISBNs for set: 978-0-470-33542-0 (print); 978-1-118-15639-1 (electronic)1. Clinical psychology–Practice. 2. Evidence-based psychotherapy. I. Sturmey, Peter. II. Hersen, Michel.

[DNLM: 1. Mental Disorders–therapy. 2. Evidence-Based Practice. 3. Psychology, Clinical–methods. WM 400]RC467.95.H36 2012616.89—dc22

2011012039

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1

Contents

Preface ix

Acknowledgments xi

Contributors xiii

I | OVERVIEW AND FOUNDATIONAL ISSUES 1

1 | EVIDENCE-BASED PRACTICE IN ADULT MENTAL HEALTH 3B. Christopher Frueh, Julian D. Ford, Jon D. Elhai, and Anouk L. Grubaugh

2 | DEVELOPING CLINICAL GUIDELINES FOR ADULTS: EXPERIENCEFROM THE NATIONAL INSTITUTE FOR HEALTH AND CLINICALEXCELLENCE 15Stephen Pilling

3 | PROFESSIONAL TRAINING ISSUES IN EVIDENCE-BASED CLINICALPSYCHOLOGY 39Andrew J. Baillie and Lorna Peters

4 | LIMITATIONS TO EVIDENCE-BASED PRACTICE 55Thomas Maier

5 | ECONOMICS OF EVIDENCE-BASED PRACTICE AND MENTALHEALTH 71Martin Knapp and David McDaid

II | SPECIFIC DISORDERS 95

6 | DEMENTIA AND RELATED COGNITIVE DISORDERS 97Bob Woods, Linda Clare, and Gill Windle

7 | ALCOHOL USE DISORDERS 133Kevin A. Hallgren, Brenna L. Greenfield, Benjamin Ladd, Lisa H. Glynn,and Barbara S. McCrady

v

8 | TOBACCO-RELATED DISORDERS 167Lion Shahab and Jennifer Fidler

9 | ILLICIT SUBSTANCE-RELATED DISORDERS 197Ellen Vedel and Paul M. G. Emmelkamp

10 | SCHIZOPHRENIA 221Christopher Jones and Alan Meaden

11 | DEPRESSION AND DYSTHYMIC DISORDERS 243Pim Cuijpers, Annemieke van Straten, Ellen Driessen, Patricia van Oppen,Claudi Bockting, and Gerhard Andersson

12 | PANIC DISORDER 285Naomi Koerner, Valerie Vorstenbosch, and Martin M. Antony

13 | OBSESSIVE-COMPULSIVE DISORDER 313Monnica Williams, Mark B. Powers, and Edna B. Foa

14 | POSTTRAUMATIC STRESS AND ACUTE STRESS DISORDERS 337Mark B. Powers, Nisha Nayak, Shawn P. Cahill, and Edna B. Foa

15 | SOMATOFORM AND FACTITIOUS DISORDERS 365Lesley A. Allen and Robert L. Woolfolk

16 | ERECTILE DYSFUNCTION (ED) 395Tamara Melnik, Sidney Glina, and Álvaro N. Atallah

17 | SEXUAL DYSFUNCTIONS IN WOMEN 413Moniek M. ter Kuile, Stephanie Both, and Jacques J. D. M. van Lankveld

18 | PARAPHILIAS AND SEXUAL OFFENDING 437Leigh Harkins and Anthony R. Beech

19 | SLEEP DISORDERS IN ADULTS 459Allison G. Harvey and Natasha Dagys

20 | PATHOLOGICAL GAMBLING 477Becky L. Nastally and Mark R. Dixon

vi Contents

21 | ADJUSTMENT DISORDER 493Brian P. O’Connor and Hilary Cartwright

22 | BORDERLINE PERSONALITY DISORDER 507Joel R. Sneed, Eric A. Fertuck, Dora Kanellopoulos, and Michelle E. Culang-Reinlieb

23 | OTHER PERSONALITY DISORDERS 531Mary McMurran

24 | RELATIONAL PROBLEMS 549Sherry A. M. Steenwyk, Michelle A. Doeden, James L. Furrow, and David C. Atkins

25 | NONPHARMACOLOGICAL INTERVENTIONSFOR CHRONIC PAIN 569John G. Arena and Rebecca L. Jump

26 | HYPOCHONDRIASIS AND HEALTH-RELATED ANXIETY 603Steven Taylor, Dean McKay, and Jonathan S. Abramowitz

27 | SOCIAL ANXIETY DISORDER 621Judy Wong, Elizabeth A. Gordon, and Richard G. Heimberg

28 | GENERALIZED ANXIETY DISORDER 651Allison J. Ouimet, Roger Covin, and David J. A. Dozois

Author Index 681

Subject Index 727

Contents vii

Preface

Evidence-based practice in adult mental healthhas become a driving force for research, pro-fessional training, allocation of mental healthresources, and service planning. It is also alightning rod for debate among mental healthprofessionals, researchers, service planners,and mental health economists. This volumebrings together some of the leading researcherswho have identified the professional, ethical,and economic issues related to evidence-basedpractice and adult mental health, and who haveconducted systematic reviews, meta-analyses,and reviewed the existing literature onevidence-based practice for all the major adultmental health disorders.Volume 2 is in two parts. Part I provides

overview chapters that summarize the field ofevidence-based practice in adult mental health,illustrate the application of principals to theplanning of adult mental health services in theBritish National Health Service and profes-sional training, and look at the economics ofmental health that sometimes drives work inthis area. Thomas Maier’s chapter offers adissenting voice by highlighting the limits toevidence-based practice. Part II consists ofmore than 20 chapters that review the currentstatus of evidence-based practice for all themajor adult mental health disorders. Thechapters differ tremendously in terms of theamount and quality of evidence available foreach disorder. As one might expect, those dis-orders that are most common and have the

greatest economic impact have a very largeevidence base—for example, there are hun-dreds of studies for tobacco-related disordersand for depression. These large literaturessometimes permit more confident answers as to“what works,” as they are based on manystudies with multiple independent replications.They also permit answers to questions that aremore subtle than “Does this therapy work forthis problem?,” such as “Is this therapy moreeffective than another therapy?” A notableobservation is that broadly defined cognitive-behavior therapy sweeps the board as anevidence-based practice whether or not onewishes to consider such diverse disorders associal anxiety disorder, sleep disorders, orpersonality disorders. There are, indeed,examples of other evidence-based practices,but they are much less frequent; there areexamples of certain therapies that research hasrobustly shown to be ineffective or evenharmful, such as brief psychological debriefingfor posttraumatic stress disorder.We believe this volume offers a compre-

hensive review of evidence-based practice inclinical psychology of adult mental health dis-orders that will be invaluable to students,teachers, and practitioners alike. Although thisfield is a rapidly changing one—as journalspublish new evidence and reviewers reanalyzeexisting literatures—this volume offers onesnapshot of the current status of what works inadult mental health.

ix

Acknowledgments

Wewould first like to thank our authors. Manyof them undertook an enormous task of sum-marizing sometimes hundreds of articles,systematic literature reviews, and consensuspanels and sometimes reviewing the outcomeliterature for many different forms of treatmentfor one disorder. They faced the challenge ofbeing accurate and fair in identifying thosepractices that the literature support, those thatresearchers had little convincing evidence to

support them, and those that research hasshown to be ineffective or harmful. We believethey all succeeded in doing so. We should bothlike to express our unending thanks to CaroleLonderee’s persistent and cheerful technicalassistance throughout this project. Finally, wewould like to express our thanks to the edi-torial staff at John Wiley & Sons who workedso hard to make this project a success.

xi

Contributors

Jonathan S. Abramowitz is Associate Chairand Professor of Psychology at the University ofNorth Carolina at Chapel Hill. He has publishedover 150 scholarly articles, book chapters, andbooks on anxiety disorders, including obses-sive-compulsive disorder. He is associate editorof the Journal of Cognitive Psychotherapy andof Behaviour Research and Therapy.Lesley A. Allen is Visiting Associate Pro-

fessor of Psychology at Princeton Universityand Adjunct Associate Professor in theDepartment of Psychiatry at Robert WoodJohnson Medical School, University of Medi-cine and Dentistry of New Jersey. She has beenawarded numerous grants from the NationalInstitute of Mental Health to study the treat-ment of somatoform disorders and has pub-lished widely on this topic. She is the coauthorof Treating Somatization: A Cognitive-Behav-ioral Approach.Gerhard Andersson is Professor of Clinical

Psychology at Linköping University, Linkö-ping and the Karolinska Institute, Stockholm,Sweden. He has published widely on Internet-delivered psychological treatments, tinnitus,depression, and anxiety disorders.Martin M. Antony is Professor and Graduate

Program Director in the Department of Psy-chology at RyersonUniversity in Toronto,wherehe also directs the Anxiety Research and Treat-ment Lab. He has published numerous books,scientific papers, and book chapters on anxietydisorders, perfectionism, cognitive behaviortherapy, and psychological assessment.John G. Arena is Psychology Executive at

the Charlie Norwood Department of VeteransAffairs Medical Center, and Professor in theDepartment of Psychiatry and Health Behaviorat the Medical College of Georgia in Augusta,Georgia. He is past president of the Association

of Applied Psychophysiology and Biofeed-back, and has published widely in the areasof psychological and psychophysiologicalassessment and treatment of chronic pain dis-orders, and medical psychology.Álvaro N. Atallah is full Professor and Head

of the Emergency Department and Evidence-Based Medicine Division of UniversidadeFederal de São Paulo Brazil and Director of theBrazilian Cochrane Centre São Paulo.David C. Atkins is a Research Associate

Professor in the Department of Psychiatry andBehavioral Sciences at the University of Wash-ington. His research has focused on sociologicaland treatment studies of infidelity as well astreatment and process research on IntegrativeBehavioral Couple Therapy. He also is activelyinvolved as a quantitative methodologist withparticular interests in multilevel models andcount regression methods.Andrew J. Baillie is a Senior Lecturer in the

Department of Psychology at Macquarie Uni-versity in Sydney. He is the Director of ClinicalPsychology Training and a member of theCentre for Emotional Health at Macquarie. Healso holds an honorary appointment as a clin-ical psychologist at Drug Health Services,Royal Prince Alfred Hospital, in Sydney.He has published on anxiety disorders andcomorbidity with alcohol use disorders from anassessment, treatment, and epidemiologicalperspective.Anthony R. Beech is Chair of Crimino-

logical Psychology and a Fellow of the BritishPsychological Society. He is the Director ofthe Forensic and Criminological Psychologyat the University of Birmingham. He hasauthored over 125 peer-reviewed articles, 30book chapters, and five books in the area offorensic science/criminal justice. He is the

xiii

current recipient of the Senior Award for asignificant lifetime contribution to ForensicPsychology in the United Kingdom, Divisionof Forensic Psychology, BPS, June 2009. Hehas also received the significant achievementaward from the Association for the Treatmentof Sexual Abusers in Dallas, Texas, October2009.Claudi Bockting is Associate Professor of

Clinical Psychology at Groningen Universityin Groningen and works as a clinician in amental health-care center, Symfora in Almere,the Netherlands. Her research focuses on long-term course of depression and anxiety dis-orders, processes that cause and maintain mooddisorders, and development and evaluation ofpsychological interventions to prevent recur-rence. In addition, she studies processes thatcause and maintain mood disorders, as well asthe treatment processes that reduce and preventrelapse and recurrence.Stephanie Both is psychologist and Assis-

tant Professor at the Department of Gynaecol-ogy at the Leiden University Medical Center inthe Netherlands. She has published widely onmale and female sexual functioning, andexperimental research in sexual motivation andarousal.Shawn P. Cahill is an Assistant Professor in

the Psychology Department at the University ofWisconsin at Milwaukee. He received his PhDfrom Binghamton University, State Universityof New York in 1997. His research interestsinclude understanding the nature and treatmentof anxiety and other emotional reactions tostress, such as anger reactions. He has par-ticular interest in posttraumatic stress disorder,obsessive-compulsive disorder, and panic inadults.Hilary Cartwright co-wrote her chapter

for this volume while she was a clinical psy-chologist and Assistant Professor in the Depart-ment of Clinical Health Psychology at theUniversity of Manitoba. She is now a practicingclinician in Fredericton, New Brunswick, Can-ada.Her researchandclinical interests are in childand adolescent psychology.

Linda Clare is Professor of Clinical Psych-ology and Neuropsychology at Bangor Uni-versity, Wales, United Kingdom. Her interestsfocus primarily on the theoretical and clinicalissues surrounding awareness and self-conceptin dementia, the impact of progressive cogni-tive impairment on self and relationships, andthe potential of neuropsychological rehabili-tation for people with early-stage dementia.She has published numerous papers andCochrane reviews and several books on thesetopics. She is coeditor of the Handbook of theClinical Psychology of Ageing (2nd edition:John Wiley & Sons, 2008).Roger Covin received his PhD in Clinical

Psychology at the University of WesternOntario. He completed his residency training inCalgary, Alberta, Canada and is a former staffpsychologist with the First Episode Mood andAnxiety Disorders Program in the Departmentof Psychology at London Health SciencesCentre, London, Canada. He has coauthored anumber of journal articles and book chapters ona variety of topics such as cognitive behaviortherapy outcomes for generalized anxiety dis-order, normative data in clinical practice, anddevelopment of the Cognitive DistortionsScale. He currently operates a private practice inMontreal, Canada.Pim Cuijpers is Professor of Clinical Psych-

ology and Head of the Department of ClinicalPsychology at the Vrije Universiteit UniversityAmsterdam, the Netherlands. He is also ViceDirector of the EMGO Institute for Health andCare Research of the Vrije UniversiteitAmsterdam and Vrije Universiteit UniversityMedical Center. He specializes in conductingrandomized controlled trials and meta-analyseson prevention and psychological treatments ofcommonmental disorders, especially depressionand anxiety disorders.Michelle E. Culang-Reinlieb is a fourth-year

student in the doctoral subprogram inNeuropsychology at Queens College of theCity University of New York. Her researchinterests focus on late-life depression with anemphasis on the role of executive dysfunction

xiv Contributors

and change in cognitive functioning in anti-depressant treatment trials.Natasha Dagys is a doctoral student in

School Psychology at the University of Cali-fornia, Berkeley. Her research interests focuson the consequences of sleep deprivation andon the role of sleep in social, emotional, andcognitive functioning, particularly duringadolescence.Mark R. Dixon is Professor of Behavior

Analysis and Therapy at Southern IllinoisUniversity and a Board Certified BehaviorAnalyst. He has published over 90 papers andauthored three books on a wide variety of topicsincluding gambling addiction, weight lossinterventions, treatment of children with aut-ism, organizational behavior management,terrorism, and verbal behavior.Michelle A. Doeden is a doctoral candidate

at Fuller Graduate School of Psychology,Pasadena, California. She has been involved incouple therapy research throughout her gradu-ate career, including work as a research fellowon an NIMH-funded grant, focused on lan-guage and couple therapy process.David J. A. Dozois is Professor of Psy-

chology and Director of the Clinical PsychologyGraduate Program at the University of WesternOntario in London, Ontario, Canada. He is aFellow of the Academy of Cognitive Therapyand a former Beck Institute Scholar at the BeckInstitute for Cognitive Therapy and Research.Dr. Dozois’s research focuses on cognitive vul-nerability to depression and anxiety.Ellen Driessen is a PhD candidate at the

department of Clinical Psychology at VrijeUniversiteit University Amsterdam, the Neth-erlands. Her research interest concerns theefficacy of psychotherapy in the outpatienttreatment of depression.Jon D. Elhai is Assistant Professor of

Psychology at the University of Toledo. Hisresearch is on psychological trauma and post-traumatic stress disorder, exploring assessment,psychopathology, and treatment issues. Heteaches undergraduate and graduate courses inclinical psychology. He also serves as an expert

witness in his role as a forensic psychologicalevaluator and consultant.Paul M. G. Emmelkamp is a licensed psy-

chotherapist and clinical psychologist and fullProfessor of Clinical Psychology at the Uni-versity of Amsterdam. Over the years, he haspublished widely on the etiology and treatmentof anxiety disorders. He is involved in therapy-outcome studies on adults with work-relateddistress, substance abuse disorders, personalitydisorders, depression, anxiety disorders; onyouth with attention-deficit/hyperactivity dis-order, conduct disorder, and anxiety disorders;and on the elderly with anxiety disorders. Hehas written and coedited many books, and over350 publications in peer reviewed journals orbooks. He has received a number of honors andawards, including a distinguished professor-ship (“Academy Professor”) by the RoyalAcademy of Arts and Sciences.Eric A. Fertuck is Associate Professor of

Psychology at City College of New York andthe Graduate Center of the City University ofNew York and a Research Scientist at Co-lumbia University, New York State PsychiatricInstitute. He investigates borderline personalitydisorder from many perspectives including thesocial, neurocognitive, physiological, andneural. His research is supported by theNational Institute of Mental Health, theAmerican Foundation for Suicide Prevention,the Neuropsychoanalysis Foundation, and theFund for Psychoanalytic Research.Jennifer Fidler is a Research Health Psy-

chologist whose research focuses on smokingbehavior, adolescent smoking, markers ofsmoking behavior and dependence, and thedevelopment of adolescent smoking behavior.Her current research examines the distribution ofcotinine as a biological marker of nicotine intakeand sociodemographic factors associated withthis objective marker of smoking.Edna B. Foa is a Professor of Clinical

Psychology in Psychiatry at the University ofPennsylvania, where she serves as the Directorof the Center for the Treatment and Study ofAnxiety. She is an internationally renowned

Contributors xv

authority on the psychopathology and treat-ment of anxiety. Her research, aimed at deter-mining causes and treatments of anxietydisorders, has been highly influential. She is anexpert in the areas of posttraumatic stress dis-orders (PTSD) and obsessive-compulsive dis-order. The program she has developed for rapevictims is considered to be one of the mosteffective therapies for PTSD. She has pub-lished over 200 articles and book chapters,lectured extensively around the world, andreceived numerous awards and distinctions.Julian D. Ford is Professor of Psychiatry at

the University of Connecticut School ofMedicine and Director of the University ofConnecticut Health Center Child TraumaClinic and the Center for Trauma ResponseRecovery and Preparedness (www.ctrp.org).He also conducts research on posttraumaticstress disorder, psychotherapy and familytherapy, health services utilization, psycho-metric screening and assessment, and psychi-atric epidemiology.B. Christopher Frueh is Professor of

Psychology and Director of the Division ofSocial Sciences at the University of Hawaii,Hilo, Hawaii. He also serves as the McNairScholar and Director of Clinical Research atThe Menninger Clinic in Houston, Texas. Hisresearch focuses on clinical trials, health ser-vices, epidemiological and qualitative studiesrelevant to the design and implementation ofinnovative treatments, and mental health ser-vice improvements in a variety of clinicalsettings.James L. Furrow is Evelyn and Frank Freed

Chair of Marital and Family Therapy at FullerGraduate School of Psychology, Pasadena,California. He is author of a number of publi-cations on the practice of Emotionally FocusedCouple Therapy. He is a certified EmotionallyFocused Therapy therapist, supervisor, andtrainer.Sidney Glina is the Director of the Instituto

H. Ellis and Head of the Department ofUrology in the Hospital Ipiranga, Sao Paolo,Brazil.

Lisa H. Glynn is a doctoral candidate inClinical Psychology at University of NewMexico. She has published in the areas ofMotivational Interviewing, treatment mechan-isms, and addictions. She is interested in pro-cesses of group-delivered alcohol treatment,coding of therapeutic interactions, and issues ofdiversity and multiculturalism.Elizabeth A. Gordon is a doctoral student in

clinical psychology at Temple University,Philadelphia, Pennsylvania. She is especiallyinterested in examining the interplay of inter-personal processes and social anxiety disorder.Elizabeth received her BA in Human Biologyfrom Stanford University and her MA in Clin-ical Psychology fromYeshiva University. Priorto studying clinical psychology, Elizabethworked in the field of animal behavior andwildlife conservation.Brenna L. Greenfield is a graduate student

in the Clinical Psychology PhD program at theUniversity of New Mexico. She is interested inadvanced statistical modeling techniques andcollaborating with American Indian commu-nities to develop and disseminate culturallyappropriate alcohol use disorders treatment andprevention programs.Anouk L. Grubaugh is Associate Professor

in the Department of Psychiatry and BehavioralSciences at the Medical University of SouthCarolina and a Research Health Scientist at theCharleston Veterans Affairs Medical Center.Her clinical and research interests includeassessment and treatment of patients withposttraumatic stress disorder and severe mentalillness, treatment adherence and attrition inpublic-sector settings, racial disparities inhealth outcomes, qualitative research methods,and mental health services methods.Kevin A. Hallgren is a graduate student in

clinical psychology at the University of NewMexico. He is interested in mechanisms ofchange in psychosocial treatments for alcoholuse disorders, with a particular interest inmethodologies for studying in-session behaviorand changes in social networks as they relate tosubsequent alcohol use.

xvi Contributors

Leigh Harkins is a Lecturer in ForensicPsychology at the University of Birmingham,United Kingdom. She has published a numberof articles and chapters on sex offender treat-ment, risk assessment, and group aggression.Allison G. Harvey is Professor of Psy-

chology at University of California, Berkeley.She has published widely on sleep disorders,mood disorders, and empirically supportedtreatments.Richard G. Heimberg is Professor and

Distinguished Faculty Fellow in Psychology atTemple University, Philadelphia, Pennsylva-nia, where he directs the Adult Anxiety Clinicof Temple. He is Past President of the Associ-ation for Cognitive and Behavioral Therapiesand Past Editor of its journal Behavior Therapy.He has published more than 325 articles andchapters, as well as 11 books, on the assessmentand treatment of anxiety disorders and relatedtopics, and his cognitive behavioral protocolsfor the treatment of social anxiety disorder havebeen implemented around the world.Christopher Jones is a Consultant Clinical

Psychologist and Senior Lecturer in ClinicalPsychology at the University of Birmingham,United Kingdom. He is an active researcher,most notably in the area of engagement withassertive outreach services, evidence-basedpractice, and clinical neuropsychology.Rebecca L. Jump is a clinical psychologist

at the Veterans Affairs Medical Center inAugusta, Georgia, and Assistant Professor atthe Medical College of Georgia. She has clin-ical expertise in the areas of chronic pain,behavioral medicine, and sexual trauma/abuse.Dora Kanellopoulos is a fifth-year doctoral

student in the doctoral subprogram in Neuro-psychology at The Graduate Center, City Uni-versity of New York. Her research interestsfocus on brain abnormalities related todepression and cognition in late life.Martin Knapp is Professor of Social Policy

and Director of the Personal Social ServicesResearch Unit at the London School ofEconomics and Political Science. He is alsoProfessor of Health Economics and Director

of the Centre for the Economics of MentalHealth at King’s College London, Institute ofPsychiatry. In 2009, he was appointed by theNational Institute for Health Research as theinaugural Director of the National School forSocial Care Research. Martin’s researchactivities are primarily in the mental healthlong-term care and social care fields, focus-ing particularly on policy analysis and eco-nomic aspects of practice.Naomi Koerner is Assistant Professor in the

Department of Psychology at Ryerson Uni-versity in Toronto, Canada, where she alsodirects the Cognition and PsychopathologyLab. She has published scientific papers andbook chapters on worry, worry-related cogni-tive processes, anxiety disorders, and psycho-logical assessment.Benjamin Ladd is a clinical psychology

graduate student at the University of NewMexico. He is interested in the influence andimpact of social support for change in thetreatment and maintenance of treatment gainsfor alcohol use disorders. He is also inter-ested in integrating the various areas ofclinical knowledge, from the neurobiologicalto psychosocial, to develop comprehensivemodels of treatment for the spectrum ofalcohol-related problems.Thomas Maier is head of the Psychiatric

Services of the Canton St. Gallen-North,Switzerland, and lecturer at Zurich University.He is a psychotraumatologist and has publishedon posttraumatic stress, obsessive-compulsivedisorders, and transcultural psychiatry, and alsoon complexity and nonlinear dynamics inpsychiatry and on limitations of evidence-basedpsychiatry.Barbara S. McCrady is a Distinguished

Professor of Psychology and the Director ofthe Center on Alcoholism, Substance Abuse,and Addictions at the University of NewMexico. Dr. McCrady has published widelyon her research on conjoint therapy, cognitivebehavior therapy, mutual help groups, andtherapies for women with substance use dis-orders. She is a fellow of the American

Contributors xvii

Psychological Association (APA), pastPresident of the Addictions Division of APA,and past member of the Board of Directors ofthe Research Society on Alcoholism. She haspublished more than 200 refereed papers,chapters, and books on her work.David McDaid is Senior Research Fellow in

health policy and health economics at both thePersonal Social Services Research Unit and theEuropean Observatory on Health Systems andPolicies at the London School of Economicsand Political Science. His primary researchinterests focus on comparative internationalanalysis of mental health, health promotion,and public health-care policy and practice.Dean McKay is Professor, Department of

Psychology, Fordham University and AdjunctProfessor of Psychiatry, Mount Sinai School ofMedicine. He serves on the editorial boardsof several journals including BehaviourResearch and Therapy and Journal of Anx-iety Disorders, and is Associate Editor ofJournal of Cognitive Psychotherapy. He haspublished over 130 journal articles and bookchapters, and is editor or coeditor of 10published or forthcoming books. His researchhas focused primarily on obsessive-compul-sive disorder (OCD), body dysmorphic dis-order and health anxiety and their link toOCD, and the role of disgust in psycho-pathology. His research has also focused onmechanisms of information processing biasfor anxiety states.MaryMcMurran is Professor of Personality

Disorder Research at the University of Not-tingham’s Institute of Mental Health, UnitedKingdom. Her research interests include socialproblem solving as a model of understandingand treating people with personality dis-orders, the assessment and treatment ofalcohol-related aggression and violence, andunderstanding and enhancing offenders’motivation to engage in therapy. She is aFellow of the British Psychological Society,and recipient of the Division of ForensicPsychology’s Lifetime Achievement Awardin 2005.

Alan Meaden is a Consultant ClinicalPsychologist who has specialized in therehabilitation of those with schizophrenia andother psychoses for over 15 years. He is anactive researcher, most notably in the area ofcognitive therapy for command hallucinationsalongside other research interests in engage-ment and staff factors.TamaraMelnik is a researcher and Professor

of Internal Medicine and Evidence-BasedMedicine at the Universidade Federal deSão Paulo (Unifesp) and Brazilian CochraneCenter.Becky L. Nastally is a Visiting Assistant Pro-

fessor in the Behavior Analysis and Ther-apy program at Southern Illinois University-Carbondale (SIUC). She was the 2009 SIUCStudent Researcher of the Year and hasauthored 11 peer-reviewed journal articles, onebook chapter, and 19 professional presenta-tions. Her research interests lie in the areaof nonsubstance-related behavioral addiction,verbal behavior, and cognitive behavior therapy.Nisha Nayak is a postdoctoral fellow at the

Center for the Treatment and Study of Anxietyat the University of Pennsylvania.Brian P. O’Connor is a Professor of

Psychology at the University of British Colum-bia Okanagan, in Kelowna, British Columbia,Canada. He conducts research on normal andabnormal personality, on personality disorders,and on interpersonal aspects of psychopathol-ogy. He also teaches advanced statistics andresearch methods courses and has written pro-grams for a variety of specialty statistical pro-cedures. Further information is available athttps://people.ok.ubc.ca/brioconn/.Allison J. Ouimet completed her master’s

degree in Clinical Psychology at The Univer-sity of Western Ontario, in Ontario, Canada.She is currently in the Clinical Psychologydoctoral program at Concordia University inMontreal, Canada. Her research at the Fearand Anxiety Disorders Laboratory focuseson the role played by basic cognitive processesin the etiology and maintenance of anxietydisorders.

xviii Contributors

Lorna Peters is a Lecturer in the Departmentof Psychology at Macquarie University, Syd-ney, Australia. She is a member of the Centrefor Emotional Health at Macquarie and haspublished widely on adult anxiety mooddisorders.Stephen Pilling is Professor of Clinical

Psychology and Clinical Effectiveness in theResearch Department of Clinical, Health, andEducational Psychology, University CollegeLondon, United Kingdom. He is the directorof the National Collaborating Centre forMental Health, which develops clinicalpractice guidelines for the National Institutefor Health and Clinical Excellence. Hisresearch focuses on the evaluation of com-plex interventions for the treatment of severemental illness, the development and evalu-ation of psychological treatments fordepression, and the competences required toprovide them effectively.Mark B. Powers is Assistant Professor and

Codirector of the Anxiety Research andTreatment Program at Southern MethodistUniversity, Dallas, Texas. He received hisbachelor’s degree in psychology at the Uni-versity of California at Santa Barbara and hismaster’s degree in psychology at Pepperdine,working with Dr. Joseph Wolpe on anxietydisorders. He received his PhD in clinicalpsychology from the University of Texas atAustin working with Dr. Michael J. Telch.Lion Shahab is currently working as a

lecturer in health psychology in the Departmentof Epidemiology and Public Health atthe University College London. His expertiselies in epidemiology, tobacco control, publichealth, and health psychology. Currentresearch interests focus on the detection ofsmoking-related diseases in the population, theuse of smoking-related biomarkers to motivatesmoking cessation, the development andimpact of potential harm reduction strategies,and public attitudes to tobacco policy.Joel R. Sneed is an Assistant Professor of

Psychology at Queens College and an adjunctAssistant Professor of Medical Psychology in

Psychiatry in the Division of Geriatric Psy-chiatry at Columbia University and the NewYork State Psychiatric Institute. He is Directorof the Laboratory for Lifespan Developmentand Psychopathology and has published widelyin the areas of geriatric, lifespan development,and personality disorders. His research onvascular depression is supported by theNational Institute of Mental Health.Sherry A. M. Steenwyk is a postdoctoral

resident at Purdue University Counseling andPsychological Services, West Lafayette, Indi-ana. Her clinical interests include working withcouples, substance abuse issues, grief and loss,anxiety, and spirituality. Her research hasfocused on exploring the process of integrativebehavioral couple therapy.Steven Taylor is a professor and clinical

psychologist in the Department of Psychiatry atthe University of British Columbia, and editor-in-chief of the Journal of Cognitive Psycho-therapy. He has published over 250 articles andbook chapters, and 18 books on anxiety dis-orders and related topics. He is a Fellow ofseveral scholarly organizations including theAmerican and Canadian Psychological Asso-ciations and the Association for PsychologicalScience. His research interests include cogni-tive behavioral treatments and mechanisms ofanxiety disorders and related conditions, aswell as the behavioral genetics of thesedisorders.Moniek M. ter Kuile is Clinical Psycholo-

gist and Associate Professor at the Departmentof Gynaecology at the Leiden UniversityMedical Center in the Netherlands. She haspublished widely on female sexual dysfunc-tion, experimental research in sexual arousaland pain, and treatment outcome.Jacques J. D. M. van Lankveld is Professor

of Sexology at Maastricht University, theNetherlands. He has published widely on maleand female sexual dysfunction, experimentalresearch in sexual arousal, and treatmentoutcome.Patricia van Oppen is Associate Professor

at the Department of Psychiatry, Vrije

Contributors xix

Universiteit Medical Center, Amsterdam, whereshe works as a clinical psychologist/behaviortherapist. Her main research interest focuses onthe evaluation of treatments of depression andanxiety disorders. She has published a substan-tial number of papers and has been an editor ofseveral books on these topics.Annemieke van Straten is a psychologist and

epidemiologist. She is Associate Professor in thedepartment of Clinical Psychology at the VrijeUniversiteit, Amsterdam, the Netherlands. Herresearch focuses on Internet interventions forcommon mental disorders in different settingsand stepped care. She has published more than60 international publications.Ellen Vedel is a cognitive behavior therapist

and treatment manager at the Jellinek Addic-tion Treatment Centre in Amsterdam. As asenior researcher, she is currently involved inclinical trials testing integrated treatmentprotocols for substance abuse and posttrau-matic stress disorder and for substance abuseand intimate partner violence. Together withPaul Emmelkamp, she is the coauthor ofEvidence-Based Treatments for Alcohol andDrug Abuse: A Practitioner’s Guide to Theory,Methods and Practice.Valerie Vorstenbosch is a doctoral student

in Clinical Psychology in the Department ofPsychology at Ryerson University, Toronto,Canada. Her research interests are in the areasof obsessive-compulsive disorder, specificphobia, and cognitive behavior therapy. Shehas presented her research findings at severalscientific meetings.MonnicaWilliams is an Assistant Professor

of Psychology at the University of Pennsyl-vania in the Center for the Treatment and Studyof Anxiety. Dr. Williams completed herundergraduate studies at Massachusetts Insti-tute of Technology and University of Califor-nia at Los Angeles, and received her doctoraldegree in clinical psychology from the Uni-versity of Virginia. Dr. Williams’s scholarlypublications include scientific articles on racial/ethnic differences in anxiety disorders and

obsessive-compulsive disorder (OCD). Hercurrent research area includes African Ameri-cans with OCD, OCD treatment outcomes, andOCD symptom dimensions. Her clinical workis focused on anxiety disorders in adults.Gill Windle is a Research Fellow in the

Dementia Services Development Centre, Ban-gor University, Wales. Her published researchhas focused on resilience and well-being inolder people, and the effects of exercise onwell-being. Her current role includes providingacademic support for research networks onaging and dementia in Wales.Judy Wong is a doctoral student in clinical

psychology at Temple University, Phila-delphia, Pennsylvania. Her interests focus onthe influence of culture on the development andtreatment of anxiety disorders. Judy receivedher BA in Psychology from the University ofCalifornia, Berkeley.Bob Woods is Professor of Clinical Psych-

ology of Older People at Bangor University,Wales, United Kingdom, and Director ofthe Dementia Services Development Centre,Wales. His work on the development andevaluation of psychological interventionswith people with dementia and their care-givers began over 30 years ago, and he haspublished widely on this and related topics,including several Cochrane reviews. He iscoeditor of the Handbook of the ClinicalPsychology of Ageing (2nd edition: JohnWiley & Sons, 2008).Robert L. Woolfolk is Professor of Psy-

chology and Philosophy at Rutgers University,New Jersey, and Visiting Professor of Psy-chology at Princeton University. He haspublished numerous papers and books onpsychotherapy and psychopathology. A prac-ticing clinician for over 30 years, he has soughtin both his work with patients and his scholarlyendeavors to integrate the scientific andhumanistic traditions of psychotherapy. He isthe coauthor of Treating Somatization: ACognitive-Behavioral Approach and author ofThe Cure of Souls.

xx Contributors

PART I

Overview and Foundational Issues

1

Evidence-Based Practicein Adult Mental Health

B. CHRISTOPHER FRUEH, JULIAN D. FORD, JON D. ELHAI, AND ANOUK L. GRUBAUGH

INTRODUCTION

There is widespread and growing awarenessthat behavioral and mental health care, likeother sectors of health care, require rigorouspractice standards and professional account-ability (Institute of Medicine, 2001; Kazdin,2008; President’s New Freedom Commissionon Mental Health, 2003). Evidence-basedpractice (EBP) and empirically supportedtreatments are a critical element of thesestandards for both child and adult populations(APA, 2006; Barlow, 2000; Spring 2007;Spring et al., 2008; Torrey et al., 2001;Weisz, Hawley, Pilkonis, Woody, & Follette,2000). Unfortunately, interventions used inclinical, behavioral, and mental health practicesettings are often not carefully based onempirical evidence, resulting in a discrep-ancy between research and practice (Cook,Schnurr, & Foa, 2004; P. W. Corrigan, Steiner,McCracken, Blaser, & Barr, 2001; Ferrell,2009; Frueh, Cusack, Grubaugh, Sauvageot, &Wells, 2006; Gray, Elhai, & Schmidt, 2007;

Henggeler, Sheidow, Cunningham, Donohue, &Ford, 2008; Kazdin, 2008; Schoenwald &Hoagwood, 2001; Stewart & Chambless, 2007).In this chapter we provide an overview of EBP inadult mental health, including definitions, pur-pose, processes, and challenges.

DEFINING EVIDENCE-BASEDPRACTICE

Evidence-based practice is an empirically basedapproach to identify and appraise the bestavailable scientific data in order to guide theimplementation of assessment and interventionpractices. This entails making decisions abouthow to integrate scientific evidence with clin-ical practice, taking account of relevant practicesetting, population, provider, and other con-textual characteristics. Exact definitions of whatconstitutes an EBP have been proposed. Somehave suggested that designation of an inter-vention as an EBP requires favorable empiricalsupport from at least two randomized con-trolled trials (RCTs) conducted by independentresearchers/labs (Chambless & Hollon, 1998),or seven to nine smaller experimental designstudies each with at least three subjectsconducted by at least two independentresearchers (Chambless & Hollon, 1998;Lonigan, Elbert, & Johnson, 1998). These

This work was partially supported by grantsMH074468 from the National Institute of MentalHealth, CD-207015 from Veterans Affairs HSR&D,OJJDP-CT-52525-JS from the Department of Just-ice, and awards from the McNair Foundation andMenninger Foundation.

3

requirements were proposed in order to definespecific treatment models as empirically sup-ported treatments (ESTs). The ESTs are a sub-category of EBT that focuses on specific(usually manualized) treatment models forwhich substantial scientific evidence of efficacyor effectiveness has been accrued.Others have proposed the value of expert

consensus panels, meta-analyses, and/orCochrane database reviews to overcome thepotential biases of individual or critical reviews(Spring et al., 2008). Further, governments andhealth insurance companies have developeddetailed EBP guidelines for specific psychiatricdisorders, such as the UK’s National Institutefor Clinical Health and Excellence (NICE,2005) and the United States’ Institute ofMedicine and National Research Council(IOM, 2007) guidelines for treating posttrau-matic stress disorder (PTSD), in order to guide(or mandate) efficacious mental health-carepractices.EBPdoesnotnecessarily imply the designation

of certain treatment models as “evidence based.”An alternative way to conceptualize EBP is toplace less emphasis on specific interventionprotocols (e.g., manualized treatment models)and focus instead on empirically supported gen-eral content-domain practice elements (Chorpita,Daleiden, & Weisz, 2005; Rosen & Davison,2003). For example, practice elements mightinclude the development of a therapeuticworkingalliance and enhancing client motivation, teach-ing of skills for coping with symptoms, orfacilitation of therapeutic processing of distress-ing emotions.In addition, research evidence is not neces-

sarily the only base for determining whatconstitutes EBP. The American Psycho-logical Association Presidential Task Force onEvidence-Based Practice (2006) explicitly pro-posed requiring evidence from clinicians’ real-world observations and from client values andpreferences in addition to research evidence as abasis for establishing EBP. These addedrequirements reflect an attempt to ensure thatEBP is not only likely to produce quantifiable

outcomes (based on the results of scientificresearch), but will also have utility for clinicians(First et al., 2003) and will be acceptable to andrespectful of the recipients of the services.Regardless of the specific evidentiary require-ments that are defined as necessary to establisha mental or behavioral health practice as evi-dence-based, EBP must be defined in terms ofbehaviorally specific practices that can bereadily and reliably taught to and followed byclinicians. Both treatment models and trans-theoretical practice elements involve compe-tencies that must be operationalized andreplicable. Practitioner competencies for EBPfall into four broad areas, including: (1)assessment skills, (2) process skills (i.e.,enhancing client motivation and the clinician-client working alliance), (3) communicationskills for collaborative decision making, and(4) intervention skills (Spring et al., 2008).Two other important concepts related to EBP

require definition. Dissemination is the targeteddistribution of synthesized scientific evidenceandmaterials related to an intervention, practice,or clinical population to relevant key stake-holders (e.g., health-care administrators, clin-icians, patients). Implementation is the use ofspecific strategies to ensure the successfuladoption of disseminated EBPs and integrationinto practice patterns within clinical settings.

PURPOSE

The EBP in mental health care is important forseveral reasons. It allows for a shared vocabularyand conceptual framework to facilitate transdis-ciplinary research and high-quality practice inmental health care, providing a framework andprocess to ensure accountability and reduce theresearch-practice gap for the sake of the publichealth (IOM, 2001; Kazdin, 2008). Additionally,the conceptual framework provided by EBPallows for improved communication amongprofessionals and disciplines, thus facilitating thedissemination and implementation of the verybest available clinical practices with sufficientfidelity to ensure high-quality services.

4 Overview and Foundational Issues

THE PROCESS OF EVIDENCE-BASEDPRACTICE

Because EBP is multifaceted and constantlyevolving as empirical knowledge is accumulated,it requires an ongoing process. This process,a central tenet of EBP, involves several steps (asoutlined by Spring 2007 and Spring et al., 2008).

1. Ask patient-centered questions relevant atthe individual, community, or populationlevel. For example, questions that haveinformed the development of EBP include: (a)Who are the patients who do not respondfavorably to the best available treatments(e.g., those with Axis II personality disordersor more chronic symptoms), and how canadaptations of these treatments or alternativenew treatments effectively address the bar-riers or problems that have limited thesepatients’ ability to benefit? (b) What are thecore symptoms or features of each disorderthat must be addressed therapeuticallyin order to produce clinically significantchange, and how can treatment be structuredto directly address those symptoms or fea-tures? (c) What modifications in treatmentmodels or practices can increase the pace atwhich change occurs, in order to relievepatients’ suffering and increase their func-tioning in the most timely and least costlymanner?2. Identify and acquire the best availableempirical evidence to address relevant ques-tions. As noted earlier, the evidenceshould include the results of scientificallyrigorous research, observations of howclinicians actually deliver services, and pref-erences expressed by patients that are relevantto effectively engaging and motivating them intreatment.3. Appraise the evidence critically (see nextsection) in order to make appropriate imple-mentation decisions.4. Apply the evidence in practice, takinginto account relevant factors such as limita-tions in the evidence base, clinical context,

patient values and preferences, and availableresources.5. Assess outcomes, adjust in an iterative(and ongoing) manner, and disseminate whenappropriate.

EVIDENCE APPRAISAL IN EVIDENCE-BASED PRACTICE

In order to make the most effective practicedecisions, the best available empirical evidencemust not only be identified and acquired, butalso critically appraised and integrated. Rele-vant data can take many forms, including singlecase, time series, or open trials; randomizedclinical trials; meta-analyses; consensus panelsor agency guidelines.Single case, time series, open trials: Smaller,

nonrandomized treatment studies are typicallyan important early step in the development andevaluation of new interventions or applicationsof established interventions to new populationsor via novel service delivery modes. Suchstudies can provide important informationabout intervention feasibility, acceptance of theintervention by patients and providers, andpotential for efficacy. Alone, however, thesetrials rarely provide sufficient evidence tosupport an intervention as an EBP.Randomized clinical trials (RCTs): Larger,

randomized trials that are designed to carefullycontrol for alternative factors that may accountfor what appear to be the outcomes of a treat-ment are usually the “gold standard” requiredfor acknowledging an intervention as an EBP.There are a number of key elements to considerwhen evaluating the quality and applicability ofan RCT (Borkovec & Castonguay, 1998;Chambless & Hollon, 1998). These include: (1)study design, (2) methods and measures, (3)sample characteristics and size, (4) cliniciancharacteristics, (5) dependent variable consid-erations, (6) data analyses, (7) results and effectsizes (statistical and clinical significance), and(8) potential side effects and adverse eventsoutcomes and considerations. See also the

Evidence-Based Practice in Adult Mental Health 5

Consolidated Standards of Reporting Trials(CONSORT) statement, which was developedto improve the quality of reports of RCTs (Begget al., 1996; CONSORT, 2009).Clinical trials are often classified according to

their phase (I to IV; NIH Guidelines, 2009)based on a system originally developed formedical outcome studies. A Phase I clinicaltrial involves testing a treatment model orpractice with a relatively small number ofrecipients (in pharmacotherapy research thistends to range between 20 and 80) who areassessed before and after (and often during) thetreatment in order to establish whetherthe treatment is safe and associated with suffi-cient benefits to warrant further testing. Phase Iclinical trials may also test different variationsof the treatment, such as fewer or more sessions(comparable to the dose of a medicine), and themechanisms by which the treatment achievesoutcomes (comparable to testing how a medi-cine is metabolized and affects the body). PhaseII clinical trials test the efficacy of a treatmentby rigorously comparing its outcomes versusthose of usual clinical care or relativelyinnocuous alternative conditions that controlfor alternative possible sources of improvement(comparable to a placebo in medical research).Phase III clinical trials test the effectiveness of atreatment by administering it to much largernumbers of recipients (several hundred tothousands) in real-world circumstances thatmay include a comparison with the best avail-able alternative treatment(s), careful monitor-ing of side effects, and follow-up assessmentsto determine if the benefits are sustained overtime. Finally, Phase IV trials typically consti-tute postmarketing studies that are gearedtoward gathering more specific informationabout the risks, benefits, and optimal use of theintervention.Critical reviews, meta-analyses, consensus

panels, and agency guidelines: Reviews ofempirical knowledge base can take a varietyof forms, which can include objective effortsto quantifiably summarize and synthesize alarge number of RCTs (e.g., meta-analyses).

Literature reviews can also help summarizewhat types of studies have been conducted andorganize evidence to address a range ofpotentially important questions that extendbeyond those addressed by a single RCT. Theseinclude questions regarding short- and long-term efficacy, efficacy for specific subgroups,effectiveness in practice settings, and com-parisons across multiple interventions, limita-tions, and future directions for research anddevelopment.Efficacy and effectiveness: Two conceptual

forms of research studies represent two broadmethods for evaluating outcomes, with efficacystudy designs emphasizing internal validity (i.e., whether the intervention works in a con-trolled research setting) and effectivenessstudies emphasizing external validity (whetherthe intervention works in real-world practicesettings; Frueh, Monnier, Elhai, Grubaugh, &Knapp, 2004; Seligman, 1996). An RCT is atype of efficacy study that includes the use ofmanualized protocols with a fixed numberof sessions and random assignment to differentconditions. Although important for drawinginferences about causality, an inherentlimitation of most RCTs is that they tend toemphasize laboratory rigor over real-worldimplementation. That is, RCTs generallyinclude lengthy assessments that may or maynot be practical in other settings, or they rely oninterventions that may not easily translate toother settings due to varying provider andpatient characteristics. Most RCTs to date haveexcluded patients with the most severe forms ofthe disorder being targeted, those with comor-bid diagnoses, and those generally consideredfragile or vulnerable. Additionally, most RCTsdo not adequately represent ethnoracialminorities. These issues have raised questionsamong clinicians regarding the effectiveness ofthese interventions for the patients seen in theirpractice settings, many of whom have thesecharacteristics.Keeping up with the literature: Because sci-

entific knowledge is constantly accumulating,EBP requires a continuous quality

6 Overview and Foundational Issues

improvement perspective (IOM, 2001). Newtreatments or practices are under developmentconstantly in the mental and behavioralhealth field, with research supporting theirefficacy and effectiveness often emerging quiterapidly (despite the fact that clinical trialsusually require several years to complete eachphase). For example, only two medicationtreatments (sertraline, paroxetine) are con-sidered sufficiently safe, efficacious, andeffective for adults with PTSD to warrantapproval by the U.S. Food and Drug Admin-istration (which establishes federal guidelinesfor EBP for all pharmaceutical treatments),despite over 30 years of vigorous clinical trialssince that diagnosis was formally recognizedby the American Psychiatric Association in1980 in the Diagnostic and Statistical Manual(3rd revision)—and no medication has beenFDA approved for the treatment of PTSD withchildren. However, between 2000 and 2002 aseries of Phase I clinical trials were reportedsuggesting that an antihypertensive medication(Prazosin) was associated with reduced night-mares in PTSD, and from 2003 to 2008 severallarge Phase II clinical trials confirmed theefficacy or Prazosin for PTSD nightmares andfor some of the core daytime symptoms ofPTSD as well (Raskind et al., 2007; F. Tayloret al., 2006; H. Taylor et al., 2008).

CULTURAL COMPETENCE IN EBP

Evidence-based practice by its very definitionrequires respect for diversity and knowledgeabout the limitations of EBPs as they pertain tovarious groups (Spring et al., 2008; Whaley &Davis, 2007). Because ethnoracial minoritiesare often not well represented in RCTs, con-cerns have been raised about the validity ofEBPs for ethnoracial minorities and whetherEBP standards are even relevant for manyunderserved/understudied groups. Certainly,more research needs to be conducted with suchgroups in a variety of practice settings, with afocus on effectiveness research. However, it is

not realistic to conduct efficacy or effectivenesstrials for every possible configuration ofintervention, comorbid condition, practicesetting, and ethnoracial or socioeconomicstatus group. This alone is not reason enoughto dismiss using theoretically sound andempirically supported interventions. Rather,it is important to follow the EBP processoutlined earlier, reviewing, synthesizing, andadapting the best available empirical data tomake contextualized practice decisions thattake into account limitations of the existingknowledge base. In fact, the perspectives ofcultural competence and EBP are comple-mentary to each other in that they eachemphasize the importance of thoughtfullyadapting interventions from RCTs for usewith specific populations and clinical con-texts (Whaley & Davis, 2007). In this regard,extant empirical data can be used to tailorand refine interventions as needed to ensurethat they are sensitive to and appropriate forspecific clinical populations.

CHALLENGES TO DISSEMINATIONAND IMPLEMENTATION OF EBP INPRACTICE SETTINGS

Empirical evidence limitations: A major bar-rier to dissemination and implementation ofEBP for many adult psychiatric disorders isthat the empirical literature base remainsundeveloped, especially with regard toco-occurring disorders and among underserved/understudied populations. We know very littleabout the efficacy of established interventionsfor patients with multiple psychiatric diag-noses, or with regard to the optimal timingof treating one disorder versus another amongthose with dual diagnoses. That is, forexample, a clinician may rightly be hesitant touse a specific EBP intervention that has beenshown in clinical trials to have efficacyfor depressed patients with the clinicians’depressed and anxious patient, since it may beunclear how well the EBP’s treatment effects

Evidence-Based Practice in Adult Mental Health 7

generalize to patients with anxiety comorbid-ity. Also, the clinician working in an inde-pendent practice may be leery of adopting anEBP that proved efficacious in an academicmedical center’s RCT (since RCTs often havestrict eligibility and exclusion criteria, as wellas tending to provide treatments in a time-limited format that often is not sufficient tofully address complicated clinical problems).However, evidence actually suggests that pri-vate practice and community setting patientsshow comparable gains to those published inacademic medical centers’ RCTs despiteRCT’s strict inclusion criteria. And, evidencesuggests that diagnostic complexity does notappear to substantially alter the effectiveness ofEBPs tested on only a single disorder. Col-laboration between researchers and clinicianshas resulted in innovative adaptations of ESTsdesigned to enhance their applicability to clin-icians and patients in real-world settings (e.g.,Cook et al., 2004; Fava et al., 2006; Kazdin,2001; Stroup et al., 2006).Barriers to dissemination and implementation

of EBP in practice settings: There is little evi-dence that EBPs are yet effectively disseminatedor implemented in the vast majority of real-worldpractice settings, or that EBPs are implemented inways that are likely to support wider dissemin-ation efforts (Drake et al., 2001; Gold, Glynn, &Mueser, 2006;Mueser, Torrey, Lynde, Singer,&Drake, 2003; Shumway & Sentell, 2004). Theliterature on effective dissemination practicesemphasizes the need to provide clinicians thetraining, tools, and ongoing supervision to deliverempirically validated treatments (P. W. Corrigan,Steiner, McCracken, Blaser, & Barr, 2001;Friedberg, Gorman, & Beidel 2009; Henggeleret al., 2008; Torrey et al., 2001). Althoughnecessary, however, these strategies are recog-nized as insufficient to overcome clinical andadministrative barriers to the implementationand maintenance of EBPs in most practicesettings, public and private. These barriersgenerally include a lack of motivation andresistance to change by providers, lackof skills and inadequate training among

providers, limited resources and incentives forproviders, deficient incentives for providersand administrators, cost concerns regardingimplementation and maintenance, lack ofongoing quality assurance or fidelity moni-toring, limited involvement and commitmentfrom key stakeholders, diffuse leadership, andinsufficient accountability at multiple organ-izational levels (Addis & Waltz, 2002; P. W.Corrigan et al., 2001; P. Corrigan, McCracken,& Blaser, 2003; Drake et al., 2001; Frueh et al.,2009; Ganju, 2003; Mueser et al., 2003;Schoenwald & Henggeler, 2003; Schoenwald& Hoagwood, 2001; Torrey et al., 2001).Practitioner beliefs and resistance: Practi-

tioner beliefs about and resistance to EBP is amajor concern. Clinicians often have concernsregarding the effectiveness of EBPs, includinga possible compromised therapeutic relation-ship when using potentially “sterile” treatmentmanuals, when individual patient needs are notmet, when treatment credibility is underminedby a formulaic lockstep approach, when there iscontraindication in the most typical patients(e.g., those with comorbid conditions, ethno-racial minorities; see the aforementioned),when clinical innovation is hampered, and thebelief that service innovations may reflectthe interests and needs of administrators orpayers of services rather than patients (Addis,2002; Barlow, Levitt, & Bufka, 1999; Frueh,Cusack, Grubaugh, Sauvageot, & Wells, 2006;Gold et al., 2006; Hoagwood, Burns, Kiser,Ringeisen, & Schoenwald, 2001). Addition-ally, even with positive attitudes toward EBP,logistical challenges frequently hamper imple-mentation efforts. These include difficulty inlearning new skills, lack of infrastructure toprovide clinicians with training, ongoingsupervision and feedback (i.e., maintain fidelityof implementation), and lack of researcher-clinician partnerships (Cook et al., 2004; P. W.Corrigan et al., 2001; Schoenwald et al., 2003;Sullivan et al., 2005; Torrey et al., 2001). In fact,a survey of practicing psychologists demon-strates that fewer than half have a clear ideaof treatment manuals, most mistakenly

8 Overview and Foundational Issues