THE EVIDENCE BASED PRACTITIONER

Michael Morrow, PhD - Arcadia University

Evidence-based practice (EBP) in clinical and counseling psychology is both an ethical and social justice imperative. Clients of all backgrounds deserve the psychosocial treatments most likely to benefit them and not cause harm (Lilienfeld, 2007). Accordingly, graduate programs are charged to provide students with sufficient preparation in EBP. Ideally, students should graduate their programs with a clear understanding of EBP, emerging skills in empirically supported assessments and treatments, and a firm commitment to maintaining an evidence-based orientation throughout their careers (Morrow, Lee, Bartoli, & Gillem, 2016). While graduates will undoubtedly require further training to master EBP, their education should plant the seeds needed to later bloom into competent evidence-based practitioners.

As a clinical psychologist (reared in a clinical science program) and a counselor educator, I am tasked with the privilege and challenge of helping MA-level counseling students begin their transformation into evidence-based practitioners, all in roughly three years of coursework and applied training. MA-level practitioners comprise the bulk of frontline mental healthcare in many communities (Weisz, Chu, & Polo, 2004); thus, it is critical to provide them with strong training in EBP. Over the past five years, I have learned that guiding students toward competence in EBP is no easy feat; in fact, simply helping them grasp the meaning of EBP is a major challenge, especially in light of the many misinterpretations that plague the field.

While definitions have evolved over time, EBP currently represents a broad framework for clinical decision making and service based on three key components: the strongest available research, clinical expertise, and client characteristics (e.g., preferences, strengths, and culture; Kazdin, 2008). When (and only when) these three components are thoughtfully and continually integrated throughout treatment, EBP occurs. Recent models also emphasize the role of the therapeutic relationship and other common factors (Ackerman et al., 2001).

Unfortunately, many students fail to internalize EBP as an overarching orientation and reduce it solely to using empirically supported treatments (ESTs): interventions supported by rigorous research for particular disorders (Norcross & Karpiak, 2012). While EBP involves using ESTs, it is a broader framework for decision making and intervention. This tendency to minimize EBP to ESTs is well documented (Luebbe, Radcliffe, Callands, Green, & Thorn, 2007) and poses a significant barrier to the proliferation of EBP. Creative teaching strategies are needed to ensure that students acquire a fuller and more accurate understanding of EBP.

Learning theory and research indicate that metaphors can be powerful teaching tools (Hansen, Richland, Baumer, & Tomlinson, 2011). Recently, I developed a metaphor to introduce EBP to counseling students. As a novice painter, I liken EBP to oil painting. I start by explaining that artists utilize a variety of tools (brushes, paint knives, and palettes) to mix and apply various materials (gesso, paint, and varnish); these tools and materials are analogous to practitioners’ knowledge and skills, including their competence in making evidence-based decisions, building strong therapeutic alliances, conducting and interpreting assessments, and delivering specific interventions (e.g., cognitive behavior therapy or exposure and response prevention).

I then add to the metaphor the adoption of an evidence-based orientation. Artists often begin oil paintings by covering the whole canvas with a wash of acrylic paint (e.g., a flat layer of light blue acrylic paint). While numerous layers of paint will be added atop, this wash provides an underlying tone for the entire piece (i.e., the blue wash will interact with each new layer of paint). This acrylic wash represents the adoption of an overarching evidence-based orientation, a guiding framework that colors key clinical decisions, such as choosing assessment tools, formulating conceptualizations, selecting treatment modalities, tailoring interventions, and monitoring progress. To illustrate this point, I ask students to visualize a blank treatment plan and imagine painting “EBP” in a light hue across the background (Figure 1).

Figure 1

Next, I add to the metaphor the process of utilizing research to guide treatment planning. Once the acrylic wash has dried, artists add their first layer of oil paint, which typically blocks out major forms (e.g., a flat grey patch denoting a mountain range) and creates a basic composition for the piece. Regarding EBP, this first layer reflects evidence from the best available research (Lilienfeld et al., 2013). When the research base is strong for treatments targeting a particular condition, it offers a very clear picture for treatment.

For instance, when working with a child with significant disruptive behavior, rigorous efficacy studies deem behavioral parent training a well-established intervention (Eyberg, Nelson, & Boggs, 2008). In this example, students can visualize themselves painting “behavioral parent training” atop a treatment plan already washed in a background of EBP (Figure 2). However, when research is lacking (e.g., ESTs for child Adjustment Disorders), it provides a much fainter picture of treatment. In these cases, practitioners must rely more heavily on the other components of EBP: clinical expertise and client characteristics.

Figure 2

I next introduce practitioners’ use of clinical expertise. Artists then add additional layers of oils and other materials (varnish, sand, stones) atop the previous layers to achieve various effects (detail, contrast, texture, depth, shine). Relative to EBP, these new layers reflect the integration of practitioners’ professional expertise to fill in any major gaps left uncovered by the extant research. In working with a child with an Adjustment Disorder, a practitioner could draw from her experience working with youth with this disorder or similar symptomology. If the child is presenting with a mix of internalizing symptoms, the practitioner could utilize well-established treatments (e.g., cognitive behavior therapies) for pediatric anxiety or depression.

Moreover, the final layers reflect practitioners’ efforts to incorporate client characteristics into treatment. In discussing this topic, it is critical to distinguish “modifying” and “tailoring” treatments. When modifying, practitioners alter treatment in a substantial way (e.g., removing elements or delivering components out of sequence). While such modifications can be justified (Lindhiem, Bennett, Trentacosta, & McLear, 2014), evidence-based practitioners are more likely to tailor by infusing client characteristics into the treatment framework (e.g., offering examples to match clients’ interests and building upon clients’ resources and values to help them reach their goals; Figure 3). This process reflects the notion of “breathing life” into an evidence-based protocol (Kendall, Chu, & Gifford, 1998), and, in my opinion, represents the precise point where the science and art of therapy intersect in the context of EBP.

Figure 3

Finally, I tack two remaining concepts onto the metaphor: progress monitoring and objective thinking. Artists frequently step back to view their work from afar (and from various angles). Similarly, evidence-based practitioners repeatedly examine clients’ progress by carefully monitoring changes in symptoms and behaviors. Stepping back to evaluate the full course of treatment offers invaluable information to further case conceptualization and treatment planning. Moreover, viewing a painting from different angles is analogous to considering alternate plausible hypotheses (e.g., reevaluating the primary factors maintaining a problematic behavior), which is critical to avoiding errors in clinical judgment (Spengler & Strohmer, 1994).

As paintings evolve with each brush stroke, the initial acrylic wash remains a unifying foundation for the entire work, just as an evidence-based orientation should guide the entire course of treatment.  While I have experienced some success with this metaphor, I encourage other educators to develop their own based on their personal interests (e.g., sport, dance, music, cooking). Further, it would be helpful to start a field-wide dialogue on methods for teaching EBP, perhaps via a dedicated listserv or even an edited volume of different pedagogical approaches. Finally, I challenge all graduate instructors to guide their students to practice teaching others about EBP in order to prepare them to “carry the torch” from their education into the mental health landscape and paint their own pictures of EBP.

Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso, C. J., Goldfried, M. R., Hill, C., et al. (2010). Empirically supported therapy relationships: Conclusions and recommendations for the Division 29 Task Force. Psychotherapy: Theory, Research, Practice, Training, 38, 495-497.

Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37, 215-237.

Hansen, J., Baumer, E. P. S., Richland, L., & Tomlinson, B. (2011). Metaphor and creativity in learning science. Paper presented at the annual conference of the American Educational Researchers Association, New Orleans, LA.

Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146-159.

Kendall, P. C., Chu, B., & Gifford, A. (1998). Breathing life into a manual: Flexibility and creativity with manual-based treatments. Cognitive and Behavioral Practice, 5, 177-198.

Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.

Lilienfeld, S. O., Lynn, S. J., Ritschel, L. A., Cautin, R. L., & Latzman, R. D. (2013). Why many practitioners are resistant to evidence-based practice in clinical psychology: Root causes and constructive remedies. Clinical Psychology Review, 33, 883-900.

Luebbe, A. M., Radcliffe, A. M., Callands, T. A., Green, D., & Thorn, B. E. (2007). Evidence-based practice in psychology: Perceptions of graduate students in scientist practitioner programs. Journal of Clinical Psychology, 63, 643-655.

Morrow, M. T., Lee, H., Bartoli, E., & Gillem, A. (2016). Strengthening counselor preparation in evidence-based practice. Submitted to the International Journal for the Advancement of Counseling.

Norcross, J. C., & Karpiak, C. P. (2012). Teaching clinical psychology: Four seminal lessons that all can master. Teaching of Psychology, 39, 301-307.

Spengler, P. M. & Strohmer, D. C. (1994). Counselor complexity and clinical judgment:  Challenging the model of the average judge. Journal of Counseling Psychology, 41, 1-10.

Published July 23, 2016

Irismar Reis de Oliveira, MD, PhD - Professor of Psychiatry, Department of Neurosciences and Mental Health, Federal University of Bahia, Brazil

TBCT is a new branch of Beckian cognitive-behavior therapy (CBT) that organizes known standard CBT and behavioral techniques into a step-by-step fashion.  In developing TBCT, my goal was to make CBT easily mastered by the therapist and more easily understood by the patients. TBCT should  also be simpler to be implemented and maintain CBT’s recognized effectiveness and transdiagnostic feature (de Oliveira, 2015; 2016). A detailed case illustration may be found on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012a).

Inspiration for the development of TBCT came initially from the novel The Trial, by Franz Kafka (1925/1998). Although it was not the first time the courtroom metaphor was used in CBT – Freeman and DeWolf (1992), Cromarty and Marks (1995), and Leahy (2003) had already used this metaphor –, my idea was conceptualizing core beliefs (CBs) as self-accusations and giving all the columns of the traditional dysfunctional thought record (DTR) the courtroom connotation (de Oliveira, 2011). For instance, the column corresponding to the evidence confirming the CB would bring the prosecutor’s plea, and the evidence not supporting it would carry the defense attorney’s statements. The newly derived 7-column DTR, named trial-based thought record (TBTR; de Oliveira, 2008), contained several well-known traditional CBT techniques like the downward arrow approach (Burns, 1980), the sentence reversal procedure (Freeman and DeWolf, 1992), and the upward arrow technique (Leahy, 2003). A more detailed case illustration may also be downloaded on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012b).

Several studies conducted in the last decade support the TBTR use in different psychiatric disorders (de Oliveira, 2008; de Oliveira, Duran, and Velasquez, 2012; de Oliveira, Hemmany, Powell, Bonfim, Duran, Novais, et al., 2012). For instance, TBTR was shown to decrease the credibility given by patients to dysfunctional negative CBs and the intensity of corresponding emotions in social anxiety disorder (de Oliveira, Powell, Caldas, Seixas, Almeida, Bomfim, et al. 2012; Powell, de Oliveira, Seixas, Almeida, Grangeon, Caldas et al. 2013). The conclusion reached by the above-mentioned studies was that TBTR might help patients reduce the credibility attached to the negative CBs and the intensity of corresponding emotions, regardless of the diagnosis.

New techniques were progressively added to the TBTR, resulting in TBCT. Such techniques were modifications of standard CBT and other approaches. Consequently, TBCT is an example of assimilative psychotherapy integration (Messer, 1992), in which various techniques from different theoretical origins are incorporated within the context of understanding provided by the home theoretical approach (Stricker, 2010). From the time of its original development, TBCT relied on Beckian CBT as the organizing theory, and subsequently added technical interventions drawn from several other approaches. Among them were Gestalt, compassion-focused therapy, metacognitive therapy, mindfulness, and Mitchell’s (1988) two-person relational model.

TBCT has its own case conceptualization, which makes it an individualized approach. It is divided into 3 levels and 3 phases, and includes a cyclic interactional mechanism in which components in each level influence the others, and flexibly allow the therapist to adapt the treatment to the individual’s features (de Oliveira, 2016).

Figure 1 depicts the three levels of information processing in the TBCT conceptualization diagram, and shows how a situation that is appraised in a biased fashion by the automatic thought (AT) elicits a dysfunctional negative emotion, which, in turn, produces undesired consequences in terms of behaviors and/or physiological responses. Figure 1 also contains arrows pointing back to the emotion, ATs and the situation, meaning that a confirmatory bias might preclude re-examination of the situation and replacement of the incorrect ATs with more functional and healthier perceptions (de Oliveira 2015; 2016).

Figure 1. TBCT case conceptualization diagram, phase 1, and its 3-level cognitive components: ATs, UAs and CBs. Here, dysfunctional negative CBs are predominantly active.

The TBCT case conceptualization diagram was also designed to help the patient realize that the behaviors that decrease anxiety and produce relief (e.g., avoidance) are little by little converted into coping strategies or safety-seeking behaviors, shown in Figure 1 as an arrow directed from the behavior and physiological response from the first to the second level on the right-hand side of the picture, meaning that situational perceptions in the first level (ATs) are progressively transformed into underlying assumptions (UAs) at the second level, which maintains and is maintained by the coping strategies/safety behaviors (de Oliveira, 2016). The table below shows the tools that were developed and are currently used during the TBCT therapy course.

Table 1. TBCT techniques and its diagrams. Column 2 informs the cognitive levels and column 3 informs in which sessions they are usually used (de Oliveira 2016).

The main TBCT technique used to restructure cognitions in the third level, namely CBs (Figure 1), is the TBTR. Besides including a courtroom metaphor, it introduces at least 12 known techniques usually used in CBT and listed below (de Oliveira, 2016):

1. Socratic dialogue;
2. Guided discovery;
3. Imagery re-scripting;
4. Empty chair or chairwork;
5. Downward arrow technique (investigation);
6. Evidence supporting the negative CB (prosecutor’s first plea);
7. Evidence not supporting the negative CB (defense attorney’s first plea);
8. Eliciting more automatic thoughts by discounting the positives (prosecutor’s second plea);
9. Sentence reversal (defense attorney’s second plea);
10. Upward arrow technique to uncover positive CBs (the defense attorney goes deeper);
11. Identifying cognitive distortions (jurors’ phase); and
12. The positive data log (preparation for the appeal), during which the patient summons the inner defense attorney as an ally to distance oneself even more and to collect daily elements that support the newly activated functional positive CBs.

In summary, TBCT is an evidence-based, three-level and three-phase Beckian branch of CBT, whose main techniques use the courtroom metaphor, and designed to facilitate the work of the therapist and the client by means of a highly structured (although flexible) protocol.

Burns, D.D. (1980). Feeling Good: The New Mood Therapy. New York: Signet.

Cromarty, P. and Marks, I. (1995). Does rational role-play enhance the outcome of exposure therapy in dysmorphophobia? A case study. British Journal of Psychiatry, 167, 399-402.

de Oliveira, I.R. (2008). Trial-based thought record (TBTR): preliminary data on a strategy to deal with core beliefs by combining sentence reversion and the use of an analogy to a trial. Revista Brasileira de Psiquiatria, 30(1), 12–18.

de Oliveira, I.R. (2011). Kafka’s trial dilemma: Proposal of a practical solution to Joseph K.’s unknown accusation. Medical Hypotheses, 77(1), 5-6.

de Oliveira, I.R. (2012a) Trial-Based Cognitive Therapy. Accepted entry in Common Language for Psychotherapy Procedures.

de Oliveira, I.R. (2012b) Trial-Based Thought Record. Accepted entry in Common Language for Psychotherapy Procedures.

de Oliveira, I.R. (2015). Trial-Based Cognitive Therapy: A Manual for Clinicians. New York: Routledge.

de Oliveira, I.R. (2016) Trial-Based Cognitive Therapy: Distinctive Features. London:Routledge.

de Oliveira, I.R., Duran, E.P. and Velasquez, M. (2012). A trans-diagnostic observation of the efficacy of the Trial-Based Thought Record in changing negative core beliefs and reducing self-criticism. NEI Psychopharmacoloy Congress, San Diego, October 18-21.

de Oliveira, I.R., Hemmany, C., Powell, V.B., Bonfim, T.D., Duran, E.P., Novais, N. et al., (2012). Trial-based psychotherapy and the efficacy of trial-based thought record in changing unhelpful core beliefs and reducing self-criticism. CNS Spectrums, 17(1), 16–23.

de Oliveira, I.R., Powell, V.B., Caldas, M., Seixas, C., Almeida, C., Bomfim, T. et al. (2012). Efficacy of the Trial-Based Thought Record (TBTR), a new cognitive therapy strategy designed to change core beliefs, in social phobia: A randomized controlled study. Journal of Clinical Pharmacy and Therapeutics, 37(3), 328-334.

Freeman, A., DeWolf, R. (1992). The 10 Dumbest Mistakes Smart People Make and How to Avoid them. New York: HyperPerennial.

Kafka, F. (1925/1998). The Trial. New York: Schoken Books.

Leahy, R.L. (2003). Cognitive therapy techniques. A practitioner’s guide. New York: Guilford Press.

Messer, S.B. (1992). A critical examination of belief structures in interpretive and eclectic psychotherapy. In J.C. Narcross and M.R. Goldfried (Eds.), Handbook of Psychotherapy Integration. New York: Basic Books.

Mitchell, S. (1988). Relational Concepts in Psychoanalysis. Cambridge, MP: Harvard University Press.

Powell, V.B., de Oliveira, O.H., Seixas, C., Almeida, C., Grangeon, M.C., Caldas, M., et al. (2013). Changing core beliefs with trial-based cognitive therapy may improve quality of life in social phobia: a randomized study. Revista Brasileira de Psiquiatria, 35(3), 243-247.

Stricker, G. (2010). Psychotherapy Integration. Washington D. C.: American Psychological Association.

Published July 12, 2016

Donna Sudak, MD - Drexel University College of Medicine

In the past twenty years there has been an enormous interest in the practice of cognitive-behavioral therapy (CBT). Substantial research has been conducted indicating that CBT is a significantly effective treatment for a variety of psychiatric illnesses. In 2001, the Residency Review Committee for Psychiatry adopted training requirements requiring competence in CBT for graduating psychiatry residents. In 2012, an inter-organizational task force produced guidelines for cognitive behavioral therapy training within doctoral Psychology programs in the United States (Klepac et al, 2012). Despite such requirements, dissemination of CBT remains poor (Shafran et al 2009) and training is lacking (Weissman et al, 2006). There is some evidence regarding specific methods of supervision and teaching that lead to effective application of CBT in clinical practice, but such evidence is even more poorly disseminated and inconsistently applied. Literature on the outcome of supervision is lacking. In spite of decades of emphasis on data-driven decision-making regarding the therapeutic process, there has been a relative lack of research to address questions of best practices in both training and supervision of CBT. Although dissemination of effective treatments for mental disorder is of paramount public health concern the field requires considerable progress to facilitate such dissemination.

There are at least two distinct points of view regarding therapist training represented in the training and supervision literature. First, a commonly articulated evidence-supported position is that more training produces more competent therapists (McManus et al 2010). A further assumption derived from this point of view is that more competent therapists have superior clinical outcomes. Several studies (Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006) support this view and point specifically to the role of supervision in producing competent therapists. Another argument, advanced from the public health perspective, is that the process of training and supervision is far too resource intensive to be practical for illnesses such as depression (Fairburn and Cooper 2011), which will soon represent the largest global disease burden (WHO). This perspective argues for a larger group of therapists trained in low intensity interventions for specific disorders along with guided self-help and internet assisted interventions to produce the widest ranging impact. Both ideas have merit, and likely an amalgam of training strategies will continue to be developed and tested worldwide.

Given the aforementioned scarcity of resources, identifying the most efficient strategies for supervision and training is imperative for the field. Regarding supervision, a small number of studies exist that indicate it improves therapist competence (Strunk et al 2010, Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006), but do not describe the most efficient and effective procedures to follow. Even more significantly, the elements of what constitutes “adequate” supervision are only recently described in the literature and have been determined by a combination of narrative and systematic reviews and expert consensus (Milne and Dunkerley). The importance of adequate training for supervisors has led to several professional organizations establishing criteria for supervisors/trainers (e.g., the Academy of Cognitive Therapy, the British Association of Behavioural and Cognitive Psychotherapy) and/or required continuing education credits pertaining to supervision.

Key principles that are derived from CBT itself, because it is rooted in learning theory, are equally applicable to the supervisory process and facilitate therapist development. These include:

These practices in supervision will help you be more effective at teaching the skills of therapy and make the work interesting to you both!

Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research,16(3), 317-331.

Fairburn, C. G., & Cooper, Z. (2011). Therapist competence, therapy quality, and therapist training. Behaviour Research and Therapy, 49(6-7), 373-378.

Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., & ... Strauman, T. J. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education. Behavior Therapy, 43(4), 687-697.

McManus, F., Westbrook, D., Vazquez-Montes, M., Fennell, M., & Kennerley, H. (2010). An evaluation of the effectiveness of diploma-level training in cognitive behaviour therapy. Behaviour Research and Therapy, 48(11), 1123-1132.

Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30(5), 496-516.

Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We Don't Train in Vain: A Dissemination Trial of Three Strategies of Training Clinicians in Cognitive-Behavioral Therapy. Journal of Consulting and Clinical Psychology, 73(1), 106-115.

Simons, A. D., Padesky, C. A., Montemarano, J., Lewis, C. C., Murakami, J., Lamb, K., & ... Beck, A. T. (2010). Training and dissemination of cognitive behavior therapy for depression in adults: A preliminary examination of therapist competence and client outcomes. Journal of Consulting and Clinical Psychology, 78(5), 751-756.

Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change. Journal of Consulting and Clinical Psychology, 78(3), 429-437.

Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., & ... Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925-934.

Published July 3, 2016