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VOLUME 38 NO. 3 FALL 2003
BULLETIN
PsychotherapyOFFIC IAL PUBL ICAT ION OF D IV IS ION 29 OF THE
AMERICAN PSYCHOLOGICAL ASSOCIAT ION
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In This Issue
Do Psychologists Have Supererogatory Obligations?
Overview of the Psychotherapy Outcome Assessment and Monitoring System
Interview With Dr. Charles Gelso, Incoming Editor of Psychotherapy
The Empirically-Validated Treatments Movement:A Practitioner Perspective
PresidentPatricia M. Bricklin, Ph.D. 2002-2004470 Gen. Washington RoadWayne, PA 19087Ofc: 610-499-1212 Fax: [email protected]
President-electLinda F. Campbell, Ph.D., 2001-2003University of Georgia402 Aderhold HallAthens, GA 30602-7142Ofc: 706-542-8508 Fax:[email protected]
SecretaryAbraham W. Wolf, Ph.D., 2002-2004Metro Health Medical Center2500 Metro Health DriveCleveland, OH 44109-1998Ofc: 216-778-4637 Fax: [email protected]
TreasurerLeon VandeCreek, Ph.D., 2001-2003The Ellis Institute9 N. Edwin G. Moses Blvd.Dayton, OH 45407Ofc: 937-775-4334 Fax: [email protected]
Past PresidentRobert J. Resnick, Ph.D., 2002-2003Department of PsychologyRandolph Macon CollegeAshland, VA 23005Ofc: 804-752-3734 Fax:[email protected]
Board of Directors Members-at-LargeNorman Abeles, Ph.D. , 2003-2005Michigan State Univ.Dept. of PsychologyE. Lansing, MI 48824-1117Ofc: 517-355-9564 Fax: [email protected]
Mathilda B. Canter, Ph.D., 2002-20044035 E. McDonald DrivePhoenix, AZ 85018Ofc/Home: 602-840-2834 Fax: 602-840-3648E-Mail: [email protected]
Patricia Hannigan-Farley, Ph.D. 2003Office: 440- 250-4302 Fax: 440-250-4301Email:[email protected]
Jon Perez, Ph.D., 2003-2005Washington, D.C. [email protected]
Alice Rubenstein, Ed.D., 2001-2003Monroe Psychotherapy Center20 Office Park WayPittsford, New York 14534Ofc: 585-586-0410 Fax [email protected]
Sylvia Shellenberger, Ph.D., 2002-20043780 Eisenhower ParkwayMacon, Georgia 31206Ofc: 478-784-3580 Fax: [email protected]
APA Council RepresentativesJohn C. Norcross, Ph.D., 2002-2004Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc:570-941-7638 Fax:[email protected]
Jack Wiggins, Jr., Ph.D., 2002-200415817 East Echo Hills Dr.Fountain Hills, AZ 85268Ofc: 480-816-4214 Fax: [email protected]
Alice F. Chang, Ph.D., 2003-20056616 E. Carondelet Dr.Tucson, AZ 85710Ofc: 520-722-4581 Fax: [email protected]
STANDING COMMITTEES
FellowsChair: Roberta Nutt, Ph.D.
MembershipChair: Craig N. Shealy, Ph.D.James Madison UniversitySchool of PsychologyHarrisonburg, VA 22807-7401Ofc: (540) 568-6835 Fax: 540-568-3322 [email protected]
Student Representative to APAGS:Anna McCarthy2400 Westheimer #306-WHouston, TX [email protected]
Nominations and ElectionsChair: Linda F. Campbell, Ph.D.
Professional AwardsChair: Robert J. Resnick, Ph.D.
FinanceChair: Leon VandeCreek, Ph.D.
Education & TrainingChair: Jeffrey A. Hayes, Ph.D.Associate Professor and Director ofTraining Counseling Psychology ProgramPennsylvania State University312 Cedar BuildingUniversity Park, PA 16802Ofc: (814) [email protected]
Continuing EducationChair: Jon Perez, Ph.D.
Student DevelopmentChair: Open
Psychotherapy ResearchChair: Clara Hill, Ph.D.Dept. of PsychologyUniversity of MarylandCollege Park, MD 20742Ofc: (301) [email protected]
ProgramChair: Alex Siegel, Ph.D., J.D.915 Montgomery Ave. #300Narbeth, PA 19072Ofc: 610-668-4240 Fax: [email protected]
TASK FORCES
Task Force on Policies & ProceduresChair: Mathilda B. Canter, Ph.D.
Diversity Chair: Dan Williams, Ph.D., FAClinP,ABPP185 Central Ave- Suite 615East Orange, New Jersey 07018Ofc: 973-675-9200 Fax: [email protected] - 1-888-269-3807
Interdivisional Task Force on HealthCare PolicyChair: Jeffrey A. Younggren, [email protected]
Task Force on Children, Adolescents& FamiliesChair: Sheila Eyberg, Ph.D.Professor of Clinical & HealthPsychologyBox 100165University of FloridaGainesville, FL 32610FEDERAL EXPRESS ADDRESS1600 SW Archer [email protected] 352-265-0468Co-Chair: Beverly Funderburk, Ph.D.
Division of Psychotherapy ! 2003 Governance StructureELECTED BOARD MEMBERS
COMMITTEES AND TASK FORCES
Chair: John C. Norcross, Ph.D., 2002-2008Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc:570-941-7638 Fax:[email protected]
Publications Board Members:Jean Carter, Ph.D., 1999-20053 Washington Circle, #205Washington, D.C. 20032Ofc: [email protected]
Lillian Comas-Dias, Ph.D., 2001-2007Transcultural Mental Health Institute908 New Hampshire Ave. N.W., #700Washington, D.C. [email protected]
Raymond A. DiGiuseppe , Ph.D., 2003-2009 Psychology Dept St John’s University 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-990-1955 [email protected]
Alice Rubenstein, Ed.D. , 2002-2003Monroe Psychotherapy Center20 Office Park WayPittsford, New York 14534Ofc: 585-586-0410 Fax 585-586-2029Email: [email protected]
Publications Board Members, continuedGeorge Stricker, Ph.D., 2003-2009 Institute for Advanced Psychol Studies Adelphi University Garden City , NY 11530 Ofc: 516-877-4803 Fax: 516-877-4805 [email protected]
Psychotherapy Journal EditorWade H. Silverman, Ph.D. 1998–20031390 S. Dixie Hwy, Suite 1305Coral Gables, FL 33145Ofc: 305-669-3605 Fax: [email protected]
Psychotherapy Bulletin EditorLinda F. Campbell, Ph.D., 2001-2003University of Georgia402 Aderhold HallAthens, GA 30602-7142Ofc: 706-542-8508 Fax:[email protected]
Internet EditorAbraham W. Wolf, Ph.D., 2002-2004Metro Health Medical Center2500 Metro Health DriveCleveland, OH 44109-1998Ofc: 216-778-4637 Fax: [email protected]
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PUBLICATIONS BOARD
DIVISION OF PSYCHOTHERAPY (29)
Central Office, 6557 E. Riverdale Street, Mesa, AZ 85215Ofc: (602) 363-9211 • Fax: (480) 854-8966 • E-mail: [email protected]
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Non-ProfitOrganizationU.S. Postage
PaidUtica, NY
Permit No. 83
PSYCHOTHERAPY BULLETIN
Published by theDIVISION OF
PSYCHOTHERAPYAmerican Psychological Association
6557 E. RiverdaleMesa, AZ 85215
602-363-9211e-mail: [email protected]
EDITORLinda Campbell, Ph.D.
CONTRIBUTING EDITORS
Washington ScenePatrick DeLeon, Ph.D.
Practitioner ReportRonald F. Levant, Ed.D.
Education and Training CornerJeffrey A. Hayes, Ph.D.
Professional LiabilityLeon VandeCreek, Ph.D.
FinanceJack Wiggins, Ph.D.
For The ChildrenSheila Eyberg, Ph.D.
Psychotherapy ResearchClara E. Hill, Ph.D.
Student CornerAnna McCarthy
STAFF
Central Office AdministratorTracey Martin
PSYCHOTHERAPY BULLETINOfficial Publication of Division 29 of the
American Psychological Association
Volume 38, Number 3 Fall 2003
CONTENTSEditor’s Column ......................................................2
Call for Award Nominations..................................3
Student Column ......................................................5
2004 Randy Gerson Memorial Award ................10
Council Report........................................................11
Practitioner Report ................................................12
Feature: Overview of the PsychotherapyOutcome Assessment and MonitoringSystem..................................................................16
2004 Nominations Ballot ......................................21
Washington Scene ..................................................23
Feature: Do Psychologists HaveSupererogatory Obligations?............................29
Feature: Interview With Dr. Charles Gelso,Incoming Editor of ourJournal Psychotherapy ........................................33
Feature: The Empirically-ValidatedTreatments Movement: A PractitionerPerspective ..........................................................36
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This is my last issue of the PsychotherapyBulletin as editor. I am honored to haveserved you in this capacity and am a privi-leged spectator of the extraordinary contri-butions you, our membership have madeto the Bulletin and to the Division throughyour participation here. Our Divisionmembers are psychologists who are mak-ing an impact on the profession and inmany different ways. Our mission of pro-moting, nurturing, and advocating for psy-chotherapy in training, practice, theory,and research is cross-cutting of thedomains, specialties, and proficiencies ofthe profession. As a result, we are fortunateto include the full spectrum of psychologywith the only common thread, but impor-tant thread, being psychotherapy. Ourmembership, through generous submis-sions to the Bulletin, has expanded thefocus of topic areas thereby providing abroader base for our readership.
Our new editor, Craig Shealy, is a dynamic,energized, creative, and proactive individ-ual who will embrace the Bulletin and itsmission with commitment and dedication.I will be interviewing Craig in the Winter,2004 issue as an introduction of him to you.In the Spring, 2004 issue of the Bulletin,Craig and I will have a conversation aboutthe growth of the Bulletin over recent yearsand the function it has served for the mem-bership and the Division. I encourage youto continue sending your articles, manu-scripts and ideas to Craig without censor-ing yourselves. Many of you talked aboutideas that you then went back and wrotedown but that were not in final form whenwe discussed them. Craig is a person whowill also encourage and support your ideasand interests. This vehicle for publication isnot refereed. It is a publication meant to
transmit the ideas of the membership tothe rest of us.
I am currently the President-Elect of ourDivision and thereby will becomePresident for the calendar year 2004. Our2003 President Pat Bricklin, our 2005President Leon VanderCreek, and myselfhave embarked on what we think is animportant initiative for the Division. YourBoard of Directors and Division leadershipare an integral part of the project and youwill be called upon to participate as youwish in the coming months. We will betalking with you more about it in the coming issues of the Bulletin.
Serving as your editor of this most impor-tant vehicle for the Division, thePsychotherapy Bulletin, has been an honorand privilege. My participation with you,the membership, has been rewarding inmany ways. I have become acquaintedwith members I would not have knownotherwise. We have an exceptionallyknowledgeable and talented membershipthat has set the standard of quality andrichness of our publication.
I also want to thank the contributing edi-tors without whom the Bulletin would nothave had the depth and diversity of topicsthat was accomplished with their contribu-tions: Ron Levant, Pat DeLeon, JohnNorcross, Leon VanderCreek, Bob Resnick,Jack Wiggins, Clara Hill, Charlie Gelso,Jeffrey Hayes, Marv Goldfried, SheilaEyberg, Gary Brooks, David Adams,Arthur Wiens, and of course the studenteditor who is currently Anna McCarthy.These people are each in a league of theirown and have enormous wealth of experi-
EDITOR’S COLUMN
Salute to Our Division of Psychotherapy MembershipLinda F. Campbell, Ph.D.
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ence and talent to contribute to our profes-sion and to our Division.
Tracey Martin has been our central officemanager for several years and hopefullywill remain so for many years to come. Sheis the true secret behind the success of theBulletin production. Since Tracey beganworking with us, every element of produc-tion has been first class. She is able to workwith all of us in an understanding and
helpful way. She is also a person who is ina league of her own.
My heart will continue to be with theBulletin every step of the way and I lookforward to watching the Bulletin bloomeven more under the capable eye of CraigShealy. For now, I salute you, our member-ship, and look forward to working withyou in many other ways.
Call for Award Nominations
The APA Division of Psychotherapy invites nominations for its two annu-al awards in 2004.
The Distinguished Psychologist Awardrecognizes lifetime contributions to psychotherapy,
psychology, and the Division of Psychotherapy.
The Jack D. Krasner Memorial Awardrecognizes promising contributions to psychotherapy, psychology, and the Division of Psychotherapy by a Division 29 member with
10 or fewer years of post-doctoral experience.
Letters of nomination outlining the nominee’s credentials and contributions should be forwarded to the Division 29 Past-President:
Patricia Bricklin, Ph.D.70 Gen. Washington RoadWayne, PA 19087 Ofc: 610-499-1212 Fax: 610-499-4625 Email: [email protected]
The applicant’s CV would also be helpful. Self-nominations are welcomed.
Deadline is January 15, 2004.
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CONGRATULATIONS TO JOHN C. NORCROSS, PH.D.
Rosalee G. Weiss Lecturer
Dr. John Norcross, Past President of Division 29 and current Chair of the PublicationsBoard, was selected as the prestigious Rosalee G. Weiss Lecturer. Dr. Norcross deliveredhis lecture, entitled Integrating Self-help into Psychotherapy: A Revolution in Mental HealthPractice, to a full and enthusiastic audience at the 2003 APA Convention in Toronto,Ontario. Dr. Norcross was introduced by the President of our Divison, Dr. Pat Bricklin.
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Nisha Nayak is a 2nd year graduate student inthe Clinical Psychology doctoral program at theUniversity of Houston. Dr. Lynn P. Rehm isher advisor. She graduated from RiceUniversity in 1996 with a B.A. in Sociologyand subsequently worked for several years for asmall R&D medical technology company. Hercurrent research interests include patterns ofautobiographical memory recall in depressionand quantitative methods. She is also interest-ed in practical implementation of psychosocialinterventions in the community.
You got to be careful if you don’t know whereyou’re going, because you might not get there.
– Yogi Berra
Successful progression towards a desiredgoal requires knowledge of the endpoint.However, students currently undergoingtraining in psychotherapy are in someimportant ways ‘shooting towards a mov-ing target’. The career path for a youngpsychologist seeking an academic careerstill follows a trajectory similar to that ofpredecessors. However, for students plan-ning to become practitioners, what thefuture holds is less clear. For example, thework settings and responsibilities of thenext generation of practicing psychologistsand therapists will very likely be very dif-ferent from that of previous prototypes,such as the independent therapist whospends most of his or her time seeingpatients one-on-one. Such a dedicatedclient contact role may be particularlyunlikely for doctoral-level psychologists.Unfortunately, academic curricula can bepainfully slow at responding to changes inthe job market. The reasons for this rela-tive immutability are manifold and are notaddressed here. Nonetheless, students,
interns, and young professionals can bene-fit greatly from an awareness of the chang-ing landscape of mental health practice.Such awareness can help guide the processof professional development. Further-more, it will facilitate pursuit and acquisi-tion of requisite knowledge and skills andthe acceptance of attitudes compatible withthe current systems and realities of practice.
The aim of this article is to provide anoverview of relatively recent changes andanticipated trends in the role of behav-ioral/mental health professionals as dis-cussed in works by Cummings, Pallak,&Cummings (1996) and Cummings,O’Donohue, Hayes, and Follette (2001).The key theme emphasized by theauthors/editors is that psychology mustrelinquish some traditional notions of howand where psychotherapy and/or behav-ioral health practice should occur. Instead,theories of practice must be developed andadopted based on psychologists’ demon-strated and potential contributions to men-tal and physical health within the contem-porary context of managed care.
The laymen’s notion of psychotherapylikely takes the form of a patient visitinghis or her therapist weekly (e.g. regularly)to discuss life problems and with the goalof curing of some personality problem,mental illness, or neurosis. The contactwould typically be one-on-one with littleor no involvement of other professionals.The setting would be in office building.The duration may vary, but therapy wouldtypically (or at least ideally) continue untilthe patient is completely ‘cured’ so thathe/she need never return to therapy.While this depiction is a bit extreme, cur-rent perspectives towards therapy may notbe terribly different, even among profes-
STUDENT COLUMN
Shooting Towards a Moving TargetNisha Nayak
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sionals. For example, while many currenttraining programs may acknowledge thatbriefer therapy and techniques withdemonstrated effectiveness are necessary,the assumptions of the practice modeldescribed above often still persist. At thecore of these assumptions is what isreferred to as the ‘dyadic model’ of therapyas a relatively long-term, continuousprocess that emphasizes the central roles ofthe therapy session and the therapist inachieving a ‘cure’ (Cummings, Pallak, &Cummings, p. 17-20). Although many ofthese assumptions regarding the nature oftherapy have been questioned in recentyears, they have nonetheless propagatedthe pervasive view that the typical orappropriate format for therapy is individ-ual or group therapy, that reimbursementgenerally is based on a fee-for-servicearrangement, and that all attempts to limitbenefits should be resisted. This view oftherapy no longer reflects the current reali-ty in terms of consumer needs or job mar-ket demand. The solo private practice isdeclining, and an emphasis on this profes-sional setting inhibits the expansion of psy-chologists into new roles that are morecompatible with the current health care cli-mate. According to Cummings, a morecontemporary model of practice involvesgroup practice, acquisition of brief therapyskills, and demonstration that therapy iseffective and efficient. Furthermore, headvocates a catalytic model of therapywhich is based on brief, intermittent thera-py throughout the life span, which depictsthe therapy session as a “yeast for growthoutside therapy,” and which stresses theclient’s ability to effect change in his/herown life.
Cummings et al. (1996) attribute the“demise of the solo practice” to marketforces, namely changes in the reimburse-ment of services, i.e. the advent of man-aged care. He terms this process the“industrialization of healthcare.” For aperiod in the 1980’s, while the rest of thehealth care industry experienced thepainful adjustment to HMO’s, service
providers in mental health and chemicaldependency fields avoided cost contain-ment owing to the difficulty in classifyingpatients and establishing clear treatmentguidelines. This market opportunity result-ed in an abuse of the system by businessinterests and skyrocketing costs in this sec-tor. This development ultimately broughtabout a sharp response in the form of man-aged behavioral health care. Methods ofcost reduction included elimination of ben-efits, limiting services that were covered,and greater use of master’s level therapists.Many of these changes adversely affectedquality but were not surprising given own-ership by those with business interests. Incontrast, psychologists might have bal-anced the demands for quality and costcontainment in a more equitable fashion.However, psychologists generally wereunable gain the foothold needed in orderto exert significant autonomy within thenew managed care system. For the mostpart, managed behavioral healthcare nowconsists of a few conglomerates that ownroughly two-thirds of the market share.The main economic effects of this entireprocess on psychology are lower privatepractitioner incomes and fewer viable pri-vate practice jobs that can be supported bythe market.
The brief historical summary presentedabove helps provide a sense of where thefield has been and the forces that have andcontinue to affect it. The take-home mes-sage is that students who plan to be practi-tioners likely need to consider optionsbeyond the traditional model of openingup an individual private practice.However, as described in both of the refer-enced books, an array of potential oppor-tunities with varied work settings andresponsibilities are available for those whoare willing to forge the path. Master’s levelpractitioners will likely continue to engagein substantial face-to-face contact,although it may be in increasingly struc-tured, brief, and/or directed formats.Psychoeducation, generally in groups, is aparticular area that will likely see future
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growth. As more junior-level practitionersengage in day-to-day client contact, thedemand for qualified and effective super-visors is expected to increase, and doctoral-level psychologists are well-suited to servein these roles. Ideally, psychologists willhave an interactive relationship with otherprofessionals and community resourcesthrough consulting work, referral, andongoing communication. Licensed psy-chologists will also function in traditionalroles of behavioral and functional assess-ment, treatment planning, and tailoringtherapies to address unique individual orcultural issues. Doctoral graduates can alsobe involved in development of informationmaterials and ready-to-implement clinicalprotocols based on empirical research find-ings. Such protocols may deal with pre-vention, psychoeducation, patient-man-agement therapies, targeted interventionsfor specific problems, etc., and can be dis-seminated by junior-level therapists. Withincreased demand for treatments withproven effectiveness, an important part ofthe psychologist’s role will be outcomeresearch in applied settings. Outcomes ofinterest may include not only traditionalclinical items of interest, such as patientstatus, but also economic factors, such ascosts and health service utilization.Quality assessment and oversight of man-aged behavioral healthcare systems is yetanother area that can benefit from profes-sionals with advanced education in psy-chology and related clinical fields.
Finally, Cummings et al. (2001) argue thatthe biggest opportunity for clinicallytrained psychologists lies in the field ofbehavioral health. This field involvesdeveloping interventions and protocolstargeted at negative health behaviors(smoking, alcohol/drug abuse, diet/exer-cise/drug/medical non-compliance, etc.)as well as addressing the needs of the largesegment of patients who present to prima-ry care physicians with nonspecific physi-cal complaints with no identifiable organiccause. The medical service utilization cost
associated with these patients is extremelyhigh, and professionals in psychology/behavioral health can develop, identify,and/or implement treatment strategies toserve this class of clients. For these andother reasons, Cummings et al. (2001) pro-pose that the optimal strategy for behav-ioral health practitioners is to join with pri-mary care physician groups. These groupsoften operate on a capitation or prospectivereimbursement basis. Such an arrange-ment involves negotiating a fixed reim-bursement per insured individual with aninsurance company (in exchange for a ser-vice agreement) and thereby assuming thefinancial liability associated with provid-ing services. While such a system requiresappropriate business management and isassociated with assumption of financialrisk, it also affords greater autonomy toprofessional practitioners, who can thenmaintain a commitment to quality services.The advantage to psychologists for beingon-site practitioners in these networks orgroups is that they become part of an inte-grated health team; somaticizing patientsare more apt to abide by physician referralsto psychologist if they just have to godown the hall. The advantage to physi-cians is the medical cost savings to theirpractice.
This article was intended to highlightdevelopments over the past decade andpredicted trends in the delivery of mentaland behavioral health services. Within theconfines of current services reimbursed bymanaged behavioral healthcare systems,there will be a limited number of opportu-nities for traditional private practice.However, while traditional venues andforms of psychotherapy seem to be on thedecline, a wide range of additional oppor-tunities are emerging for the next genera-tion of practitioners. The range of job rolespoints to the difficulties involved in ade-quately training psychologists over thecoming years. As psychology programsgrapple with issues of training and compe-tency, it will fall on the shoulders of the
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student to identify gaps in his/her educa-tion/training and to attempt to addresssuch deficiencies. Important areas that mayoften be omitted by academic and profes-sional training programs include formaltraining in supervision, exposure to issueswith managed health care systems, andsystems evaluation and development. Abasic principle that is driving the newclasses of jobs (described above) for psy-chologists is accountability of the practi-tioner (e.g. therapist) as a health care ser-vice provider. It is important for futurepsychologists to recognize this responsibil-ity and to become knowledgeable regard-ing relevant issues. The goal of this processof professional development and educa-
tion? To bring the ‘moving target’ a bitmore into focus.
ReferencesCummings, Nicholas A., O’Donohue,
William, Hayes, Stephen C., andVictoria M. Follette (Eds.). Integratedbehavioral healthcare : positioning mentalhealth practice with medical/surgical prac-tice. San Diego: Academic Press, 2001.
Cummings, Nicholas A., Pallak, Michael S.,and Janet L. Cummings (Eds.).Surviving the demise of solo practice : men-tal health practitioners prospering in the eraof managed care. Madison, Conn.:Psychosocial Press, 1996.
Find Division 29 on the Internet. Visit our site atwww.divisionofpsychotherapy.org
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DIVISION 29 RECOGNITIONS AND AWARDS
The Division of PsychotherapyDistinguished Psychologist Award
Charles Gelso and Clara Hill, both of the University of Maryland Counseling Psychologyprogram have made significant contributions to the Division. Dr. Gelso has served asChair of the Education and Training Committee and editor of the Education and Trainingcolumn in the Psychotherapy Bulletin.
Dr. Clara Hill has served as Chair of the Psychotherapy Research Committee and editorof the Research Corner. Both Dr. Gelso and Dr. Hill have made unsurpassed contributionsto psychotherapy research and training. They continue to be leaders in the advancementof psychotherapy. Dr. Gelso and Dr. Hill were both presented with the DistinguishedPsychologist Award by Division 29 Past President Dr. Robert Resnick.
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AMERICAN PSYCHOLOGICAL FOUNDATION
2004 RANDY GERSON MEMORIAL GRANT
The American Psychological Foundation (APF) announces the Randy GersonMemorial Grant to be given in 2004. For the 2004 cycle of the grant, professional aca-demicians or practitioners engaged in relevant research projects are invited to apply.The grant has been created to advance the systemic understanding of family and/orcouple dynamics and/or multi-generational processes. Work that advances theory,assessment, or clinical practice in these areas shall be considered eligible for grantsthrough the fund.
Preference will be given to projects using or contributing to the development ofBowen family systems. Priority also will be given to those projects that serve toadvance Dr. Gerson’s work.
Eligibility Requirements:Applicants from a variety of professional or educational settings are encouraged toapply. Awards are given in alternate years to students and professionals. The 2004grant will go to a professional academician or practitioner. To qualify for the 2004cycle of the award, all applicants (including co-investigators) must have a doctoraldegree (e.g. Ph.D., Psy.D., Ed.D., or M.D.), or an equivalent terminal degree withintheir field.
Applications must include:
➡ Statement of the proposed project
➡ Rationale for how the project meets the goals of the fund
➡ Budget for the project
➡ Statement about how the results of the project will be disseminated (published paper, report, monograph, etc.)
➡ Personal reference material (vita and two letters of recommendation)
Applicants must submit seven (7) copies of their entire application packets. Sendapplication packets by February 1, 2004, to the APF Awards Coordinator (addressbelow). Applicants will be notified on or after April 15, 2002.
Amount of Grant: $5,000.00
Deadline: February 1, 2004
For additional information:
Contact the APF Awards Coordinator/Gerson, 750 First Street, NE, Washington, DC20002-4242. Telephone: (202) 336-5843. Internet: [email protected].
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The APA Council of Representatives meton Wednesday, August 4 and again onSunday, August 10 in conjunction with the111th annual APA convention in Toronto,Canada. The Division of Psychotherapywas ably represented by Drs. PatriciaBricklin (substituting for Jack Wiggins),John Norcross, and Jon Perez (substitutingfor Alice Chang).
The Council considered, debated, andapproved a large number of agenda items.Among the highlights of Council’s actionswere:
! Renewed recognition of clinical neu-ropsychology as a specialty.
! Clarified procedures on the creationand promulgation of Standards andGuidelines either by APA as a whole orits divisions. A lengthy process of gov-ernance and legal review is required;the new rules are designed to clarifyAPA policy and to protect practitioners.All standards and guidelines must pub-lish appropriate disclaimer language.Further, all approved standards andguidelines will be sunset in 10 yearsunless formally renewed.
! Passed a preliminary 2004 budget of$85,800,000 with a modest surplus. The surplus was made possible by refi-nancing the APA buildings, voluntarystaff reductions at APA, and difficultcost-containment decisions.
! Established and funded a new APAelectronic database known as Psyc-EXTRA. This database will containmaterial relevant to psychology that isnot currently covered in PsycINFO orPsycARTICLES and will be orientedtoward the general public and libraries,as opposed to professionals or scientists.
! Adopted a new edition of Principles forthe Validation and Use of PersonnelSelection Procedures as revised by theAPA Society for Industrial andOrganizational Psychology (SIOP).
! Approved Guidelines for PsychologicalPractice with Older Adults, which will soon appear in the AmericanPsychologist.
! Received an update on the APA PublicEducation Campaign, which continuesto focus on promoting resilience follow-ing trauma, particularly among chil-dren.
! Adopted the Final Report of thePresidential Task Force on Governance,which is designed to increase theinvolvement of the Council ofRepresentatives and streamline its gov-ernance process.
As always, please contact Alice, Jack, ormyself directly ([email protected]) ifyou would like to speak about the actionsand directions of the APA Council ofRepresentatives.
COUNCIL REPORT
Highlights of the 2003 Council of Representatives Meeting
John C. Norcross, PhDCouncil Representative
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Ronald F. Levant, Ed.D., A.B.P.P., is a candi-date for APA President. He is in his secondterm as Recording Secretary of the AmericanPsychological Association. He was the Chair ofthe APA Committee for the Advancement ofProfessional Practice (CAPP) from 1993-95, amember at large of the APA Board of Directors(1995-97), and APA Recording Secretary(1998-2000). He is Dean, Center forPsychological Studies, Nova SoutheasternUniversity, Fort Lauderdale, FL.
We are living in truly interesting times. The21st century promises monumentalchanges in health care, education, commu-nication, and science in general. The tech-nology currently available has providedthe tools whereby educated consumers canmake critical decisions regarding their ownhealth care and health care providers cancall up databases (such as Epocrates ®) toprovide up to date information on pharma-ceutical agents. Yet despite these promis-ing developments, the status of health carein the U.S. is not good.
Health care costs have once again begun toescalate faster than other segments of theeconomy, and the number of uninsured isnow 43.6 million Americans. In June, 2002,the Secretary of the Department of Healthand Human Services (HHS) met with lead-ers from the National Academies and chal-lenged them to propose bold ideas thatmight change conventional thinking aboutthe most serious problems facing the healthcare system today. The Institute ofMedicine (IOM) reported: “The Americanhealth care system is confronting a cri-sis…Tens of thousands die from medical
errors each year, and many more areinjured. Quality problems, includingunderuse of beneficial services and overuseof medically unnecessary procedures, arewidespread. And disturbing racial and eth-nic disparities in access to and use of ser-vices call into question our fundamentalvalues of equality and justice for all. Thehealth care delivery system is incapable of meet-ing the present, let alone the future needs of theAmerican public.” (emphasis added).
A new development in the area of healthcare reform is emerging from the Wye RiverGroup on Healthcare (WRGH), which helda National Summit Meeting on Health Carein Washington at the prestigious UniversityClub on September 23, 2003. I had the honorof representing APA at this event, alongwith Russ Newman (who graciously invitedme to join him). The Summit Meeting wasthe culmination of a project initiated in July2002, titled “Communities Shaping a Visionfor America’s 21st Century Health andHealthcare.”
Quoting from sections of the WRGHreport, “This project is fairly unusual in itseffort to understand how health care stake-holders and consumers view the valuesand principles underlying our health caresystem…. WRGH held a series ofHealthcare Leadership Roundtables in 10diverse communities around the country.During these roundtable discussions, com-munity health care leaders were asked fun-damental questions, such as whether thereis, or should be, a social contract for healthcare in this country….
“In each community, WRGH assembled adiverse cross-section of public and private
PRACTITIONER REPORTA Social Contact on Health Care?
Ronald F. Levant, Ed.D., MBA, ABPPNova Southeastern UniversityAPA Recording Secretary
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stakeholders with detailed knowledge ofhealth and health care. They includedphysician leaders, hospital and health sys-tem executives, community and publichealth officials, pharmaceutical and phar-macy representatives, business leaders,consumer representatives, and govern-ment officials. WRGH also worked toensure that important constituencies suchas the elderly, the uninsured, minorities,and people with chronic illnesses werewell represented….
“After roundtable discussions were held inall 10 communities and the advisory boardswrapped up their work, WRGH hosted aretreat July 9-11, 2003, at the Aspen InstituteWye River Conference Center inMaryland…. To announce the “sharedvision” that arose from this project, WRGHorganized a national summit designed toshowcase the findings of the 10-city tourand launch a national dialogue on healthcare among the American public, policy-makers and health care stakeholders…
“Most community health care leadersagreed that our country has not developeda social contract for health care that is well-articulated and broadly understood. As aresult, most Americans do not know whatthey can and should expect from theirhealth care system. Nor do they under-stand their responsibility to contribute tothe health care system…
“Community health care leaders identifiedAmericans’ expectations as a key area thatneeds to be addressed in a national conver-sation on health care. There is a generalconsensus among health care leaders thatthe public’s expectations are often out ofline with the reality of what the health caresystem is able to deliver. There is alsorecognition that the health care systemitself has helped foster these unrealisticexpectations, in part by not providing ade-quate information about the true costs andavailability of services…
“According to community health care lead-ers, most Americans expect high-quality
care, on demand, and at little or no cost.Americans don’t want to make trade-offsand we don’t want to hear about limits.Because of financial constraints on thehealth care system, this kind of access toinexpensive services may become increas-ingly unrealistic. Americans need to revisitthe discussion about health care as a socialcontract and also may need to make toughchoices about access and availability ofhealth care services...
“There is a need to address the expecta-tions that we have of our health care sys-tem by increasing Americans’ sense of col-lective responsibility about their healthand health care. Instead of focusing onlyon whether we, as individuals, have accessto high-quality, affordable health care, weneed to begin thinking about health care asa collective resource. The choices we makeabout our health and our use of the healthcare system have an impact beyond ourown quality of life and our own pocket-book; they affect whether there will bemore or less resources available for others.We need to start seeing the connections inhow our personal decisions affect otherpeople and how we are affected by thechoices that others make…
“Americans need to have the informationto be empowered to make good choicesthat will benefit their own health, and theyneed to be aware of the finite availability ofsome health care resources. This willrequire a shift in the way many of us thinkabout our health. Empowering consumers,and giving them the necessary support andaccess to appropriate health care serviceswill help them to make good health carechoices about their health. It could alsoimprove quality of life and reduce unnec-essary costs for the health care system…”
It is important to stress the ongoinginvolvement of the APA in this process. Dr.Sarah Brennen from NM, Sally Cameronfrom NC, Dr. Dee Yates from TX, Dr. CrissLott from MS, and Russ Newman all par-ticipated in community roundtables. Russ
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has been attending other related meetingssince January, working to insure that themessages that were being created at thecommunity level were finding their wayinto the national materials. Also Dr. NanKlein helped draft a case study of commu-nity action in Utah related to passing amental health parity law in the state whichis included in the final report.
Although there are many different aspectsto the proposal (of which I have cited onlya few), its central thrust seems to be aimedat transforming the role of consumers. Thespeakers quite appropriately zeroed-in onthe facts that seven of the top health riskfactors are behavioral (tobacco use, alcoholabuse, poor diet, injuries, suicide, violenceand unsafe sex), and that seven of the nineleading causes of death have significantbehavioral components. They viewed con-trolling these “life-style” factors as criticalin reducing health care costs. However, theproposed solution was to “make costsmore transparent to consumers.” Whatdoes that mean? My understanding is thatpeople who engage in unhealthy behaviorswould pay more for health care. I was apanelist, so at two of my three turns “atbat” I acknowledged that incentives (suchas the prospect of lower health care costs)can influence behavior, but pointed outthat all behavior, including unhealthybehavior, is motivated. I further suggestedthat changing motivated behavior mayrequire more than changing the financialincentives for engaging in that behavior. Iwas able to draw on my clinical experiencein helping clients quit smoking, moderateor quit drinking, and lose weight, to high-
light the difficulties many have in control-ling these unhealthy behaviors. The audi-ence seemed to understand and appreciatethis perspective.
It should be noted that among the support-ing organizations for the WRGH was theWhite House Council of EconomicAdvisors. Further, there were several Bushadministration officials in attendance,including Rex Cowdry and MarkShowalter from the Council of EconomicAdvisors, and FDA commissioner MarkMcClellan, who keynoted the meeting. Allof this suggests that the project might havethe ear of the White House. In addition,the project has attracted bipartisan interest,as Senator Leiberman’s staff was presentand Senator Wyden was the featuredspeaker at a “kickoff” press conference.Furthermore, the current phase of the pro-ject is attempting to get messages placedand questions raised with as many of theexisting presidential hopefuls as possible.
There are many coalitions and processessimilar to this one, but this one seems tohave more potential than most. To QuoteRuss Newman: “Although this projectcould come up dry given the overwhelm-ing challenges we face in health care today,it seemed to us in the Practice Directorateto be among the more promising projectswe’ve seen. This effort to stimulate grass-roots dialogue and community involvementcould very well prove to be the missingpieces for successful healthcare reform.”
As always, I welcome your thoughts onthis column. You can most easily contactme via email: [email protected].
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DIVISION 29 RECOGNITIONS AND AWARDS
Craig Shealy was selected to receive the Jack D. Krasner Early Career Award. This recog-nition is given to a psychologist who has made exceptional contributions to the professionwithin the first ten years of earning a doctoral degree. Dr. Shealy is Director of ClinicalTraining Combined-Integrated (C-I) Doctoral Program at James Madison University. Dr.Shealy was presented the Krasner Award by Past President Dr. Robert Resnick.
Patricia Hannigan-Farley, Past President of Division 29, received recognition as outgoingBoard member from President Pat Bricklin.
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There are many excellent instruments thatwe, as clinicians and researchers, may useto understand whether our patients areimproving in psychotherapy (e.g., SCL-90-R, BASIS-32, BDI, OQ-45). Although mostof us only use them anecdotally to assesshow our patients are progressing, reliableand valid models of change exist that allowus to more fully employ outcome instru-ments to inform our treatment—not only tomonitor and track patient progress, but alsoto predict the course of improvement andincrease patient benefit. This ground-break-ing line of research began with the discov-ery of the dose-effect relationship in 1986,by Howard, Kopta, Krause, and Orlinsky.
The Dose-Effect and Phase Models ofPsychotherapyHoward et al.’s (1986) model illustrates therelationship between “doses” of psycho-therapy (one dose equal to one session)and patient outcome/improvement (morespecifically, the log-linear function of sessions, and normalized probability ofimprovement). Using meta-analysismethodology, the authors found thatapproximately 50% of patients showedimprovement by session 8, 75% by session26, and 85% by session 52; In essence, themore psychotherapy, the better, withdiminishing returns at higher doses (i.e.,numbers of session). Howard et al. alsofound that patients with different diagnosticsyndromes (e.g., borderline personalitydisorder and depression) required differentdoses of therapy to achieve similar levelsof improvement. Subsequent researchershave found similar, differential dose-effectpatterns regarding the responsiveness ofacute, chronic, and characterological psy-chological symptoms and/or syndromes
(e.g., Kopta, Howard, Lowry, & Beutler,1994) and interpersonal problems (e.g.,Maling, Gurtman, & Howard, 1995). Theseexciting discoveries provided a wealth ofdata to which mental health professionalscan compare their own patients’ progress.Psychotherapeutic effectiveness was movingcloser to being demonstrated as a reliable,scientific treatment.
Another exciting advance in psychotherapyresearch was the extension of dose-effectmethodology to examine the stages ofchange in psychotherapy. The phasemodel, discovered by Howard, Lueger,Maling, and Martinovich (1993), demon-strates that change in psychotherapy followsa sequentially dependent, progressiveprocess where the client first experiencesan increase in feelings of well-being(remoralization), then symptom distress isreduced (remediation), and finally, afterapproximately 10 sessions, life functioning(rehabilitation) begins to improve. Thismodel, combined with patient-profilingmodels (Howard, Moras, Brill, Martinovich,& Lutz, 1996; Leon, Kopta, Howard, & Lutz,1999; Lutz, Martinovich, & Howard, 1999),completes the picture of how much isenough, as we can now predict how muchtherapy is needed to achieve the best objec-tives for our patients in each of the threestages (see Lutz, Lowry, Kopta, Einstein, &Howard, 2001).
The Psychotherapy Outcome Assessmentand Monitoring System (POAMS)Findings from the dosage and phase modelsinspired me to work with Mark Kopta todevelop the Psychotherapy Outcome Assess-ment and Monitoring System (POAMS®;Kopta & Lowry, 1997)—a comprehensive
FEATURE
Overview of the Psychotherapy Outcome Assessment and Monitoring System Jenny Lowry, Ph.D.
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method for assessing adult outpatients’progress and outcome in therapy. Much ofthe aforementioned research on the phasemodel and patient profiling was conductedusing the COMPASS® system (see Sperry,Brill, Howard, & Grissom, 1996)—thePOAMS contains the critical variables thatmade COMPASS a success. Briefer thanCOMPASS, POAMS assesses the essentialdimensions that have been validated topredict and improve treatment outcomes—well-being, symptoms, life functioning,readiness for psychotherapy, and the bondbetween the therapist and patient. ThePOAMS was developed as a comprehen-sive, yet efficient, tool to help cliniciansbetter understand their psychotherapyoutpatients’ needs, assist in treatmentplanning, and help clinicians gauge howtheir clients are responding during thecourse of psychotherapy. It may also beused with dose-effect, and other method-ologies to perform cost-benefit and cost-efficiency analyses.
POAMS Scales
! Well-being Scale The four items of thewell-being scale were designed toassess a patient’s feelings of general dis-tress, satisfaction with life, energyand/or motivation, and emotionality.
! Symptoms Scale Twenty-nine itemsare used to assess 9 symptom clusters,such as depression, anxiety, obsessive-compulsive thoughts/behaviors, moodswings, hostility, somatization, psychot-ic experiences, drug and/or alcoholproblems, and sleep difficulties.
! Life Functioning Scale Life function-ing is assessed in 9 areas, such aswork/school, friendships, intimate rela-tionships, relationships with children,sexual functioning, life enjoyment,physical health, self-management,money management.
! Global Mental Health Patient scoreson the Well-being, Symptoms, and LifeFunctioning scales may be used sepa-
rately to track patient progress throughthe phase model stages, and/or com-bined to determine the client’s GlobalMental Health score, which is anoverview, or snapshot, of a client’s over-all functioning.
! Psychotherapy Scale Five items areused at intake to assess a patient’s per-ceived need for treatment, the chronici-ty of the problems, past treatment expe-rience (if applicable), as well as confi-dence in overcoming the difficulties thatbrought the patient to therapy. Thesetypes of items have been demonstratedto contribute to successfully predictingpatient responses to treatment (see Leonet al., 1999; Lutz et al., 2001).
! Therapeutic Bond Scale Six items maybe used to assess a patient’s perceptionsof the therapist on such factors as thera-pist’s interest, understanding, andacceptance of the patient, as well aswhether the patient would likely refer afriend with similar problems or needs tothe therapist. Research has shown thattherapeutic bond is a useful variable forpredicting patient progress in therapy(e.g., Saunders, 2000).
! Outcome Monitoring Scale TheOutcome Monitoring Scale is comprisedof 13 items that assess well-being,selected psychological symptoms, andfour life functioning areas. The scalealso contains a question which asks thepatient’s perceived benefit from psy-chotherapy thus far. The OutcomeMonitoring Scale was designed to beused at specified session points duringtreatment to allow for adjusting the psy-chotherapeutic process. Used alone, orin conjunction with the TherapeuticBond Scale, information gained at eachsession may be compared to the intakebaseline data to track therapeuticgains/effectiveness, provide data to dis-cuss in treatment (e.g., a particularsymptomatic difficulty, bond issue,etc.), and improve outcome and effi-ciency of treatment.
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! Client Satisfaction Scale Patients areasked to complete this 12-item scale atdischarge. Areas assessed include apatient’s overall satisfaction with ser-vice, the likelihood of recommendingservices to a friend, the degree to whichhe or she felt “helped” with his or herproblems, as well as logistical issues,such as ease of making appointments,etc. These types of data may be benefi-cial to clinicians in terms of identifyingstrengths and problem areas in order toimprove delivery of services.
Psychometric InformationThe POAMS scales are patient self-reportand efficient to administer. Intake scales typically take 7 minutes for the patient to complete (Psychotherapy, Well-Being,Symptoms, Life Functioning). TherapeuticBond and Outcome Monitoring Scales,which are optional but recommended, canusually be completed by within 4 minutes.At discharge, patients typically complete theWell-Being, Symptoms, Life Functioning, aswell as the Client Satisfaction Scale (usuallywithin 9 minutes).
One unique aspect of the POAMS is thescaling—all scales and items use the sameLikert-type continuum of 0 (extreme dis-tress/poor functioning) to 4 (no distress/excellent functioning). Therefore, it is con-venient to compare client scores acrossscales without performing any mathemati-cal conversions. For interpretive purposes,scores of 3 or higher suggest that clients are functioning in the “healthy” range,while clients with scores of less than 2 aresymptomatic, or in distress, for that itemand/or scale.
The POAMS has demonstrated good inter-nal consistency reliability, as measured byCronbach’s Alpha (.75 to .85 for the Well-Being Scale; .91 to .93 for Symptoms Scale;.77 to .87 for the Life Functioning Scale;and .94 to .95 for the Global Mental Healthcomposite—GMH), and strong concurrentvalidity when compared to instruments
measuring similar constructs (e.g., GMHcorrelates .83 with the OQ-45.2, .86 withBasis-32, and .92 with the SCL-90-R; seeGreen, Lowry, & Kopta, 2003). Normativedata are available for adult outpatient,community adult, college student, and col-lege counseling center populations. Inaddition, two alternate versions of theinstrument are available: the POAMS—Trauma Version, which includes 10 addi-tional psychological symptoms (that assessPTSD, DID, and depersonalization), andone additional life functioning item (abusesusceptibility); and the POAMS—CollegeCounseling Center Version, which assesseslife functioning for work and school sepa-rately (10 domains total).
Clinicians and researchers are encouragedto choose the POAMS version that will bestsuit their particular needs. The POAMS isuseful as a time- and cost-efficient systemnot only to assess and monitor therapyprogress, but may be combined with dose-effect, patient profiling, and phase modelmethodologies to increase the efficiencyand outcome in outpatient practice (personal practice, college counseling cen-ters, research, etc.). For clinicians andresearchers who would like a user-friendlymethod to quantify patient change, for personal, scholarly, and/or administrativepurposes, research suggests that the POAMSis a reliable and valid tool, based on a long,well-validated research history, and mayassist them in this process.
There are many possibilities for researchand clinical practice with the POAMS. Forexample, several college counseling cen-ters are currently utilizing the POAMS—College Counseling Center version to helptheir clinicians gauge progress of individ-ual clients, examine aggregate data of theirclientele, better plan for the needs of thera-py groups, as well as plan for outreach pro-grams at the college-wide level. My ownprogram of research is beginning to focuson the use of the POAMS—Trauma Versionto assess populations who have been
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impacted by critical incidents, such asflight attendants after the events ofSeptember 11, 2001 (e.g., Lating, Sherman,Everly, Lowry, & Peragine, in press). ThePOAMS—Trauma Version is well suited toassess people who have experienced criti-cal events, particularly with regard to thethree components that comprise mentalhealth according to Howard et al.’s (1993)Phase Model. Moreover, given the recentcontroversy regarding the efficacy of criti-cal incident stress debriefings (CISD;Mitchell & Everly, 2001), I plan to use thePOAMS—Trauma Version to better under-stand and clarify the process of CISD, aswell as the resultant outcome, through thelens of the phase model.
ReferencesGreen, J. L., Lowry, J. L., & Kopta, S. M.(2003). College students versus collegecounseling center clients: What are the dif-ferences? Journal of College StudentPsychotherapy, 17(4), 25-37.Howard, K. I., Kopta, S. M., Krause, M. S.,
& Orlinsky, D. E. (1986). The dose-effectrelationship in psychotherapy. AmericanPsychologist, 41, 159-164.
Howard, K. I., Lueger, R. J., Maling, M. S.,and Martinovich, Z. (1993). A phasemodel of psychotherapy: Causal media-tion of outcome. Journal of Consultingand Clinical Psychology. 61, 678-685.
Howard, K. I., Moras, K., Brill, P. L.,Martinovich, D., & Lutz, W. (1996).Evaluation of psychotherapy: Efficacy,effectiveness, and patient progress.American Psychologist, 51, 1059-1064.
Kopta, S. M., Howard, K. I., Lowry, J. L., &Beutler, L. E. (1994). Patterns of sympto-matic recovery. Journal of Consulting andClinical Psychology, 62, 1009-1016.
Kopta, S. M., & Lowry, J. L. (1997).Psychotherapy Outcome and AssessmentMonitoring System. Copyrighted ques-tionnaire, available from the authors.
Lating, J., Sherman, M.F., Everly, G. S.,Lowry, J. L., & Peragine, T. F. (in press).
Psychological reactions of copingresponses of American Airlines flightattendants to the events of September 11and beyond. Journal of Nervous andMental Diseases.
Leon, S. C., Kopta, S. M., Howard, K. I., &Lutz, W. (1999). Predicting patients’responses to psychotherapy: Are somemore predictable than others? Journal ofConsulting and Clinical Psychology, 67,698-704.
Lutz, W., Lowry, J.L., Kopta, S.M., Einstein,D., & Howard, K.I. (2001). Prediction ofdose-response relations based on patientcharacteristics. Journal of ClinicalPsychology, 57(7), 889-900.
Lutz, W., Martinovich, Z., & Howard, K. I.(1999). Patient profiling: An applicationof random coefficient regression modelsto depict the response of a patient to out-patient psychotherapy. Journal ofConsulting and Clinical Psychology, 67,571-577.
Maling, M. S., Gurtman, M. B., & Howard,K. I. (1995). The response of interperson-al problems to varying doses of psy-chotherapy. Psychotherapy Research, 5, 63-75.
Mitchell, J., & Everly, G. S. (2001). Criticalincident stress debriefing: An operationsmanual for the prevention of traumatic stressamong emergency services and disasterworkers (3rd ed.). Ellicott City, MD:Chevron Publishing Company.
Saunders, S. (2000). Examining the rela-tionship between therapeutic bond andthe phases of treatment outcome.Psychotherapy: Theory, Research, Practice,Training, 37(3), 206-218.
Sperry, L., Brill, P. L., Howard, K. I., &Grissom, G. R. (1996). Treatment outcomesin psychotherapy and psychiatric interven-tions. New York: Brunner/Mazel, Inc.
Correspondence regarding this article should beaddressed to Dr. Jenny Lowry, Dept. ofPsychology, Loyola College in Maryland, 4501N. Charles Street, Baltimore, MD 21210.
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DIVISION 29 RECOGNITIONS
Linda Campbell received acknowledgementfrom President Pat Bricklin for her service as editor of the Psychotherapy Bulletin. She will beincoming president of the Division in 2004.
Bob Resnick is recognized for his out-standing contribution as past president ofDivision 29 by President Pat Bricklin.
Leon VandeCreek was acknowledged by President Pat Bricklin for his service as treasurer of Division 29. He is theincoming president-elect for 2004.
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Dear Division 29 Colleague:
The best talent in the American Psychological Association belongs to the Division of Psycho-therapy (29), and we hope to draw from that pool to serve in the governance structure. It istime for us to put our combined talents to work for the advancement of psychotherapy.
NOMINATE YOURSELF OR SOMEONE YOU KNOW TO RUN FOR OFFICE IN THE DIVISION OF PSYCHOTHERAPY. THE OFFICES OPEN FOR ELECTION IN 2004 ARE:
President-elect (1)Member-at-large (2)
Representatives to APA Council (2)All persons elected will begin their terms on January 2, 2005.
The Division’s eligibility criteria are:
1. Candidates for office must be Members or Fellows of the division.2. No member many be an incumbent of more than one elective office.3. A member may only hold the same elective office for two successive terms.4. Incumbent members of the Board of Directors are eligible to run for some position
on the Board only during their last year of service or upon resignation from theirexisting office prior to accepting the nomination. A letter of resignation must besent to the President, with a copy to the Nominations and Elections Chair.
Simply return the attached nomination ballot in the mail. The deadline for receipt of all nominations ballots is December 31, 2003. We cannot accept faxed copies. Original signatures must accompany ballot.
EXERCISE YOUR CHOICE NOW!If you would like to discuss your own interest or any recommendations for identifyingtalent in our division, please feel free to contact Dr. Leon VandeCreek at The Ellis Institute,9 N. Edwin G. Moses Blvd., Dayton, OH 45407, Ofc: 937-775-4334, EMail:[email protected]
Sincerely,
Patricia Bricklin, Ph.D. Linda Campbell, Ph.D. Leon VandeCreek, Ph.D.President President-elect Chair, Nominations and
Elections Committee---------------------------------------------------------------------------
Indicate your nominees, and mail now! In order for your ballot to be counted, you mustput your signature in the upper left hand corner of the reverse side where indicated.
President-elect Members-at-large Council Representative
_______________________ _______________________ _______________________
_______________________ _______________________
2004 NOMINATIONS BALLOT
FOLD THIS FLAP IN.
Fold Here.
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Division29Central Office6557 E. Riverdale St.Mesa, AZ 85215
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I recently had the opportunity to partici-pate in the Arizona PsychologicalAssociation’s annual convention,Psychology—Surviving & Thriving InTurbulent Times. I was very impressed bytheir vision in inviting their state legislatorsto attend a special Saturday morning breakfast, “Creating Positive PoliticalPartnerships.”As APA’s Mike Sullivan hasconsistently noted, our nation is currentlyexperiencing a devolution of the public pol-icy process, and it is at the local and statelevels that national health policies are beingdetermined. Times will change. However,today our state psychological associationsare more than ever absolutely critical topsychology’s successful evolution into the21st Century. Warren Littleford chaired thishighly impressive event which was attend-ed by 10 members of the Arizona Houseand Senate (interestingly, the majoritybeing Republican). At the table where I sat,there were eight colleagues with their owndistrict’s State Senator. We were joinedbriefly by a House member, but she wasushered to a different table which did nothave an elected official. Not surprisingly,former APA President Jack Wiggins raisedthe issue of psychology prescribing (RxP-)and how this would enhance the quality ofhealth care within Arizona. The ensuingdiscussion sounded most reasonable. Theevent concluded with each of the legislators(or their psychologist designee) brieflydescribing to those gathered what topicshad been discussed at their table. The widerange of psychology’s potential contribu-tions to society were enumerated in variousscenarios. The psycho-social and culturalaspects of health care, effectively address-ing problems children were having inschool, the area’s aging population, and the
ever escalating costs of health care werenoted—not to mention state budgetdeficits. It was quite evident that both theelected officials and our colleagues learnedquite a bit about each other’s worlds thatmorning. My sincerest congratulations toLibby Howell, chair of the convention pro-gram committee. This was truly an out-standing weekend.
Children Are Not Merely Little Adults:Psychology has much to offer to societyand particularly, to our patients. As one ofthe “learned professions,” we mustdemonstrate proactive leadership. We cannot assume that non-clinicians, and partic-ularly the media and our nation’s healthpolicy experts, will appreciate our poten-tial contributions. Collectively, psychologymust become more personally involved inthe public policy process. Over the years, Ihave become particularly interested in pro-grams and services that are targetedtowards children and adolescents. Thoseinvolved in this area are acutely aware ofthe unique skills and resources (increasing-ly, including technologies) required. And,that particularly for these populations the dynamic interchange between psychological-social-environmental-cul-tural-biological and developmental factorsis absolutely critical. Interdisciplinary col-laboration must be proactively encour-aged. Interestingly, the more I reflect, themore I have also come to conclude that thekey for ensuring quality care is really notproviding additional funding per se, butinstead addressing the present scarcity ofprogram and provider accountability andthe real need for more active involvementby behavioral experts (i.e., psychologists).
WASHINGTON SCENE
Psychological Expertise — Truly A National Investment
Pat DeLeon, Ph.D.former APA PresidentDivision 29 - October, 2003
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This year the recommendations of the U.S.Senate Appropriations Committee for theDepartment of Health and HumanServices (HHS) included $20 million foremergency medical services for children.HHS had recommended that the program(Pediatric-EMS), which was funded lastyear at $19.37 million, be moved to thePublic Health and Social ServicesEmergency Fund in the Office of theSecretary. However, the Committee insteadcontinued to provide funding within the Health Resources and ServicesAdministration (HRSA) account, which isalso responsible for the Department’s vari-ous health professions training and servicedelivery initiatives. The Pediatric-EMSprogram supports demonstration grantsfor the delivery of emergency medical ser-vices to acutely ill and seriously injuredchildren. The Appropriations Committeenoted that it was pleased with the effortsmade for the emergency medical servicesfor children and that it would like anupdate on the program. The ten yearInstitute of Medicine (IOM) report wasfound to be extremely helpful and accord-ingly, the Committee strongly urged a 20year program study and update to the ear-lier IOM report. The program has histori-cally included mental health within itsjurisdiction and over the years has con-tracted with various non-physician associ-ations, including APA, to both obtain theirprofessional recommendations and also toassist them in educating their own mem-bership regarding the unique needs of ournation’s children.
During the nearly three decades that I haveworked on Capitol Hill, I have graduallycome to appreciate that national healthpolicies frequently evolve over time and asa direct result of the deliberations of recog-nized “think tanks” and/or extensiveCongressional and Administration publichearings. The public policy process isextraordinarily open to diverse views. TheRand Corporation is one of the most highlyrespected nonprofit research organizations.
It recently announced its OctoberCongressional briefing which was to focusupon mental health services for children.The highlights: 20-50 percent of sixth gradestudents in the U.S. have been a witness to,or victim of, violence in their community.The Cognitive Behavioral Intervention forTrauma in School (CBITS) program is thefirst mental health program for childrenthat research has demonstrated to be effec-tive. The CBITS program is an inexpensive,school-based program that both deals withthe impact of the violence and gives thechildren a tool kit to help them deal in thefuture with stressful or anxious situations,negative thoughts, and other real-life prob-lems. The development and evaluation ofthis program was funded in part by a grantfrom the National Child Traumatic StressNetwork, created by Congress in 2001. It isprovided in schools, and therefore is acces-sible to many families who face obstaclessuch as lack of insurance, transportationproblems, and time conflicts in bringingtheir children to more traditional treatmentsettings. And, today’s children are increas-ingly exposed to violence, ranging fromwitnessing violent acts to being victimsthemselves. Unless these children receivehelp now in coping with violence-relatedpsychological trauma, they are more likelyto suffer from emotional and behavioralproblems that will follow them into adult-hood. We are pleased to note that within theCenters for Disease Control and Prevention(CDC) Rodney Hammond has long beenspearheading creative, behavioral sciencebased violence prevention efforts.
This year the Senate AppropriationsCommittee also provided $98 million forthe children’s mental health services initia-tive within the Substance Abuse andMental Health Services Administration(SAMHSA), which was the same as lastyear ’s level. The Administration hadrequested an increase to $106.6 million.This particular program provides grantsand technical assistance to support com-munity-based services for children and
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adolescents with serious emotional, behav-ioral or mental disorders. Grantees mustprovide matching funds, and services mustinvolve the educational, juvenile justice,and health systems. Acutely aware of the clinical importance of integrating phys-ical and psychological care, the SenateCommittee further expressed its strongsupport for full and timely implementationof the National Children’s Study by theNational Institute of Child Health andHuman Development (NICHD) at theNational Institutes of Health (NIH). Thisstudy aims to quantify the impacts of envi-ronmental influences (including physical,chemical, biological and social influences)on child health and development. TheCommittee urged the NICHD Director tocontinue to closely coordinate with theCDC, EPA, other Institutes and agenciesand non-Federal partners conductingresearch on children’s environmentalhealth and development, such that thisstudy will be ready for the field by no laterthan 2005. To that end, in Fiscal Year 2004,the Committee expected the Director ofNICHD to increase financial support forstudy planning, administration, and initialpilots that will provide the informationnecessary to develop and implement thefull national study.
The Senate Committee further noted thatbetween 7 million to 10 million teenagerssuffer from a mental health conditionwhich, for many, may lead to seriousbehavioral problems including droppingout of school, substance abuse, violence,and suicide. The Committee is aware thatsome school districts, juvenile justice facilities, and community-based clinicshave taken advantage of relatively simplescreening tools now available to detectdepression, the risk of suicide, and othermental disorders in teenagers. TheCommittee believes that screening shouldoccur with the consent of the adolescentand his or her parents or guardian, andwith a commitment by the screener tomake counseling and treatment for those
found to be at-risk. The Committee strong-ly urged SAMHSA to make the availabilityof these screening programs more widelyknown, and to collaborate with theDepartment of Education, Department ofJustice, CDC, HRSA, and other pertinentagencies to encourage implementation ofsimilar teenage screening programs. TheCommittee expects a report on steps beingtaken to promote this effort prior to theFiscal Year 2005 appropriations hearings.
For those colleagues within the Division whoare primarily interested in education andtraining, one could stress the importance ofAPA obtaining eligibility for psychology’sinclusion under the Children’s HospitalGraduate Medical Education program ofHRSA. This year the Senate Committeerecommended that at least $290 million beallocated, as it was in Fiscal Year 2003. Theprogram provides support for health pro-fessions training in children’s teaching hos-pitals that have a separate Medicareprovider number (“free-standing” chil-dren’s hospitals). Children’s hospitals arestatutorily defined under Medicare asthose whose inpatients are predominatelyunder the age of 18. The funds in this pro-gram are intended to make the level ofFederal Graduate Medical Education sup-port more consistent with other teachinghospitals, including children’s hospitals,which share provider numbers with otherteaching hospitals. Payments are deter-mined by formula, based on a national per-resident amount. Payments support train-ing of resident physicians as defined byMedicare in both ambulatory and inpatientsettings.
The Committee recognized the success ofthe Children’s Hospitals Graduate MedicalEducation Payment program in providingcritical support for training pediatric andother residents in graduate medical educa-tion programs in teaching hospitals that donot receive support through the Medicareprogram. It had come to the Committee’sattention that a limited number of
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free-standing perinatal hospitals and chil-dren’s psychiatric hospitals have beenexcluded from participation in the pro-gram despite the fact that these teachinginstitutions are not eligible for GraduateMedical Education funding underMedicare. Accordingly, the Committeeexpects HRSA to study and report back tothe Committee on this matter by April 1,2004. The Committee further expectsHRSA to explore the appropriateness ofincluding these hospitals in the Children’sHospital Graduate Medical Education pro-gram and to offer recommendations thatmight allow for their inclusion. UnderMarilyn Richmond’s effective leadershipthe Practice Directorate has been workingclosely with the Centers for Medicare andMedicaid Services (CMS) for the past sev-eral years to expressly include psychologyunder the Medicare GME initiative forboth internship and post-doctoral training.Once fully operational, the HRSAChildren’s Hospital GME account mightlogically become APA’s next GME legisla-tive initiative. For it should be evident toall concerned that hospitalized childrenand their families clearly require the ser-vices of a wide range of health care profes-sionals, including psychologists. For thisto become a viable APA legislative priority,however, the interest of our Division’spediatric colleagues must first be effective-ly expressed.
A Time For Reflection: During my tenureas APA President, Surgeon General DavidSatcher held a special conference onChildren’s Mental Health: Developing ANational Action Agenda. That year, APABoard Member Ron Levant and President-Elect Norine Johnson participated in delib-erations at the White House with theSurgeon General and Mrs. Clinton.Highlights of the final report: The burdenof suffering experienced by children withmental health needs and their families hascreated a health crisis in this country. Growing numbers of children aresuffering needlessly because their emotion-
al, behavioral, and developmental needsare not being met by those very institutionswhich were explicitly created to take careof them. It is time that we as a Nation tookseriously the task of preventing mentalhealth problems and treating mental ill-nesses in youth. One of the chief prioritiesin the Office of the Surgeon General andAssistant Secretary for Health has been towork to ensure that every child has an opti-mal chance for a healthy start in life. Whenwe think about a healthy start, we oftenlimit our focus to physical health. But men-tal health is fundamental to overall healthand well-being. And that is why we mustensure that our health system responds asreadily to the needs of children’s mentalhealth as it does to their physical wellbeing. Responsibilities for children’s men-tal healthcare are dispersed across multiplesystems: schools, primary care, the juvenilejustice system, child welfare and substanceabuse treatment. But the first system is thefamily, and this agenda reflects the voicesof youth and family. The vision and goalsoutlined in this agenda represent an unpar-alleled opportunity to make a difference inthe quality of life for America’s children.
The Overarching Vision of the conferencewas that mental health is clearly a criticalcomponent of children’s learning and gen-eral health. Fostering social and emotionalhealth in children as a part of healthy childdevelopment must therefore be a nationalpriority. Both the promotion of mentalhealth in children and the treatment ofmental disorders should be major publichealth goals. To achieve these goals, theSurgeon General’s National Action Agendafor Children’s Mental took as its guidingprinciples a commitment to: 1) Promotingthe recognition of mental health as anessential part of child health; 2) Integratingfamily, child and youth-centered mentalhealth services into all systems that servechildren and youth; 3) Engaging familiesand incorporating the perspectives of chil-dren and youth in the development of allmental healthcare planning; and 4)
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Developing and enhancing a public-pri-vate health infrastructure to support theseefforts to the fullest extent possible.
The nation is facing a public crisis in mentalhealthcare for infants, children and adoles-cents. Many children have mental healthproblems that interfere with normal devel-opment and functioning. In the UnitedStates, one in ten children and adolescentssuffer from mental illness severe enough tocause some level of impairment. Yet, in anygiven year, it is estimated that about one infive of such children receive specialty men-tal health services. Unmet need for servicesremains as high now as it was 20 years ago.Concerns about inappropriate diagnosis ofchildren’s mental health problems andabout the availability of evidence-based(i.e., scientifically proven) treatments andservices for children and their families havesparked a national dialogue around theseissues. There is broad evidence that thenation lacks a unified infrastructure to helpthese children, many of whom are fallingthrough the cracks. Too often, children whoare not identified as having mental healthproblems and who do not receive servicesend up in jail. Children and families are suf-fering because of missed opportunities forprevention and early identification, frag-mented treatment services, and low priori-ties for resources. Impressive thoughts. Anoutstanding vision. However, one mustalso wonder if collectively psychology willseek to effectively address these pressingissues as we enter the 21st Century.
Personal Involvement IS The Key: Thoseof us captivated by the extraordinary suc-cess in March of 2002 of Elaine LeVine,Mario Marquez, and their New Mexico col-leagues in enacting RxP- legislation trulyappreciate, above all else, the extent towhich they were ultimately successful ingalvanizing “grassroots” community sup-port for their initiative. The political (i.e.,public policy) process sincerely attempts tobe responsive to the needs and expressedwishes of an enlightened constituency.That is what I experienced at the ArizonaPsychological Association legislativebreakfast this fall. In Louisiana, Jim Quillinand John Bolter have established theirLaFact support network, which is essen-tially a consumer/public citizen “grassroots” organization sympathetic toLouisiana’s psychology RxP- agenda.They successfully worked to receive clear-ance from the APA ethics committee and asof this summer, they had enrolled in excessof 3500 members, surpassing NAMI ofLouisiana. Currently colleagues in at least32 State Psychological Associations haveestablished RxP- task forces. With the num-ber of Americans without health insurancehaving increased to 43.6 million and withyoung adults (18-24 years of age) less like-ly to have coverage than other age groups,it is our societal responsibility to strive toeffectively address these pressing needs.For former APA Presidents Ron Fox, JackWiggins, and myself, RxP- has always firstbeen about providing quality health care ina highly cost effective fashion.
Bulletin ADVERTISING RATESFull Page (8.5” x 5.75”) $300 per issueHalf Page (4.25” x 5.75”) $200 per issueQuarter Page (4.25” x 3”) $100 per issue
Send your camera ready advertisement, along with a check made payable to Division 29, to:Division of Psychotherapy (29)6557 E. RiverdaleMesa, AZ 85215
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DIVISION 29 BOARD OF DIRECTORS MEETING
2004 APA Annual Convention — Toronto, Ontario
Pat Bricklin, president, and LindaCampbell, president-elect
Leon VandeCreek, treasurer, and JonPerez, member-at-large and CE chair
Bob Resnick, past president Abe Wolf, secretary
Roberta Nutt, Fellows ChairMember-at-large Norm Abeles, Pub Board Chair JohnNorcross, Secretary Abe Wolf, Membership Chair Craig
Shealy, Fellows Chair Roberta Nutt, AdministratorTracey Martin, and President Pat Bricklin
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Consider these vignettes that represent thecontributions of three psychologists:
! Helping Underserved Populations
One psychologist donated hundreds ofhours to a struggling clinic servinginner city poor who otherwise wouldnot receive mental health services. Hisefforts kept the clinic afloat and ensuredcontinuity of care until it was eventuallytaken over by another agency.
! Addressing an Important Social Need
A second psychologist researched andspoke about domestic violence andtreated victims of abuse. Her researchled to a better understanding of thecauses and ways to prevent abuse. Herspeaking engagements enlightenedmany professionals and laypersons.Each year she directly provided orsupervised low cost or free services todozens of abused women. Many wouldhave been severely injured, or evenkilled, if it were not for these services.
! Research That Has Saved Many Lives
A third psychologist conducted researchwith inner city youth with, or at risk forcontracting, HIV. Her research led to abetter understanding of effective STDand HIV prevention programs. Her pro-grams probably saved thousands of livesand gave direction to other researchersand practitioners.
These psychologists engaged in commend-able actions. Society is better off and psychology is strengthened as a discipline
because of their contributions. These exam-ples may be especially dramatic, but psy-chologists commonly contribute to otherswithout obvious personal advantage.Other common examples include workingto become especially skilled in an area ofpractice, or donating extra hours a week topatient care without compensation. Ascommendable as these acts are, are theysupererogatory (performing beyond theminimum that is expected by disciplinarycodes; doing more than is required) or doall psychologists have similar responsibili-ties? These questions overlap, but are notidentical, with the question as to whetherpsychologists should be altruistic. Somestriving for excellence or work on behalf ofapparently disenfranchised groups may,under some circumstances, representsenlightened self-interest as opposed toaltruism. However, the motivation forthese actions is incidental to the issue ofwhether they are supererogatory.
The Obligations of Psychologists?The APA Ethics Code, licensing laws andregulations, standards of malpracticecourts, and other laws impose specialobligation on psychologists. According tothe APA Ethics Code (APA, 2002), psychol-ogists must, among other things, avoidharmful conflicts of interests (Standard3.06), protect patient confidentiality (4.01),be competent in their duties (2.01), andavoid unfair discrimination (3.04). Theseand other obligations are further expandedand clarified in the APA Ethics Code.Other psychologists have special obliga-tions to their research participants, organi-zational clients, students, or supervisees.
FEATURE
Do Psychologists Have Supererogatory Obligations?
Samuel Knapp, Ed.D.Pennsylvania Psychological Association
Leon VandeCreek, Ph.D.Wright State University
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In addition, the APA Ethics Code and otherregulatory codes place some obligations tothe public upon psychologists. For example,psychologists must take reasonable steps toprotect the public when they learn ofmisconduct by a psychologist (Standards1.06 and 1.07). Also, according to the dutyto warn or protect, they must take protec-tive measures when a patient presents animminent danger of substantial physicalharm to an identifiable third party (see forexample, VandeCreek & Knapp, 2001).
The disciplinary codes of psychologistsand the standards of malpractice courtsmay subject psychologists to penalties ifthey deliver services below minimal stan-dards. However, are psychologists obligat-ed to go beyond those minimal standardsof behavior? The methodology we will useto answer this question is to considersupererogatory obligations from the stand-point of prima facie or principle-basedethics, which has become very popular indiscussions of health care.
Prima Facie or Principle-Based EthicsAccording to W. D. Ross’ concept of princi-ple-based or prima facie (from the Latin for“first appearance”) ethics, ethical theoryrests on several and not one moral princi-ple. Ross referred to these principles asprima facie duties, meaning an obligationthat holds unless it is overridden by asuperior obligation. Ross identified someof these moral duties as fidelity, gratitude,justice, beneficence, self-improvement, andnonmaleficence, but acknowledged thatthere may be others as well (1930/1998).
However, these moral principles are notabsolute and may be over-ridden if theyconflict with another moral principle.There is no inherent hierarchy to follow indetermining when one moral principleshould override another. When a moralprinciple is overridden, efforts should bemade to make the infringement the leastpossible, commensurate with achieving theprimary goal.
From a principle-based perspective wewould argue that the principle of benefi-cence would obligate psychologists to actto their highest level of ability (such asstriving for high levels of competence ordonating services), subject to the limita-tions placed on them by other obligations.According to principle-based ethics,supererogatory obligations should: (a) notdivert us from our obligation to those withwhom we have special relationships (fami-ly, friends, current patients); (b) be moder-ate and not cause us more suffering thanthey produce relief to others; and (c) bethought out deliberately and done selec-tively (Beauchamp & Childress, 2001).
According to the first point, Ross mighthave criticized the actions of MahatmaGandhi when, in his efforts to ensure jus-tice and well-being for India, he failed toattend to the needs of his family andrefused to pay (or allow his friends to pay)for the education of his children (Fischer,1983). As applied to psychology, psychol-ogists may have obligations to their ownfamily members that require them torestrict their working hours, even thoughmore people would be assisted and theoverall good of the community might beimproved if they worked more hours.
According to the second point, psycholo-gists ought not to donate time and resourcesif doing so causes as much suffering to them-selves as they would relieve through theirgiving. Also, giving to others to the point ofpersonal exhaustion would result in the lossof the gift in the first place. Competence as apsychologist requires emotional compe-tence. Effective psychologists need balancein their personal lives and outside sources ofsocial support and strength. They can gaindistance from their professional lives andhave a breadth of activities and life experi-ences that enrich their work as psycholo-gists. Those psychologists who fail to carefor their personal needs may loose theireffectiveness and their ability to performtheir minimal professional obligations.
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Other Moral TheoriesWe could conduct similar analyses ofsupererogatory behaviors from the stand-point of other ethical theories as well. Forexample, accordingly to Kant’s deontologicalor duty-based ethics, behavior needs to bejudged by the categorical imperative, oneformulation of which can be paraphrasedas “do unto others as you would havethem do unto you” (Kant, 1785/1988).Since we would want other professionalsto show high levels of concern and compe-tence for us if we were patients, we shouldshow high levels of concern and compe-tence for others, even if that concernexceeds the bare minimum required in thedisciplinary codes.
According to utilitarian ethical theory, therightness of an action is determined by theprinciple of utility or the greatest amountof good for the greatest number of persons(Ewing, 1953). The standard of producingthe greatest good for the greatest numberwould require actions exceeding the mini-mum required by legal standards.
According to virtue ethics, the goal ofbehavior is moral excellence (Ewing, 1953).However, it is hardly moral excellence tobe guided only by a desire to avoid sanc-tions for violating a professional standardof conduct.
Application to the Question ofSupererogatory EthicsThe ethical systems reviewed here havestandards of conduct higher than the mini-mum found in the ethics and disciplinarycodes of the profession. Consequently, thequestion that should be asked is not “whatis the minimum that the Ethics Coderequires me to do?” Instead it should be,“what must I do to fulfill my ethical ideals?”If psychologists strive to become moralmaximalists, instead of moral minimalists,they would still follow the disciplinarycodes, but only as the beginning of theirethical responsibilities. Ethics would not beconcerned exclusively with ways to conformto disciplinary codes, but with ways to con-
form to personal ethical ideals. This perspec-tive has been called “positive ethics”(Handelsman, Knapp, & Gottlieb, 2001).
Accordingly, ethics education that focusesexclusively on the minimal standardsfound in the disciplinary codes is incomplete.Ideally ethics education in graduate schoolcourses and continuing education coursesalso will consider how psychologists canintegrate their ethical beliefs into theirwork and rise above minimal obligations.According to Beauchamp and Childress(2001), the “concentration on minimalobligations has diluted the moral life... Ifwe expect only the moral minimum wehave lost an ennobling sense of excellencein character and performance” (p. 44).
ReferencesAmerican Psychological Association.
(2002). Ethical principles of psychologistsand code of conduct. AmericanPsychologist, 57, 1060-1073.
Beauchamp, T., & Childress, J. (2001).Principles of biomedical ethics (5th ed).New York: Oxford.
Ewing, A.C. (1953). Ethics. New York:Free Press.
Fisher, L. (1983). The life of Mahatma Gandhi.New York: Harper & Row.
Handelsman, M., Knapp, S., & Gottlieb, M.(2002). Positive Ethics. In C. R. Snyder &S. Lopez (Eds.), Handbook of positive psychology. (pp. 731-744). New York:Oxford University Press.
Kant, I. (1785/1988). Fundamental principlesof the metaphysics of morals. Amherst, NewYork: Prometheus.
Ross, W. D. (1930; 1998). The right and thegood. In J. Rachels (Ed.). Ethical Theory. (pp. 265-285). New York: OxfordUniversity press.
VandeCreek, L., & Knapp, S. (2001). Tarasoffand beyond (3rd ed.). Sarasota, FL:Professional Resource Press.
1 The views expressed do not necessarilyrepresent those of the PennsylvaniaPsychological Association.
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MEMBERS ATTENDING AWARDS RECEPTION
Linda Campbell, John Norcross,Jennifer Stoddard, Lori Fleckenstein,Kevin Shepard, Jenny VanOverbeek
Bob Resnick, Kal Heller, Jina Carvalho
Tania Lecomte, Louis Castonguay, ConradLecomte
Lorraine Braswell and Brian Glaser
Alan Campbell, Patricia Hannigan-Farley,and Tom DeMaio Susan Neufeldt and Lisa Firestone
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Division 29 is pleased to introduce ourmembership to our new editor ofPsychotherapy: Theory, Research, Practice, andTraining. Dr. Wade Silverman has been oureditor since 1992 and Wade is now leavingthe role as editor. The Division 29Publications Board interviewed three verystrong candidates for the editorship. TheBoard determined that Dr. Charles Gelsohas the understanding of the spirit andpurpose of the Division. Further, he has thepublication and editorial abilities, collegialskills, professional vision, and the passionfor psychotherapy that will represent avery central contribution to our mission.
By way of introducing Dr. Gelso to you,our membership, I have interviewed Dr.Gelso on his own professional journey andon his goals for the journal.
Campbell: Dr. Gelso, congratulations onyour selection as our incoming editor ofPsychotherapy. I am very pleased that youare taking on the job and I’m sure that ourDivision will be greatly benefited by yourleadership. I would like to ask you severalquestions about your interest and experi-ence in psychotherapy and then talk a bitabout your ideas for the Journal.
You have made very important contribu-tions to psychotherapy research and train-ing. How did you first become interestedin psychotherapy research?
Gelso: When I took my very first counsel-ing course (it must have been 100 or soyears ago), I read an article that presentedthe results of an outcome study. I remem-ber my amazement and excitement like itwas yesterday. The logic and method of thestudy fascinated me, and I had a clearsense of wanting to do something like thatin my career. It was a kind of “love at first
sight.” The idea that an enormously com-plex and intriguing process like psy-chotherapy could be studied and quanti-fied really grabbed me, and it still does.
Campbell: In what way has your interestin psychotherapy either changed or refo-cused over time?
Gelso: My early interests were pretty dif-fuse. Studying anything therapy relatedwas fascinating. Then I became morefocused on time-limited therapy and howabbreviating therapy affected the processand outcome of treatment. This interestwas driven by very practical concerns. Atthe University of Maryland’s counselingcenter, we had a huge waiting list and along wait for treatment. Something had tobe done. But could shortening therapyresult in good outcomes? This practicalconcern formed the basis for a researchprogram that I and my colleagues carriedout for several years. Gradually my inter-ests became more theoretical and clinical.Based on my clinical work and the work ofsome of my graduate students, I becameinterested in studying aspects of the thera-py relationship. Topics like countertrans-ference, transference, working alliance,and most recently what I term the real rela-tionship in therapy have captured mycuriosity for the last 20 years or so.Figuring out how to study some of theseconstructs can be brain breaking, but it isalso very intellectually exciting and clini-cally meaningful. I think I’ll stay with thesetopics for a while longer.
Campbell: What do you think are the morecritical areas for continued study in psy-chotherapy research today?
Gelso: I really do not think it is helpful,scholarly, or just plain interesting to think
FEATURE
Interview with Dr. Charles GelsoIncoming Editor of the journal Psychotherapy
Linda Campbell, Ph.D.
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about what topics are the most importantand, by implication, the least or perhapsless important. The important thing is thatwe want to try to understand the processand outcome of diverse forms of therapy,and each scholar/practitioner has his orher own agenda and passion about whatspecifically is important. I suppose in ageneral sense I would say that our growingedge may be to move forward in tacklingwhat I refer to as the “who, what, when,and where question”, e.g., what treatmentsoffer by which practitioners are most effec-tive (and least effective) with what clientspossessing which problems? This of coursewill involve a generation and more ofresearch and theory.
Campbell: How have the important areasfor study changed over the years?
Gelso: Interesting question. When I was agraduate student, the “does it work” ques-tion absorbed the field. I believe that ques-tion has been answered on the whole, andwe are now about the business of address-ing more specific questions. Managed carehas introduced a whole new level of prag-matism into our field, and pushed us in thedirection of figuring out specific treatmentsthat work in the briefest time for specificproblems, often framed in terms of disor-ders. This is a certain version of the “who,what, when, and where” question, and in away it formed the basis for the empirically-validated treatments movement. However,at least initially it was framed in such a cir-cumscribed and, shall I say, theoreticallybiased manner that it was not very helpfulor enlightening. Beyond this general evolu-tion from does it work to more specific andrefined questions, many hot topics havecome and gone over the years, and proba-bly each has left its mark. As this has hap-pened, knowledge has very graduallyaccrued, so that we now actually know atremendous amount about psychotherapy.And yet, the scientific spirit involves neverbeing satisfied—always feeling that we donot know enough. Of course, we shallnever know enough, and when we feel wedo, it is probably time to more on to anoth-er endeavor.
Campbell: You have made very significantcontributions not only to research, but totraining and teaching. Is there a way thatyour expertise in training and teaching cancontribute to your role as editor or to influ-ence the direction of the Journal?
Gelso: If I may dichotomize the world, youmay think of two roles an editor can take:That of gatekeeper and that of educator. Thegatekeeper’s job is to keep all of the junk andworse (a.k.a, bad research and theory) out ofthe journal. The educator, on the other hand,seeks to aid authors in producing the bestwork possible. Naturally the review processis a key part of this, and in this sense, I can-not overestimate the importance of highquality reviews by the editorial board. Theeditor-educator, however, must also workwith these reviews, integrating them andcommunicating to authors in a way that ishelpful, even when the manuscript is notaccepted for publication
Campbell: What do you see as your initialgoals as editor of the Journal?
Gelso: At a very practical level, we need anincrease in submissions if we are to main-tain the number of pages we are allotted.My initial goals are to do the very best jobpossible in reviewing and working withthe manuscripts that are submitted. Iwould like to see some excitement aboutthe Journal, and have it seen as an outletthat scholars and practitioners are eager topublish there work in.
Campbell: How do you see the role of ourjournal among other psychotherapy journals?
Gelso: We have historically and currentlyhad a special place in psychology in thatwe (1) focus exclusively on psychotherapy(2) seek a balance of research, theory, andpractice, and (3) are not theoreticallybiased. Our uniqueness rests in the combi-nation of these three thrusts. The Journalhas a history of being highly relevant topractitioners as well as scientists, of beingopen to all views of psychotherapy, and alsoof being methodologically open, as well.
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Campbell: Our Division mission is to pro-mote training, theory development,research and practice. How do you see therole of the Journal in this mission?
Gelso: I think I just addressed that. As edi-tor, I really do want to seek a balance of allof these areas. Any given article of coursewill not likely be relevant to each of thesedomains, but it is important to me that theJournal is a place that readers go to in orderto find pieces that are highly relevant topractice, highly relevant to science, and ofcourse highly relevant to the integration ofthe two. Well, I’m probably beginning tosound like a politician, which I am not, soI’ll just end by saying that the Journal’s rolein this mission is to publish a balance ofarticles on all of the domains you mention.
Campbell: Making the Journal a home forpsychotherapy research, practice, theory,and training could be a formidable challenge.How will you approach this challenge?
Gelso: Eagerly!
Campbell: What are some topic areas youwould like to see more represented in theJournal?
Gelso: I plan to have some special issuesand special subsections. The first one that Iam already seeking manuscript submis-sions for is the “interplay of therapy tech-niques and the therapeutic relationship.”To me, how the relationship and tech-niques work together in affecting the ther-apy process is a vital area of inquiry.Similarly, variations on the “who, what,when, and where question” are vital. Iwould also like to see continued increasesin submissions pertaining to multiculturalissues in therapy and training. I haven’tthought through other topics, and in fact, Iwant to be cautious about promoting toomany topics. I believe there is a naturalevolution of topics and that editors should-n’t promote their own views too much(although some of this is okay). Most basi-cally, I want the Journal to be methodolog-ically open and also be open to all content.It is the quality of the work that mattersmost, and I am very happy to have the
individual scientist and practitioner decidewhat topics get submitted.
Campbell: Are there emerging issues inpsychotherapy research, practice, training,and theory that you might see as specialfocus area in the Journal?
Gelso: Nope. This would be too limitingand, more important, too, should I say, dom-inating for an editor. Let the field decidewhat topics become hot and thus get studiedand written about. What the Journal can dothat is most helpful to the field is concentrateon improving the quality of research andpresentation through the review process. Ifthe readers, in fact, have ideas for specialsections or issues, I’m all ears.
Campbell: What would you like theDivision 29 members to know about yourprofessional direction and purpose inworking with the Journal?
Gelso: I have always had a great liking forthis journal, and have loved its way of pre-senting a combination of think pieces, clin-ical papers, and research pieces. My “direc-tion and purpose” is to help this journalbecome the very best psychotherapy jour-nal it can be, given its mission. One of thefeatures of Psychotherapy since its earlydays that made it very special to me hasbeen its focus on creativity. I think it hasplaced a premium of creative thinking inpsychotherapy more than just about anyjournal I know. This came through loudand clear in the editorial statements of theearly editors and has been maintained tothe present day. Some of the articles that Iliked best as a reader were pretty theoreti-cally outrageous, i.e., often ahead of theirtimes. One of my goals is to keep this cre-ative focus, while also enhancing method-ological and theoretical rigor. A pretty tallorder, isn’t it.
Campbell: Are there other comments youwould like to make that I haven’t asked?
Gelso: I think I have been redundantenough for one day! Thanks for the oppor-tunity to share some of my views.
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Ronald F. Levant, Ed.D., A.B.P.P., is a fellow ofDivision 29 and a candidate for APA President.He is in his second term as Recording Secretaryof the American Psychological Association. Hewas the Chair of the APA Committee for theAdvancement of Professional Practice (CAPP)from 1993-95, a member at large of the APABoard of Directors (1995-97), and APARecording Secretary (1998-2000). He is Dean,Center for Psychological Studies, NovaSoutheastern University, Fort Lauderdale, FL.
I would like to weigh in on the issue ofwhat has been called, sequentially, “empir-ically-validated treatments” (APA Divisionof Clinical Psychology, 1995), “empirically-supported treatments” (Kendall, 1998), andnow “evidence-based practice” (Instituteof Medicine, 2001).
Empirically-validated treatments is a diffi-cult topic for a practitioner to discuss withclinical scientists. In my attempts to discussthis informally, I have found that some clini-cal scientists immediately assume that I amanti-science, and others emit a guffaw, askingincredulously: “What, are you for empirical-ly unsupported treatments?” McFall (1991,p. 76) reflects this perspective when hedivides the world of clinical psychologyinto “scientific and pseudoscientific clinicalpsychology,” and rhetorically asks “what isthe alternative [to scientific clinical psychol-ogy]? Unscientific clinical psychology.” (seealso Lilienfeld, Lohr, & Morier, 2001).
There are, thus, some ardent clinical scien-tists (e.g., McFall and Lilienfeld) whoappear to subscribe to scientistic faith, andbelieve that the superiority of scientificapproach is so marked that otherapproaches should be excluded. Since this
is a matter of faith rather than reason, argu-ments would seem to be pointless.Nonetheless, clinical psychologists haveargued over it, a lot, for the last eight years.Punctuating these interactions from thepractitioner perspective, the controversyseems to stem from the attempts of someclinical scientists to dominate the discourseon acceptable practice, and impose verynarrow views of both science and practice.
Let’s start with a brief recapitulation of theevents. Division 12, under the leadership ofthen-President David Barlow, formed aTask Force “ to consider methods to edu-cate clinical psychologists, third party pay-ors, and the public about effective psy-chotherapies” (APA Division of ClinicalPsychology, 1995, p. 3). The Task Forcecame up with lists of “Well-EstablishedTreatments” and “Probably EfficaciousTreatments.” Not surprisingly, the liststhemselves emphasized short term behav-ioral and cognitive-behavioral approaches,which lend themselves to manualization;longer term, more complex approaches(e.g., psychodynamic, systemic, feminist,and narrative) were not well represented.
The empirically-validated treatmentsmovement has had quite an impact onpractitioners. It provided ammunition tomanaged care and insurance companies touse in their efforts to control costs byrestricting the practice of psychologicalhealth care (Seligman & Levant, 1998). Ithas also influenced many local, state andfederal funding agencies, who now requirethe use of empirically-validated treat-ments. Moreover, this movement couldhave an even greater impact on practition-ers in the future. For example, it could cre-ate additional hazards for practitioners inthe courtroom if empirically-validated
FEATURE
The Empirically-Validated Treatments Movement:A Practitioner Perspective1
Ronald F. Levant
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treatments are held up as the standard ofcare in our field. Further, adherence toempirical-validated treatments couldbecome a major criterion in accreditationdecisions and approval of CE sponsors, asthe Task Force urged (APA Division ofClinical Psychology, 1995, p. 3). Some clin-ical scientists have gone so far as to call forAPA and other professional organizations“to impose stiff sanctions, including expul-sion if necessary,” against practitionerswho do not practice empirically-validatedassessments and treatments (Lohr, Fowler& Lilienfeld, 2002, p. 8).
Given all of this fallout, it should be no sur-prise that the Task Force report was soonsteeped in controversy. Critics argued firstand foremost that the Task Force used avery narrow definition of empiricalresearch. For example, Koocher (personalcommunication, 7/20/03), observed that“‘empirical’ is in the eye of the beholder,and sadly many beholders have very nar-row lens slits. That is to say, qualitativeresearch [and] case studies… have longbeen a valuable part of the empirical foun-dation for psychotherapy, but aredemeaned or ignored by many for whom‘empirical validation’ equates to ‘random-ized clinical trial’ [RCT]. In addition, a ran-domized clinical trial demands a treatmentmanual to assure fidelity and integrity ofthe intervention; however, the real worldof patient care demands that the therapist(outside of the research arena) constantlymodify approaches to meet the idiopathicneeds of the client…Slavish attention to‘the manual’ assures empathic failure andpoor outcome for many patients.”
Furthermore, Seligman and Levant (1998)argued that, whereas efficacy research pro-grams based on RCT’s may have highinternal validity, but they lack external orecological validity. On the other hand effec-tiveness research, such as the ConsumerReports study (Seligman, 1995), has muchhigher external validity and fidelity to theactual treatment situation as it exists in thecommunity. Additional effectiveness stud-ies are needed, and could be conducted bythe Practice-Research Networks that have
recently appeared (Borkovec, Echemendia,Ragusea, & Ruiz, 2001). Finally, othershave pointed that many treatments havenot been studied empirically, and thatthere is a big difference between a treat-ment that has not been tested empirically,and one that has not been supported by theempirical evidence.
A few years later, John Norcross, then-President, of Division 29 (Psychotherapy),countered by establishing a Task Force on Empirically Supported TherapyRelationships in 1999, which emphasizedthe person of the therapist, the therapyrelationship and the non-diagnostic char-acteristics of the patient (Norcross, 2001).Lambert and Barley (2001) summarizedthis research literature, pointing out thatspecific techniques (namely those thatwere the focus of the studies underlyingthe Division 12 Task Force Report) account-ed for no more than 15% of the variance intherapy outcomes. On the other hand, thetherapy relationship and factors commonto different therapies accounted for 30%,patient qualities and extra therapeuticchange accounted for 40%, and expectancyand the placebo effect accounted for theremaining 15%.
Westen and Morrison (2001) reported a mul-tidimensional meta-analysis of treatmentsfor depression, panic disorder, and GAD, inwhich they found that “the majority ofpatients were excluded from participating inthe average study,” due to the presence of comorbid conditions (p. 880). Approxi-mately 2/3 of the patients in the studies theyreviewed were excluded, which seems like ahigh percentage, but is actually a bit lowerthan national figures for comorbidity.Meichenbaum (2003) noted that fewer than20% of mental health patients have only oneclearly definable Axis I diagnosis. Thus, thevast majority of cases seen by practitionersdo not meet the exact diagnostic criteriaused in the RCT’s that established efficacyfor various treatments.
Furthermore, the empirically-validatedtreatments on these lists have typically
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been studied using homogeneous samplesof white, middle class clients, and thereforehave not often been shown to be efficaciouswith ethnic minority clients.
So what does this all mean? Suppose wehad lists of empirically-validated manual-ized treatments for all DSM Axis I diag-noses (which we are actually a long waysaway from). We would then have treat-ments for only 20% of the white, middleclass, patients who come to our doors,namely those who meet the diagnostic cri-teria used in studies that validated thesetreatments. That’s bad enough, but that’snot all. In order to limit services to onlythese 20% of the white, middle class,patients who come to us, the average prac-titioner would have to spend many, manyhours, perhaps years, in training to learnthese manualized treatments. And if werestricted ourselves to use only these man-ualized treatments, we would be limitingour role to that of a technician. And, in theend, these treatments would only accountfor 15% of the variance in therapy outcomesin these patients. One can readily see whyfew practitioners embraced the empirical-ly-validated treatments movement.
My view is although one of psychology’sstrengths is its scientific foundation, thepresent body of scientific evidence is notsufficiently developed to serve as the solefoundation for practice. Practitioners mustbe prepared to assess and treat those whoseek our services. To be sure, we all getreferrals of clients that we decide to refer toothers because we don’t think that we arethe best clinician for that case, but thosewho are in general practice have to workwith the clients that come to us. Whetherwe operate from a single theoretical per-spective or are more eclectic, we bring tobear all that we know from the empiricalliterature, the clinical case studies literature,and prior experience, as well as our clinicalskills and attitudes, to help the client that issitting in front of us. This is what is oftenreferred to as clinical judgement. Some con-demn clinical judgement as subjective. To
them I say that clinical judgement is simplythe sum total of the empirical and clinicalknowledge and practical experience andskill which clinicians bring to bear when itis our job to understand and treat a particu-lar and very unique person.
Fox (2003) goes even further, pointing outthat in many learned fields science andpractice are often separate endeavors, andthat practice often has to precede science.Physicians were treating cancer long beforethey had much of an idea of what it was,and were using pharmaceutical agents likeaspirin long before the pharmacodynamicswere known. To quote Fox (2003):
The fact of the matter is that if cliniciansrestrict themselves to applying only narrow-ly validated or known techniques, they willnever be of much value to society. Lest youthink that statement is an invitation to char-latanism, remember that clinicians do nothave the luxury to start from what is known.They must start with the needs of the peoplewho come to them and then apply all theknowledge, information and skill they haveto help resolve those problems.
On the other hand, we do have a problemof accountability in health care, one thatwill surely affect psychology. For example,the current lag between the discovery ofmore effective forms of treatment in healthcare and their incorporation into routinepatient care is, on the average, 17 years.DeLeon (2003) predicts that health care inthe 21st century, abetted by technology,will be characterized by even greateraccountability for practitioners, due to thecombined effects of the increasingly well-informed health care consumer, whogathers relevant health care informationfrom the internet, the increasingly well-informed practitioner, who will be able toobtain best practice information from aPDA, and increased monitoring of healthcare practices, to flush out variation intreatment for specific diagnoses. In thisenvironment we are going to need bettersways to evaluate practice. I would suggest
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that we consider using the broad and inclu-sive definition of evidence-based practiceadopted by the Institute of Medicine(2001). This definition consists of threecomponents: best research evidence, clinicalexpertise and patient values. The definitiondoes not imply that one component is priv-ileged over another, and provides a broadperspective that allows the integration ofthe research (including that on empirically-validated treatments and that on empiri-cally supported therapy relationships)with clinical expertise and, finally, bringsthe topic of patient values into the equa-tion. Such a model that values all threecomponents equally will better advanceknowledge related to best treatment, andprovide better accountability.
As always, I welcome your thoughts onthis column. You can most easily contactme via email: [email protected].
ReferencesAmerican Psychological Association
Division of Clinical Psychology (1995).Training in and dissemination of empiri-cally-validated psychological treat-ments: Report and recommendations.The Clinical Psychologist, 48, 3-27.
Borkovec, T. D., Echemendia, R. J., Ragusea,S. A., and Ruiz, M. (2001). ThePennsylvania Practice Research Networkand possibilities for clinically meaningfuland scientifically rigorous psychotherapyeffectiveness research. Clinical Psychology:Science and Practice, 8, 155-167.
DeLeon, P.H. (2003). Remembering ourfundamental societal mission. PublicService Psychology, 28, 8, 13.
Fox, R. E. (2003, August). Toward creating areal profession of psychology. Paper pre-sented at the Annual Meeting of theAmerican Psychological Association,Toronto, Ontario, Canada.
Gonzales, J.J., Rngeisen, H. L., & Chambers,D. A. (2002). Clinical Psychology: Scienceand Practice, 9, 204-220.
Institute of Medicine (2001). Crossing theQuality Chasm: A new Health System forthe 21st Century. (2001). Institute ofMedicine: Washington, DC.
Kendall, P. C. (1998). Empirically support-ed psychological therapies. Journal ofConsulting and Clinical Psychology, 66, 3-6.
Lambert, M. J., & Barley, D. E. (2001).Research summary on the therapeuticrelationship and psychotherapy outcome.Psychotherapy: Theory/Research/ Practice/Training, 38, 357-361.
Lilienfeld, S.O., Lohr, J. M., & Morier,D.(2001). The teaching of courses in thescience and pseudoscience of psychology:Useful resources. Teaching of Psychology,28, 182-191
Lohr, J. M., Fowler, K. A., & Lilienfeld, S.O. (2002).The dissemination and promo-tion of pseudoscience in clinical psychol-ogy: The challenge to legitimate clinicalscience. The Cliical Psychologist, 55, 4-10
McFall, R. M. (1996). Manifesto for a sci-ence of clinical psychology. The ClinicalPsychologist, 44, 75-88.
Meichenbaum, D. (2003, May). TreatingIndividuals with Angry and AggressiveBehaviors: A Life-Span Cultural Perspective.Paper presented at the Annual Meetingof the Georgia PsychologicalAssociation, Atlanta, GA.
Norcross, J. C. (2001). Purposes, processes,and products of the Task Force onEmpirically Supported Therapy Relation-ships. Psychotherapy: Theory/Research/Practice/Training, 38, 345-356
Seligman, M.E.P. (1995). The effectivenessof psychotherapy. American Psychologist,50, 965-974.
Seligman, M. E. P., & Levant, R. (1998).Managed care policies rely on inade-quate science. Professional Psychology:Research and Practice, 29, 211-212.
Westen, D. and Morrison, K. ( 2001). A mul-tidimensional meta-analysis of treatmentsfor depression, panic, and generalizedanxiety disorder: An empirical examina-tion of the status of empirically supportedtherapies. Journal of Consulting and ClinicalPsychology, 60, 875-899.
1 Adapted from Levant, R. (in press). Theempirically-validated treatments move-ment: A practitioner/educator perspective.Clinical Psychology: Science and Practice.
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