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Treatment development: Can we find a better way?
Treatment Development: Can We Find a Better Way? Steven C. Hayes, Douglas M. Long, Michael E. Levin, William C. Follette PII: DOI: Reference:
S0272-7358(13)00050-0 doi: 10.1016/j.cpr.2012.09.009 CPR 1310
To appear in:
Clinical Psychology Review
Received date: Revised date: Accepted date:
2 March 2012 17 August 2012 13 September 2012
Please cite this article as: Hayes, S.C., Long, D.M., Levin, M.E. & Follette, W.C., Treatment Development: Can We Find a Better Way?, Clinical Psychology Review (2013), doi: 10.1016/j.cpr.2012.09.009
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ACCEPTED MANUSCRIPT A Reticulated Functional Contextual Approach to Treatment Development Treatment Development: Can We Find a Better Way? Steven C. Hayes
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Douglas M. Long
William C. Follette
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University of Nevada
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Michael E. Levin
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Address editorial correspondence to Steven C. Hayes, Department of Psychology / 298,
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University of Nevada, Reno, NV 89557-0062
Key words: Treatment development, stage model, functional analysis, theory, contextual behavioral science
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Abstract
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The present paper argues that traditional approaches to treatment development, including
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a technological approach, a stage model, and existing inductive approaches such as functional analysis are inadequate in various ways. Treatment developing needs to focus more on
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theoretical development, practicality, and the fit with clients and practitioners. We argue that
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progress requires greater philosophical clarity, and steps to ensure a connection between philosophy of science assumptions and an analytic agenda which fits naturally with applied
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psychology. Theoretical progress requires distinguishing between clinical and basic models and harmonizing their relationship, and more focus on the manipulable context of action. Applied
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psychology needs to join in a common cause with basic psychology in domains of mutual interest, and develop basic analyses and mid-level terms that can be both scientifically
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progressive and clinically useful. Issues of practicality, capacity for dissemination, and public health impact need to be considered at the beginning and throughout treatment development. Issues of effectiveness, change processes, mediation, moderation, training, active components, and similar issues should be part of the evaluation system from the beginning. It is time to create a more coherent approach to treatment innovation.
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Treatment Development: Can We Find a Better Way? There is no well articulated and agreed upon contemporary model of treatment
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development in psychology. Outside forces such as research funding requirements, changes in
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psychiatric nosology, or agency regulations regarding evidence-based treatments, seem to have as much or more influence on methods of treatment development than do strategic visions of
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clinical researchers. As a result, psychosocial treatment development is based on a patchwork of
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strategies, many ad hoc, conducted in diverse research traditions. The field needs to consider how the various methods at its disposal can be integrated into a long-term strategy to create real
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progress. The purpose of the present article is to suggest one possible way to rise to this challenge.
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Some of our suggestions rise directly from concerns regarding mainstream views of treatment development, and others rise from positive developments we have observed in the
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field. In its most general form, the purpose of the present article is to argue for an approach to treatment development that is more practical, theoretically focused, and sensitive to the issues raised by those individuals to whom treatment is directed and the individual practitioners who apply these methods. In its most specific form, the purpose of this article is to argue for a reticulated (that is, based on a network of research methods) functional contextual approach to treatment development – what we have termed a “contextual behavioral science” (CBS) approach – in which treatment development is targeted by an integrated network of research methods based on a philosophy of science and set of analytic goals consciously harmonized with practical aims.
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A Reticulated Functional Contextual Approach In a series of papers we have laid out the CBS approach to knowledge development
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(Hayes, Barnes-Holmes, & Wilson, in press; Hayes, Levin, Plumb, Boulanger, & Pistorello, in press; Levin & Hayes, 2009; Vilardaga, Hayes, Levin, & Muto, 2009). An elaboration of the
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inductive, functional contextual strategy used in behavior analysis, CBS is “a principle-focused,
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inductive strategy of psychological system building, which emphasizes developing interventions
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based on theoretical models tightly linked to basic principles that are themselves constantly upgraded and evaluated. It involves the integration and simultaneous development of multiple
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levels of a research program including philosophical assumptions, basic science, basic and applied theory, intervention development, and treatment testing” (Hayes, Levin et al., in press).
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Our point is that treatment development cannot be considered separately from the development
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of behavioral science as a whole – it is the tip of a much larger iceberg – and a weakness in one
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area tends to be a weakness for the entire enterprise. Our goal in the present paper is broader that an explication of CBS per se, and in the present paper we will outline the key facets of treatment development from a reticulated functional contextual perspective in a way that other philosophical and theoretical perspectives can use. Figure 1 describes the elements of the approach and their relationship to each other. Each of these facets will be introduced and discussed in the sections that follow with specific examples taken from various areas in clinical psychology and suggestions for how functional contextual strategies can be integrated into treatment development. We should point out before we begin that all of the various elements of this model are already at play in the psychological sciences, and several have regularly been explicitly linked to treatment development by major researchers (e.g., Barlow, 2004; King & Ollendick, 2008).
ACCEPTED MANUSCRIPT A Reticulated Functional Contextual Approach to Treatment Development Some of the elements we will discuss have recently been receiving increased emphasis by funders, as we will note. At the same time, the harmonious integration of all of these various
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elements seems important, and provides an alternative that may have advantages. No single individual or laboratory is likely to mount all elements of the strategy we will
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describe but we would argue that treatment development is best viewed as a disciplinary issue –
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as a problem for the field as a whole, not just a single laboratory or a single approach. If
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individuals have an overall awareness of how their work may fit into the progress of the field overall in rising to the challenge of treatment development, they are better positioned to
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communicate what they learn in a way that can be used effectively by others. We will set the stage for our suggestions by highlighting important historical
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developments and shortcomings of traditional models of therapy development. We will then provide specific suggestions for treatment development based on the functional
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contextual or CBS approach including the role of philosophical assumptions in theory development and treatment research, how to develop theoretical models that fit with the pragmatic goals of treatment development, important practical considerations for treatment development, and how various methodologies can be used to meet the goals of treatment development.
The Limits of a Topographical / Technological Approach, and the Need for Theory and Philosophy At least in an ad hoc sense, the core focus of treatment development in the last 30 years has been based on the creation and evaluation of well-specified treatment manuals focused on well-defined syndromal categories. Sometimes called the “FDA model” after the standards for safe and effective pharmacotherapy established by the United States Food and Drug
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Administration, this approach is topographical and technological, and arose in an explicitly atheoretical historical context. While the early and middle part of the last century saw a rise in
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interest in psychological theory, culminating in the central role of learning theory, the latter half
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of the century was much more methodologically and technologically focused. Methodological writings from this time period (e.g., Paul, 1967; London, 1964) are very clear that this change
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was deliberate. In his 1967 argument for technical eclecticism, for example, Lazarus vented that
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theories are, “often able to explain everything but to accomplish almost nothing” (p. 416). In a review of studies published in the Journal of Consulting and Clinical Psychology across the next
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three decades, Omer and Dar (1992) found that in the 1960’s, 69% of the studies had a clear theoretical rationale. That proportion had dropped by more than half in the next two decades,
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with such rationales being presented in 30% of the studies in the 1970’s, and 31% in the 1980’s. Similar trends were found for studies investigating treatment processes, and studies giving a
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theoretical rationale for the isolation of variables. This a-theoretical trend coincided with an effort to solve the unreliability of psychiatric diagnosis, wherein the DSM-III (American Psychiatric Association, 1980) took a prototypical approach in which diagnoses would be based on checklists of signs and symptoms (see Kirk & Kutchins, 1992 for an interesting version of the history of DSM-III). The DSM-III quickly became the organizing theme for much of the research on mental health problems supported by the federal government in the US. Journals emerged carrying the names of various disorders identified by the DSM; clinics organized themselves around these categories. Efforts to identify useful treatments were organized around these diagnostic entities as well. Funding sources began demanding technologically well-specified treatment protocols that detailed techniques, therapist training, and adherence monitoring (e.g., Carroll & Rounsaville, 1990; Waskow, 1984). This
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approach increased the internal validity and replicability of psychotherapy research and lists of evidence-based treatments such as that of the American Psychological Association (Task Force
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on Promotion and Dissemination of Psychological Procedures, 1995) appeared that organized
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treatments by their targeted syndromal categories.
While progress has been made over the last 30 years, the combination of topographically
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defined syndromes and technologically-well specified treatment manuals has proven itself to be
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problematic as an adequate model of treatment development, as distinct from treatment evaluation. We will begin on the diagnosis side. Syndromal diagnosis is based on the idea that
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collections of signs and symptoms can lead to the identification of problems with a known etiology, course, and response to treatment. Said more directly, the purpose of syndromes is
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progress toward the ultimate identification of diseases, which are functional, not topographical entities. So far that effort has failed. The American Psychiatric Association DSM-V workgroup
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reach the dire conclusion that “research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur.” (Kupfer et al., 2002, p. xix). The progress on response to treatment has been equally limited. As the list of empirically supported treatments has grown, it has become apparent that many evidence-based therapies are helpful for a wide variety of problems. Cognitive behavior therapy for depression, was not that different than cognitive behavior therapy for anxiety, cognitive behavior therapy for personality disorders, cognitive behavior therapy for PTSD and so on. The DSM-V workgroup concluded “with regard to treatment, lack of specificity is the rule rather than the exception.” (Kupfer et al., 2002, p. xviii).
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The topographical strategy has a decent chance of working when a given etiological process gives rise to a characteristic result but it is of little help when common etiological
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processes can give rise to many different topographical outcomes; or when many different
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etiological processes can lead to similar outcomes. The very intransigence of the search for psychiatric etiology suggests that behavioral health problems may be of this variety. In the
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absence of etiological clarity, a topographical approach gives treatment developers little
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guidance other than the common sense strategy of targeting the content of syndromal checklists. This has a characteristic effect: treatments tend to be multifaceted packages, with different
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techniques focused on the different topographical properties of the syndrome itself. For example, if a given disorder has “anxiety” on the checklist, treatment packages will tend to include
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components such as relaxation training that purportedly target that element. Multi-element packages are often loosely bound as a result, having the quality of collections of elements. As
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new manuals are written they combine elements of older packages, mixed together into a kind of technological stew.
The inclusions of previously validated elements in multi-element packages is fostered by another aspect of the technological approach: in order to secure funding, developers need to already have in hand well crafted manuals, therapist training programs, adherence measures, and preliminary data on acceptability and efficacy. It is much easier to rise to that challenge when portions of a treatment approach are already validated. As new and interesting treatments emerge, these elements are often simply added to old methods, without much concern for theoretical coherence. For example, as mindfulness and acceptance methods have emerged in cognitive behavior therapy, new treatment packages are assembled that contain mindfulness
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components along side a wide variety of other methods, some of which may fit poorly with the core ideas behind mindfulness work.
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The mountain of manuals and methods that result from these “slice and dice” tendencies
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are difficult even to describe in ways other than mere lists or groupings based on broad philosophical or theoretical traditions. The evidence-based treatments list maintained by Division
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12 of the American Psychological Association currently has no requirement that new treatment
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methods work by putative processes. The debates regarding the extent to which Eye Movement Desensitization and Reprocessing (EMDR) is distinct from exposure techniques offers an
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excellent example of this issue (Herbert et al., 2000; Rosen, 1999). The practical problem this produces in terms of techniques is incoherence. Techniques
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alone do not explain how to simplify methods, approach new problems or situations, or develop new methods. It becomes difficult to assimilate the mountain of seemingly disconnected bits of
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information and the field becomes an incoherent mass, difficult to master and difficult to teach. Meanwhile other well-developed areas of science cannot readily be be related to clinical techniques due to the shallow level of analysis (Hayes, Strosahl, & Wilson, 1999, p. 15). From a functional point of view, researchers need to be clearer about what is being created and evaluated in treatment development. Precisely speaking, psychological scientists create verbal rules and principles that guide action and implementation. Even a purely technological description (e.g., a step-by-step description of a therapeutic technique) fits that categorization. The difference between a purely technological description and a theoretical one is the scope of the verbal rules and principles. Those that have high scope (e.g., apply across a range of specific problems, situations, backgrounds, and so on) have a practical advantage, providing they can retain their precision and impact. That has proven difficult, for reasons we
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will explore, but it is a good place to begin with implications from a functional contextual perspective (what we will call here “CBS Suggestions”).
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CBS Suggestion 1: Be Deliberate about Theory and Principle Development The rejection of the classical systems-era theories in psychology (Omer & London,
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1988) resulted in “an endless stream of almost disconnected studies” (Omer & Dar, 1992, p. 92).
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There have been frequent calls over the years for the importance of theory to treatment
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development (e.g., Barlow, 2004; Barlow, Hayes, & Nelson, 1984; Hayes, Barlow, & NelsonGray, 1999; King & Ollendick, 2008) and in recent years the pendulum seems to be swinging
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back in a theoretical direction. For example, critics of the Division 12 EBT list approach to empirically supported treatments have pointed out the importance of treatment distinctiveness to
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scientific progress in clinical psychology (Herbert, 2003). Logically, treatments are only distinct in a functional sense if they differ by their causal processes, or by the methods they use to alter
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these processes (O'Donohue & Yeater, 2003). If this idea were taken seriously, however, the field would begin to move more toward empirically supported principles of change (Rosen & Davison, 2003) as the specific procedures that alter specific processes were identified. That is an inherently theoretically focused idea in which procedures are clustered and defined according to the theoretical processes they alter. If it is true in clinical psychology that ‘There is nothing so practical as a good theory’ (Lewin, 1951, p. 169), it is because theory and principles seem to be needed to apply knowledge to novel problems and situations, to have a systematic way of developing new technologies, and to organize current knowledge into a coherent whole (Hayes, 1998a). The problem is that there seems to be little discussion of the kind of theories needed to accomplish such ends, the conditions under which they are likely to be derived, and how that can be evaluated. Very little
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has been written about theory-selection criteria in applied psychology. What are the methodological standards to which theoretical concepts and their relations to one another should
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be adapted for those interested in treatment development? The assessment of scientific progress
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is the ultimate metric, but that is necessarily a historical exercise. Scientists need more proximal rules-of-thumb by which they can decide which theories to disseminate, amend, or abandon.
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Giving preliminary guidance of that kind is a key purpose of the present paper.
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CBS Suggestion 2: Use Philosophy to Guide Theory Development Paul Meehl once noted that “there is no guaranteed, automated truth-generating
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machinery” (1992, p. 273). In the technological era that is now waning, facts were sometimes thought to speak for themselves, but philosophers of science have warned that there is an
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underdetermination of theory by data (Laudan, 1996), and that observation statements are theory laden (Kuhn, 1962). To the extent that is true, atheoretical science is an illusion (see Moore,
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2010) and the choice is not whether we have theory or no theory as treatment developers, but rather one of whether theoretical concepts are overt, owned, and deliberately tailored to serve a stated analytic agenda. The fact that there is no one “scientific method” that dictates conceptual choices is exemplified by the ambiguities inherent in statistical analyses (Scarr, 1985; Forster, 2000), as well as in diagnostic categories (Wonderlich, Crosby, Mitchell, & Engel, 2007). Some of the key assumptions that scientists therefore need to clarify are their domains, units of analysis, what they mean by truth, what is valued and progressive, and how various conceptual standards are prioritized (Laudan, 1977). It is the task of philosophy of science to own one’s assumptions and values – to take responsibility for the coherence and purpose of one’s own intellectual activity. Clarity about one’s philosophy of science states for oneself and others “here I stand.”
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While everyone can agree that scientific progressivity is desirable, there is marked disagreement about what it means for a theory to be progressive or even what a theory is. We
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will adopt the view that the goal of theory is to accomplish analytic goals with precision, scope,
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and depth (the first two criteria we have described; last refers to consilience across levels of analysis, for example, nothing seen at the level of biology should contradict principles that apply
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at the level of behavior).
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Some scientists, what we term here “elemental realists,” seek to discover and describe the parts, relations, and forces that are assumed to exist and to make up the psychological world.
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From the elemental realist viewpoint, the aim of science is to model the world so that it can be ontologically understood and predicted, and precision, scope, and depth emerge naturally when
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accurate models of reality are developed.
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Others, labeled as contextualists, seek to appreciate the historical, purposive action – the
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act in context – and they see their own scientific work as itself an act in context. Just as one’s goals can vary, so too can one’s assessment of a theory’s utility, and thus there are types of contextualists defined by the kind of theories they seek. While descriptive contextualists (hermeneutics, dramaturgy, narrative psychology, and the like) seek an appreciation of the participants in the whole, functional contextualists seek the prediction-and-influence of behavior (Hayes, Hayes, Reese, & Sarbin, 1993; the goal is hyphenated to indicate that it is not severable). In conjunction with such divergences, research traditions have very different criteria for theoretical evaluation. Several authors have noted how different sets of assumptions lead to different standards for knowledge and progressivity that can impact theory development (e.g., Cacioppo, Semin, and Bernston, 2004). This can be tangibly felt in many of the activities involved in treatment model
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development, such as research methods (e.g., Fishman, 1999) and assessment (e.g., Borsboom, 2005). Furthermore, what is taken to be “causal” varies across research traditions and in ways
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that have been felt in discussions of treatment development (e.g., Bandura, 1995; Hayes &
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Wilson, 1995). We shall revisit the issue of causality shortly. For the time being, our point is merely that scientific values and assumptions serve to establish selection criteria to which
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theories are adapted, and thus if theories are key to treatment development, philosophy of science
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cannot be ignored.
CBS Suggestion 3: Seek Harmony between the Natural Analytic Agenda of Treatment Research
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and Philosophical Assumptions
So far there is little in this discussion about treatment development per se. In order to
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examine this we need to consider the natural analytic agenda of treatment research and applied research more generally (i.e., the generally agreed upon goals of such research). We define
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treatment development as the process of creating systematic methods of change that accomplish practical goals in behavioral health and human development. Thus, the natural analytic agenda of treatment development is to create methods of change, systematized and organized by conceptual and empirical scientific analysis and evaluation, and held to account to the accomplishment of practical goals. It is philosophically dogmatic to criticize scientific assumptions because assumptions enable analysis, they are not the results of analysis. Nevertheless, it is not dogmatic to insist that the natural analytic agenda of treatment development be consciously integrated with a scientist’s assumptions if they are going to do treatment development. For example, some learning theorists have argued against the development of principles and theories via a focus on pragmatic criteria. In their eyes, principles should be focused on what was unobserved, hypothesized or deduced,
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and not what was observed or manipulated. Spence went so far as to claim that if there was a functional relation that was “always the same … then we would have no need of theory” (1944,
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p. 71). He added that theoretical constructs are “guesses as to what variables other than the ones
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under the control of the experimenter are determining the response” (1944, p. 71, italics added). If this is what theory is, it is useless for practitioners who seek consistent and functional relations
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that can be changed and manipulated to accomplish practical goals. Entity-postulating
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hypothetico-deductive theories (i.e., models that give a causal role to theoretical concepts that are not directly observable, or manipulable and must be inferred from a variety of indicators such as
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self-esteem, or intentions), seem especially prone to this problem (Kane, 2001). We know of no philosophies of science that actively conflict with the natural analytic
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agenda of treatment development, but in some cases overlap between the two has to be fostered because nothing in the assumptions of the scientist ensures it. For example, a scientist who sees
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science merely as a matter of recognizing consistent forms (being able to properly categorize nature) might produce a nosology that is entirely consistent and broadly applicable but that is not linked to treatment implications and thus has no treatment utility (Hayes, Jarrett, & Nelson, 1987). The disconnection between such formistic assumptions and the pragmatic nature of the treatment developer’s natural analytic agenda can be repaired, however, by adding treatment responsivity as a key characteristic of the nosology itself (i.e., identifying categories of clinical problems that are predictive of response to treatment, and rejecting any categories that fail this test). By taking the natural analytic agenda of treatment development more seriously, the needed philosophical adjustments can be made. CBS Suggestion 4: Purportedly Functional Processes Must be Manipulable
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Functional contextualists, such as those in the Skinnerian tradition, constrain “causal” attributions to manipulable variables. This constraint is made strategically, according to the goals
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of the prediction and influence of behavior (O’Donohue & Szymanski, 1996). With such a
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constraint, one psychological action can never be said to “cause” another in the same individual (Hayes & Brownstein, 1986). With more elemental realist assumptions, the predictive capacity
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of models of the world are not limited by manipulability. Dependent variables such as thoughts
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or emotions can be said to “cause” other dependent variables such as overt action, for example. I would be dogmatic to rule out such analyses on philosophical grounds, but it is not dogmatic to
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consider them incomplete on practical grounds. It is part of the natural analytic agenda of clinicians to predict and influence behavior. This simple fact gives favor to processes or
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variables in therapy models that are directly manipulable. Where functional status is entertained for variables that are non-manipulable, either in principle or due to current technical inability, the
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analysis should be viewed as practically incomplete until the manipulable variables are understood. In practical terms that means that contextual variables have to be given favor in effective treatment development.
These ideas are easily understood within a CBS approach because it is the core of functional contextual thinking (Hayes & Brownstein, 1986), but it can be more difficult for other scientific models. The best prediction of future action is past action, and thus it is quite possible to create effective predictive models consisting entirely of dependent variables such as attitudes, intentions, expectations, or overt behavior. The problem is that when these models are used in application, sooner or later the practitioner needs to do something. The practitioner is in the clients context and that doing will be an independent contextual variable. It needs to be included it in the analysis.
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Consider, for example, the difference between a theory of clinical change that oriented toward the self-esteem of clients, versus a superficially similar theory that focused on the
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empowering effects of validation in the therapeutic relationship and its effect on self esteem.
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Until context is specified, the former theory treats dependent variables as causes, whereas the latter example points to a directly manipulable variable in the form of the actions of the clinician.
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Many theories never fully specify the contexts in which various psychological events have
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effects, and when they are tested, that gap in knowledge is exposed. In one disturbing example, efforts made by the US state of California at improving academic performance through
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enhancing self-esteem may have actually backfired (Baumeister, Campbell, Krueger, & Vohs, 2005). Thus, even if it is not demanded by core assumptions, treatment developers from all
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scientific models need to be sure that their theories ultimately include variables that can be changed and manipulated directly. That is the only way to foster a good fit between theories and
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the natural analytic agenda of treatment development. Summary. While programmatic treatment development research has been described in and evolved over time (c.f., Mercer, DeVinney, Fine, Green, & Dougherty, 2007; Rounsaville, Carroll, & Onken, 2001), there is limited clarity about the role of theory and the kinds of theories that are needed. Treatment developers need to take a purposeful approach to developing the types of theories that will comport both with one’s philosophical assumptions and the goals of treatment development. That seemingly can be done for all scientific approaches and philosophies but only if it is done deliberately. Using Translational Exchanges Between Basic and Applied Science to Fuel Theory Development
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From the beginning of psychology there has been a hope by some that bottom up accounts can guide treatment development. Instead of digging down toward functional entities
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from topographical ones, some have preferred to start with functional variables and see if it is
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possible to model human complexity. We will now move to a discussion of this major approach to treatment development, exploring its benefits and limitations.
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Functional Analysis
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Perhaps the classic example is functional analysis. Functional analysis has had a wide variety of meanings within behavior analysis and therapy (Haynes, O'Brien, & Kaholokula,
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2011) but "classical functional analysis" involved: 1. Identify potentially relevant characteristics of the individual client, his or her behavior, and the context in which it occurs via broad
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assessment; 2. Organize the information collected in Step 1 into a preliminary analysis of the client's difficulties in terms of behavioral principles so as to identify important causal
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relationships that might be changed; 3. Gathering additional information based on Step 2 and clarifying the conceptual analysis; 4. Devising an intervention based on the principles identified within that analysis; 5. Implementing that treatment method and assessing change, and; 6. Recycling through these steps if necessary. This approach showed promise as a form of treatment development in the early days of evidence-based treatment, and some classic behavior therapy methods were developed in this general way. The area of developmental disabilities is one in which functional analysis has become a robust and replicable empirical method following the classic work of Carr (1977) and Iwata (e.g., Iwata, Dorsey, Slifer, Bauman & Richard, 1982). In these areas, however, descriptive analyses were replaced by well-specified analogue tasks that identified whether specific behaviors were maintained by particular consequences (e.g., positive reinforcement, negative
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reinforcement, or sensory reinforcement) and this distinction was in turn linked to a limited set of treatment alternatives. Indeed in applied behavior analysis the very term “functional analysis”
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now refers only to organized environmental manipulations for the purpose of identifying the
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functions of behavior, not to conceptual functional analyses as it did historically. In some areas, such as self-injurious behavior, systematic methods of experimental functional analysis have
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become a very well-organized system of assessment within a known range of treatment options
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(Kahng, Iwata & Lewin, 2002). This is not “treatment development” in the sense we are addressing here, however – it is more a matter of functional behavioral assessment – and it has
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been confined to a very limited range of populations. Over 90% of the published studies using experimental functional analyses have been conducted with individuals diagnosed with
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developmental disabilities (Hanley, Iwata, & McCord, 2003). Regardless of how it is defined, functional analysis has not become a central and agreed
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upon method of treatment development across the wide range of clinical problems (Friman, 2010; Gadaire, Kelley, & DeRosa, 2010). Among other problems, functional analysis relies on the idea that a relatively adequate set of behavioral principles already exists with which to analyze client difficulties, their history, and context. It requires that the principles be sufficiently precise and that the specific steps that need to be taken to alter these functional processes be known or at least constitute a small enough set that plausible treatment alternatives can be generated quickly. In some areas, such as the application of operant interventions to developmental disabilities, those assumptions may apply reasonably well, but in many other areas they may not. If the sets of available principles are not adequate in areas for problem analysis or the identification of intervention alternatives, the bottom up strategy is silent about
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what to do next. Thus, to be successful, functional analysis depends on a basic science that can provide the knowledge and principles needed to address clinical problems.
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Translational Research
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One barrier to the broad application of bottom up approaches is that clinicians can wait a long time for basic scientists to provide the technical concepts needed for clinical work. This is
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the exact problem that harmed functional analysis as a method of treatment development. Early
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behavior therapists warmed to the idea of using functional analysis in a broadly applicable way, and they proposed sophisticated systems for doing so (e.g., Kanfer & Grimm, 1977; Kanfer &
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Saslow, 1969) but basic behavioral principles could not explain human cognition, so there was a huge hole in the proposed systems of analysis. Behavior therapists quickly tired of that situation,
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and cognitive behavior therapy (CBT) was the result, but that required the adoption of clinical models of cognition, not basic science models (e.g., Mahoney, 1974).
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No one objects to using available basic science principles in treatment development when they are available and known – indeed the etymological metaphor underlying the very term “applied” psychology connotes that it is a field that will bring basic knowledge (the word “basic” comes from a term for a pedestal or foundation) into contact with practical problems (like an “appliqué”). An immediate practical problem, however, is that the basic literature is vast. Most basic behavioral scientists read regularly or thoroughly in a handful of research areas, but a clinical researcher wanting to use basic knowledge would have to be far more catholic. In effect treatment developers seemingly have to be more broadly knowledgeable about basic science than most basic researchers (Hayes, 1998b). In the United States, the National Institutes of Health has decided to overcome this problem by creating research centers and multidisciplinary teams specifically accountable for
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moving basic science findings into clinical interventions. The first Request for Applications for the National Institutes of Health Clinical and Translational Research Award defined
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“translational research” as including two areas: “One is the process of applying discoveries
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generated during research in the laboratory, and in preclinical studies, to the development of trials and studies in humans. The second area of translation concerns research aimed at
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enhancing the adoption of best practices in the community.”
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(http://grants.nih.gov/grants/guide/rfa-files/RFA-RM-06-002.html). As of 2012 almost 60 research centers have been funded to pursue these goals.
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In a similar development, NIMH has proposed a new way of classifying psychopathology based on combinations of observable behaviors and neurobiological processes with its Research
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Domain Criteria initiative ([RDoC], National Institute on Mental Health, 2011). This plan specifically seeks to cut across disorders as commonly defined by DSM, and is the result of a
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series of translational research conferences that have been held over the years to bridge applied and basic clinical sciences. The goal seems to be to understand basic processes across units of analysis ranging from the genetic to the overtly behavioral. One intended result is the development of experimental classification of psychopathology based on the understanding of the underlying mechanisms of problems. This approach seems to appreciate that there are multiple routes to a particular clinical problem and that multiple topographies can result from common process. The RDoC appears to be building its classification system on the basis of multiple sources of measurement ranging from genetic, neuroscience, and behavioral. The hope is that discussions and research will occur to develop, as DSM has, consensus definitions on variables that can be used to classify participants in clinical studies (paraphrased from http://grants.nih.gov/grants/guide/notice-files/NOT-MH-11-005.html). This may be a better
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approach to understanding behavioral variability and might provide a means of examining both adaptive and psychopathological behavior that relate to similar processes rather than
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dichotomized classes of behavior clustered into hypothesized syndromal diagnoses.
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Translational research acknowledges the importance of basic science ideas to treatment development (and the need to carry innovative treatments into rapid dissemination), but it does
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not necessarily solve a second problem in the use of bottom up approaches: how can we ensure
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that basic scientists will be working on the basic principles clinicians need? The usual answer to that problem is superficially satisfying but difficult to mount: basic behavioral scientists should
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test the hypotheses of clinicians. It is usually not explained why a basic researcher would want to do that. Basic researchers are curious about what they are curious about, and it does little good to
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wag fingers about what those interests “should” be. But even if that were not the case, the idea that basic scientists will pick clinical hypotheses to test calls on a degree of clinical
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sophistication basic scientists do not have. Many clinical hypotheses are undoubtedly flawed, and basic researchers would have to have to be extremely clinically sophisticated to know which ideas were viable and which were not (Hayes, 1998b). CBS Suggestion 5: Establish a Mutual Interest Exchange between Basic and Applied Researchers
The solution within in a CBS strategy is called the “mutual interest model” (Hayes & Berens, 2004). It is arguably one of the more important parts of the treatment development model shown in Figure 1. In this approach, a variety of content issues that overlap between applied and basic psychology are identified as being of mutual interest to each area, considered against their own criteria. Only a very small number of researchers need to be willing to pursue both sides of the issue (basic and applied) to allow an overall team to cooperate.
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An example is provided in the history of ACT development. Early work on rulegovernance (Hayes, 1989) began to slow down when it was not possible to define what was
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meant by “verbal stimuli.” ACT developers did basic science work on the pragmatics of human
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language until a basic science answer began to take shape, Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001). Early studies on RFT (e.g., Devany, Hayes, & Nelson,
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1986; Steele & Hayes, 1991), were placed in basic science journals, not clinical journals, and
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little was made of their clinical relevance even though this interest drove the work. Basic scientists eventually became interested for their own reasons, not for applied reasons, and
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extended the work. Because there was a mutual interest, however, these new basic studies were of immediate interest to clinicians applying this work.
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As mutual interest grows, it can be sustained by only a small number of basic scientists who carry basic interests into application or a small number of applied scientists who carry
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applied interests into basic studies. Thus, although a reticulated network of research is needed to ensure that new treatment ideas are theoretically powerful, the vast amount of this work can be done in the more narrowly focused way in which sub-disciplines normally operate. Many issues that seem key to treatment development (current examples within the CBS community include such topics as implicit cognition, sense of self, or values) are inherently interesting to both basic and applied scientics and could yield to a mutual interest model. CBS Suggestion 6: Use a Multi-leveled Approach to Theoretical Concepts when Translating Between Basic and Applied Settings One of the reasons that applied psychology went through a technological era is that a proper appreciation of theory seemed to require that that practitioners (or even clients) learn to
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speak in sophisticated basic terms. That is a bad idea, because clinical theories and models need to be practically useful.
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Applied theories, however, tend not to be progressive. Practically useful concepts tend to
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be somewhat less precise, but that creates a gap between concepts and the auxiliaries and conditions that are needed to collect data testing these concepts (a point forcefully made by
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Meehl’s classic article on the progressivity of “soft psychology”, 1978; but see also Hayes,
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2004). The measurement of clinically assessable but metaphorical concepts like “stress,” for example, is so variable and loosely related to the concept that the term has become almost
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impervious to test (Patmore, 2009).
Thus, the problem is that practical models tend not to be precise and precise theories tend
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not to be practical. On the one hand, practitioners need to make quick decisions about how to intervene with culturally and diagnostically diverse populations. As such, they require models
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and principles that are easy to remember, broadly applicable, and that guide effective and innovative treatment choices. On the other hand, scientific progress requires the use of terms and models that are technically precise, broad in scope, and coherent across levels of analysis. The CBS solution to this tension between basic and applied theories is broadly applicable: create interlocking conceptual systems with less technical middle level terms organized into clinical models, each of which is then unpacked into technical basic science concepts and theories studied in basic science laboratories. There are many areas in life where we encounter multi-leveled conceptual systems. Consider, for example, the relationship between cooking and chemistry. A person wanting to bake a cake needs to know how to mix flour, eggs, sugar, and water in approximate amounts and bake them at a certain temperature for a certain time period. It is likely not necessary to have an in-depth understanding of lipids, acids, bases,
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and the periodic table in order to make a cake, and a recipe cast in these terms would not be very useful. A chemist wanting to generalize baking knowledge to the process of brewing beer may
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need this kind of basic knowledge, however. It is important that nothing in the cake-baking recipe contradicts basic chemistry (if it does, the cake will not be very good), but it is fine to use
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terms like “eggs” or “flour” even though these categories are not very meaningful for the work of
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the chemist. One might think of “eggs” and “flour” as middle level terms. They might not carry
achieve the pragmatic goal of baking a cake.
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all the complexity the chemist might desire, but they are sufficiently precise to allow one to
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An example of a multi-leveled conceptual system in CBS is the psychological flexibility model that underlies Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson,
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2011). For example, one element of that model is a sense of self as pure awareness (variously
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termed as “self as perspective” or “self as context”). It is treated as a middle level term, and is
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linked clinically to various contemplative and experiential exercises (e.g., see Chapter 8 in Hayes et al., 2011). This middle-level concept is in turn linked to a basic behavioral science of the deictic cognitive relations (I-You / Here-There / Now-Then) RFT argues gave rise to this sense of self (for a book length treatment of that basic science evidence see McHugh & Stewart, 2012). This multi-level approach to theoretical concepts enhances the opportunity to have both clinically accessible models and a progressive basic science. CBS Suggestion 7: Mediators and Moderators are Key If the goal is the development of pragmatically useful accounts, mediation and moderation are in some ways more important than outcomes per se, in that treatment models aim to orient clinicians to putatively key processes. Qualitative research has a role in this process, as do measures of actual in-session behavior, neurobiological assessment, assessment of implicit
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cognition, and other areas -- not merely self-report. If these activities are theory-guided, progress in these areas demonstrates the utility of linkages between basic and mid-level terms. Mid-level
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terms such as “mindfulness” and “cognitive distancing” may be purported mediators, for
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example, and their assessment can be guided by developments in basic sciences. Data from studies of mediation and moderation, can therefore help to fuel mutual-interest exchanges
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between basic and applied labs.
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In addition to motivating mutual-interest exchanges, mediation and moderation analyses can provide more stringent tests of the treatment model. It is possible, for example, for a model
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to be correct and technology to fail, or for technology to be correct and models to fail (Follette, 1995). In the former case, the theory gives developers a clear target for change. In the latter case,
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minimal guidance is provided beyond “more of the same.” Thus, if predicted mediation or moderation fails, it is important to determine where this occurred (Follette, 1995) to see of it was
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a failure of technology (i.e., the intervention did not impact the processes of change) or a model failure (i.e., the intervention did impact processes of change, but this did not account for changes in outcome).
Given its importance, it is rather startling that mediation has played such a small role until quite recently, as funders and others have begun to insist on its importance. Researchers often treat mediation as a matter of causality, however, which could ironically interfere with practical progress. A third variable could always explain meditational findings (cf., Kraemer, Wilson, Fairburn, & Agras, 2002), and since most mediators are dependent variables, they would not fit the standards for “causality” demanded of clinicians’ natural analytic agenda. But perhaps because of their implications for causality it is becoming fashionable to raise higher and higher barriers to the publication of meditational results (e.g., due to failures of temporality in which
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mediators were measured after outcomes began to change; or issues of randomization of mediators and so on). This is a false form of scientific conservatism. If processes do not account
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for differential outcomes, this is an incremental indication of model failure. Thus, mediation
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analysis (or the equivalent path analysis, even if formal mediation is not claimed due to the absence of ideal conditions such as those specified in Stice, Pressnel, & Gau, 2007) seems
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relevant in virtually every randomized trial as part of the process of treatment development.
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This line of thinking in CBS helps explain why research on ACT has dozens of published mediation analyses. No meta-analysis has yet been published of these studies (beyond an early
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one in Hayes, Bond, Luoma, Masuda, & Lillis, 2006), but a way to document that fact and to show how unusual it is provided by Öst’s comparison of 13 ACT studies with a set of 13
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matched CBT studies (Öst, 2008). Öst claimed that the ACT studies were less rigorous, but subsequent examination of the two sets of studies showed this was accounted for by the level of
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grant funding (Gaudiano, 2009). When we contacted the senior authors of all 26 studies, none of the authors of the 13 CBT studies said meditational analyses had been published, in press or under review from these data sets, while 9 of the 13 ACT studies (69%) were in that status, a significant difference (Fisher’s exact p = .0005, two tailed). Mediation and moderation data simultaneously examine the utility and coherence of the relationship between theory, technology, and outcomes. If the theories are multi-level these analyses can help examine the utility of the relationship between basic science and mid-level terms. Consistent model performance gives a target for further treatment development to researchers and clinicians, who can then focus more on empirically supported processes than packages (Rosen & Davison, 2003).
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Summary. Basic science has an important role in treatment development. This simple statement is sobering because it means that treatment developers must have a vision for how to
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develop and use basic science itself. Clinical psychology cannot stand apart from behavioral
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science as a whole – it cannot just consume basic science, it needs to impact it. Applied psychology needs a knowledge development system that will lead, on the basic side, to an
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account of key domains that consists of manipulable principles organized into theories, and an
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easily accessible model of pathology, intervention, and health on the applied side that can be linked to the basic account. The mutual interest model identified in CBS offers one strategy for
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achieving these goals; mediation and moderation are key to maintaining a pragmatic conceptual focus that provide tests of progress.
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Maintaining a Practical Focus in Treatment Development We have discussed in previous sections ways in which philosophical clarity and findings
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from basic science can inform treatment model development. Important theory selection criteria can also be derived, however, from practical considerations contacted through dissemination, training, and treatment evaluation efforts. This is one way in which the treatment development needs to be reticulated: standards for model development need to be based upon the purposes, abilities, and preferences of clients and those who serve them, whether these are individual clinicians, self-help publishers, healthcare facilities, or any other intervention system. Such factors traditionally have been taken into account only after many years of treatment evaluation. This helps explain why current methods of treatment development appear lumbering, expensive, slow, and poorly focused on actual needs. The current system of treatment development presents practical challenges for researchers, agencies, and clients alike.
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The strengths and limitations of the stage model provide an example. In the 1990’s the National Institute on Drug Abuse launched a treatment development initiative (Onken, Blaine &
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Battjes, 1997) that was quickly imitated by other institutes within the National Institute of
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Health. This was aimed at coming to grips with the heavy burden placed on treatment developers to have manuals, training programs, measures, and preliminary data before being able to secure
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funding for treatment evaluation. The approach was termed the “Stage Model” (Rounsaville,
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Carroll, & Onken, 2001). In this approach, Stage 0 is translational research; Stage I consisted of manual development, work on therapist training, the development of adherence measures and
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pilot tests. Stage II consisted of efficacy testing, particularly through randomized clinical trials (RCTs), and extending into Stage III efficacy tests in community settings. Stages IV and V
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consisted of research on the transportability of successfully evaluated interventions, including work on effectiveness, implementation methods, cost effectiveness, and consumer acceptability
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or marketability.
Although these stages were argued not to be linear (Rounsaville et al., 2001), the very metaphor of sequentially numbered stages fights against that flexibility. Furthermore, funders of behavioral therapies treatment development research (Onken et al., 1997) placed effectiveness and dissemination research at the end of a long process of treatment development and evaluation. Carroll and Nuro (2002) suggested that effectiveness trials should occur only after several successful efficacy trials. As Addis and Waltz (2002) point out, this means a minimum of 9 to 15 years delay between treatment development and dissemination. If studies fail at that point it could mean that decades of resources put into developing and testing a treatment were largely wasted. Delaying studies on effectiveness and dissemination also means that modifying treatments could be difficult, in part due to investment by treatment developers in existing
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treatment technologies, manuals and training materials. Dismantling studies designed to identify the essential components of treatment packages present the same set of challenges, with such
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research often being delayed until after multiple RCTs have been conducted at which point
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treatments may have already been refined and disseminated. These are only two examples. Efficacy without effectiveness is not useful (Clarke, 1995; Nathan, 2007). Advocates of
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effectiveness research have called for a more flexible approach in which practical concerns enter
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earlier into treatment development and efficacy testing (Hoagwood, Hibbs, Brent, & Jensen, 1995).
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CBS Suggestion 8: Account for Dissemination/Implementation Issues When Designing Treatment Models. With the emphasis in the field on internal validity and highly controlled
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RCTs, treatment researchers sometimes fail to fully consider and adjust for the pragmatic limits of front line treatment providers. This can lead to the development of sophisticated, multi-
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component interventions that can be difficult for clinicians to learn and implement with fidelity and competence in the treatment environment. Detailed treatment manuals that provide minimal flexibility, although useful for ensuring internal validity in RCTs, may not match the varied demands put on clinicians in practice. The mismatch between treatments developed and validated by researchers and the limitations and needs of clinical practice may account, in part, for the low adoption rates of evidence-based treatments by clinicians (e.g., Becker, Zayfert & Anderson, 2004; Garner, 2009). There are several examples, however, of researchers who have placed a strong emphasis on addressing dissemination issues within treatment development. One promising approach has been to focus on creating treatments with the smallest number of “moving parts”, limiting the number of treatment components, technologies and theoretical targets to keep the intervention as
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small and simple as possible. For example, Behavioral Activation for depression represents a precise theoretical model and treatment approach that itself was developed from a component
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within Cognitive Therapy for depression. This more parsimonious treatment has served to reduce
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the intensity of training needed to produce effective therapists to treat depression (Jacobson & Gortner, 2000) and has opened up the possibility of having treatment conducted by
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paraprofessionals (Ekers et al., 2011).
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The concept of evidence-based kernels (Embry & Biglan, 2008) provides another example of movement in this direction. A kernel is conceptualized as the smallest divisible unit
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for behavior change at which point removing any additional components would lead to the intervention being inert. Embry and Biglan (2008) conducted a review identifying 52 such
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kernels with notable empirical support (i.e., public commitment, self monitoring, progressive muscle relaxation). These kernels provide simple and focused intervention tools that often can be
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applied to a variety of problem areas. These features can make kernels easier for clinicians and other professionals to learn and implement relative to larger, multi-component treatment packages. Thus, in addition to developing more parsimonious treatment packages such as Behavioral Activation, researchers are also focusing on smaller evidence-based behavior change interventions/components as a means of overcoming existing barriers to implementation. Coincidentally, study design methods are improving to allow for optimizing and sequencing therapy components (e.g., Collins, Murphy, & Strecher, 2007). CBS Suggestion 9: Consider treatment approaches within the public health perspective. A different set of practicality issues have been raised by considering the standard treatment development approach relative to the public health goal of reducing the burden of mental illness (Kazdin & Blase, 2011). In many areas it is not obvious that developing efficacious treatments
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within a model of individual psychotherapy will significantly reduce the burden of mental illness given the number of those needing treatment relative to number of providers, and the variety of
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barriers that lead to low treatment seeking rates (Kazdin & Blase, 2011).
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Treatments can do a better job rising to the challenge of psychological problems as a public health issue if they consider provider issues, length, format, disseminability, and the like
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from the beginning of the development cycle (Kazdin & Blase, 2011). Examples of relatively
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straightforward methods that have been tested with a wider variety of professional and paraprofessional providers include Motivational Interviewing (MI; Hettema, Steele & Miller,
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2005) and Behavioral Activation (Ekers et al., 2011). Treatment methods can be designed so that they can readily be transported to a guided self-help format (Cuijpers, Donker, van Straten, Li &
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Andersson, 2010), that can be conducted by paraprofessionals with limited training (Mohr, Cuijpers & Lehman, 2011). Interventions can also be designed to be computer-assisted, with the
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program delivering information to the client and prompting the provider to discuss or model particular skills in the room (Craske et al., 2009). New treatment methods can be tested not just in direct care delivery but also thorough bibliotherapy (e.g., Muto, Hayes, & Jeffcoat, 2011). These alternative methods of intervention can fit within stepped care models in which clients receive the least invasive and costly treatment given their presenting problem and “step up” to more intensive treatment as indicated by ongoing monitoring (O’Donohue & Draper, 2011). CBS Suggestion 10: Refine and Test Multi-Component Treatments. It is practically important to be able to disassemble large treatment packages containing many elements. Component research helps ensure the efficiency of treatment and may be able to provide clinicians reassurance that they can use specific procedures linked to specific processes and not
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just an entire package, thus increasing the degree to which models can be rapidly scaled to fit settings and treatment needs.
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One way to do this is to evaluate theoretically meaningful treatment components as part
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of the process of assembling packages. An illustrative example of this approach is provided by Borkovec, Newman, Castonguay and colleagues in their work on CBT for Generalized Anxiety
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Disorder (GAD). They conducted an RCT comparing the applied relaxation component of CBT
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to the full CBT package and a control condition (Borkovec & Costello, 1993) as well as a RCT comparing the cognitive therapy component, self-control desensitization component, and full
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CBT package (Borkovec et al., 2002). More recently they have examined whether adding emotional processing and interpersonal functioning treatment components to CBT would
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improve outcomes relative to a CBT plus supportive listening condition (Newman et al., 2011). Such research has been instrumental in identifying how the components of CBT contribute to
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treatment effects and informing the further development and refinement of the multi-component treatment package for GAD.
Another way forward is emphasized within the CBS approach: the early use of theoretically focused laboratory-based component studies (Hayes, Levin, Plumb, Boulanger & Pistorello, in press), which can occur even earlier in the cycle of treatment development. Such laboratory-based component studies are fast, relatively inexpensive, and provide a methodology in which relevant sample, intervention, and contextual variables can be carefully controlled and manipulated. Laboratory-based component studies do not demonstrate clinical efficacy – rather they test theoretical models that underlie treatment development and thus strengthen the linkage between basic principles and mid-level terms. A recent example is a meta-analysis of laboratorybased component studies of the psychological flexibility model underlying ACT (Levin,
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Hildebrant, Lillis, & Hayes, in press). The 66 component studies on psychological flexibility processes provided broad support for the model, suggesting that the components of the model
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were theoretically meaningful.
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CBS Suggestion 11: Test Effectiveness Early. Despite the tendency in the stage model to delay effectiveness and dissemination research, it can occur throughout treatment development
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and testing (Hayes, 2002). For example, even a brand new treatment method could be tested by
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comparing client outcomes in a heterogeneous clinical sample produced by front line clinicians who were trained in the new method relative to clinicians who did not receive such training. That
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“manipulated training” test was done as one of the very first studies of ACT in the modern era (Strosahl, Hayes, Bergan & Romano, 1998) and its positive outcome provided early guidance
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regarding the possible clinical effectiveness of the approach, in effect testing the practical impact of real world dissemination even before controlled outcome research was extensively available.
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CBS Suggestion 12: Research Novel Methods for Training and Implementation. The emphasis on conducting training, dissemination and implementation research has been growing rapidly in recent years, and the NIH has sponsored several initiatives in this area. With this has come the realization that some traditional training methods such as providing workshops are not adequate to ensure newly trained clinicians implement treatments with adherence and competence (e.g., Walters et al., 2005). Innovative training approaches are needed to ensure the effective and efficient dissemination of evidence-based therapies. An example of a treatment approach that has successfully moved into such training research is MI. A recent review of MI training research identified 27 independent studies (Madson, Loignon & Lane, 2009), with many more studies since published. Research has included a number of innovative models such as a criterion-based stepwise approach where
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clinicians receive a web-based training and proceed through more intensive training methods if they fail to meet competency criteria (Martino, Canning-Ball, Carroll & Rounsaville, 2011). This
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emphasis on training research with MI may be due in part to a combination of a fairly
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parsimonious treatment, knowledge of the active components and mechanisms of change of the intervention, its applicability to a range of providers, and valuing such training research within
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the treatment development community. Thus, MI provides an exemplary model for moving to an
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emphasis on training research.
Summary. There has been increasing focus in the field of clinical psychology on practical
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concerns including public health impact, effectiveness, training and dissemination. Although innovative solutions have begun to be identified, it is generally unclear how best to meet these
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concerns. By maintaining a functional approach it is possible to address practical concerns early and throughout treatment development. As in Figure 1, these concerns need to be both an early
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filter and an ultimate empirical goal.
Fitting Methods to Individuals
A final area of concern has to do with the individual client and clinician, the degree to which evidence-based treatments fit with individual clients, empower practitioners, and support or interfere with the relationship between them. This issue appears in a number of forms, and we will name but a few. It is reflected in concerns over diversity and the cultural match between client history and evidence based methods (e.g., Hayes, Muto, & Masuda, 2011; Hall, Hong, Zane & Meyer, 2011). Practitioners are concerned over rigid treatment manuals, and they worry about how manuals fit with individual clients and may negatively impact treatment process (Ashcraft et al., 2011). Practitioners want treatments to be developed that are flexible, with movable elements that can deal with client complexity. The traditional concern over the degree
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to which group averages found in RCTs reflect individual processes (Hayes et al., 1999), the use of transdiagnostic factors to fit treatment to individuals (Norcross & Wampold, 2011), and
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research on common factors and the therapeutic relationship (Wampold, 2010) all can be seen as
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issues of how treatment development can occur in a way that empowers individual clients, practitioners, and the relationship between them.
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Some of the dimensions we have already considered are relevant to this issue (e.g.,
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identifying components that can be used to fit specific client needs). Two additional areas should be mentioned.
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CBS Suggestion 13: Consider Time Series and Single Case Analysis. There is no way to assess the impact of treatment on individuals without frequent assessment collected at that level.
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Many of the most robust empirically supported treatments began with time series analyses and single case experimental designs. This is highly desirable, especially in the early stages of
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treatment development, because that allows the identification of individuals who are known to improve due to treatment (Hayes, Barlow et al., 1999). Group comparison methods are by design not capable of doing so.
CBS Suggestion 14: Test Transdiagnostic Breadth. With advancements in the understanding of psychopathology and treatment mechanisms has come an increasing focus on transdiagnostic treatments that seek to treat a range of psychological problems with a single intervention approach by targeting common mechanisms of action. Examples include the Unified Protocol for emotional disorders (Barlow, Allen & Choate, 2004), Cognitive Behavioral Therapy-Enhanced for eating disorders (Fairburn et al., 2009), and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 2011). One contributor to this increased focus on transdiagnostic treatment is their potential for overcoming existing barriers to dissemination
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(McHugh, Murray & Barlow, 2009). The availability of such approaches could potentially reduce the training burden on clinicians to learn the range of evidence-based therapies needed to
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meet the diverse mental health needs of their clients and provide a treatment that is more flexible in adapting to clients with comorbid and subthreshold disorders. Transdiagnostic treatments thus
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represent, in part, an example of researchers’ attempts to develop therapies that may better fit the
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practical needs of clinicians.
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The emergence of an interest in transdiagnostic factors has been less fostered by federal money than by the search for a viable alternative to syndromal classification. In a sense,
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transdiagnostic approaches sit in the middle between a fully idiosyncratic approach and syndromal diagnosis (McManus, Shafran, & Cooper, 2010), which is why we have listed this
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issue in this section. A transdiagnostic approach can include the effort to identify a wide number of processes that are universally applied (Harvey, Watkins, Mansell & Shafran, 2004), processes
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that are limited in the range of disorders covered, and single processes that are widely applicable (Mansell, Harvey, Watkins, & Shafran, 2009). Summary. Innovations in treatment development have to be more focused on the development of broadly useful principles and theories, more practical development strategies, and strategies that are more mindful of individual issues such as values, culture, preference, relationships, and the like. A progressive treatment development system needs to be sensitive to all of these goals and assessed on how well these goals are met. Adoption of a Reticulated Approach Figure 1 displays a reticulated functional contextual model of treatment development, drawn from the contextual behavioral science tradition. We have attempted to present it in a way that might be useful beyond that specific community.
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It needs to be acknowledged that the model we have presented is explicitly communitarian. It shifts the focus of treatment development from the individual laboratory,
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researcher, or clinician, to a set of networked actions that only a group can accomplish or at least
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accomplish well. As with all group activities, this requires some subordination of selfish interests for the sake of the common good, but humans as a species are inclined toward such cooperative
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ventures (Nowak, Tarnita, & Wilson, 2010), and in the networked modern world many young
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researchers come to their work having already learned of the power of virtual communities. The grouping of researchers and practitioners needed to mount this model is already
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occurring in areas such as mainstream CBT and indeed contextual behavioral science itself, which has grown enormously in the last decade as a reticulated and communitarian approach to
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treatment development has been consciously adopted and both basic and applied scientists have come together under its banner (see www.contextualpsychology.org). It is common place for
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funders and Deans alike to encourage the development of networked scientific teams and centers that cross traditional boundaries, so there is nothing inherently disadvantageous in a political or scientific sense about a reticulated treatment development model. What has been missing is a larger vision for the field that highlights the elements needed for long-term success. We as a field need to develop such a vision. This article is meant as a goad in that direction. Conclusion We can summarize our suggestions for treatment development in the form of a conclusion, attempting to make it applicable to any scientific approach interested in treatment development. Treatment development is fostered by a mix of innovation, practicality, and evaluation that stretches across the whole of behavioral science. In a sense, that means that treatment development cannot be fully separated from the whole of psychology and behavioral
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science. If psychology is weak, treatment development within psychology will be weak. Thus, treatment development needs to be thought about in a way that fosters the progressivity of the
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entire field.
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A progressive process of treatment development requires both philosophical clarity and clarity of practical purpose. The two align naturally in functional contextual thinking due to its
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analytic goals but other perspective can maintain that alliance by emphasizing practicality and
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attention to directly manipulable events. Manipulable events are always context for action, not action itself, and thus the focus of treatment development needs to begin with processes that
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involve manipulable contextual features.
Progress in basic and applied psychology is interlinked, but the commonly accepted
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vision of their relationship in which applied psychologists use basic principles, and basic psychologists test clinical hypotheses, is not optimal or at times even viable. It envisions a two
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way street, but unfortunately it is impassible in both directions. Applied psychology needs to instead form common cause with basic psychology in domains of mutual interest, and develop reticulated basic analyses and mid-level terms that can be both scientifically progressive and clinically useful. That requires learning to speak in different ways for difference purposes and to organize these analyses into larger analytic-abstractive theories. As components, packages, and assessment methods are generated from principles and theories, they need to be considered from the first moment in terms of their practicality, capacity for dissemination, and public health impact. After early testing, methods that are viable need to be examined in a reticulated way, so that issues of effectiveness, change processes, mediation, moderation, training, active components, and similar issues are considered from the very first randomized trial forward. That way, as the empirical basis of the work expands, broader issues of
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impact across problem areas and settings, and issues of training and dissemination, will have the process, component, and moderation knowledge needed to enhance further technological and
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theoretical development, and to fit treatment development to the needs of clients, practitioners,
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and systems.
This approach may seem difficult to surmount at first when one considers practical issues
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such as funding agencies requirements, the dominant role of the DSM, personal knowledge gaps
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in areas such as philosophy of science or basic science, and time/budget limitations. However, we are not proposing that every researcher involved in treatment development gain expertise in
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all of the areas outlined. Rather, the model highlights ways to more purposefully integrate ongoing research methods that are already being used as a research community to better meet the
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shared goals of alleviating human suffering. Although this model likely appears complex relative to the more linear and stage-based treatment development approaches, such complexity reflects
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the range of factors that must be addressed in order to better harmonize ongoing research efforts and overcome existing barriers to progressivity in treatment development. In many ways, each researcher participating in this model can continue with the same research program they have already been conducting, albeit with a greater sensitivity to this expanded set of issues ranging from philosophy to basic science to applied issues so that their work can be better integrated within the shared purposes of a larger treatment development community. Although expertise is not required in all areas, this approach does require researchers to be willing to expand beyond their traditional methods and considerations at times. A certain level of familiarity with philosophy of science, theoretical considerations, basic science, and practical applied issues is important. The specific suggestions outlined in this paper can provide a useful starting point on this path. Examining one’s philosophical assumptions,
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identifying how to better integrate one’s work with basic science, and more actively considering practical issues in treatment development and testing, among other suggestions outlined in this
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paper, all represent potential steps researchers can take in exploring an alternative, and
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potentially more progressive, approach to treatment development.
Progress depends on the creativity and hard work of our discipline as a community, but it
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also depends on our developmental strategy. It seems time to move beyond traditional models
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and to engage in a broader and more coherent search for innovation and advancement that will
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advance our field and strengthen its interconnections.
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A Reticulated Functional Contextual Approach to Treatment Development
Figure 1. The Contextual Behavioral Science Model of Treatment Development
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ACCEPTED MANUSCRIPT A Reticulated Functional Contextual Approach to Treatment Development Highlights Traditional approaches to treatment development are inadequate
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Models need to be practical, theory focused, and sensitive to clinical issues
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A reticulated functional contextual approach to treatment development is presented
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S0272-7358(13)00050-0 doi: 10.1016/j.cpr.2012.09.009 CPR 1310
To appear in:
Clinical Psychology Review
Received date: Revised date: Accepted date:
2 March 2012 17 August 2012 13 September 2012
Please cite this article as: Hayes, S.C., Long, D.M., Levin, M.E. & Follette, W.C., Treatment Development: Can We Find a Better Way?, Clinical Psychology Review (2013), doi: 10.1016/j.cpr.2012.09.009
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ACCEPTED MANUSCRIPT A Reticulated Functional Contextual Approach to Treatment Development Treatment Development: Can We Find a Better Way? Steven C. Hayes
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Douglas M. Long
William C. Follette
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University of Nevada
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Michael E. Levin
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Address editorial correspondence to Steven C. Hayes, Department of Psychology / 298,
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University of Nevada, Reno, NV 89557-0062
Key words: Treatment development, stage model, functional analysis, theory, contextual behavioral science
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Abstract
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The present paper argues that traditional approaches to treatment development, including
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a technological approach, a stage model, and existing inductive approaches such as functional analysis are inadequate in various ways. Treatment developing needs to focus more on
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theoretical development, practicality, and the fit with clients and practitioners. We argue that
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progress requires greater philosophical clarity, and steps to ensure a connection between philosophy of science assumptions and an analytic agenda which fits naturally with applied
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psychology. Theoretical progress requires distinguishing between clinical and basic models and harmonizing their relationship, and more focus on the manipulable context of action. Applied
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psychology needs to join in a common cause with basic psychology in domains of mutual interest, and develop basic analyses and mid-level terms that can be both scientifically
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progressive and clinically useful. Issues of practicality, capacity for dissemination, and public health impact need to be considered at the beginning and throughout treatment development. Issues of effectiveness, change processes, mediation, moderation, training, active components, and similar issues should be part of the evaluation system from the beginning. It is time to create a more coherent approach to treatment innovation.
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Treatment Development: Can We Find a Better Way? There is no well articulated and agreed upon contemporary model of treatment
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development in psychology. Outside forces such as research funding requirements, changes in
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psychiatric nosology, or agency regulations regarding evidence-based treatments, seem to have as much or more influence on methods of treatment development than do strategic visions of
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clinical researchers. As a result, psychosocial treatment development is based on a patchwork of
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strategies, many ad hoc, conducted in diverse research traditions. The field needs to consider how the various methods at its disposal can be integrated into a long-term strategy to create real
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progress. The purpose of the present article is to suggest one possible way to rise to this challenge.
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Some of our suggestions rise directly from concerns regarding mainstream views of treatment development, and others rise from positive developments we have observed in the
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field. In its most general form, the purpose of the present article is to argue for an approach to treatment development that is more practical, theoretically focused, and sensitive to the issues raised by those individuals to whom treatment is directed and the individual practitioners who apply these methods. In its most specific form, the purpose of this article is to argue for a reticulated (that is, based on a network of research methods) functional contextual approach to treatment development – what we have termed a “contextual behavioral science” (CBS) approach – in which treatment development is targeted by an integrated network of research methods based on a philosophy of science and set of analytic goals consciously harmonized with practical aims.
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A Reticulated Functional Contextual Approach In a series of papers we have laid out the CBS approach to knowledge development
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(Hayes, Barnes-Holmes, & Wilson, in press; Hayes, Levin, Plumb, Boulanger, & Pistorello, in press; Levin & Hayes, 2009; Vilardaga, Hayes, Levin, & Muto, 2009). An elaboration of the
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inductive, functional contextual strategy used in behavior analysis, CBS is “a principle-focused,
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inductive strategy of psychological system building, which emphasizes developing interventions
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based on theoretical models tightly linked to basic principles that are themselves constantly upgraded and evaluated. It involves the integration and simultaneous development of multiple
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levels of a research program including philosophical assumptions, basic science, basic and applied theory, intervention development, and treatment testing” (Hayes, Levin et al., in press).
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Our point is that treatment development cannot be considered separately from the development
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of behavioral science as a whole – it is the tip of a much larger iceberg – and a weakness in one
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area tends to be a weakness for the entire enterprise. Our goal in the present paper is broader that an explication of CBS per se, and in the present paper we will outline the key facets of treatment development from a reticulated functional contextual perspective in a way that other philosophical and theoretical perspectives can use. Figure 1 describes the elements of the approach and their relationship to each other. Each of these facets will be introduced and discussed in the sections that follow with specific examples taken from various areas in clinical psychology and suggestions for how functional contextual strategies can be integrated into treatment development. We should point out before we begin that all of the various elements of this model are already at play in the psychological sciences, and several have regularly been explicitly linked to treatment development by major researchers (e.g., Barlow, 2004; King & Ollendick, 2008).
ACCEPTED MANUSCRIPT A Reticulated Functional Contextual Approach to Treatment Development Some of the elements we will discuss have recently been receiving increased emphasis by funders, as we will note. At the same time, the harmonious integration of all of these various
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elements seems important, and provides an alternative that may have advantages. No single individual or laboratory is likely to mount all elements of the strategy we will
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describe but we would argue that treatment development is best viewed as a disciplinary issue –
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as a problem for the field as a whole, not just a single laboratory or a single approach. If
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individuals have an overall awareness of how their work may fit into the progress of the field overall in rising to the challenge of treatment development, they are better positioned to
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communicate what they learn in a way that can be used effectively by others. We will set the stage for our suggestions by highlighting important historical
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developments and shortcomings of traditional models of therapy development. We will then provide specific suggestions for treatment development based on the functional
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contextual or CBS approach including the role of philosophical assumptions in theory development and treatment research, how to develop theoretical models that fit with the pragmatic goals of treatment development, important practical considerations for treatment development, and how various methodologies can be used to meet the goals of treatment development.
The Limits of a Topographical / Technological Approach, and the Need for Theory and Philosophy At least in an ad hoc sense, the core focus of treatment development in the last 30 years has been based on the creation and evaluation of well-specified treatment manuals focused on well-defined syndromal categories. Sometimes called the “FDA model” after the standards for safe and effective pharmacotherapy established by the United States Food and Drug
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Administration, this approach is topographical and technological, and arose in an explicitly atheoretical historical context. While the early and middle part of the last century saw a rise in
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interest in psychological theory, culminating in the central role of learning theory, the latter half
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of the century was much more methodologically and technologically focused. Methodological writings from this time period (e.g., Paul, 1967; London, 1964) are very clear that this change
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was deliberate. In his 1967 argument for technical eclecticism, for example, Lazarus vented that
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theories are, “often able to explain everything but to accomplish almost nothing” (p. 416). In a review of studies published in the Journal of Consulting and Clinical Psychology across the next
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three decades, Omer and Dar (1992) found that in the 1960’s, 69% of the studies had a clear theoretical rationale. That proportion had dropped by more than half in the next two decades,
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with such rationales being presented in 30% of the studies in the 1970’s, and 31% in the 1980’s. Similar trends were found for studies investigating treatment processes, and studies giving a
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theoretical rationale for the isolation of variables. This a-theoretical trend coincided with an effort to solve the unreliability of psychiatric diagnosis, wherein the DSM-III (American Psychiatric Association, 1980) took a prototypical approach in which diagnoses would be based on checklists of signs and symptoms (see Kirk & Kutchins, 1992 for an interesting version of the history of DSM-III). The DSM-III quickly became the organizing theme for much of the research on mental health problems supported by the federal government in the US. Journals emerged carrying the names of various disorders identified by the DSM; clinics organized themselves around these categories. Efforts to identify useful treatments were organized around these diagnostic entities as well. Funding sources began demanding technologically well-specified treatment protocols that detailed techniques, therapist training, and adherence monitoring (e.g., Carroll & Rounsaville, 1990; Waskow, 1984). This
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approach increased the internal validity and replicability of psychotherapy research and lists of evidence-based treatments such as that of the American Psychological Association (Task Force
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on Promotion and Dissemination of Psychological Procedures, 1995) appeared that organized
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treatments by their targeted syndromal categories.
While progress has been made over the last 30 years, the combination of topographically
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defined syndromes and technologically-well specified treatment manuals has proven itself to be
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problematic as an adequate model of treatment development, as distinct from treatment evaluation. We will begin on the diagnosis side. Syndromal diagnosis is based on the idea that
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collections of signs and symptoms can lead to the identification of problems with a known etiology, course, and response to treatment. Said more directly, the purpose of syndromes is
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progress toward the ultimate identification of diseases, which are functional, not topographical entities. So far that effort has failed. The American Psychiatric Association DSM-V workgroup
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reach the dire conclusion that “research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur.” (Kupfer et al., 2002, p. xix). The progress on response to treatment has been equally limited. As the list of empirically supported treatments has grown, it has become apparent that many evidence-based therapies are helpful for a wide variety of problems. Cognitive behavior therapy for depression, was not that different than cognitive behavior therapy for anxiety, cognitive behavior therapy for personality disorders, cognitive behavior therapy for PTSD and so on. The DSM-V workgroup concluded “with regard to treatment, lack of specificity is the rule rather than the exception.” (Kupfer et al., 2002, p. xviii).
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The topographical strategy has a decent chance of working when a given etiological process gives rise to a characteristic result but it is of little help when common etiological
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processes can give rise to many different topographical outcomes; or when many different
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etiological processes can lead to similar outcomes. The very intransigence of the search for psychiatric etiology suggests that behavioral health problems may be of this variety. In the
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absence of etiological clarity, a topographical approach gives treatment developers little
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guidance other than the common sense strategy of targeting the content of syndromal checklists. This has a characteristic effect: treatments tend to be multifaceted packages, with different
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techniques focused on the different topographical properties of the syndrome itself. For example, if a given disorder has “anxiety” on the checklist, treatment packages will tend to include
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components such as relaxation training that purportedly target that element. Multi-element packages are often loosely bound as a result, having the quality of collections of elements. As
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new manuals are written they combine elements of older packages, mixed together into a kind of technological stew.
The inclusions of previously validated elements in multi-element packages is fostered by another aspect of the technological approach: in order to secure funding, developers need to already have in hand well crafted manuals, therapist training programs, adherence measures, and preliminary data on acceptability and efficacy. It is much easier to rise to that challenge when portions of a treatment approach are already validated. As new and interesting treatments emerge, these elements are often simply added to old methods, without much concern for theoretical coherence. For example, as mindfulness and acceptance methods have emerged in cognitive behavior therapy, new treatment packages are assembled that contain mindfulness
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components along side a wide variety of other methods, some of which may fit poorly with the core ideas behind mindfulness work.
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The mountain of manuals and methods that result from these “slice and dice” tendencies
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are difficult even to describe in ways other than mere lists or groupings based on broad philosophical or theoretical traditions. The evidence-based treatments list maintained by Division
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12 of the American Psychological Association currently has no requirement that new treatment
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methods work by putative processes. The debates regarding the extent to which Eye Movement Desensitization and Reprocessing (EMDR) is distinct from exposure techniques offers an
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excellent example of this issue (Herbert et al., 2000; Rosen, 1999). The practical problem this produces in terms of techniques is incoherence. Techniques
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alone do not explain how to simplify methods, approach new problems or situations, or develop new methods. It becomes difficult to assimilate the mountain of seemingly disconnected bits of
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information and the field becomes an incoherent mass, difficult to master and difficult to teach. Meanwhile other well-developed areas of science cannot readily be be related to clinical techniques due to the shallow level of analysis (Hayes, Strosahl, & Wilson, 1999, p. 15). From a functional point of view, researchers need to be clearer about what is being created and evaluated in treatment development. Precisely speaking, psychological scientists create verbal rules and principles that guide action and implementation. Even a purely technological description (e.g., a step-by-step description of a therapeutic technique) fits that categorization. The difference between a purely technological description and a theoretical one is the scope of the verbal rules and principles. Those that have high scope (e.g., apply across a range of specific problems, situations, backgrounds, and so on) have a practical advantage, providing they can retain their precision and impact. That has proven difficult, for reasons we
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will explore, but it is a good place to begin with implications from a functional contextual perspective (what we will call here “CBS Suggestions”).
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CBS Suggestion 1: Be Deliberate about Theory and Principle Development The rejection of the classical systems-era theories in psychology (Omer & London,
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1988) resulted in “an endless stream of almost disconnected studies” (Omer & Dar, 1992, p. 92).
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There have been frequent calls over the years for the importance of theory to treatment
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development (e.g., Barlow, 2004; Barlow, Hayes, & Nelson, 1984; Hayes, Barlow, & NelsonGray, 1999; King & Ollendick, 2008) and in recent years the pendulum seems to be swinging
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back in a theoretical direction. For example, critics of the Division 12 EBT list approach to empirically supported treatments have pointed out the importance of treatment distinctiveness to
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scientific progress in clinical psychology (Herbert, 2003). Logically, treatments are only distinct in a functional sense if they differ by their causal processes, or by the methods they use to alter
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these processes (O'Donohue & Yeater, 2003). If this idea were taken seriously, however, the field would begin to move more toward empirically supported principles of change (Rosen & Davison, 2003) as the specific procedures that alter specific processes were identified. That is an inherently theoretically focused idea in which procedures are clustered and defined according to the theoretical processes they alter. If it is true in clinical psychology that ‘There is nothing so practical as a good theory’ (Lewin, 1951, p. 169), it is because theory and principles seem to be needed to apply knowledge to novel problems and situations, to have a systematic way of developing new technologies, and to organize current knowledge into a coherent whole (Hayes, 1998a). The problem is that there seems to be little discussion of the kind of theories needed to accomplish such ends, the conditions under which they are likely to be derived, and how that can be evaluated. Very little
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has been written about theory-selection criteria in applied psychology. What are the methodological standards to which theoretical concepts and their relations to one another should
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be adapted for those interested in treatment development? The assessment of scientific progress
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is the ultimate metric, but that is necessarily a historical exercise. Scientists need more proximal rules-of-thumb by which they can decide which theories to disseminate, amend, or abandon.
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Giving preliminary guidance of that kind is a key purpose of the present paper.
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CBS Suggestion 2: Use Philosophy to Guide Theory Development Paul Meehl once noted that “there is no guaranteed, automated truth-generating
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machinery” (1992, p. 273). In the technological era that is now waning, facts were sometimes thought to speak for themselves, but philosophers of science have warned that there is an
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underdetermination of theory by data (Laudan, 1996), and that observation statements are theory laden (Kuhn, 1962). To the extent that is true, atheoretical science is an illusion (see Moore,
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2010) and the choice is not whether we have theory or no theory as treatment developers, but rather one of whether theoretical concepts are overt, owned, and deliberately tailored to serve a stated analytic agenda. The fact that there is no one “scientific method” that dictates conceptual choices is exemplified by the ambiguities inherent in statistical analyses (Scarr, 1985; Forster, 2000), as well as in diagnostic categories (Wonderlich, Crosby, Mitchell, & Engel, 2007). Some of the key assumptions that scientists therefore need to clarify are their domains, units of analysis, what they mean by truth, what is valued and progressive, and how various conceptual standards are prioritized (Laudan, 1977). It is the task of philosophy of science to own one’s assumptions and values – to take responsibility for the coherence and purpose of one’s own intellectual activity. Clarity about one’s philosophy of science states for oneself and others “here I stand.”
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While everyone can agree that scientific progressivity is desirable, there is marked disagreement about what it means for a theory to be progressive or even what a theory is. We
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will adopt the view that the goal of theory is to accomplish analytic goals with precision, scope,
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and depth (the first two criteria we have described; last refers to consilience across levels of analysis, for example, nothing seen at the level of biology should contradict principles that apply
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at the level of behavior).
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Some scientists, what we term here “elemental realists,” seek to discover and describe the parts, relations, and forces that are assumed to exist and to make up the psychological world.
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From the elemental realist viewpoint, the aim of science is to model the world so that it can be ontologically understood and predicted, and precision, scope, and depth emerge naturally when
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accurate models of reality are developed.
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Others, labeled as contextualists, seek to appreciate the historical, purposive action – the
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act in context – and they see their own scientific work as itself an act in context. Just as one’s goals can vary, so too can one’s assessment of a theory’s utility, and thus there are types of contextualists defined by the kind of theories they seek. While descriptive contextualists (hermeneutics, dramaturgy, narrative psychology, and the like) seek an appreciation of the participants in the whole, functional contextualists seek the prediction-and-influence of behavior (Hayes, Hayes, Reese, & Sarbin, 1993; the goal is hyphenated to indicate that it is not severable). In conjunction with such divergences, research traditions have very different criteria for theoretical evaluation. Several authors have noted how different sets of assumptions lead to different standards for knowledge and progressivity that can impact theory development (e.g., Cacioppo, Semin, and Bernston, 2004). This can be tangibly felt in many of the activities involved in treatment model
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development, such as research methods (e.g., Fishman, 1999) and assessment (e.g., Borsboom, 2005). Furthermore, what is taken to be “causal” varies across research traditions and in ways
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that have been felt in discussions of treatment development (e.g., Bandura, 1995; Hayes &
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Wilson, 1995). We shall revisit the issue of causality shortly. For the time being, our point is merely that scientific values and assumptions serve to establish selection criteria to which
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theories are adapted, and thus if theories are key to treatment development, philosophy of science
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cannot be ignored.
CBS Suggestion 3: Seek Harmony between the Natural Analytic Agenda of Treatment Research
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and Philosophical Assumptions
So far there is little in this discussion about treatment development per se. In order to
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examine this we need to consider the natural analytic agenda of treatment research and applied research more generally (i.e., the generally agreed upon goals of such research). We define
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treatment development as the process of creating systematic methods of change that accomplish practical goals in behavioral health and human development. Thus, the natural analytic agenda of treatment development is to create methods of change, systematized and organized by conceptual and empirical scientific analysis and evaluation, and held to account to the accomplishment of practical goals. It is philosophically dogmatic to criticize scientific assumptions because assumptions enable analysis, they are not the results of analysis. Nevertheless, it is not dogmatic to insist that the natural analytic agenda of treatment development be consciously integrated with a scientist’s assumptions if they are going to do treatment development. For example, some learning theorists have argued against the development of principles and theories via a focus on pragmatic criteria. In their eyes, principles should be focused on what was unobserved, hypothesized or deduced,
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and not what was observed or manipulated. Spence went so far as to claim that if there was a functional relation that was “always the same … then we would have no need of theory” (1944,
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p. 71). He added that theoretical constructs are “guesses as to what variables other than the ones
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under the control of the experimenter are determining the response” (1944, p. 71, italics added). If this is what theory is, it is useless for practitioners who seek consistent and functional relations
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that can be changed and manipulated to accomplish practical goals. Entity-postulating
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hypothetico-deductive theories (i.e., models that give a causal role to theoretical concepts that are not directly observable, or manipulable and must be inferred from a variety of indicators such as
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self-esteem, or intentions), seem especially prone to this problem (Kane, 2001). We know of no philosophies of science that actively conflict with the natural analytic
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agenda of treatment development, but in some cases overlap between the two has to be fostered because nothing in the assumptions of the scientist ensures it. For example, a scientist who sees
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science merely as a matter of recognizing consistent forms (being able to properly categorize nature) might produce a nosology that is entirely consistent and broadly applicable but that is not linked to treatment implications and thus has no treatment utility (Hayes, Jarrett, & Nelson, 1987). The disconnection between such formistic assumptions and the pragmatic nature of the treatment developer’s natural analytic agenda can be repaired, however, by adding treatment responsivity as a key characteristic of the nosology itself (i.e., identifying categories of clinical problems that are predictive of response to treatment, and rejecting any categories that fail this test). By taking the natural analytic agenda of treatment development more seriously, the needed philosophical adjustments can be made. CBS Suggestion 4: Purportedly Functional Processes Must be Manipulable
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Functional contextualists, such as those in the Skinnerian tradition, constrain “causal” attributions to manipulable variables. This constraint is made strategically, according to the goals
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of the prediction and influence of behavior (O’Donohue & Szymanski, 1996). With such a
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constraint, one psychological action can never be said to “cause” another in the same individual (Hayes & Brownstein, 1986). With more elemental realist assumptions, the predictive capacity
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of models of the world are not limited by manipulability. Dependent variables such as thoughts
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or emotions can be said to “cause” other dependent variables such as overt action, for example. I would be dogmatic to rule out such analyses on philosophical grounds, but it is not dogmatic to
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consider them incomplete on practical grounds. It is part of the natural analytic agenda of clinicians to predict and influence behavior. This simple fact gives favor to processes or
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variables in therapy models that are directly manipulable. Where functional status is entertained for variables that are non-manipulable, either in principle or due to current technical inability, the
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analysis should be viewed as practically incomplete until the manipulable variables are understood. In practical terms that means that contextual variables have to be given favor in effective treatment development.
These ideas are easily understood within a CBS approach because it is the core of functional contextual thinking (Hayes & Brownstein, 1986), but it can be more difficult for other scientific models. The best prediction of future action is past action, and thus it is quite possible to create effective predictive models consisting entirely of dependent variables such as attitudes, intentions, expectations, or overt behavior. The problem is that when these models are used in application, sooner or later the practitioner needs to do something. The practitioner is in the clients context and that doing will be an independent contextual variable. It needs to be included it in the analysis.
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Consider, for example, the difference between a theory of clinical change that oriented toward the self-esteem of clients, versus a superficially similar theory that focused on the
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empowering effects of validation in the therapeutic relationship and its effect on self esteem.
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Until context is specified, the former theory treats dependent variables as causes, whereas the latter example points to a directly manipulable variable in the form of the actions of the clinician.
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Many theories never fully specify the contexts in which various psychological events have
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effects, and when they are tested, that gap in knowledge is exposed. In one disturbing example, efforts made by the US state of California at improving academic performance through
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enhancing self-esteem may have actually backfired (Baumeister, Campbell, Krueger, & Vohs, 2005). Thus, even if it is not demanded by core assumptions, treatment developers from all
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scientific models need to be sure that their theories ultimately include variables that can be changed and manipulated directly. That is the only way to foster a good fit between theories and
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the natural analytic agenda of treatment development. Summary. While programmatic treatment development research has been described in and evolved over time (c.f., Mercer, DeVinney, Fine, Green, & Dougherty, 2007; Rounsaville, Carroll, & Onken, 2001), there is limited clarity about the role of theory and the kinds of theories that are needed. Treatment developers need to take a purposeful approach to developing the types of theories that will comport both with one’s philosophical assumptions and the goals of treatment development. That seemingly can be done for all scientific approaches and philosophies but only if it is done deliberately. Using Translational Exchanges Between Basic and Applied Science to Fuel Theory Development
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From the beginning of psychology there has been a hope by some that bottom up accounts can guide treatment development. Instead of digging down toward functional entities
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from topographical ones, some have preferred to start with functional variables and see if it is
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possible to model human complexity. We will now move to a discussion of this major approach to treatment development, exploring its benefits and limitations.
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Functional Analysis
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Perhaps the classic example is functional analysis. Functional analysis has had a wide variety of meanings within behavior analysis and therapy (Haynes, O'Brien, & Kaholokula,
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2011) but "classical functional analysis" involved: 1. Identify potentially relevant characteristics of the individual client, his or her behavior, and the context in which it occurs via broad
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assessment; 2. Organize the information collected in Step 1 into a preliminary analysis of the client's difficulties in terms of behavioral principles so as to identify important causal
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relationships that might be changed; 3. Gathering additional information based on Step 2 and clarifying the conceptual analysis; 4. Devising an intervention based on the principles identified within that analysis; 5. Implementing that treatment method and assessing change, and; 6. Recycling through these steps if necessary. This approach showed promise as a form of treatment development in the early days of evidence-based treatment, and some classic behavior therapy methods were developed in this general way. The area of developmental disabilities is one in which functional analysis has become a robust and replicable empirical method following the classic work of Carr (1977) and Iwata (e.g., Iwata, Dorsey, Slifer, Bauman & Richard, 1982). In these areas, however, descriptive analyses were replaced by well-specified analogue tasks that identified whether specific behaviors were maintained by particular consequences (e.g., positive reinforcement, negative
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reinforcement, or sensory reinforcement) and this distinction was in turn linked to a limited set of treatment alternatives. Indeed in applied behavior analysis the very term “functional analysis”
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now refers only to organized environmental manipulations for the purpose of identifying the
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functions of behavior, not to conceptual functional analyses as it did historically. In some areas, such as self-injurious behavior, systematic methods of experimental functional analysis have
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become a very well-organized system of assessment within a known range of treatment options
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(Kahng, Iwata & Lewin, 2002). This is not “treatment development” in the sense we are addressing here, however – it is more a matter of functional behavioral assessment – and it has
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been confined to a very limited range of populations. Over 90% of the published studies using experimental functional analyses have been conducted with individuals diagnosed with
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developmental disabilities (Hanley, Iwata, & McCord, 2003). Regardless of how it is defined, functional analysis has not become a central and agreed
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upon method of treatment development across the wide range of clinical problems (Friman, 2010; Gadaire, Kelley, & DeRosa, 2010). Among other problems, functional analysis relies on the idea that a relatively adequate set of behavioral principles already exists with which to analyze client difficulties, their history, and context. It requires that the principles be sufficiently precise and that the specific steps that need to be taken to alter these functional processes be known or at least constitute a small enough set that plausible treatment alternatives can be generated quickly. In some areas, such as the application of operant interventions to developmental disabilities, those assumptions may apply reasonably well, but in many other areas they may not. If the sets of available principles are not adequate in areas for problem analysis or the identification of intervention alternatives, the bottom up strategy is silent about
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what to do next. Thus, to be successful, functional analysis depends on a basic science that can provide the knowledge and principles needed to address clinical problems.
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Translational Research
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One barrier to the broad application of bottom up approaches is that clinicians can wait a long time for basic scientists to provide the technical concepts needed for clinical work. This is
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the exact problem that harmed functional analysis as a method of treatment development. Early
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behavior therapists warmed to the idea of using functional analysis in a broadly applicable way, and they proposed sophisticated systems for doing so (e.g., Kanfer & Grimm, 1977; Kanfer &
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Saslow, 1969) but basic behavioral principles could not explain human cognition, so there was a huge hole in the proposed systems of analysis. Behavior therapists quickly tired of that situation,
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and cognitive behavior therapy (CBT) was the result, but that required the adoption of clinical models of cognition, not basic science models (e.g., Mahoney, 1974).
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No one objects to using available basic science principles in treatment development when they are available and known – indeed the etymological metaphor underlying the very term “applied” psychology connotes that it is a field that will bring basic knowledge (the word “basic” comes from a term for a pedestal or foundation) into contact with practical problems (like an “appliqué”). An immediate practical problem, however, is that the basic literature is vast. Most basic behavioral scientists read regularly or thoroughly in a handful of research areas, but a clinical researcher wanting to use basic knowledge would have to be far more catholic. In effect treatment developers seemingly have to be more broadly knowledgeable about basic science than most basic researchers (Hayes, 1998b). In the United States, the National Institutes of Health has decided to overcome this problem by creating research centers and multidisciplinary teams specifically accountable for
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moving basic science findings into clinical interventions. The first Request for Applications for the National Institutes of Health Clinical and Translational Research Award defined
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“translational research” as including two areas: “One is the process of applying discoveries
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generated during research in the laboratory, and in preclinical studies, to the development of trials and studies in humans. The second area of translation concerns research aimed at
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enhancing the adoption of best practices in the community.”
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(http://grants.nih.gov/grants/guide/rfa-files/RFA-RM-06-002.html). As of 2012 almost 60 research centers have been funded to pursue these goals.
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In a similar development, NIMH has proposed a new way of classifying psychopathology based on combinations of observable behaviors and neurobiological processes with its Research
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Domain Criteria initiative ([RDoC], National Institute on Mental Health, 2011). This plan specifically seeks to cut across disorders as commonly defined by DSM, and is the result of a
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series of translational research conferences that have been held over the years to bridge applied and basic clinical sciences. The goal seems to be to understand basic processes across units of analysis ranging from the genetic to the overtly behavioral. One intended result is the development of experimental classification of psychopathology based on the understanding of the underlying mechanisms of problems. This approach seems to appreciate that there are multiple routes to a particular clinical problem and that multiple topographies can result from common process. The RDoC appears to be building its classification system on the basis of multiple sources of measurement ranging from genetic, neuroscience, and behavioral. The hope is that discussions and research will occur to develop, as DSM has, consensus definitions on variables that can be used to classify participants in clinical studies (paraphrased from http://grants.nih.gov/grants/guide/notice-files/NOT-MH-11-005.html). This may be a better
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approach to understanding behavioral variability and might provide a means of examining both adaptive and psychopathological behavior that relate to similar processes rather than
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dichotomized classes of behavior clustered into hypothesized syndromal diagnoses.
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Translational research acknowledges the importance of basic science ideas to treatment development (and the need to carry innovative treatments into rapid dissemination), but it does
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not necessarily solve a second problem in the use of bottom up approaches: how can we ensure
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that basic scientists will be working on the basic principles clinicians need? The usual answer to that problem is superficially satisfying but difficult to mount: basic behavioral scientists should
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test the hypotheses of clinicians. It is usually not explained why a basic researcher would want to do that. Basic researchers are curious about what they are curious about, and it does little good to
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wag fingers about what those interests “should” be. But even if that were not the case, the idea that basic scientists will pick clinical hypotheses to test calls on a degree of clinical
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sophistication basic scientists do not have. Many clinical hypotheses are undoubtedly flawed, and basic researchers would have to have to be extremely clinically sophisticated to know which ideas were viable and which were not (Hayes, 1998b). CBS Suggestion 5: Establish a Mutual Interest Exchange between Basic and Applied Researchers
The solution within in a CBS strategy is called the “mutual interest model” (Hayes & Berens, 2004). It is arguably one of the more important parts of the treatment development model shown in Figure 1. In this approach, a variety of content issues that overlap between applied and basic psychology are identified as being of mutual interest to each area, considered against their own criteria. Only a very small number of researchers need to be willing to pursue both sides of the issue (basic and applied) to allow an overall team to cooperate.
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An example is provided in the history of ACT development. Early work on rulegovernance (Hayes, 1989) began to slow down when it was not possible to define what was
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meant by “verbal stimuli.” ACT developers did basic science work on the pragmatics of human
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language until a basic science answer began to take shape, Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001). Early studies on RFT (e.g., Devany, Hayes, & Nelson,
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1986; Steele & Hayes, 1991), were placed in basic science journals, not clinical journals, and
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little was made of their clinical relevance even though this interest drove the work. Basic scientists eventually became interested for their own reasons, not for applied reasons, and
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extended the work. Because there was a mutual interest, however, these new basic studies were of immediate interest to clinicians applying this work.
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As mutual interest grows, it can be sustained by only a small number of basic scientists who carry basic interests into application or a small number of applied scientists who carry
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applied interests into basic studies. Thus, although a reticulated network of research is needed to ensure that new treatment ideas are theoretically powerful, the vast amount of this work can be done in the more narrowly focused way in which sub-disciplines normally operate. Many issues that seem key to treatment development (current examples within the CBS community include such topics as implicit cognition, sense of self, or values) are inherently interesting to both basic and applied scientics and could yield to a mutual interest model. CBS Suggestion 6: Use a Multi-leveled Approach to Theoretical Concepts when Translating Between Basic and Applied Settings One of the reasons that applied psychology went through a technological era is that a proper appreciation of theory seemed to require that that practitioners (or even clients) learn to
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speak in sophisticated basic terms. That is a bad idea, because clinical theories and models need to be practically useful.
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Applied theories, however, tend not to be progressive. Practically useful concepts tend to
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be somewhat less precise, but that creates a gap between concepts and the auxiliaries and conditions that are needed to collect data testing these concepts (a point forcefully made by
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Meehl’s classic article on the progressivity of “soft psychology”, 1978; but see also Hayes,
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2004). The measurement of clinically assessable but metaphorical concepts like “stress,” for example, is so variable and loosely related to the concept that the term has become almost
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impervious to test (Patmore, 2009).
Thus, the problem is that practical models tend not to be precise and precise theories tend
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not to be practical. On the one hand, practitioners need to make quick decisions about how to intervene with culturally and diagnostically diverse populations. As such, they require models
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and principles that are easy to remember, broadly applicable, and that guide effective and innovative treatment choices. On the other hand, scientific progress requires the use of terms and models that are technically precise, broad in scope, and coherent across levels of analysis. The CBS solution to this tension between basic and applied theories is broadly applicable: create interlocking conceptual systems with less technical middle level terms organized into clinical models, each of which is then unpacked into technical basic science concepts and theories studied in basic science laboratories. There are many areas in life where we encounter multi-leveled conceptual systems. Consider, for example, the relationship between cooking and chemistry. A person wanting to bake a cake needs to know how to mix flour, eggs, sugar, and water in approximate amounts and bake them at a certain temperature for a certain time period. It is likely not necessary to have an in-depth understanding of lipids, acids, bases,
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and the periodic table in order to make a cake, and a recipe cast in these terms would not be very useful. A chemist wanting to generalize baking knowledge to the process of brewing beer may
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need this kind of basic knowledge, however. It is important that nothing in the cake-baking recipe contradicts basic chemistry (if it does, the cake will not be very good), but it is fine to use
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terms like “eggs” or “flour” even though these categories are not very meaningful for the work of
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the chemist. One might think of “eggs” and “flour” as middle level terms. They might not carry
achieve the pragmatic goal of baking a cake.
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all the complexity the chemist might desire, but they are sufficiently precise to allow one to
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An example of a multi-leveled conceptual system in CBS is the psychological flexibility model that underlies Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson,
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2011). For example, one element of that model is a sense of self as pure awareness (variously
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termed as “self as perspective” or “self as context”). It is treated as a middle level term, and is
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linked clinically to various contemplative and experiential exercises (e.g., see Chapter 8 in Hayes et al., 2011). This middle-level concept is in turn linked to a basic behavioral science of the deictic cognitive relations (I-You / Here-There / Now-Then) RFT argues gave rise to this sense of self (for a book length treatment of that basic science evidence see McHugh & Stewart, 2012). This multi-level approach to theoretical concepts enhances the opportunity to have both clinically accessible models and a progressive basic science. CBS Suggestion 7: Mediators and Moderators are Key If the goal is the development of pragmatically useful accounts, mediation and moderation are in some ways more important than outcomes per se, in that treatment models aim to orient clinicians to putatively key processes. Qualitative research has a role in this process, as do measures of actual in-session behavior, neurobiological assessment, assessment of implicit
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cognition, and other areas -- not merely self-report. If these activities are theory-guided, progress in these areas demonstrates the utility of linkages between basic and mid-level terms. Mid-level
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terms such as “mindfulness” and “cognitive distancing” may be purported mediators, for
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example, and their assessment can be guided by developments in basic sciences. Data from studies of mediation and moderation, can therefore help to fuel mutual-interest exchanges
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between basic and applied labs.
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In addition to motivating mutual-interest exchanges, mediation and moderation analyses can provide more stringent tests of the treatment model. It is possible, for example, for a model
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to be correct and technology to fail, or for technology to be correct and models to fail (Follette, 1995). In the former case, the theory gives developers a clear target for change. In the latter case,
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minimal guidance is provided beyond “more of the same.” Thus, if predicted mediation or moderation fails, it is important to determine where this occurred (Follette, 1995) to see of it was
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a failure of technology (i.e., the intervention did not impact the processes of change) or a model failure (i.e., the intervention did impact processes of change, but this did not account for changes in outcome).
Given its importance, it is rather startling that mediation has played such a small role until quite recently, as funders and others have begun to insist on its importance. Researchers often treat mediation as a matter of causality, however, which could ironically interfere with practical progress. A third variable could always explain meditational findings (cf., Kraemer, Wilson, Fairburn, & Agras, 2002), and since most mediators are dependent variables, they would not fit the standards for “causality” demanded of clinicians’ natural analytic agenda. But perhaps because of their implications for causality it is becoming fashionable to raise higher and higher barriers to the publication of meditational results (e.g., due to failures of temporality in which
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mediators were measured after outcomes began to change; or issues of randomization of mediators and so on). This is a false form of scientific conservatism. If processes do not account
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for differential outcomes, this is an incremental indication of model failure. Thus, mediation
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analysis (or the equivalent path analysis, even if formal mediation is not claimed due to the absence of ideal conditions such as those specified in Stice, Pressnel, & Gau, 2007) seems
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relevant in virtually every randomized trial as part of the process of treatment development.
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This line of thinking in CBS helps explain why research on ACT has dozens of published mediation analyses. No meta-analysis has yet been published of these studies (beyond an early
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one in Hayes, Bond, Luoma, Masuda, & Lillis, 2006), but a way to document that fact and to show how unusual it is provided by Öst’s comparison of 13 ACT studies with a set of 13
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matched CBT studies (Öst, 2008). Öst claimed that the ACT studies were less rigorous, but subsequent examination of the two sets of studies showed this was accounted for by the level of
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grant funding (Gaudiano, 2009). When we contacted the senior authors of all 26 studies, none of the authors of the 13 CBT studies said meditational analyses had been published, in press or under review from these data sets, while 9 of the 13 ACT studies (69%) were in that status, a significant difference (Fisher’s exact p = .0005, two tailed). Mediation and moderation data simultaneously examine the utility and coherence of the relationship between theory, technology, and outcomes. If the theories are multi-level these analyses can help examine the utility of the relationship between basic science and mid-level terms. Consistent model performance gives a target for further treatment development to researchers and clinicians, who can then focus more on empirically supported processes than packages (Rosen & Davison, 2003).
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Summary. Basic science has an important role in treatment development. This simple statement is sobering because it means that treatment developers must have a vision for how to
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develop and use basic science itself. Clinical psychology cannot stand apart from behavioral
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science as a whole – it cannot just consume basic science, it needs to impact it. Applied psychology needs a knowledge development system that will lead, on the basic side, to an
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account of key domains that consists of manipulable principles organized into theories, and an
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easily accessible model of pathology, intervention, and health on the applied side that can be linked to the basic account. The mutual interest model identified in CBS offers one strategy for
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achieving these goals; mediation and moderation are key to maintaining a pragmatic conceptual focus that provide tests of progress.
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Maintaining a Practical Focus in Treatment Development We have discussed in previous sections ways in which philosophical clarity and findings
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from basic science can inform treatment model development. Important theory selection criteria can also be derived, however, from practical considerations contacted through dissemination, training, and treatment evaluation efforts. This is one way in which the treatment development needs to be reticulated: standards for model development need to be based upon the purposes, abilities, and preferences of clients and those who serve them, whether these are individual clinicians, self-help publishers, healthcare facilities, or any other intervention system. Such factors traditionally have been taken into account only after many years of treatment evaluation. This helps explain why current methods of treatment development appear lumbering, expensive, slow, and poorly focused on actual needs. The current system of treatment development presents practical challenges for researchers, agencies, and clients alike.
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The strengths and limitations of the stage model provide an example. In the 1990’s the National Institute on Drug Abuse launched a treatment development initiative (Onken, Blaine &
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Battjes, 1997) that was quickly imitated by other institutes within the National Institute of
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Health. This was aimed at coming to grips with the heavy burden placed on treatment developers to have manuals, training programs, measures, and preliminary data before being able to secure
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funding for treatment evaluation. The approach was termed the “Stage Model” (Rounsaville,
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Carroll, & Onken, 2001). In this approach, Stage 0 is translational research; Stage I consisted of manual development, work on therapist training, the development of adherence measures and
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pilot tests. Stage II consisted of efficacy testing, particularly through randomized clinical trials (RCTs), and extending into Stage III efficacy tests in community settings. Stages IV and V
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consisted of research on the transportability of successfully evaluated interventions, including work on effectiveness, implementation methods, cost effectiveness, and consumer acceptability
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or marketability.
Although these stages were argued not to be linear (Rounsaville et al., 2001), the very metaphor of sequentially numbered stages fights against that flexibility. Furthermore, funders of behavioral therapies treatment development research (Onken et al., 1997) placed effectiveness and dissemination research at the end of a long process of treatment development and evaluation. Carroll and Nuro (2002) suggested that effectiveness trials should occur only after several successful efficacy trials. As Addis and Waltz (2002) point out, this means a minimum of 9 to 15 years delay between treatment development and dissemination. If studies fail at that point it could mean that decades of resources put into developing and testing a treatment were largely wasted. Delaying studies on effectiveness and dissemination also means that modifying treatments could be difficult, in part due to investment by treatment developers in existing
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treatment technologies, manuals and training materials. Dismantling studies designed to identify the essential components of treatment packages present the same set of challenges, with such
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research often being delayed until after multiple RCTs have been conducted at which point
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treatments may have already been refined and disseminated. These are only two examples. Efficacy without effectiveness is not useful (Clarke, 1995; Nathan, 2007). Advocates of
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effectiveness research have called for a more flexible approach in which practical concerns enter
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earlier into treatment development and efficacy testing (Hoagwood, Hibbs, Brent, & Jensen, 1995).
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CBS Suggestion 8: Account for Dissemination/Implementation Issues When Designing Treatment Models. With the emphasis in the field on internal validity and highly controlled
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RCTs, treatment researchers sometimes fail to fully consider and adjust for the pragmatic limits of front line treatment providers. This can lead to the development of sophisticated, multi-
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component interventions that can be difficult for clinicians to learn and implement with fidelity and competence in the treatment environment. Detailed treatment manuals that provide minimal flexibility, although useful for ensuring internal validity in RCTs, may not match the varied demands put on clinicians in practice. The mismatch between treatments developed and validated by researchers and the limitations and needs of clinical practice may account, in part, for the low adoption rates of evidence-based treatments by clinicians (e.g., Becker, Zayfert & Anderson, 2004; Garner, 2009). There are several examples, however, of researchers who have placed a strong emphasis on addressing dissemination issues within treatment development. One promising approach has been to focus on creating treatments with the smallest number of “moving parts”, limiting the number of treatment components, technologies and theoretical targets to keep the intervention as
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small and simple as possible. For example, Behavioral Activation for depression represents a precise theoretical model and treatment approach that itself was developed from a component
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within Cognitive Therapy for depression. This more parsimonious treatment has served to reduce
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the intensity of training needed to produce effective therapists to treat depression (Jacobson & Gortner, 2000) and has opened up the possibility of having treatment conducted by
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paraprofessionals (Ekers et al., 2011).
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The concept of evidence-based kernels (Embry & Biglan, 2008) provides another example of movement in this direction. A kernel is conceptualized as the smallest divisible unit
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for behavior change at which point removing any additional components would lead to the intervention being inert. Embry and Biglan (2008) conducted a review identifying 52 such
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kernels with notable empirical support (i.e., public commitment, self monitoring, progressive muscle relaxation). These kernels provide simple and focused intervention tools that often can be
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applied to a variety of problem areas. These features can make kernels easier for clinicians and other professionals to learn and implement relative to larger, multi-component treatment packages. Thus, in addition to developing more parsimonious treatment packages such as Behavioral Activation, researchers are also focusing on smaller evidence-based behavior change interventions/components as a means of overcoming existing barriers to implementation. Coincidentally, study design methods are improving to allow for optimizing and sequencing therapy components (e.g., Collins, Murphy, & Strecher, 2007). CBS Suggestion 9: Consider treatment approaches within the public health perspective. A different set of practicality issues have been raised by considering the standard treatment development approach relative to the public health goal of reducing the burden of mental illness (Kazdin & Blase, 2011). In many areas it is not obvious that developing efficacious treatments
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within a model of individual psychotherapy will significantly reduce the burden of mental illness given the number of those needing treatment relative to number of providers, and the variety of
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barriers that lead to low treatment seeking rates (Kazdin & Blase, 2011).
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Treatments can do a better job rising to the challenge of psychological problems as a public health issue if they consider provider issues, length, format, disseminability, and the like
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from the beginning of the development cycle (Kazdin & Blase, 2011). Examples of relatively
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straightforward methods that have been tested with a wider variety of professional and paraprofessional providers include Motivational Interviewing (MI; Hettema, Steele & Miller,
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2005) and Behavioral Activation (Ekers et al., 2011). Treatment methods can be designed so that they can readily be transported to a guided self-help format (Cuijpers, Donker, van Straten, Li &
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Andersson, 2010), that can be conducted by paraprofessionals with limited training (Mohr, Cuijpers & Lehman, 2011). Interventions can also be designed to be computer-assisted, with the
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program delivering information to the client and prompting the provider to discuss or model particular skills in the room (Craske et al., 2009). New treatment methods can be tested not just in direct care delivery but also thorough bibliotherapy (e.g., Muto, Hayes, & Jeffcoat, 2011). These alternative methods of intervention can fit within stepped care models in which clients receive the least invasive and costly treatment given their presenting problem and “step up” to more intensive treatment as indicated by ongoing monitoring (O’Donohue & Draper, 2011). CBS Suggestion 10: Refine and Test Multi-Component Treatments. It is practically important to be able to disassemble large treatment packages containing many elements. Component research helps ensure the efficiency of treatment and may be able to provide clinicians reassurance that they can use specific procedures linked to specific processes and not
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just an entire package, thus increasing the degree to which models can be rapidly scaled to fit settings and treatment needs.
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One way to do this is to evaluate theoretically meaningful treatment components as part
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of the process of assembling packages. An illustrative example of this approach is provided by Borkovec, Newman, Castonguay and colleagues in their work on CBT for Generalized Anxiety
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Disorder (GAD). They conducted an RCT comparing the applied relaxation component of CBT
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to the full CBT package and a control condition (Borkovec & Costello, 1993) as well as a RCT comparing the cognitive therapy component, self-control desensitization component, and full
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CBT package (Borkovec et al., 2002). More recently they have examined whether adding emotional processing and interpersonal functioning treatment components to CBT would
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improve outcomes relative to a CBT plus supportive listening condition (Newman et al., 2011). Such research has been instrumental in identifying how the components of CBT contribute to
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treatment effects and informing the further development and refinement of the multi-component treatment package for GAD.
Another way forward is emphasized within the CBS approach: the early use of theoretically focused laboratory-based component studies (Hayes, Levin, Plumb, Boulanger & Pistorello, in press), which can occur even earlier in the cycle of treatment development. Such laboratory-based component studies are fast, relatively inexpensive, and provide a methodology in which relevant sample, intervention, and contextual variables can be carefully controlled and manipulated. Laboratory-based component studies do not demonstrate clinical efficacy – rather they test theoretical models that underlie treatment development and thus strengthen the linkage between basic principles and mid-level terms. A recent example is a meta-analysis of laboratorybased component studies of the psychological flexibility model underlying ACT (Levin,
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Hildebrant, Lillis, & Hayes, in press). The 66 component studies on psychological flexibility processes provided broad support for the model, suggesting that the components of the model
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were theoretically meaningful.
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CBS Suggestion 11: Test Effectiveness Early. Despite the tendency in the stage model to delay effectiveness and dissemination research, it can occur throughout treatment development
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and testing (Hayes, 2002). For example, even a brand new treatment method could be tested by
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comparing client outcomes in a heterogeneous clinical sample produced by front line clinicians who were trained in the new method relative to clinicians who did not receive such training. That
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“manipulated training” test was done as one of the very first studies of ACT in the modern era (Strosahl, Hayes, Bergan & Romano, 1998) and its positive outcome provided early guidance
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regarding the possible clinical effectiveness of the approach, in effect testing the practical impact of real world dissemination even before controlled outcome research was extensively available.
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CBS Suggestion 12: Research Novel Methods for Training and Implementation. The emphasis on conducting training, dissemination and implementation research has been growing rapidly in recent years, and the NIH has sponsored several initiatives in this area. With this has come the realization that some traditional training methods such as providing workshops are not adequate to ensure newly trained clinicians implement treatments with adherence and competence (e.g., Walters et al., 2005). Innovative training approaches are needed to ensure the effective and efficient dissemination of evidence-based therapies. An example of a treatment approach that has successfully moved into such training research is MI. A recent review of MI training research identified 27 independent studies (Madson, Loignon & Lane, 2009), with many more studies since published. Research has included a number of innovative models such as a criterion-based stepwise approach where
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clinicians receive a web-based training and proceed through more intensive training methods if they fail to meet competency criteria (Martino, Canning-Ball, Carroll & Rounsaville, 2011). This
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emphasis on training research with MI may be due in part to a combination of a fairly
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parsimonious treatment, knowledge of the active components and mechanisms of change of the intervention, its applicability to a range of providers, and valuing such training research within
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the treatment development community. Thus, MI provides an exemplary model for moving to an
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emphasis on training research.
Summary. There has been increasing focus in the field of clinical psychology on practical
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concerns including public health impact, effectiveness, training and dissemination. Although innovative solutions have begun to be identified, it is generally unclear how best to meet these
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concerns. By maintaining a functional approach it is possible to address practical concerns early and throughout treatment development. As in Figure 1, these concerns need to be both an early
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filter and an ultimate empirical goal.
Fitting Methods to Individuals
A final area of concern has to do with the individual client and clinician, the degree to which evidence-based treatments fit with individual clients, empower practitioners, and support or interfere with the relationship between them. This issue appears in a number of forms, and we will name but a few. It is reflected in concerns over diversity and the cultural match between client history and evidence based methods (e.g., Hayes, Muto, & Masuda, 2011; Hall, Hong, Zane & Meyer, 2011). Practitioners are concerned over rigid treatment manuals, and they worry about how manuals fit with individual clients and may negatively impact treatment process (Ashcraft et al., 2011). Practitioners want treatments to be developed that are flexible, with movable elements that can deal with client complexity. The traditional concern over the degree
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to which group averages found in RCTs reflect individual processes (Hayes et al., 1999), the use of transdiagnostic factors to fit treatment to individuals (Norcross & Wampold, 2011), and
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research on common factors and the therapeutic relationship (Wampold, 2010) all can be seen as
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issues of how treatment development can occur in a way that empowers individual clients, practitioners, and the relationship between them.
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Some of the dimensions we have already considered are relevant to this issue (e.g.,
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identifying components that can be used to fit specific client needs). Two additional areas should be mentioned.
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CBS Suggestion 13: Consider Time Series and Single Case Analysis. There is no way to assess the impact of treatment on individuals without frequent assessment collected at that level.
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Many of the most robust empirically supported treatments began with time series analyses and single case experimental designs. This is highly desirable, especially in the early stages of
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treatment development, because that allows the identification of individuals who are known to improve due to treatment (Hayes, Barlow et al., 1999). Group comparison methods are by design not capable of doing so.
CBS Suggestion 14: Test Transdiagnostic Breadth. With advancements in the understanding of psychopathology and treatment mechanisms has come an increasing focus on transdiagnostic treatments that seek to treat a range of psychological problems with a single intervention approach by targeting common mechanisms of action. Examples include the Unified Protocol for emotional disorders (Barlow, Allen & Choate, 2004), Cognitive Behavioral Therapy-Enhanced for eating disorders (Fairburn et al., 2009), and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 2011). One contributor to this increased focus on transdiagnostic treatment is their potential for overcoming existing barriers to dissemination
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(McHugh, Murray & Barlow, 2009). The availability of such approaches could potentially reduce the training burden on clinicians to learn the range of evidence-based therapies needed to
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meet the diverse mental health needs of their clients and provide a treatment that is more flexible in adapting to clients with comorbid and subthreshold disorders. Transdiagnostic treatments thus
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represent, in part, an example of researchers’ attempts to develop therapies that may better fit the
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practical needs of clinicians.
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The emergence of an interest in transdiagnostic factors has been less fostered by federal money than by the search for a viable alternative to syndromal classification. In a sense,
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transdiagnostic approaches sit in the middle between a fully idiosyncratic approach and syndromal diagnosis (McManus, Shafran, & Cooper, 2010), which is why we have listed this
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issue in this section. A transdiagnostic approach can include the effort to identify a wide number of processes that are universally applied (Harvey, Watkins, Mansell & Shafran, 2004), processes
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that are limited in the range of disorders covered, and single processes that are widely applicable (Mansell, Harvey, Watkins, & Shafran, 2009). Summary. Innovations in treatment development have to be more focused on the development of broadly useful principles and theories, more practical development strategies, and strategies that are more mindful of individual issues such as values, culture, preference, relationships, and the like. A progressive treatment development system needs to be sensitive to all of these goals and assessed on how well these goals are met. Adoption of a Reticulated Approach Figure 1 displays a reticulated functional contextual model of treatment development, drawn from the contextual behavioral science tradition. We have attempted to present it in a way that might be useful beyond that specific community.
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It needs to be acknowledged that the model we have presented is explicitly communitarian. It shifts the focus of treatment development from the individual laboratory,
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researcher, or clinician, to a set of networked actions that only a group can accomplish or at least
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accomplish well. As with all group activities, this requires some subordination of selfish interests for the sake of the common good, but humans as a species are inclined toward such cooperative
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ventures (Nowak, Tarnita, & Wilson, 2010), and in the networked modern world many young
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researchers come to their work having already learned of the power of virtual communities. The grouping of researchers and practitioners needed to mount this model is already
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occurring in areas such as mainstream CBT and indeed contextual behavioral science itself, which has grown enormously in the last decade as a reticulated and communitarian approach to
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treatment development has been consciously adopted and both basic and applied scientists have come together under its banner (see www.contextualpsychology.org). It is common place for
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funders and Deans alike to encourage the development of networked scientific teams and centers that cross traditional boundaries, so there is nothing inherently disadvantageous in a political or scientific sense about a reticulated treatment development model. What has been missing is a larger vision for the field that highlights the elements needed for long-term success. We as a field need to develop such a vision. This article is meant as a goad in that direction. Conclusion We can summarize our suggestions for treatment development in the form of a conclusion, attempting to make it applicable to any scientific approach interested in treatment development. Treatment development is fostered by a mix of innovation, practicality, and evaluation that stretches across the whole of behavioral science. In a sense, that means that treatment development cannot be fully separated from the whole of psychology and behavioral
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science. If psychology is weak, treatment development within psychology will be weak. Thus, treatment development needs to be thought about in a way that fosters the progressivity of the
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entire field.
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A progressive process of treatment development requires both philosophical clarity and clarity of practical purpose. The two align naturally in functional contextual thinking due to its
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analytic goals but other perspective can maintain that alliance by emphasizing practicality and
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attention to directly manipulable events. Manipulable events are always context for action, not action itself, and thus the focus of treatment development needs to begin with processes that
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involve manipulable contextual features.
Progress in basic and applied psychology is interlinked, but the commonly accepted
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vision of their relationship in which applied psychologists use basic principles, and basic psychologists test clinical hypotheses, is not optimal or at times even viable. It envisions a two
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way street, but unfortunately it is impassible in both directions. Applied psychology needs to instead form common cause with basic psychology in domains of mutual interest, and develop reticulated basic analyses and mid-level terms that can be both scientifically progressive and clinically useful. That requires learning to speak in different ways for difference purposes and to organize these analyses into larger analytic-abstractive theories. As components, packages, and assessment methods are generated from principles and theories, they need to be considered from the first moment in terms of their practicality, capacity for dissemination, and public health impact. After early testing, methods that are viable need to be examined in a reticulated way, so that issues of effectiveness, change processes, mediation, moderation, training, active components, and similar issues are considered from the very first randomized trial forward. That way, as the empirical basis of the work expands, broader issues of
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impact across problem areas and settings, and issues of training and dissemination, will have the process, component, and moderation knowledge needed to enhance further technological and
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theoretical development, and to fit treatment development to the needs of clients, practitioners,
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and systems.
This approach may seem difficult to surmount at first when one considers practical issues
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such as funding agencies requirements, the dominant role of the DSM, personal knowledge gaps
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in areas such as philosophy of science or basic science, and time/budget limitations. However, we are not proposing that every researcher involved in treatment development gain expertise in
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all of the areas outlined. Rather, the model highlights ways to more purposefully integrate ongoing research methods that are already being used as a research community to better meet the
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shared goals of alleviating human suffering. Although this model likely appears complex relative to the more linear and stage-based treatment development approaches, such complexity reflects
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the range of factors that must be addressed in order to better harmonize ongoing research efforts and overcome existing barriers to progressivity in treatment development. In many ways, each researcher participating in this model can continue with the same research program they have already been conducting, albeit with a greater sensitivity to this expanded set of issues ranging from philosophy to basic science to applied issues so that their work can be better integrated within the shared purposes of a larger treatment development community. Although expertise is not required in all areas, this approach does require researchers to be willing to expand beyond their traditional methods and considerations at times. A certain level of familiarity with philosophy of science, theoretical considerations, basic science, and practical applied issues is important. The specific suggestions outlined in this paper can provide a useful starting point on this path. Examining one’s philosophical assumptions,
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identifying how to better integrate one’s work with basic science, and more actively considering practical issues in treatment development and testing, among other suggestions outlined in this
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paper, all represent potential steps researchers can take in exploring an alternative, and
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potentially more progressive, approach to treatment development.
Progress depends on the creativity and hard work of our discipline as a community, but it
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also depends on our developmental strategy. It seems time to move beyond traditional models
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and to engage in a broader and more coherent search for innovation and advancement that will
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advance our field and strengthen its interconnections.
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A Reticulated Functional Contextual Approach to Treatment Development
Figure 1. The Contextual Behavioral Science Model of Treatment Development
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ACCEPTED MANUSCRIPT A Reticulated Functional Contextual Approach to Treatment Development Highlights Traditional approaches to treatment development are inadequate
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Models need to be practical, theory focused, and sensitive to clinical issues
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A reticulated functional contextual approach to treatment development is presented
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