The Theory-Practice Gap in Cognitive Behavioral Therapy: Reflections and a Modest Proposal to Bridge the Gap

BETH-00398; No of Pages 9; 4C: Available online at www.sciencedirect.com Behavior Therapy xx (2013) xxx–xxx www.elsevier.com/locate/bt The Theory-Practice Gap in Cognitive Behavioral Therapy: Reflections and a Modest Proposal to Bridge the Gap Keith Dobson Shadi Beshai University of Calgary adolescents in the United States show serious This paper examines the issues related to the gap between psychological distress and are in need of treatment theory and practice in the area of cognitive-behavioral (Kessler, Chiu, Demler, & Walters, 2005; Kessler et therapy. The article begins with a review of the evidence for al., 2009; Lopez-Duran, 2011). These rates appear to such a gap, and having demonstrated that the gap exists, be similar around the globe. Fortunately, there are provides a discussion of some of the factors that are likely over 400 psychological treatments currently in important in its genesis and maintenance. The article then practice (Corsini & Wedding, 2011). Even more focuses on potential strategies to reduce the theory-practice fortunately, there is a growing trend to empirically gap that go beyond the common recommendation for both identify efficacious, effective, and efficient psychother- efficacy and effectiveness research. In particular, we provide apies. This trend has been referred to as the emphasis recommendations for protocol planning and design, train- on empirically supported treatment or the develop- ing and competency maintenance, dissemination research, ment of evidence-based practice (herein referred to as and implementation and policy change. We conclude with ESTs; Lambert, 2010). ESTs are treatments that have the proposition that theory and research should not only demonstrated efficacy in clinical research trials inform practice, but that practice should have a reciprocal (Kazdin, 2008), but many also incorporate sound benefit on theory and research. procedures for psychotherapy in general. ESTs are primarily the product of clinical theorists, are most often conducted in the clinical laboratory, Keywords: cognitive-behavior therapy; theory; practice; dissemination and are mostly conducted by clinical researchers. Clinical scientists have begun to notice a disquieting THE UNDERSTANDING OF PSYCHOPATHOLOGY has steadi- trend, however, which is that ESTs are seldom put ly increased with the scientific and technological into use by practitioners in the community and health advances made in recent decades. Both psychological care at large (Kazdin, 2008; McHugh & Barlow, assessment tools as well as the classification systems 2012). Despite the fact that a number of interven- used to diagnose and predict the course of mental tions have been found to be efficacious for a variety illness have dramatically improved over the last 30 of major psychological disorders (e.g., depression, years (Hyman, 2011; Meyer et al., 2001). These anxiety, bulimia nervosa, etc.), surveys of practi- recent advances shed new light on the prevalence tioners indicate that these treatments are rarely and perniciousness of psychological disorders. For utilized to treat patients who suffer from these instance, 30% of adults and 19% of children and conditions. Low utilization of ESTs in community mental health clinics has also been noted for eating disorders (Haas & Clopton, 2003), substance-use Address correspondence to Keith Dobson, Ph.D., Department of disorders (Santa Ana et al., 2008), and mood Psychology, University of Calgary, Calgary, Alberta Canada T2N disorders (Kessler, Merikangas, & Wang, 2007). 1N4; e-mail: [email protected]. For instance, a study by Ehlers, Gene-Cos, and Perrin 0005-7894/xx/xxx-xxx/$1.00/0 © 2013 Association for Behavioral and Cognitive Therapies. Published by (2009) of family physicians in the United Kingdom Elsevier Ltd. All rights reserved. revealed that only 11% of patients treated for Please cite this article as: Keith Dobson, Shadi Beshai, The Theory-Practice Gap in Cognitive Behavioral Therapy: Reflections and a Modest Proposal to Bridge the Gap, Behavior Therapy (2013), http://dx.doi.org/10.1016/j.beth.2013.03.002 2 dobson & beshai posttraumatic stress disorder (PTSD) were provided Many practitioners have questioned the relevance of with evidence-based treatment for the disorder. efficacy trials, and claim that the conditions studied Further, only 6.9% of bulimia nervosa patients in in such trials are often less severe than what is the U.S. were provided with cognitive-behavioral typically observed in practice (Kazdin, 2008). therapy (CBT), despite its established efficacy for this Furthermore, some practitioners have indicated disorder (Chambless & Ollendick, 2001). Finally, that the samples typically allowed in clinical trials although clinical guidelines suggest the use of CBT include too many exclusion criteria and, as a result, with all patients who display signs of psychosis are too homogeneous and do not resemble the (NICE, 2009), only about 50% of schizophrenia diverse, heterogeneous clientele observed in routine sufferers are apparently provided with this treatment practice, who present with dual diagnoses and/or (Berry & Haddock, 2008). multiple problems. It should be noted, however, that It appears that the lack of utilization for ESTs in it is also possible to question how diverse clinical routine practice is not the only characteristic of this samples truly are, and recommend the use of treat- gap. Emerging evidence suggests that even when ment manuals for those patients who most closely practitioners attempt to implement ESTs, this approximate the presentation of cases treated in implementation is less than optimal. In other clinical trials (Stirman, Crits-Christoph & DeRubeis, words, treatment manuals are loosely followed, 2004). and thus the application of treatments bear only a Second, some practitioners have questioned the loose resemblance to the empirically tested protocols. practicality of using treatment manuals, as man- For example, a relatively recent study (Stobie, dated by the EST movement. For instance, some Taylor, Quigley, Ewing, & Salkovskis, 2007)found have claimed that treatment manuals are too rigid, that 40% of patients who suffered from obsessive- and thus do not account for individual differences compulsive disorder and who were allegedly offered in, or the preferences of, their clients (Borntrager, CBT had in actuality undergone a treatment that met Chorpita, Higa-McMillan, & Weisz, 2009). In an minimal criteria for CBT. Similarly, Kessler et al. early survey of this area, Addis and Krasnow (2007) found that only 20.9% of individuals who (2000) found that the major concern about treat- suffered from depression in a 12-month period were ment manuals was that they were rigid, inflexible, offered adequate psychological or pharmacological and did not allow for the integration of the art of intervention. psychotherapy into clinical practice. Difficulties in the transfer of laboratory produced Barlow, Levitt, and Bufka (1999) have reported and tested treatments to the community has been that a number of practitioners harbor misconceptions termed theory-practice gap. In describing this gap, regarding ESTs, which act as a major barrier to their Brownson, Colditz, and Proctor (2012) indicated adoption in routine practice. McHugh and Barlow that it signifies a discrepancy from “care that could (2012) more recently argued that these misconcep- be, where health care is informed by scientific tions largely stem from practitioners’ doubt of the knowledge, and the care that is in routine practice” applicability of the scientific approach to practice. (p. xi; italics in original). Thus, the theory-practice Such doubt is often centered in the belief that gap can simply be defined as the poor transport and psychotherapy is more “art” than science (McHugh uptake of knowledge and technology, as related to & Barlow). Similarly, Baker, McFall, and Shoham health care, from clinical science to clinical practice. (2009) have suggested that psychologists have yet to Acknowledging the magnitude of this problem, the assume a leadership role in using and disseminating Institute of Medicine (2001) described this gap as a empirically supported interventions, despite the “chasm.” impressive scientific record of CBT and other Although there is sometimes a willingness to blame psychosocial interventions. Baker et al. maintained clinicians for their apparent refusal to take up and that the relatively scarce use of ESTs among employ evidence-based therapies, in fact there are psychologists may stem from ambivalence among many factors that contribute to the theory-practice practitioners in regards to the role of science in gap in CBT. Expanding upon Shafran et al.’s(2009) practice, coupled with inadequacies in scientific evaluation, these factors can be grouped into three training, both of which conspire to lead to higher broad categories. The first two of these categories value upon clinical anecdotes than group-based concern practitioner beliefs regarding the relevance research outcomes. and practicality of ESTs. The remaining barrier, Third, some practitioners are either unaware of which acts to perpetuate the first two barriers, ESTs and/or are unable to effectively implement concerns the relatively poor training about and these interventions in their clinics or practice knowledge of dissemination of ESTs, which in turn settings (McHugh & Barlow, 2012). In this regard, stems from the underfunded nature of the field. the apparent gap between theory and practice may Please cite this

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