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Electronic Theses, Treatises and Dissertations The Graduate School
2009 The Use of Novel Unsupported and Empirically Supported Therapies by Licensed Clinical Social Workers Monica Pignotti
Follow this and additional works at the FSU Digital Library. For more information, please contact [email protected] THE FLORIDA STATE UNIVERSITY
COLLEGE OF SOCIAL WORK
THE USE OF NOVEL UNSUPPORTED AND EMPIRICALLY SUPPORTED THERAPIES
BY LICENSED CLINICAL SOCIAL WORKERS
By
MONICA PIGNOTTI
A Dissertation submitted to the College of Social Work in partial fulfillment of the requirements for the degree of Doctor of Philosophy
Degree Awarded: Fall Semester, 2009
The members of the committee approve the dissertation of Monica Pignotti defended on June 18, 2009.
______Bruce A. Thyer Professor Directing Dissertation
______Kenneth Brummel Smith University Representative
______Martell Teasley Committee Member
Approved:
______Nicholas Mazza, Dean, College of Social Work
The Graduate School has verified and approved the above named committee members.
ii
I dedicate this to my parents, Alfio and Ruth Pignotti, who have always supported and encouraged me in pursuing my education and excellence in all I do and who instilled in me the strong work ethic it takes to complete a doctoral program.
iii ACKNOWLEDGEMENTS
I would like to acknowledge and thank all of the people who stimulated and encouraged my interest in the topics of evidence based practice, critical thinking, and distinguishing science from pseudoscience in mental health practice including Drs. Brandon A. Gaudiano, Richard Gist, James D. Herbert, Scott O. Lilienfeld, Jeffrey M. Lohr, Steven Jay Lynn, Richard J. McNally, John Riolo, and Gerald Rosen. Dr. Riolo was the first person in the social work profession I had contact with who expressed concerns and skepticism about unsupported claims being made about novel interventions on the Internet and I am very grateful for the issues he made me aware of. The other individuals listed above began as critics of earlier views I held, but through my own examination of their criticism, I have come to recognize the validity of many of the points they raised, which I now thank them for raising and for the support and encouragement they gave me to pursue my studies in this area. I would also like to thank each of my Committee members. Thanks go to my committee chair, Bruce Thyer for all of the tremendous support and encouragement he has given me throughout my doctoral program, not only for the writing of my dissertation but also for giving me the opportunity to co author publications and for all the support he has given me with my job search. I also wish to thank Charles Figley, who was initially part of my committee before his move to a different faculty position, for all his support and passion for developing effective interventions for trauma. Dr. Figley was the one who initially encouraged me to apply to and attend Florida State University’s doctoral program. I also thank Dr. Martell Teasley for stepping in as a committee member after Dr. Figley’s departure and for all the support he has given me as a professor, in my job search, and as a committee member. Thanks also go to Dr. Kenneth Brummel Smith for being my outside committee member and contributing his expertise and his excellent feedback that has improved this manuscript. I am also grateful to Drs. Brandon Gaudiano and Ian Sharp for being my expert reviewers for classification of the interventions my respondents reported. As published experts in this area, their expertise was very much valued and appreciated and greatly approved the validity of my assignment of interventions to categories and thus, the quality of this dissertation.
iv TABLE OF CONTENTS
List of Tables vii
Abstract viii
1. CONCEPTUAL OVERVIEW AND PROBLEM STATEMENT 1 1.1 Introduction 1 1.2 Pseudoscience 2 1.3 Antiscience 7 1.4 New Age Therapies 8 1.5 Novel Unsupported Therapies (NUTs) 9 1.6 Evidence Based Practice and Empirically Supported Therapies 11
2. LITERATURE REVIEW 15 2.1 Inclusion Criteria 15 2.2 Database and Search Terms 15 2.3 Summary of Studies on Social Workers Prior to 1990 16 2.4 In Depth Review of Studies Conducted since 1990 18 2.5 Summary and Conclusions 27 2.6 Identification of Gaps in the Literature and Recommendations for Future Research 28
3. RESEARCH QUESTIONS, HYPOTHESES AND METHODS 30 3.1 Research Questions 30 3.2 Hypotheses 31 3.3 Methods 31
4. RESULTS 41 4.1 Sample Description 41 4.2 Practice Characteristics 42 4.3 Analysis of early vs. late responders 45 4.4 Research Question 1 45 4.5 Research Question 2 45 4.6 Research Question 3 49 4.7 Research Question 4 50 4.8 Research Question 5 51 4.9 Research Question 6 51 4.10 Research Question 7 56 4.11 Research Question 8 57 4.12 Hypothesis 1 57 4.13 Hypothesis 2 58 4.14 Hypothesis 3 58 4.15 Hypothesis 4 60 4.16 Hypothesis 5 60
v 5. DISCUSSION, CONCLUSIONS AND IMPLICATIONS FOR SOCIAL WORK PRACTICE 62 5.1 Key Findings 62 5.2 Study Limitations 66 5.3 Recommendations for Future Research 67 5.4 Implications for Social Work Practice 70
APPENDICES 73
A. NOVEL UNSUPPORTED PRACTICES ON THE INTERNET 73
B. SYSTEMATIC LITERATURE REVIEW 76
C. DATA COLLECTION INSTRUMENT 98
D. IRB APPROVAL LETTER 107
REFERENCES 109
BIOGRAPHICAL SKETCH 120
vi LIST OF TABLES
Table 1 Sample Description: Demographics 41
Table 2 Practice Description 42
Table 3 Areas of specialization named by participants 44
Table 4 Interventions mentioned most frequently by each particular respondent 46
Table 5 Interventions and assessment procedures respondents reported currently using in any frequency within the past year and in the past/discontinued 47
Table 6 Usage of NUTs, CUTs, CNUTs, and ESTs 50
Table 7 Relationship between Demographics and Number of NUTs, CUTs, CNUTs, and ESTs 51
Table 8 Relationship between Demographics and Usage of NUTs, CUTs, and CNUTs (dichotomized) 52
Table 9 Relationship between Practice Characteristics and Number of NUTs, CUTs, CNUTs, and ESTs 53
Table 10 Relationship between Practice Characteristics and Usage of NUTs, CUTs, and CNUTs (dichotomized) 54
Table 11 Relationship of use of NUTs, CUTS, and ESTs and CBT Theoretical Orientation to EBPAS scores 56
Table 12 Relationship of reasons for choosing interventions to CBT theoretical orientation 59
Table 13 Examples of novel unsupported practices by licensed clinical social workers promoted on the worldwide web 73
Table 14 Summary of studies reviewed on theoretical orientation, therapy choice, and attitudes towards EBP or ESTs 76
vii ABSTRACT
In recent years there has been a growing interest regarding the integration of evidence based practice into social work curricula and practice (Howard, McMillen, & Pollio, 2003; Thyer, 2004). However, there has also been a growing concern about the proliferation of novel interventions that lack empirical support and yet make claims of efficacy in the absence of evidence (Thyer, 2007) as well as conventional social work interventions that lack empirical support and yet remain unquestioned (Gambrill, 2006). Although studies have been conducted that have examined the theoretical orientations and other practice patterns of clinical social workers, to date, with the exception of the pilot study (Pignotti & Thyer, 2009) that preceded this dissertation, no study has systematically examined the intervention choices of licensed clinical social workers (LCSWs) including the use of novel unsupported therapies. The present dissertation examined the reported usage of novel and conventional unsupported and empirically supported therapies by 400 LCSWs from 39 different states who responded to an Internet survey. The purpose of the study was to determine what interventions were reported currently being used by LCSWs, reasons for choosing interventions, and their attitudes towards evidence based practice. Prior to data analysis, the list of the therapies reported being used by LCSWs was presented to a panel of expert reviewers and therapies were classified as empirically supported therapies (ESTs), novel unsupported therapies (NUTs) or conventional unsupported therapies (CUTs). The study hypotheses were that: 1) females would be more likely than males to use CUTs and NUTs; 2) respondents who report an affiliation with eastern/new age or nondenominational/spiritual religions would be more likely to use NUTs; 3) clinical experience would be more highly rated than empirical evidence as a reason for selecting a therapy; 4) LCSWs with a theoretical orientation of cognitive behavioral would value evidence from research more highly than LCSWs of other orientations and 5) LCSWs who use NUTs and/or CUTs will score higher on the Divergence subscale of the Evidence Based Practice Attitudes Scale (EBPAS; Aarons, 2004) than those who did not use such therapies. The results showed that although an overwhelming majority of the sample reported using ESTs (98%), three quarters of participants also reported using at least one NUT and 86% used at least one CUT. The hypothesis that females were more likely to use NUTs and CUTs was supported and females also used a higher number of NUTs. The hypothesis that participants
viii reporting eastern/new age and nondenominational/spiritual religious beliefs use a higher number of NUTs was also supported, although they were not more likely to use any NUT. It was found that participants, as hypothesized, valued clinical experience over research evidence and LCSWs with a theoretical orientation of cognitive behavioral were found to value research evidence more highly than those of other theoretical orientations. The hypothesis that LCSWs who use NUTs and/or CUTs will score higher on the Divergence subscale of the EBPAS was not supported. This study offers preliminary evidence that the use of NUTs is widespread among LCSWs, although the limitation is noted that the present sample may not necessarily be representative of all LCSWs. It also appears that given the fact that actuarial judgment has been shown to be more accurate than clinical judgment (Dawes, Faust & Meehl, 1989) LCSWs may be under valuing research evidence. It is also evident that the use of ESTs and NUTs are not necessarily mutually exclusive and although the EBPAS indicates that overall our sample had a positive attitude towards EBP, future research needs to examine a fuller definition of the term that includes their understanding of the term and specific practices.
ix CHAPTER 1
CONCEPTUAL OVERVIEW AND PROBLEM STATEMENT
1.1 Introduction
Clinical social workers comprise the largest number of psychotherapy providers in the United States, outnumbering psychologists 34:26 and psychiatrists 34:11 per 100,000 in the U.S. population although specific ratios may differ by region (Hartston, 2008). Although the profession of social work appears to be moving more towards an evidence based practice orientation, concern has been expressed about the proliferation of interventions being practiced by clinical social workers and other mental health professionals that lack empirical support and yet make unsubstantiated claims (Thyer, 2004; Lilienfeld, Lynn & Lohr, 2003a). The social work profession has been characterized as largely authority based, employing the strategy to “simply pronounce what is and what is not even though there is no evidence for claims” (Gambrill, 1999, p. 341) which may result in highly undesirable consequences for clients and for social work as a profession. Specht and Courtney (1994) have noted that some social workers have lost sight of the mission of the profession to help the poor and the vulnerable and have replaced this with an entrepreneurial focus, using questionable approaches with mainly middle classed and wealthy clients. These authors provide examples of offerings from clinical social workers that include a social worker who “does psychic readings and past lives” (p.1) and another who “holds sessions on ‘Awakening: Rosen Method Body Work” (p.1) and yet another who gives workshops on “Making Money Doing What You Love. . .your Higher Self knows your purpose in the universe and how to create work you truly love” (p.2). Another example given is a social worker who describes her approach as incorporating “conscious breathwork, hypnotherapy, past life regressions, process work, subtle energy technology and the healing of conception, birth and prenatal trauma” (p. 2). More recently, it has been observed that the advent of the internet has resulted in an increased ability of proponents of novel interventions to more widely advertise their practices
1 and training seminars (Gaudiano & Herbert, 2000). This has resulted in a proliferation of such therapies by mental health professionals including clinical social workers, that are often commercially trademarked and vigorously promoted, making grandiose claims on the basis of anecdotes and testimonials rather than evidence (Lilienfeld et al., 2003a). In some cases, to create an aura of professional respectability, these therapies, which are sometimes trademarked and proprietary, have developed their own professional associations and certification programs (Herbert et al., 2000). Some have even gone so far as to require participants sign confidentiality agreements not to reveal trade secrets (Pignotti, 2005; 2007). One can readily observe by browsing the worldwide web and conducting a search on the terms “LCSW” and the names of any of these questionable practices, that a number of licensed clinical social workers (LCSWs) are promoting such practices on their websites. Some examples of such promotions, obtained through the internet search engine Google (www.google.com) are provided in Appendix A. These examples are only intended to serve as illustrations of what some LCSWs are offering and are not claimed to necessarily be representative of all or most LCSWs. It is important to clarify that the intention of the present investigation is not to dismiss these novel interventions out of hand by making a priori assumptions that they are ineffective or harmful. Rather, the problem with such interventions is the claims proponents are making that exceed the evidence available and this may not be in the best interest of the client and they may lower the credibility of social work as a profession. Nevertheless, the assumption I make is to give clinical social workers the benefit of the doubt by assuming that most are well intentioned and sincerely believe in the interventions they offer, whether supported by empirical evidence or not. However, when claims are being made for such interventions, the claimant “has the burden of proving to experts and to the community at large that his or her belief has more validity than the one almost everyone else accepts” (Shermer, 1997, p. 50).
1.2 Pseudoscience
Many of the practices described in Appendix A have been characterized as pseudoscientific (Lilienfeld et al., 2003a). Pseudoscience has been defined by the philosopher of science, Mario Bunge, as “a body of beliefs and practices whose practitioners wish, naively or maliciously, pass for science although it is alien to the approach, the techniques, and the fund of
2 knowledge of science” (Bunge, 1998, p. 41). Ten hallmark indicators of pseudoscience have been outlined (Lilienfeld et al., 2003a) based upon Bunge’s (1998) conceptualization. While noting that legitimate therapies with empirical support can also exhibit some of these characteristics, “the more warning signs a discipline exhibits, the more it begins to cross the murky dividing line separating science from pseudoscience” (Lilienfeld et al., p.5). The ten indicators are as follows: 1. —An overuse of ad hoc hypotheses designed to immunize claims from falsification“ (Lilienfeld et al., p. 6). When claims for a pseudoscientific practice are falsified through experimentation or results are not as predicted, proponents of such practices may attempt to explain such disconfirmation by producing explanations, after the fact, for the failure. For example, one such approach called Thought Field Therapy (Callahan & Trubo, 2001) claims to be able to eliminate trauma, phobias, and other mental health problems within minutes by finger tapping on purported acupressure points. However, when it does not appear to work and the client does not report relief, Callahan explains this with another concept where he proposes that their energy is reversed. After employing a tapping correction for that, if the person continues to fail to respond, that is explained by exposure to toxins and if that still does not work, more toxins are searched for (Gaudiano & Herbert, 2000; Pignotti, 2005; 2007). If these explanations are accepted, the claims are protected from falsification, weakening the scientific legitimacy of the approach. 2. —Absence of self-correction“ (p. 6). This refers to the propensity of pseudoscientific approaches to not admit to errors and correct them. Legitimate science, by contrast, will be transparent and correct errors. 3. —Evasion of peer review“ (p. 6). Proponents of pseudoscientific practices may rationalize their dearth of refereed publications by claiming that the scientific community, journal editors and reviewers are biased against them and will not accept their submitted articles for publication. A more recent variation on this is trademarked therapies starting their own journals and publishing favorable articles, claimed to be peer reviewed, albeit by people who are promoters of the approach (Mercer & Pignotti, 2007).
3 4. —Emphasis on confirmation and refutation“ (p. 7). This is based upon Popper’s (1979) notion that it is easy to find supportive evidence for most claims and thus the emphasis in science ought to be on refutation. 5. —Reversed burden of proof“ (p. 7). This is the notion that the onus of proof for any claim is on the proponent. In scientific skepticism, it is the unusual claim which requires unusual evidence. Promoters of pseudoscience tend to reverse this burden and demand that critics prove that their approaches do not work. 6. —Absence of connectivity“ (p. 7) refers to the tendency of pseudoscientific approaches to claim to have new paradigms when scientific principles already established might constitute more parsimonious explanations. While it is possible that a completely new theory could have been discovered warranting a dramatic paradigm shift, one “must insist of very high standards of evidence before drawing such a conclusion” (p. 8). 7. —Overreliance on testimonial and anecdotal evidence“ (p. 8). This is self explanatory and the LCSWs described in Appendix A provide examples. 8. —Use of obscurantist language“ (p. 8) refers to the use of specialized jargon that sounds scientific and technical but does not explain anything or refers to instances where more ordinary language would suffice in explaining existing phenomenon. 9. —Absence of boundary conditions“ (p. 9). Pseudoscientific approaches claim, without evidence, to be able to treat a wide array of different types of problems whereas scientific approaches will limit their claims to areas for which evidence exists. 10. —The mantra of holism“ (p. 9) describes an attempt to rationalize the use of unsupported practices by maintaining that they are being used in conjunction with other approaches and should not be evaluated apart from those. This is another way to protect claims from falsification. Criticisms and Defenses of the Concept of Pseudoscience McNally (2003) has criticized the concept of pseudoscience for being fuzzy and difficult to define, commenting that “Pseudoscience is like pornography: we cannot define it, but we know it when we see it. Or so it seems” (p. 97). Additionally, McNally criticized the first
4 indicator and Popper’s (1979) use of falsifiability as the primary demarcation criteria between science and pseudoscience by pointing out that legitimate scientists also engage in ad hoc hypothesizing on a regular basis. The main difference is that legitimate scientists do so only with theories that have a past record of sound research evidence. McNally indicated that such reasoning is parasitic upon the notion of evidential support, rather than falsification and moreover, that it is unclear what constitutes overuse of such hypotheses. McNally concluded that science operates by both confirmation and falsification. He further criticized the concept of pseudoscience for being “little more than an inflammatory buzzword for quickly dismissing one’s opponents in media sound bites” that “generates more heat than light” (p. 99). Nevertheless, he clarified that his criticisms should not be taken as a defense of therapies that deserve to be criticized, but rather, that the basis for such criticism should be only evidential warrant, a critical evaluation of the evidence adduced in support of claims being made (McNally, 2004). In a response to McNally, Lilienfeld, Lynn and Lohr (2003b) defended the construct of pseudoscience by noting that it does not necessarily follow that all fuzzy distinctions (for example night and day) are non existent or arbitrary. While acknowledging that the term can be used in a pejorative or ad hominem manner that is not helpful, these authors maintained that the term is useful in making a distinction between “evidence for claims and the ways in which the proponents of a research program handle the evidence concerning these claims” (p. 107 108). That is, it is not enough to only evaluate what evidence exists for a particular claim; it is also important to examine ways in which proponents deal with claims and evidence that is purported to refute such claims. Understanding and learning to identify pseudoscience can help the mental health professional tell the difference between genuine scientific approaches and those that appear scientific but are lacking in substance. Herbert (2003a) agreed, suggesting that pseudoscience can be used as a “pedagogical heuristic” (p. 102) that can help alert consumers to warning signs that a therapy might not be what is claimed. Even though care must be taken to not use the term pseudoscience as a buzzword to attack a novel therapy without cause, learning warning signs can be helpful to consumers and clinicians. Thyer and Pignotti (in press) have noted the following warning signs of pseudoscientific assessment methods:
5 ñ Claims that the assessment method yields exceedingly remarkable and effective results. ñ Someone making large sums of money from selling the assessment method, providing training in it, or lecturing about it. ñ Someone receiving significant personal or professional recognition or accolades as an ‘expert’ in the novel training method. ñ Requiring practitioners being trained in the assessment method to sign pledges of secrecy or promises not to teach others the method. ñ The use of florid language in make claims, using words such as ‘unbelievable’, ‘incredible’, etc. ñ The complaint that the assessment method is being ignored or excluded by the ‘establishment’ or mainstream of the profession. ñ The use of neologisms, made up words describing the assessment method and how it works. ñ The inappropriate application of genuine scientific terminology to describe the use or application of the assessment method (e.g., quantum, chaos theory, neurolinguistic programming) ñ Failure to conduct research on the method’s reliability and validity, and to publish this research in independent peer reviewed journals. ñ An overreliance on anecdotal claims and testimonial evidence regarding the assessment method’s usefulness. ñ Over reaching Claims – Stating that the assessment method is remarkably effective for assessing a wide array of problems, often seemingly unrelated. ñ The invocation of theological or religious language (e.g., chakras, Qi, Reiki, prana, angels, spirits of the dead, etc.) to describe what the assessment method measures. ñ Claiming to assess non religious but otherwise metaphysical forces or energy fields unknown to science (e.g., auras, bioenergetic fields, meridian points). *No single one of these warning signs is a indictment branding the assessment method as pseudoscientific or bogus, but generally the more of these features characterize a given
6 method, the greater the likelihood that the method is a form of hucksterism or extreme naïveté (Thyer & Pignotti, in press, p. 40).
1.3 Antiscience
Another threat to scientific clinical practice is the promotion of antiscientific rhetoric and approaches (Olatunji, Parker, & Lohr, 2005). Antiscientific approaches, rather than pretending to be scientific, propose the postmodernist position that there are different ways of knowing that can be used in place of science or are purported to be superior to science. Although postmodernism is also considered a fuzzy concept, some of its central tenets have been noted as follows: (a) all knowledge is contextual and therefore relative and (b) science represents only “one mode of discourse” among many, and that scientific claims to knowledge are no more privileged than alternative claims (e.g., assertions based on intuition and personal experience).. . Postmodernist modes of thinking lend themselves in many cases to a willingness to accept claims on the basis of subjective convictions (Olatunji et al., 2005, p. 22). Witkin (1999) noted that “a defining feature of the postmodern era has been the challenging of assumptions about the nature of truth and reality” (p. 5). The root premise of postmodernism is that objective reality independent of human consciousness does not exist and that what people refer to as reality is no more than a social construct (Meinert, Pardeck, & Kreuger, 2000). Since reality is not believed to exist, the epistemological position follows that objective knowledge of reality would be impossible and that what people commonly think of as objective knowledge are no more than grand narratives that are socially constructed (Meinert, 1998). Moreover, postmodernists view science (characterized as grand narratives) as totalistic and oppressive, especially to human beings in our society who are not in positions of power and thus, deconstruction of these grand narratives is deemed necessary. Social work proponents of postmodernism view this as being consistent with the goals of the social work profession in achieving equity and social justice for all, whereas the scientific perspective is viewed as oppressive and antithetical to social work, creating distance from the actual lives of human beings (Weick & Saleebey, 1998). By deconstructing these grand narratives and recognizing
7 multiple narratives without regard for objective knowledge or truth, proponents of postmodernism believe that people in our society who are marginalized can be given a voice (Witkin, 1999). Moreover, the social constructionist movement, which has arisen from postmodernism, views language as socially constructed and having an indeterminate relationship with the external world (Witkin, 1999). In contrast, social work proponents of postmodernism have been taken to task for accepting it in an uncritical manner without taking into consideration the possibility of negative consequences (Meinert, 1998). Concern has been expressed (e.g., Meinart et al., 2000) about the influence of postmodernism and constructivism on the social work profession, noting that: Given this tradition, the field of social work continues to define and redefine itself with each new fad that emerges in the popular literature. . .Under these conditions, theory development is often chaotic; each collective of social workers has their own unique idiosyncrasies in which they ground their practice worldviews (p. 47). Moreover, clinical social workers who value intuition and other ways of knowing over science may be unlikely to be motivated to seek out the latest research to guide their practices. An example of an antiscientific practice would be medical intuition, a practice that claims to be able to pinpoint, through the use of intuition, diseases in the human body that sophisticated medical tests might miss (Collins, 2006). Appendix A contains examples of LCSWs who are practicing medical intuition.
1.4 New Age Therapies
Another proposed category of questionable therapies is New Age therapies (Singer & Nievod, 2003). The new age movement (although containing beliefs said to be derived from eastern religions and nineteenth century theosophy) arose from the astrological belief that human beings are currently making the transition from the Piscean age to the age of Aquarius resulting in dramatic paradigm shifts and personal transformation (Ferguson, 1980). It consists of a loose and diverse collection of individuals, although some new age practices and therapies have developed into more authoritarian cult like practices (Singer & Nievod, 2003). Singer and Nievod point out that while the more traditional therapies are conducted for the purpose of restoration and rehabilitation, the new age therapies often promise personal transformation and
8 fulfillment in addition to making unsubstantiated claims of symptom elimination. New age therapies can have both pseudoscientific and antiscientific characteristics. For example, many energy therapies claim to be based on the science of quantum physics (McTaggart, 2002) and make unwarranted extrapolations from the work of well known physicists, stating: We are poised on the brink of a revolution – a revolution as daring and profound as Einstein’s discovery of relativity. At the very frontier of science new ideas are emerging that challenge everything we believe about how our world works and how we define ourselves. . . At its most fundamental, this new science answers questions that have perplexed scientists for hundreds of years. At its most profound, this is a science of the miraculous (p. xiii). At the same time, new age approaches can be antiscientific, asserting the superiority of intuition over scientific testing, as illustrated by the claims of practitioners of medical intuition (described in the previous section).
1.5 Novel Unsupported Therapies (NUTs)
The present paper will employ the term Novel Unsupported Therapies (NUTs), a term coined by the author, which refers to novel therapies that make claims for efficacy that go beyond the available evidence, give the superficial appearance of science in absence of evidence, or denigrate science in favor of other ways of knowing. Not all new therapies are NUTs. A novel therapy that has major proponents engaging in an ongoing research program and does not make claims beyond the evidence will not be considered a NUT. For example, Motivational Interviewing ([MI] Arkowitz, Westra, Miller & Rollnick, 2008) is an approach that is just beginning to accumulate evidence. Even though MI does not appear to meet criteria such as the American Psychology Association’s for an empirically supported treatment (Chambless et al., 1998) for most conditions, key proponents such as Arkowitz and his colleagues accurately represent the state of the evidence and do not make claims that go beyond the evidence. How are Novel Unsupported Therapies a Problem to the Social Work Profession? Given that many of these approaches, although unusual and unsupported, do not appear to be doing direct harm, a question that needs to be addressed is why they would be considered a problem. In 1915, Flexner (1915/2001) challenged the legitimacy of social work as
9 a profession and outlined some criteria for professions. One criterion was the existence of a scientific body of knowledge and research. Since NUTs do not have a scientific basis, the use of such practices may call the legitimacy of the profession of social work into question. Moreover, the practice of NUTs conflicts with the National Association of Social Workers (NASW) Code of Ethics which states that social workers should “fully utilize evaluation and research evidence in their professional practice” (National Association of Social Workers, 1996, p. 12). More important than professional reputation, however, is the possibility of detrimental effects on clients. Even if not directly harmful, the use therapies that make claims in the absence of empirical support could result in opportunity costs (Lilienfeld, 1998, 2002). That is, the use of such approaches by practitioners, particularly if they claim superiority to approaches that do have empirical support, can mislead and deprive the client of a treatment that has evidence for efficacy. NUTs can be expensive and drain the client of financial resources or waste a client’s time, even if used by well intentioned therapists. Additionally, the potential exists for unscrupulous practitioners to fraudulently use such practices to manipulate and financially exploit vulnerable people (Beyerstein, 2001; Singer & Lalich, 1996). It has also been noted, from a pedagogical standpoint, that lack of critical thinking about such interventions, even if not directly harmful, can lead to a “slippery slope” (Lilienfeld, Lohr & Morier, 2001, p. 183) which could potentially lead to faulty thinking on matters that have serious consequences and thus potentially present a danger. Evidence exists that some therapies can actually do more harm than good for some clients (Lilienfeld, 2007) and criteria have been proposed for probable (Level 1) and possible (Level 2) harmful therapies ([PHTs] Lilienfeld, 2007; Lilienfeld, Fowler, Lohr & Lynn, 2005). Lilienfeld and his colleagues have further noted that the list is open to revision based on future empirical data. The criteria for Level 1 (probable harm to some individuals) consist of a clinical trial that has been independently replicated at least once and has to have demonstrated harm or harmful effects that must have been consistently observed immediately following the therapy’s first administration. Level 2 (possible harmful therapies) are defined as those therapies that have demonstrated harm in quasi experiments independently replicated at least once or in replicated single case designs. One of the therapies identified as a Level 1 PHT, Rebirthing, was responsible for the death of a ten year old child administered by two therapists who had Masters in Social Work
10 degrees. The child had been tightly wrapped in a flannel sheet from head to toe, had four adults put pressure on her with pillows, and in spite of the child’s pleas that she could not breathe, would not let her out (Mercer, Sarner & Rosa, 2003). They did not respond to the child’s terrified pleas for release because they believed that such protests were part of the a therapeutic process that needed to continue until the process was deemed complete (Mercer, 2002). Other identified PHTs included Critical Incident Stress Debriefing, Scared Straight Programs, Boot Camps, DARE programs, Recovered Memory interventions, Dissociative Identity Disorder Oriented Therapy, and Facilitated Communication (Lilienfeld, 2007; Lilienfeld et al., 2005). Additionally, the National Association of Social Workers (NASW, 2005) has issued a resolution against any social worker using restraints with children in their practices and the American Professional Society on the Abuse of Children (APSAC) has also condemned the use of coercive restraint therapies (Chaffin et al., 2006).
1.6 Evidence-Based Practice and Empirically Supported Therapies
Different definitions of evidence based practice (EBP) have existed, which has resulted in a degree of confusion and lack of clarity regarding what constitutes EBP (Gambrill, 2006) and misrepresentations of EBP (Thyer, 2007). However, efforts have been made to clarify the definition and the manner in which EBP ought to be used in the social work profession (Howard, McMillen, & Pollio, 2003; Thyer, 2004; 2007). The most common definition of EBP found in recent social work literature is “integration of the best research evidence with clinical expertise and [client] values” (Sackett, Strauss, Richardson, Rosenberg & Haynes, 2000, p. 1). Clinical expertise refers to relationship skills, past clinical experience and identifying unique client circumstances, individual risks, and benefits and client values refers to “unique preferences, concerns, and expectations each client brings to the encounter” (p. 1). EBP is “is not a static state of knowledge but rather represents a constantly evolving state of information” (Thyer, 2004, p. 168). EBP consists of five steps: 1. Convert one’s need for information into an answerable question. 2. Track down the best clinical evidence to answer that question. 3. Critically appraise that evidence in terms of its validity, clinical significance, and usefulness.
11 4. Integrate this critical appraisal of research evidence with one’s clinical expertise and the patient’s values and circumstances. 5. Evaluate one’s effectiveness and efficiency in undertaking the four previous steps, and strive for self improvement. (p. 168). Some people confuse EBP with empirically supported therapies (ESTs). However, as illustrated in the five steps, EBP is a process rather than simply a list of therapies. EBP involves critical appraisal, as well as integration of evidence with client values and clinical expertise. Kazdin (2008), making the same distinction, defines ESTs (which he refers to as evidence based treatments or EBTs) as interventions that research has shown through controlled clinical trials, to produce therapeutic change. A wide variety of different classification systems exist for the classifications of ESTs (see Mercer & Pignotti, 2007, for a review of some of these systems). The Oxford Centre for Evidence Based Medicine (CEBM) has proposed a system with five levels of evidence. The categories are: 1) Randomized controlled trials with concealed allocation; 2) Quasi experimental designs (studies without randomization that utilize a comparison group); 3) Cohort studies or case control studies; 4) Observational studies that lack any control group; and 5) Expert opinion (Centre for Evidence Based Medicine, 2001). One of the most popular systems in the mental health professions for the classification of ESTs are the criteria provided by the American Psychological Association (APA). These criteria have been specified (Chambless et al., 1998) for well established treatments: I. At least two good between group design experiments demonstrating efficacy in one or more of the following ways: A. Superior (statistically significantly so) to pill or psychological placebo or to another treatment. B. Equivalent to an already established treatment in experiments with adequate sample sizes. OR II. A large series of single case design experiments (n >9) demonstrating efficacy. These experiments must have: A. Used good experimental designs and B. Compared the intervention to another treatment as in IA. FURTHER CRITERIA FOR BOTH I AND II:
12 III. Experiments must be conducted with treatment manuals. IV. Characteristics of the client samples must be clearly specified. V. Effects must have been demonstrated by at least two different investigators or investigating teams (p. 4). For probably efficacious treatments: I. Two experiments showing the treatment is superior (statistically significantly so) to a waiting list control group. OR II. One or more experiments meeting the Well Established Treatment Criteria IA or IB, III, and IV, but not V. OR III. A small series of single case design experiments (n >3) otherwise meeting Well Established Treatment (p. 4) These criteria have been criticized for not taking harm into account (Lilienfeld, 2007), and for focusing only on confirmatory studies rather than studies that may have produced null results (Herbert, 2003b). For example, an intervention could have five supportive controlled clinical trials and ten such trials with null results and yet be classified as efficacious. More recently, the APA’s initial list of ESTs is undergoing revision and additional categorizations such as “controversial” and “harmful” are being added. Although these have not yet been formally published, the APA Division 12 has made their work, to date, available on the worldwide web (Klonsky, 2008). An example of a therapy classified as controversial (with strong support) under the revised guidelines is Eye Movement Desensitization and Reprocessing (EMDR). Although EMDR meets the APA criteria for a well established treatment, controversy has existed regarding the lack of evidence that EMDR is effective for reasons unique to EMDR such as eye movements, and it has been proposed that the psychological principles related to exposure therapy are the most parsimonious explanation for EMDR’s possible benefits (Devilly, 2002). An intervention classified as harmful under the revised system is Critical Incident Stress Debriefing ([CISD] see Lilienfeld, 2007, for a review). Others have proposed eliminating lists of ESTs altogether and instead categorizing therapies by principles of therapeutic change rather than names of particular
13 therapies (Rosen & Davison, 2003). However, the problem with this is that little research exists supporting the specific mechanisms of change for any therapy, nor does any clear dividing line exist to define degree of specificity necessary, leading some to propose practice guidelines of best practices as an alternative (Herbert & Gaudiano, 2005). Presently, however, few such guidelines exist in the social work or psychology professions. These differing perspectives reveal that attempts to classify therapies according to empirical support is a complex issue, with advantages and disadvantages to any such classification system. Nevertheless, there are therapies that most mental health experts would agree lack empirical support, regardless of classification system. A survey of psychologists (Norcross, Garofalo, & Koocher, 2006) was conducted to determine a preliminary consensus on which therapies are considered to be discredited. Although the study was not designed to actually test the efficacy of any of the therapies listed and did not include social workers, the results provide an indication of which therapies, by consensus are considered discredited. Defining EBP, pseudoscience, and the classification of interventions is a complex task that does not appear to produce clear cut solutions. Researchers studying the use of such interventions by clinicians need to be aware of such complexity and make defensible choices, recognizing that any such choices will have advantages and drawbacks. The next chapter will contain a thorough literature review that examines such complexities including therapist choice of intervention and the theoretical orientations that may in some cases guide therapists in such choices.
14 CHAPTER 2
REVIEW OF THE LITERATURE AND IDENTIFICATION OF GAPS
2.1 Inclusion Criteria
The literature review that follows includes studies that examined: 1) therapist theoretical orientation, which may be relevant in guiding some therapists to choose certain interventions; 2) attitudes, knowledge, and/or behaviors involving any aspect of evidence based practice (EBP) and/or empirically supported treatments (ESTs); and 3) therapist choice of specific interventions in practice including ESTs and/or complementary, alternative or novel unsupported therapies. A summary of studies published prior to 1990 pertaining to social workers in the areas outlined above will be presented, followed by a more in depth review of more recent studies on social workers and/or other mental health professionals. For the in depth review, quantitative or qualitative studies that were published in peer reviewed journals since 1990, comprised exclusively of social workers or studies that included but were not limited to social workers were identified for review. Studies conducted since 1998 on mental health professionals such as psychologists, psychiatrists, licensed counselors, and other mental health professionals that did not include social workers were also identified. The decision was made to limit this search to studies conducted in the past ten years since a number of recent studies were identified.
2.2 Databases and Search Terms
Searches were conducted through Cambridge Scientific Abstracts of the ERIC, Medline, PILOTS, PsycInfo, Sage (psychology, sociology), Social Services Abstracts, and Sociological Abstracts databases using the following search terms (note that some overlap occurred in the studies identified so studies already identified in a search were not included in the count on subsequent searches):
15 1. Theoretical Orientation and psychotherapists or social workers or psychologists Yielded 16 results that met inclusion criteria 2. Evidence Based Practice or Evidence Based Practice and psychotherapists or social workers or psychologists Yielded 7 results not identified in previous searches that met inclusion criteria 3. Search on “Evidence Based Practice Attitude Scale” Yielded 7 results not identified in previous searches that met inclusion criteria. 4. Empirically Supported Treatment or Empirically Supported Therapies and psychotherapists or social workers or psychologists Yielded 6 results not included in previous searches that met inclusion criteria 5. Pseudoscience and psychotherapists or social workers or psychologists did not yield any results 6. Scientist practitioner gap or Science practice gap did not yield any results. 7. Alternative therapies or Complementary therapies and psychotherapists or social workers or psychologists Yielded 2 results that met inclusion criteria Additionally, studies identified prior to 1990 through the above searches or previously known to the author that pertained to social workers are reviewed in the summary presented below.
2.3 Summary of Studies on Social Workers Prior to 1990
The earliest empirical study identified that examined the theoretical orientations of clinical social workers (Jayaratne, 1978) was a survey conducted in 1976. The participants were obtained through a random sample of 1,037 clinical social workers from the NASW Register of Clinical Social Workers, resulting in a 47% response rate. Of those who responded, 267 (54.6%) identified their theoretical orientation as eclectic and further analyses was conducted on that subset of respondents. The theoretical orientations of the remainder of the sample were not reported. No demographic differences were identified between those who identified as eclectic and other participants. Of those who identified as eclectic, the most common theories and therapies reported being combined
16 were: Psychoanalytic (53%), Reality Therapy (47.7%), Humanistic (41.7%), Neo Freudian (32.7%), Behavior Therapy (32.3%), Gestalt (27.8%), Rogerian (21.2%), Existential (20.7%), Transactional Analysis (20.3%) and Rational Emotive (11.3%). A higher percentage of those who were trained before 1951 reported psychoanalysis as most characteristic of their eclecticism (60.6%) than those who were trained in later years (20% after 1971). A similar trend was identified for most frequently used orientation. However, no statistical tests for significance were conducted. Some respondents reported using orientations that appeared to conflict (e.g. psychoanalytic and behavioral or psychoanalytic and feminist). The author noted that this presented a problem in the formulation of a definition of eclecticism. When asked to explain their eclecticism, responses fell into four categories: 1) the combining of different theories (29.6%); 2) choosing the theory that is best for the client (22.5%) 3) choosing whatever seems to work in a situation (17.2%) or 4) the idea that no single theory is adequate (5.6%). Twenty percent of respondents reported using five or more theories in their practices. In a survey of 199 clinical social workers from the Midwest, Cocozzelli (1985) administered a 63 item Therapist’s Orientation Questionnaire (TOQ, Sundland & Barker, cited in Cocozelli, 1985) and through factor analysis identified eleven dimensions. However, only two of the identified dimensions were theoretical orientations (family therapy, Gestalt therapy) with the other nine dimensions being related to practice beliefs (e.g. a preference for intensive therapy techniques, belief that therapist personality is more important to outcome than training, the importance of caring and involvement with clients). Cocozelli administered another scale, consisted of 30 items to participants and identified six factors: psychodynamic, behavior, existential, family, experiential/Gestalt and problem solving therapies. Another study (Cocozelli & Constable, 1985) using the same sample as above, investigated the relationship between theoretical concepts (as measured by the TOQ) and practice (measured by six categorical responses representing the dimensions identified in the previous study, to five clinical vignettes). The results revealed that the highest scores for theoretical orientation in response to the vignettes, were for family therapy, followed by problem solving and existential therapy, with psychodynamic, behavior, and experiential therapies being the lowest. The authors concluded “This shows that in
17 hypothetical clinical interviews these social workers prefer family therapy/ interactional practice behavior, emphasize logical problem solving, and encourage the development of supportive, empathic relationships with clients” (p. 56). The authors further noted that significant correlations between the responses to the vignettes and the TOQ revealed a relationship between beliefs about therapy and in session behavior. However, responses to the vignettes were still self reports about what the respondents would do in hypothetical situations, not actual behavior. No studies prior to 1990 pertaining to clinical social workers’ attitudes towards research or empirical empirically supported therapies were identified and the term evidence based practice (Sackett, Richardson, Rosenberg & Haynes, 1997) had not yet been coined.
2.4 In-Depth Review of Studies Conducted since 1990
In addition to the 38 studies produced by the database searches reported above, studies that did not come up on searches were included that were known to the author through her doctoral coursework and practica, previous personal communication with authors about “in press” studies, or cited in conference presentations attended. Four such studies were obtained for theoretical orientation and/or choice of therapy (Sharp et al., in press; Sprang, Craig & Clark, 2008; Strom, 1994; Timberlake, Sabatino, & Martin, 1997) and three studies were obtained for EBP or ESTs (Aarons, 2005; Becker, Zayfert & Anderson, 2004; Luebbe, Radcliffe, Callands, Greene & Thorn, 2007). Four additional relevant studies were identified either through the reference sections of articles reviewed or by searching on authors’ names for studies that were stated in the articles as “in press” that were subsequently published (Boisvert & Faust, 2006; Orlinsky, Ronnestad et al., 1999b; Orlinsky, Botermans, Ronnestad & the SPR Collaborative Research Network, 2001; Sprang, & Craig, 2007). A total of 49 studies were identified for review that met the inclusion criteria: five studies on exclusively social workers; 21 studies that included social workers and other mental health professionals (percentage of social workers included ranged from 6% to 72%) and 23 studies that included other mental health professionals but not social workers. A table summarizing study
18 characteristics and relevant findings is presented in Appendix B. For ease of reference, the studies are listed chronologically, except studies by the same group of authors, which are presented consecutively. Some studies examined various combinations theoretical orientation, treatment choice, and attitudes towards evidence based practice and because of this overlap, the choice was made to list the studies chronologically, rather than present them in the table by these categories (i.e. theoretical orientation, EBP attitudes, therapy choice). A limitation that applies to most of the studies reviewed is low response rate, which limits generalizability of the findings. For the 25 studies that reported response rates for their full sample, the average was 39% (SD=17) ranging from 12 to 77%. Half of the studies reviewed had response rates of 41% or below and a quarter had response rates of 27% or lower. Other studies that did not use a known sampling frame or recruited an unknown number of participants by electronic mail, were not able to determine response rate. The studies that had the two highest response rates were from a convenience, snowball sample with a limited population (von Ranson & Robinson, 2006, at 74%) and a sample collected from an agency (Lucock, Hall & Nobel, 2006, at 77%). Theoretical Orientation Twenty seven studies were identified that examined theoretical orientation (TO). However, direct comparisons of the studies on TO are problematic because the questions on TO were asked in a variety of ways and the categories offered were not consistent. For instance, some studies (see Appendix B for specifics), offered respondents the choice of Eclectic as one a number of mutually exclusive categories of TOs, whereas other studies allowed respondents to indicate more than one TO and did not include the option of Eclectic. Still others designed measures of TO in addition to or in lieu of directly asking respondents to identify their TO (Coleman, 2004, 2007; Sprang & Craig, 2007; Sprang et al., 2008). Moreover, one group of researchers (Orlinsky, Ambuhl et al., 1999) reported that they intentionally sampled from various organizations to make sure all TOs were adequately represented. Other researchers limited their focus to certain specialties such as trauma (Gray, Elhai & Schmidt, 2007; Sprang & Craig, 2007; Sprang et al., 2008), eating disorders (Musssell et al., 2000; von Ranson & Robinson, 2006), borderline personality disorder (Sharp, Henriques, Chapman, Jegelic, Brown & Beck, 2005) or substance abuse (Ball et al., 2002; Henggeler et al., 2007), which could have an impact on the generalizability of their findings. Still others conducted surveys at institutions where CBT was
19 the predominant TO (Luebbe et al., 2007) that may have influenced participants’ choices and thus might not be representative of other mental health professionals not educated in such institutions. Timberlake et al. (1997) allowed respondents to select as many theories as they wished, with the average respondent listing eight different theories. Nevertheless, bearing these limitations in mind, it is evident from examination of the overall study results presented in Appendix B, that the TOs that are the most prevalent appear to be Eclectic and Cognitive Behavioral (CB). Moreover, it is evident from an examination of the earlier studies (Saltman, Ephross, Greene & Roberta, 1993; Strom, 1994; Timberlake et al., 1997) and from a recent study that compared their own data with earlier studies conducted in 1960 and 1981 (Norcross, Karpiak & Santoro, 2005) there appears to have been a shift in TO over time. That is, the psychodynamic orientation appears to be declining and the CB orientation increasing, with eclectic remaining fairly constant. Another limitation in all of the studies was that they consisted of therapist self report and thus, self reported TO or even choices of specific interventions might not necessarily represent what the therapists actually do in their sessions. This is particularly problematic with the Eclectic orientation because eclecticism can be defined in different ways and four different types of eclecticism have been identified (Norcross, Karpiak & Lister, 2005): 1) theoretical integration, which involves the intentional synthesis of multiple theories; 2) technical eclecticism which involves a more pragmatic practice of a variety of techniques without theoretical considerations based on what seems to work for the client and/or what has empirical support; 3) common factors, where the clinician synthesizes factors believed to be common to all therapies and 4) assimilative integration, which consists of taking various techniques from a variety of different orientations and relating them to a single chosen theory. Norcross and his colleagues surveyed 187 psychologists who had identified themselves as eclectic or integrative with definitions for the different types of eclecticism and asked them which type they identified with most (see Appendix B for results). McClure, Livingston & Gage (2005) in their study consisting of 279 Texas psychologists and licensed counselors, also made a distinction between types of eclecticism using Lazarus & Beutler’s (1993) categories of unsystematic eclecticism (an arbitrary combination of various therapies); therapeutic eclecticism (theoretical integration as described above) or technical eclecticism. It is important to bear in mind, however, that the term technical eclecticism appears to place into the same category, therapists who choose therapies
20 based upon clinical experience of what seems to work and therapists who choose therapies based upon empirical evidence. That is, some technical eclectic therapists may be using empirical evidence as a basis for selecting interventions whereas others may not. None of the other studies made distinctions between types of eclecticism, although vonRanson & Robinson (2006) identified specific therapies reported by eclectic therapists (see Appendix B for details). A problem also exists with the self reported CB orientation. Although a number of empirically supported, manualized CB interventions exist (Chambless et al., 1998), in the absence of data on specific interventions used by the respondent who reported a TO of CB, it is not possible to know whether therapists who report CB as their primary TO are actually using ESTs based on CBT and adhering to the manualized protocols or if they are doing something that could be more loosely defined as CBT that does not have such evidence. While self reported TO can provide a generalized notion of the therapist’s preferences, these data do not inform us as to whether the therapies used by such therapists are based on empirical evidence. TO and personality traits. Two studies examined the relationship between TO and the personality traits of therapists (Poznanski & McLennan, 2003; Topolinski & Hertel, 2007). Topolinski and Hertel examined the relationship between TO and the sensing/intuition dimension of the Myers Briggs Type Indicator (MBTI). However, numerous criticisms have been made of the MBTI, calling its reliability and validity into question (see Pittenger, 2005, for a review). Both studies found that therapists who reported a psychodynamic or psychoanalytic TO scored higher on the personality trait from the NEO Five Factor Inventory, Openness to Experience, than CBT therapists. Additional findings of these studies are reported in Appendix B. Studies on Attitudes, Knowledge, and/or Behaviors involving EBP and/or ESTs Twenty three studies were identified that examined attitudes, knowledge, and/or behaviors involving any aspect of evidence based practice (EBP) and/or empirically supported treatments (ESTs). Problems with Definition of EBP vs. ESTs. Some of the authors and participants appeared to be equating EBP with ESTs. For example, in a qualitative study purported to examine attitudes towards evidence based practice (Bates, 2006) the author equated EBP with “evidence based practices” (p. 97). Participants interviewed were all reported as understanding EBP “to mean a way of practicing that entailed adhering to specific techniques determined to be ‘effective’ based upon formal research” (p. 98) a definition the author agreed with. Not
21 recognizing that EBP also includes clinical expertise and client values (Sackett et al., 2000) led participants interviewed to believe that EBP could be antithetical to flexibility with regard to individual client needs and values. Participants also indicated that an advantage to EBP is that it provided them with a sense of certainty. This attitude runs contrary to other descriptions of EBP which encourage open minded skepticism, critical thinking and questioning of claims (Gambrill, 2006) and “thoughtful uncertainty” (Lohr, 2008, p. 35), given that the conclusions of scientific evidence are always tentative and open to revision. The authors of a larger study (Henggeler et al., 2007) also appeared to be equating EBP and manualized ESTs, referred to as evidence based practices. These misconceptions about EBP were also apparent in a survey of 1195 clinical psychology graduate students (Luebbe et al., 2007). The authors, who were aware of the three part definition, asked respondents to write what they understood as the definition of EBP and 81% mentioned only the research component, neglecting to mention the other two components of clinical expertise and client values. Eighteen percent directly equated EBP with ESTs. Discrepancy between attitudes and reported practices. Some studies found that a discrepancy exists between largely positive attitudes towards research informing practice and reports on what is actually practiced. In a study of 85 recent graduates from three London universities (31% were social workers who worked in agencies) Caldwell, Coleman, Copp, Bell & Ghazi (2007) found that although 96% viewed research as very or fairly relevant to practice, only 22% reported research findings were frequently discussed at work. Only 42% were able to provide an example of professional practice changing because of research and 40% reported never using databases to conduct literature searches within the past year. Gray et al., (2007) found that although their sample of 461 trauma professionals, on the whole, indicated a positive attitude towards EBP, this was true even for most of the participants who endorsed novel interventions that lacked empirical support. In a study on 1226 social service workers in the UK (Sheldon & Chilvers, 2002) 90% indicated that they viewed research as relevant to practice. However, only 5% reported actually reading clinical trials and 43% reported reading articles on evaluation and only a small percentage of those who reportedly read articles were able to actually describe a study they had read about. Clinical experience versus evidence from research. Another theme that emerged from the literature was clinicians’ ratings of direct clinical experience with clients as more
22 important and influential on their practice than findings from research. This finding warrants concern because meta analyses and reviews of the literature comparing predictions based on clinical experience and judgment to predictions based on actuarial (statistical) sources have consistently found predictions based on actuarial sources to be significantly more accurate (see Dawes, Faust & Meehl, 1989 and Dawes, 1994, for a review). Orlinsky, Botermans, Ronnestad, & the SPR Collaborative Research Network (2001) in an international study of 4923 clinicians (6% were social workers) found that the most highly rated influence on therapist development and practice was direct clinical experience. Moreover, formal supervision, getting personal therapy, personal life outside of therapy, and informal case discussions with colleagues were all rated higher than reading relevant journal articles. Likewise, von Ranson & Robinson found that respondents rated clinical experience (60%) higher than research (39%) as an influence on practice choices in treating clients with eating disorders. Lucock, Hall & Noble (2006) in their survey of 154 UK psychotherapists and trainees found that literature, manuals and evidence based guidelines were not highly rated by their participants, whereas supervision, client feedback, client characteristics and intuition were more highly rated. Luebbe et al. (2007) also found that advice from supervisor and patient specific factors were rated as more highly influential in treatment planning than research evidence. Riley et al. (2007) found that although 64% of those they surveyed reported using ESTs, the most highly rated influential factor on practice was clinical experience. In the only study reviewed that employed inferential statistics to compare ratings of influences on practice, Stewart & Chambless (2007) conducted a repeated measures ANOVA. They found that clinical experience was rated significantly more important than outcome research. Additionally, they found that the greatest source for increasing therapy skills reported by therapists in their study was past experience with clients, which was rated as significantly more important than research. Evidence-Based Practice Attitudes Scale (EBPAS). Ten articles were identified reporting on studies that utilized the EBPAS. The initial psychometric analyses were conducted on agency mental health service providers from San Diego, California (Aarons, 2004, 2005, 2006) and a subsequent Confirmatory Factor Analysis was conducted (Aarons, McDonald, Sheehan, & Walrath Greene, 2007) with mental health providers working in agencies from 17 different states. Even though the description of the items relate to EBP, the scale mainly focuses
23 on attitudes related to ESTs rather than the broader aspects and process of EBP. Factor analysis (limited details provided in Appendix B) produced four subscales: 1) Appeal which represents the intuitive appeal of EBP; 2) Requirements, which refers to the willingness to adopt EBP if required to by state, supervisor, or agency; 3) Openness, which refers to whether the respondent is open to change and adopting new practices and 4) Divergence, meaning the degree to which EBP is perceived to perceived to diverge from the therapist’s usual practices. A total score for the EBPAS is obtained by summing each dimension and reverse scoring the items on the Divergence subscale. The EBPAS has been used in three other studies involving agency settings (Aarons & Sawitsky, 2006; Goia, 2007; Henggeler et al., 2007) and in three studies comprised mostly of clinicians in private practice (Gray et al., 2007; Stewart & Chambless, 2007; 2008). Stewart and Chambless focused their analyses on the Divergence subscale and combined it with a measure they developed, the Esteem for Research Utilization Scale, which correlated fairly strongly with the Divergence subscale of the EBPAS (r= .56) with an alpha for the combined scales of .82 and alpha for the Divergence subscale was .72, an improvement over Aaron’s (2004) original alpha for that subscale, which was .59. Studies on Therapist Choice of Interventions Nine studies were identified that investigated (to varying extents) therapists’ choice of specific interventions in practice (Becker et al., 2004; Freiheit, Vye, Swan, & Cady, 2004; Gray et al., 2007; Henderson, 2000; Mussell et al., 2000; Sharp et al., 2005; Sharp et al., in press; Sprang et al., 2008; vonRanson & Robinson, 2006). An additional study that examined the views of psychology students on alternative therapies (Wilson & White, 2007) was also included. This study was deemed relevant, because it may provide insight into the beliefs of future psychotherapists with regard to choice of therapies. Another study that surveyed directors of psychology internship training programs (Hays et al., 2002) that examined which ESTs were most endorsed in training clinicians, was also included for the same reason. Their main findings are summarized in Appendix B. Studies that examined complementary and alternative therapies (CATs). Henderson (2000) conducted a survey on 321 NASW clinical social workers, inquiring about their knowledge of alternative therapies, using what was at the time of publication, the Office of Alternative Medicine (OAM) classification system: 1) mind body therapies (e.g. medication, imagery, biofeedback, yoga); 2) community based health care practices such as support groups
24 or Native American practices, herbal remedies or shamanistic healing; 3) Professionalized alternative practices (e.g. acupuncture, homeopathy); 4) Manual healing methods (e.g. chiropractic, massage); 5) Botanical, pharmacological or biological treatments such as chelation therapy; 6) Diet and nutrition and 7) Parapsychology (e.g. astrology, ESP, Tarot). Respondents were asked whether they had used any of these therapies in practice or referred anyone for such therapies. Three quarters of the social workers surveyed reported having used or referred clients to therapies in the first two categories. However, the response rate was only 36% so it is possible that those who had an interest in such therapies may have been more likely to respond, resulting in an over representation of proponents of such approaches. Additionally, the second category defined alternative therapies very broadly to include support groups. It appears that the more unusual alternative therapies had less endorsement. For example, only 7.2% of the sample had practiced or referred clients to practices in the parapsychology category. However 30.8% reported having either used or referred people for acupuncture. The survey did not inquire about some of the newer therapies being promoted by therapists on the internet such as power and energy therapies (see review of Sharp et al. below for a description). Wilson and White (2007) conducted a survey of 163 graduate and undergraduate psychology students in Australia. They found that 41% of their sample had personally used CATs within the past 12 months, with the majority believing that CATs ought to be integrated into the practice of psychotherapy, although they also indicated an awareness of the risks. Sharp et al. (in press) surveyed 79 psychologists on their use of Power/Energy Therapies (PETs). PETs are therapies that make claims of achieving more powerful and faster results than conventional therapies, although research evidence for that claim is lacking. Many such approaches are based on the theory that the body has an energy system that, although it has not been scientifically measured, is believed to play a role in healing. One of the most popular PETs is Thought Field Therapy (see Chapter 1 for a description). Sharp and his colleagues intentionally included proponents of PETs in their sample by surveying members of an association of therapists who practice PETS, the Association for Comprehensive Energy Psychology (ACEP). They also included a random sample of APA members. However, only 16 participants were from ACEP, so small sample size was a limitation. Nevertheless, they found a negative relationship between use of PETs and critical thinking. That is, ACEP members (users
25 of PETs) scored significantly lower than the APA sample on the interpretation and deduction subscales of a measure on critical thinking. Studies that examined therapies for specific disorders. Von Ranson and Robinson (2006) conducted telephone interviews with 52 therapists (19% social workers) in Calgary, Canada to determine what interventions they were using for their clients with eating disorders. Percentage of respondents who reported using specific CBT techniques ranged from 57.7% to 92.3%. Other therapies reported included Interpersonal Therapy (53.8%); Supportive Therapy (71.2%) EMDR (15%); Hypnotherapy (11.5%); Meditation (3.8%) and alternative therapies (naturopathy, guided imagery, and integrative body psychotherapy 1.9%). Participants were also asked why they chose particular interventions and the most common influence was favorable clinical experiences, followed by favorable research and consistency with TO. Mussell et al. (2000) also investigated what therapies were used for eating disorders by 271 licensed psychologists. They also found that specific CBT techniques were reported by a high percentage of therapists, ranging from 50 72%, although 78% reported no formal training in CBT ESTs for eating disorders. Sharp et al. (2005) conducted a survey of 123 clinical psychologists on their choice of interventions for treating borderline personality disorder (BPD). Through logistical regression analysis, they found that techniques reported by participants were consistent with their self reported TOs. The most commonly used therapies for treating BPD were CBT (60.2%), followed by psychodynamic therapy (39.0%). However, only a small percentage (10.6%) used Dialectical Behavior Therapy (DBT), a therapy shown to have empirical support for BPD (Chambless et al., 1998). Gray et al. (2007) surveyed 461 trauma professionals and found that approximately 16% of their sample endorsed non evidence based approaches as their favored approaches to trauma treatment. The most commonly endorsed non evidence based interventions included bioenergetics, nutritional approaches, somatic experiencing therapy, body psychotherapy, and sensorimotor therapy. However, 26.1% of their respondents reported that exposure based CBT was their preferred treatment for trauma. Sprang et al. (2008) examined the trauma treatment practices of 1121 mental health professionals. They asked participants an open ended question about what their treatment approach of choice was for treating trauma and coded the responses into eight categories with the
26 following results: CBT (29.2%), EMDR (4.7%), supportive psychotherapy (6.1%), eclectic approaches (5.2%), psychoeducational interventions (2.1%), and therapies selected by less than 2%: grief therapy, art/play therapy, solution focused therapy, psychodynamic, psychopharmacological. However, 45.6% did not identify any treatment of choice. Sprang and her colleagues also found that the therapy for PTSD with the most empirical support, exposure therapy, was infrequently reported as a favored approach to treating trauma. Becker et al. (2004), in an investigation of attitudes of psychologists towards exposure therapy for PTSD, reported similar findings with 72% of their sample reporting that they were not comfortable using exposure therapy. Only 17% of their sample reported using imaginal exposure for PTSD, whereas 37% of their sample reported using approaches with less evidence such as psychodynamic trauma focused therapy or hypnosis. The most commonly reported barriers to using exposure therapy were limited training, concern about patient harm (decompensation), and preference for individualized over manualized therapy. Freiheit et al. (2004) conducted a survey of 189 Minnesota psychologists to determine whether empirically supported therapies were being used to treat anxiety disorders (obsessive compulsive disorder, panic disorder, and social anxiety disorder. They found that while the majority were using CBT, the percentage using exposure based therapies for anxiety disorders ranged from 12 37%, depending upon the type of anxiety disorder. A minority were found to be using novel unsupported therapies, namely, EMDR (18%) and energy therapy (8%).
2.5 Summary and Conclusions
A number of studies have been identified that investigated attitudes towards EBP and ESTs, theoretical orientations, and/or interventions used by social workers and other mental health professionals. A number of patterns have emerged. With regard to theoretical orientation, there appears to be a shift that has been occurring over the past two decades from a psychodynamic to a cognitive behavioral orientation, although at least since the 1970s, a number of therapists have been eclectic in their practice. Although mental health professionals appear to have a generally positive attitude towards EBP, many appear to have misconceptions, believing that it is limited to the practice of ESTs (Bates, 2006; Luebbe et al., 2007), rather than the process described by Sackett et al. (2000).
27 Even though therapists indicate that they are interested in EBP, a number have reported barriers, such as a lack of time to keep up with the research in their area or to train in therapies that have empirical support (Gray et al., 2007; Hatfield & Ogles, 2007; Upton & Upton, 2006). Studies on therapists who work for agencies have shown that an organizational climate that is favorable towards evidence based practice can be a positive influence on therapist interest (Aarons & Sawitzky, 2006; Henggler et al., 2007). However, therapists who are in private practice may not have that kind of structural support. Moreover, it is possible that such therapists may not desire to make learning about EBP a priority in their busy schedules because a number of studies reviewed revealed that clinical experience is valued over empirical evidence (Stewart & Chambless, 2007; Lucock et al., 2006; Orlinsky et al., 2001; Riley et al., 2007; vonRanson & Robinson, 2006) and some therapists appear to see the two as being in conflict and thus feel ambivalent about EBP, as they understand it (Bates, 2006). Although a high percentage of mental health professionals report using interventions that have an empirical basis, some therapists also appear to be using interventions that lack empirical support and have shown interest in integrating complementary and alternative therapies into their practice (Henderson, 2000; Wilson & White, 2007). It also appears that some clinicians are using therapies that are making claims of power, efficacy and superiority to conventional therapies in the absence of evidence (Sharp et al., in press).
2.6 Identification of Gaps in the Literature and Recommendations for Future Research
Even though studies have been conducted on social workers’ use of and interest in complementary and alternative therapies based on a medical classification system (Henderson, 2000) prior to the author’s pilot work reported herein, no study has done a systematic investigation of clinical social workers’ use of the novel unsupported therapies, conventional therapies that may be lacking in empirical support, and empirically supported therapies in the same study. Although other studies have included social workers and have inquired about the practice of novel therapies, the number of social work participants was relatively small and restricted to one area of practice such as trauma (Gray et al., 2007) or participants were asked to name therapies with an open ended question rather than being presented with a prepared list (Sprang et al., 2008). Moreover, the aforementioned studies had low response rates and thus
28 results need to be interpreted with caution. A number of the studies reviewed focused primarily on psychologists and social workers may differ from psychologists. Thus, a need exists for a study that examines the use of empirically supported, conventional unsupported, and novel unsupported therapies that focuses exclusively on a relatively large sample of clinical social workers from a variety of different areas of specialization. Additionally, an investigation of how self reported TO is related to specific interventions reported by clinical social workers, similar to the analysis conducted by Sharp and his colleagues (2005) on psychologists, would be informative. Moreover, it may be helpful to identify a clinical social worker’s TO and determine how important this is as a reason for selecting an intervention. An examination of the relationship between the reported use of interventions and attitudes towards evidence based practice would also be helpful in gaining a better understanding of the practices of clinical social workers.
29 CHAPTER 3
RESEARCH QUESTIONS, HYPOTHESES, AND METHODS
The present study is an internet survey of licensed clinical social workers (LCSWs), that investigates their theoretical orientations, choice of interventions, influences on those choices, and attitudes towards evidence based practice (EBP). The focus on attitudes towards EBP was primarily based on the first part of Sackett’s (2000) three part definition, attitudes towards using research evidence to inform practice. Pilot data were collected on 191 respondents and a preliminary analysis was conducted (Pignotti & Thyer, 2009). The present research contains additional analyses (see research questions and hypotheses) and includes data that have been collected on 209 additional respondents that have not previously been analyzed, which added to the pilot data, brought the total sample size to 400.
3.1 Research Questions
The following research questions will be addressed: R1. What are the theoretical orientations of the respondents? R2. What interventions and/or assessment procedures are LCSWs choosing to use most often? R3. What percentage of the sample is using NUTS, CUTs, and ESTs? R4. What reasons do the respondents give for selecting interventions? R5. What attitudes do respondents have towards evidence based practice? R6. How are the use of NUTs, CUTs, and ESTs related to demographics and practice characteristics? R7. Are attitudes towards evidence based practice statistically significantly related to the use of NUTs, CUTs, CNUTs, or ESTs? R8. Are attitudes towards evidence based practice statistically significantly related to theoretical orientation?
30 3.2 Hypotheses
The following hypotheses are based on the literature review and/or the preliminary results from the pilot data. H1. Females will be statistically significantly more likely than males to use NUTs, CUTs and CNUTs and will use a higher number of NUTs, CUTs and CNUTs H2. Respondents who report affiliation with eastern/new age religions and nondenominational/spiritual will be statistically significantly more likely to use NUTs and will use a higher number of NUTs than those who report other religious affiliation or no affiliation H3. Clinical experience will be a statistically significantly more highly rated influence on choice of therapies than empirical evidence (i.e. studies published in peer reviewed journals) for the entire sample H4. LCSWs who report a theoretical orientation of CBT will rate empirical evidence as statistically significantly more influential in choice of therapy than those who report other theoretical orientations H5. LCSWs who use NUTs, CUTs, and/or CNUTs will score statistically significantly higher on the Divergence subscale of the EBPAS than those who do not (note that a high score on this subscale means a belief that EBP diverges from their actual practice).
3.3 Methods
Measures The survey instrument included questions on demographics (age, sex, race, religion, geographic location, education); theoretical orientation; therapies used in practice; reasons for choosing interventions; and attitudes towards evidence based practice. The complete data collection instrument is presented in Appendix C. Part 1: Your practice. The first page of the survey asks participants questions about their practice including the following: state in which they practice; type of area (i.e. large city, town, suburban or rural); number of years in practice, areas of specialization (can name up to
31 three); age group of clients in practice; theoretical orientation and type of practice setting (e.g. private practice, hospital, outpatient clinic). Part 2: Interventions used in practice. First, participants were asked in an open ended question, to name the three interventions they used most in their practice. Next, they were presented with an alphabetized list of specific interventions commonly used by clinical social workers. The list included empirically supported therapies (ESTs), conventional therapies that lacked empirical support (CUTs), and novel unsupported therapies (NUTs) but were not identified as such to respondents. The interventions presented were selected on the basis of being mentioned in the social work and other professional literatures, mention of commonly used unorthodox therapies (derived from Lilienfeld, 2007; Lilienfeld, et al. 2003a; Norcross, et al. 2006) and selected therapies advertised by LCSWs on the internet on the website www.helppro.com. Three assessment procedures used by LCSWs (Myers Briggs Type Indicator, Eneagram, and Genogram) were also included. Participants were asked to indicate (by clicking on the box adjacent to each intervention) whether they currently use the intervention (used within the past year) in the first column of the questionnaire or if they had previously used the intervention and discontinued. These were dichotomous variables. If a participant indicated both using an intervention within the past year and discontinuing, this was coded as discontinued. Participants were also asked to list other interventions they used within the past year that were not on the list. Next, participants were presented with a list of possible sources of interventions, asked how they first heard about interventions they currently use in practice and allowed to check all that applied. In the next question, participants were presented with a list (based on the literature review) of possible reasons for selecting interventions and asked to rate their importance of these reasons on a scale of one to seven where one is “not at all important” and seven is “very important.” They were also invited to list other reasons they considered important and were asked an open ended question about reasons for discontinuing any of the interventions they had indicated no longer using. Part 3: Opinions about Interventions. This part of the survey consists of the Evidence Based Practice Attitudes Scale (EBPAS; Aarons, 2004). A full description of the EBPAS and its development has been provided in Chapter 2.
32 Part 4. Educational background and continuing education. This section of the survey contains questions about the respondents’ educational background and subsequent training and seminars. Respondents were asked to name the institution from which they obtained their MSW and the year. They were also asked what other graduate degrees they held (e.g. DSW, PhD in social work). Next, participants were asked to list any continuing education seminars or certification trainings they had taken in the past two years. Participants were then asked to rate the importance (on a scale of 1 7) of possible reasons for choosing education seminars and workshops and invited to write in other reasons. The final question in this section asked participants which professional organizations they belonged to (e.g. the National Association of Social Workers). Part 5. Demographics. This section asked participants their gender, age, race/ethnicity, and religious preference. Data Collection and Participants Study participants were LCSWs who advertised their practice on the website http://www.helppro.com, as describe in more detail below. The helppro.com website, described as “the most comprehensive, user friendly National Social Worker Finder” (Helppo.com, ¶1) is linked to the website of the National Association of Social Workers and contained a listing, by zip code of LCSWs in the United States (Since the data collection for this research was undertaken, individual social worker emails appear to have been omitted from this database by the NASW). Contact information for each therapist, along with their licensure information and area of practice specialty is listed. Approximately three fourths of those listing services provided e mail addresses. This website was selected because it provided a listing of LCSWs with a wide variety of practice specialties. Moreover, since the focus of the study is therapies that are widely promoted on the internet, a sample of therapists who advertise their services on the internet would be appropriate. Most are members of NASW. For the pilot study, 96.5% of the respondents were NASW members. Data were collected through the www.surveymonkey.com website, as described in more detail below. In order to prevent duplicate responses, the Survey Monkey website program was set up so that participants could respond only once to the survey. The survey was confidential rather than anonymous, so that e mail addresses could be initially
33 connected to the responses and follow up could be conducted on those who did not respond. A limitation of this survey method (as with any mailed survey) is that there is a chance that someone other than the intended respondent could have answered the survey, a possible confound also present using postally mailed survey methodology. Pilot study. The following excerpt from the pilot project (Pignotti & Thyer, 2009) describes the data collection procedures used in the pilot study conducted in October through December of 2007 and the response rate: Permission for the study was granted by Florida State University’s Institutional Review Board. Study participants were LCSWs throughout the United States who advertised their services on the Internet and published their electronic mail addresses on the Web site http://www.helppro.com. This database of LCSWs is linked to the NASW Web site. This Web site, described as “the most comprehensive, user friendly National Social Worker finder” (Helppro, n.d., ¶1) was selected as appropriate for this study because LCSWs from a wide variety of specialties listed e mail addresses that were publicly accessible and our purpose was to explore the phenomenon of NUTs being promoted via the Internet. Approximately 25% of LCSWs in that database did not have published e mail addresses and thus had to be excluded. Because the addresses were accessible only through a search by zip code, the database was first searched by randomly selected zip codes. Our goal was to obtain as complete a list as possible, so we concluded the search by zip code when we were no longer getting any new names (after 2,000 randomly selected zip codes). The resulting list consisted of 2,200 potential participants. A sample of approximately 150 to 200 people would be sufficient for the descriptive statistics and bivariate analyses planned for this exploratory study. Because we anticipated an approximately 45% to 55% response rate, 400 LCSWs were randomly selected and sent invitations to participate in our survey. Twenty six invitations were returned, undeliverable, leaving 374 LCSWs who presumptively received our invitation to participate. Dillman’s (2007) methods were used for invitations to participate, which included an e mailed pre letter informing participants about the survey, an initial invitation, and three follow up requests sent to nonrespondents. Dillman’s recommendation
34 for the final request to be in a different form (for example, overnight mail) was not followed because of funding restrictions of the present study. (Copies of the invitation letters and survey are available from the authors upon request.) A survey instrument was constructed and the Survey Monkey Web site (see http://www.surveymonkey.com) was used for data collection via the Internet. The program was set up in such a way that prevented participants from taking the survey more than once. A total of 193 participants responded, resulting in a 52% response rate. However, three participants indicated that they were not LCSWs, and two of those left the remainder of the survey blank. The other respondent was from a state with recent licensure (Michigan) and completed the survey. That respondent’s data were retained, given that the majority of Michigan social workers listed in the database were not yet licensed as LCSWs. Sixteen respondents completed only the first page of the survey (which included the following variables: licensure, state, theoretical orientation, years in practice, area of specialty, practice setting, age group of clients) and left the remaining pages blank. We were limited to the data on the first Web page of our survey, for comparisons. No significant differences were found on the first page variables between completers and noncompleters of the survey, with the exception of practice setting. Chi square testing revealed that respondents who were in private practice were more likely to complete the survey (N = 151, 87.3%) than those who were not (N = 9; 64.3%), and those who worked in a general hospital were less likely to complete the survey (for completers, N = 5, 2.9%; for noncompleters, N = 3, 21.4%) (Pignotti & Thyer, 2009, p. 7 8). Additional Data Collected. Additional data were collected in January through February of 2008. An additional 600 randomly selected participants from the original compiled list were invited to participate. However, 80 of those invitations were undeliverable, leaving a total of 520 participants who presumably received the invitation to participate. The same procedures described following Dillman’s (2007) methods were employed. The response rate for this round of data collection was 40%, with 209 responses, bringing the combined sample size to 400 and a 45% response rate for the combined samples. The reason for the decrease in response rate for the second round of data collection is unknown. Given that the same methods were used for
35 invitation and follow up, it is possible that in the two months that passed, the list became more outdated and thus less people responded. Nevertheless, the 40% response rate obtained is well above the average response rate identified in the literature reviewed of similar surveys. A total of 33 of the 400 respondents did not continue past the first page of the survey. The fist page contained the following variables: licensure, state, theoretical orientation, years in practice, area of specialty, practice setting, and age group of clients. Thus, analyses that contained variables that were not on the first page of the survey will have missing data, as indicated by the lower numbers reported in the tables on these analyses. The variables beyond the first page of the survey included demographics, interventions used in practice, and reasons for using the interventions. Data Analysis Plan Upon completion of the data collection carried on out through the Survey Monkey website (www.surveymonkey.com), the data were downloaded onto an Excel spreadsheet and were then exported into the SPSS statistical software program for data analysis. Since the data were directly downloaded from the responses, it was unnecessary to manually enter the data and thus, cleaning on a case by case basis was not necessary. The data were exported to SPSS, frequencies for each variable were obtained and no anomalies were found. Items that were missing were coded in SPSS with missing values. Recoded and Composite variables. The variable “Religion” was recoded. The original categories were: 1=Catholic; 2=Protestant; 3=Jewish; 4=Muslim; 5=Buddhist; 6=Atheist, 7=Agnostic; 8=Other (please specify). No respondents indicated that they were Muslim, so that category was eliminated. The written in responses for the “other” were examined. These responses were put into existing categories, where appropriate, and the following new categories created to accommodate responses that did not fit into existing categories: ñ Other Christian: Any other Christian denomination that does not fall into the first two categories ñ Eastern/New Age/New Thought: Any Eastern, New Age or New Thought religion. Buddhist was also subsumed under this category. The decision was made to combined New Age with Eastern religions and New Thought because New Age has considerable influence from Eastern religions and New Thought (Singer & Nievod, 2003).
36 ñ Spiritual/non denominational (a number of participants indicated that they were “spiritual” but did not belong to any particular denomination) ñ Respondents who wrote in “none”, “no religion” or words to that effect were combined with atheists and agnostics The final recoded categories were as follows: 1=Christian (Catholic, Protestant, and Other Christian combined); 2=Eastern/New Age; 3=Jewish; 4=Nondenominational/Spiritual; 5=Atheist/Agnostic/None. The categorization of Catholic, Protestant and “other Christian” denominations as Christian is consistent with the classification system used by the largest survey of religious identification in the United States, the American Religious Identification Survey (ARIS; Kosmin, Mayer & Keysar, 2001). Expert review and creation of categories for types of interventions. Composite variables were created for Novel Unsupported Therapies (NUTs), Conventional Unsupported Therapies (CUTs), combined NUTs and CUTs (CNUTs), and ESTs by summing the affirmative responses for each therapy that fall into those categories. Both continuous (number used) and dichotomous (used or did not use) versions of each of these variables were created. The definitions are as follows: ESTs: Therapies that meet the APA criteria (Chambless et al., 1998) for empirically supported therapies for either a probably or a well established treatment and does not have key proponents who make claims that go beyond the evidence. NUTs: Therapies that are relatively new, not widely accepted and or widely taught in graduate programs, have not met the APA criteria for empirical support and have major proponents who are making claims based only on anecdotes, uncontrolled case reports, and/or testimonials that go beyond the evidence. Therapies that do meet the APA criteria for certain conditions, but make claims that go beyond the evidence will also be considered NUTs (e.g. a therapy that meets the APA criteria for PTSD but makes claims for being successful with other conditions that are unsupported). CUTs: Therapies that are conventionally accepted and taught, and yet do not meet the APA criteria for ESTs. These are therapies that are accepted, based on favorable clinical experience or authority but lack published clinical trials to support their efficacy.
37 The decision was made to use the APA criteria, rather than the Oxford criteria because the APA criteria apply more specifically to mental health therapies and the Oxford criteria are for the classification of studies rather than particular therapies. Results of expert review. Categorization of specific therapies as a NUT for the pilot study (Pignotti & Thyer, 2009) was initially determined by the author and her practicum supervisor (now committee chair), Bruce Thyer. For the present analysis, however, for the purpose of providing support for content validity, categorization of specific therapies as a NUT, CUT, EST was determined by an expert review procedure, as based on recommendations by Springer, Abell & Hudson (2002). A panel of two expert reviewers in addition to Thyer, was presented with the list of therapies used in the survey, accompanied by the above definition of NUTs, CUTs, and ESTs. The two expert reviewers were Brandon Gaudiano, Ph.D. and Ian Sharp, Ph.D., two psychologists who are experts in the area of science and pseudoscience in mental health practice and have published in that area. The expert reviewers indicated, by placing an “X” in the appropriate column, whether they thought the therapy fit the construct. The option of “not familiar with this therapy” was also offered. Springer et al. indicate that this procedure can either be done in person or remotely. Inter rater agreement was calculated by the summing the number of agreements and dividing that by the number of agreements plus disagreements and then multiplying this by 100 to obtain the percentage (Bloom, Fischer & Orme, 2006). This calculation was made between each of the two reviewers with one another and with Thyer. Inter rater agreement ranged from 95 98% for ESTs; 84 94% for NUTs; and 84 92% for CUTs. Therapies that received at least two votes for a particular category were classified in that category. In some cases, due to one of the reviewers not being familiar with a particular therapy, there were ties. The ties were resolved through Pignotti and Thyer forming a rationale and reaching consensus. Based on analysis of the expert review and decisions regarding ties, the final classifications are as follows: ESTs: Acceptance and Commitment Therapy, Anxiety Management Training, Assertive Community Treatment, Behavior Modification/Behavior Therapy, Cognitive Behavioral Therapy, Cognitive Therapy, Dialectical Behavior Therapy, Emotionally Focused Couples Therapy, Exposure Therapy for Phobias, OCD, or Panic Disorder, Exposure Therapy for PTSD/Trauma, EMDR for PTSD/Trauma, Interpersonal Therapy, Motivational Interviewing, Social Problem
38 Solving Therapy, Social Skills Training, Solution Focused Therapy, Stress Inoculation, Supported Employment Therapy, Systematic Desensitization, Task Centered Practice NUTs: Age regression methods for adults sexually abused as children, Applied Kinesiology (for allergy/food sensitivity or for emotional problems), Attachment Therapy, Bioenergetic Therapy, EEG Biofeedback (Neurofeedback), Body Centered Psychotherapy, Critical Incident Stress Debriefing, Critical Incident Stress Management, DARE programs, Emotional Freedom Technique, Eneagram, EMDR for conditions other than PTSD, Facilitated Communication for autism, Healing Touch, Holding Therapy, Holotropic Breathwork, Imago Relationship Therapy, Jungian Sandtray Therapy, Love and Logic, Lucid Dreaming, Myers Briggs Type Indicator, Neuro linguistic programming, Past Lives Therapy, Psychosynthesis, Primal Therapy, QiGong, Radionics, Rebirthing Therapy, Reiki, Reparenting Therapy, Scared Straight, Seemorg Matrix, Sensory Motor Integration, Sexual Reorientation/Reparative therapy for gays/lesbians, Tapas Acupressure Technique, Therapeutic Touch, Thought Field Therapy, Traumatic Incident Reduction CUTs: Dream interpretation, Psychoanalysis, Psychodrama, Genogram The following interventions did not receive enough votes from the expert review panel to be classified into any of those categories: Biofeedback (non EEG, Hypnosis, Insight Oriented Marital Therapy, Mindfulness Based Stress Reduction, Play Therapy, Relaxation training for PTSD, and Thought Stopping Procedures). Since it was not the goal of the study to classify every intervention on the list into one of the proposed categories, these interventions were left unclassified. Descriptive Statistics. Research questions 1 5 were addressed by presenting frequency distributions (N and percent for categorical variables and N, means and standard deviations for continuous variables). Analysis of the EBPAS. Composite variables for the EBPAS were created according to its author’s instructions (Aarons, 2004). A total score for each subscale was created by summing the items. A total score for the entire scale was created by reverse scoring the Divergence dimension items and then summing the items for the entire scale with the reversed coding for the Divergence subscale items. A high score for the entire scale indicates a positive attitude towards evidence based practice. Alphas were obtained for each subscale and stratified alpha was computed for the entire scale.
39 Bivariate Analyses. To address research questions 6, 7 and 8 and hypotheses 1 and 2, and 5, bivariate analyses were conducted appropriate to the level of measurement (e.g. chi square, t tests, ANOVAs, correlations). However, it was not possible to do this for race/ethnicity because 93.7% of the participants were white/Caucasian. Repeated measures and split plot ANOVA. An ANOVA with within subject (repeated measure) factors as recommended and carried out by Stewart and Chambless (2007) was conducted to determine whether significant differences exist for ratings by respondents of reasons for using interventions (hypothesis 3). A split plot ANOVA with one within subject factor (reasons for choosing therapies) and one between subjects factor (theoretical orientation of CBT or not) was conducted to test hypothesis 4. Effect Size Calculations. Each time a statistically significant difference was found, appropriate effect sizes were reported. Cohen‘s d was used for t tests (Cohen, 1988), η2 (eta squared) for ANOVA, r2 for correlations, and phi (Ф) for chi squares ((Howell, 2002). Missing data analysis. Since less than half the people invited to participate in the survey responded, an analysis comparing the earliest and latest respondents was conducted to determine if differences exist. Given that later respondents are considered to be similar to non respondents, a comparison between the earliest and the latest respondents is recommended to provide an indication of whether response bias exists (Siebert & Siebert, 2007; Trinkoff & Storr, 1997). Appropriate bivariate analyses (e.g. chi square, ANOVA) were conducted on demographics and practice characteristic variables to determine whether significant differences exist between people who responded on the first request and those who responded on the last two requests.
40 CHAPTER 4
RESULTS
4.1 Sample Description
Demographics for survey respondents are presented in Table 1.
Table 1. Sample Description: Demographics
Total N N %
Sex 350 Female 271 77.4 Male 79 22.6
Geographic region 399 Northeast 175 43.8 South 82 20.5 Midwest 75 18.8 West 67 16.8 U.S. Military overseas 1 0.3
Race/Ethnicity 349 White/Caucasian 327 93.7 African American/Black 9 2.6 Hispanic/Latino 7 2.0 Asian/Pacific Islander 3 0.9 Other 3 0.9
Religion 338 Christian 146 43.2 Eastern/New Age 32 9.5 Jewish 82 24.3 Nondenominational/spiritual 34 10.1 Atheist/Agnostic/none 44 13.0
41 Table 1 Continued Study Sample % NASW (2003) % Age (according to NASW categories) (n=344) (n=1560) N % Under age 33 11 3.2 7.0 33 42 48 14.0 17.0 43 52 83 24.1 34.0 53 62 149 43.3 34.0 Over age 62 53 15.4 5.0 Mean (s.d.) 53.13 (10.28) Not reported Median 54 50 Range 27 – 82 Not reported
The sample was comprised of 77% females, which is consistent with the percentage of 79% reported by the National Association of Social Workers according to a survey done on 1,560 randomly selected members (NASW, 2003). However, the present sample appears to be older than NASW’s (see Table 1 for a comparison). Ages of participants ranged from 27 to 82 and the mean age was 53 (SD=10.28). An overwhelming majority of our respondents were white/Caucasian (93.7%) and this is also the case with the NASW sample, although their percentage was slightly lower at 87%. Respondents were located in 39 different states, plus one respondent who was serving in the U.S. Military overseas. The largest percentage of respondents came from the northeast (43.8%). This is consistent with a map of NASW’s membership, showing more states with larger concentrations of members in the northeast (NASW, n.d.).
4.2 Practice Characteristics
Descriptive statistics for the practice characteristics of respondents are displayed in Table
2.
Table 2. Practice Description
Description Total N N % Practice Setting* 392 Private practice 336 85.7 Outpatient clinic 39 9.9 School 24 6.1 Community mental health 23 5.9 General hospital 17 4.3
42 Table 2 – Continued
Description Total N N % University 15 3.8 Mental hospital 10 2.6 Residential treatment facility 7 1.8 Nursing home 4 1.0 Military 3 0.8 Prison 2 0.5
Theoretical Orientation 391 Eclectic or specified combinations 123 31.5 Cognitive, Behavioral, or Cognitive 116 29.7 Behavioral Family Systems/Interpersonal 48 12.3 Humanistic/client centered/ 40 10.2 transpersonal/Gestalt/TA/ positive Psychodynamic//analytic/ 43 11.0 neo Freudian Energy or body oriented 9 2.3 Other theoretical orientations written in 12 3.1 (Included: Child centered, Dyadic Developmental Psychotherapy, EMDR, Equine Assisted Psychotherapy, Instinctual Trauma Response Model, Mindfulness, Narrative, Neurofeedback, Prevention, Solution focused)
Type of area of practice* 398 Large city (>100,000) 204 51.3 Suburban 119 29.9 Small city/town 107 26.9 Rural 34 8.5
N Mean (sd) Range
Years in practice 394 18.85 (10.20) 1 56 Year graduated with MSW 351 1987 (10.54) 1949 2007 Practice age group percentage 389 Older adults (age 65+) 11.17 (20.23) 0 100 Adults (age 18 64) 64.85 (29.85) 0 –100 Adolescents 14.68 (20.56) 0 – 100 School age children 7.24 (13.15) 0 – 72 Pre school children 1.82 (6.47) 0 – 50 Infants 0.35 (2.75) 0 35
*Total percentages add up to > 100% because respondents were allowed to respond in more than one category.
Respondents had an average of 18.85 years of experience in practice (SD=10.20) which was somewhat higher than NASW’s reported average of 16 years of experience (NASW, 2003). The vast majority (85.7%) were in private practice and almost all (97.2%) were members of
43 NASW. About half (51.3%) practiced in large cities. The largest age group client percentage was adults ages 18 64, although adolescents, children, and infants comprised an average of more than 20% of practices and older adults, 11.17%. Reported areas of specialization indicated by respondents are listed in Table 3.
Table 3. Areas of specialization named by participants*
total N=396 N % Trauma/PTSD/abuse/loss 141 35.6 Depression/bipolar/mood disorders 110 27.8 Marital/relationship/family issues 99 25.0 Anxiety disorders (other than PTSD) 79 19.9 Addictions/codependency 64 16.2 Geriatric/older adult issues 29 7.3 Disabilities/chronic illness/pain 28 7.1 Eating disorders 21 5.3 ADHD/learning disabilities 17 4.3 Gay, bisexual, lesbian, transgender (GBLT) issues 17 4.3 Womens’ issues 16 4.0 Co occurring disorders, severe mental illness 13 3.3 Transitional issues 12 3.0 Sexual problems 10 2.5 Divorce/mediation/custody 9 2.3 Parenting issues 8 2.0 Stress management 8 1.0 Adoption/foster care 7 1.8 Attachment disorders 7 1.8 Child conduct/behavioral disorders 7 1.8 Personality disorders (unspecified) 7 1.8 Spiritual/existential issues 7 1.8 Caregivers 5 1.3 Anger management 4 1.0 Borderline/self injury 4 1.0 Employee assistance 4 1.0 Mens’ issues 4 1.0 Pre/perinatal/postpartum 4 1.0 Infant mental health issues 3 0.8 Autism/Pervasive developmental disorders 2 0.5 Hospice/end of life issues 1 0.3 Criminal/juvenile justice 1 0.3
*Total percentages add up to > 100% because some respondents were allowed to name more than one area.
44
The most commonly given specialties were trauma (35.6%), mood disorders (27.8%), marital/relationship/family issues (25.0%), anxiety disorders other than PTSD (19.9%) and addictions/codependency (16.2%). Respondents were allowed to name more than one area and collectively listed 32 different areas of specialization (see Table 3 for detailed list and percentages).
4.3 Analysis of Early vs. Late Responders
Since late responders may be considered to be similar to non responders (Siebert & Siebert, 2007; Trinkoff & Storr, 1997), an analysis was conducted to compare late responders (those who responded only to the final two requests) with early responders (those who responded to the first request). Early and late responders were compared on all the demographics and practice characteristics listed in Tables 1 and 2 and also on NUTs, CUTs, CNUTs, and EBPAS scores. The only statistically significant difference [t(260)=2.44, p<.05; d=.32] found was that late responders (M=50.70 SD= 9.22) were younger than early responders (M=53.90, 10.77). This indicates that non respondents may have been younger than those who responded. The difference appears to be similar to the difference between responders to the present survey and the median age of NASW members, as displayed in Table 1 (NASW did not report the mean age). 4.4 Research Question 1
What are theoretical orientations reported by respondents? The most reported theoretical orientation was “Eclectic” (31.5%), closely followed by Cognitive Behavioral (29.7%). Other orientations included Family Systems/interpersonal (12.3%); Humanistic/client centered (10.2%) and Psychodynamic/Neo Freudian (11.0%). The remainder of the participants listed a wide variety of orientations, listed in Table 2.
4.5 Research Question 2
What interventions and/or assessment procedures are LCSWs choosing to use most often?
45 Interventions respondents listed in response to the question asking them to name the three interventions they used most frequently in their practices within the past year are presented in Table 4.
Table 4. Interventions listed as the most frequently used by each particular respondent (respondents were asked to name the three interventions they used most frequently within the past year)
(total N = 331) N % Top 33 Most Frequently Used Interventions Reported by Participants Cognitive Behavioral Therapy 140 42.3 Psychodynamic 68 20.5 Solution focused 56 16.9 Cognitive Therapy/Restructuring 58 17.5 Behavior Modification/Evaluation 45 13.6 Family systems/interventions 38 11.5 EMDR 32 9.7 Interpersonal Therapy 28 8.5 Anxiety Management Training 21 6.3 Mindfulness 18 5.4 Play Therapy 18 5.4 Motivational Interviewing 14 4.2 Relaxation/Calming 14 4.2 Supportive Therapy 14 4.2 Psychoanalysis 13 3.9 Reframing 13 3.9 Empathy/Active listening 12 3.6 Dialectical Behavior Therapy (DBT) 11 3.3 Hypnotherapy 11 3.3 Crisis Intervention 10 3.0 Rational Emotive Behavior Therapy (REBT) 9 2.7 Body Oriented/Bioenergetic Therapies 7 2.1 Emotion Focused Therapy 7 2.1 Imagery/Visualization 7 2.1 Exposure Therapy 6 1.8 Gestalt Therapy 6 1.8 Acceptance 5 1.5 Acceptance and Commitment Therapy (ACT) 5 1.5 Couples Therapy 5 1.5 Critical Incident Stress Debriefing (CISD) 5 1.5 Emotional Freedom Technique (EFT) 5 1.5 Genogram 5 1.5 Thought Stopping 5 1.5
Most frequently used interventions mentioned by fewer than five respondents: Advice, Affect reglation, Affirmations, Anger Management, Applied behavior analysis, Art Therapy, Attachment Therapy, Assertive Community Treatment, Assertiveness Training, Bioenergetic, Biofeedback, Brainspotting, Brief treatment, Career counseling, Child centered, Clarifying questions, Client directed, Coaching, Collaboration/referral, Community organization, Confrontation, Contracts, Controlled breathing/breathwork, Coping skills, Curiosity, Desensitization, Developmental Needs Meeting Strategy,
46 Table 4 Continued
Developmental Skills Training, Direct intervention, Disease model of addictions, Downward Arrow, Eclectic CBT, Ego Psychology, Equine Facilitated Psychotherapy, Emotional awareness, Emotional Self Management, Emotional Freedom Technique, Energy Work/Therapy, Environmental modification, Ericksonian, Evolutionary Psychology, Existential, Exploration, Expressive Therapy, Fair Fighting, Feminist, Focusing, Goal directed, Gottman method, Group therapy, Guided self healing, Homework, Imago Relationship Therapy, Infant parent psychotherapy, Inner child, Insight Oriented Marital Therapy, Johnson Model, Joining, Journaling, Jung/Post Jungian, Life coaching, Lifespan integration, Love and Logic, Medical management, Metaframeworks, Modern analytic, Motivational enhancement, Narrative Therapy, Neurofeedback, Neurolinguistic Programming, Object relations, Outcome informed, PAIRS Communication skills, Paradoxical change, Parent Child Interaction Therapy, Parent coaching, Psycho education, Psychodrama, Psychosocial, Reading, Reality Therapy/testing, Referral for meds, Reiki, Reparenting, Repeating of problem, Respite, Sacred healing space, Safety contracting, Sandtray Therapy, Schema, SEL, Self Psychology, Self Talk Cycle, Social Skills Training, Somatic Experiencing, Spirituality, Strengths based, Structural Family Therapy, Substance Abuse intervention, Systemic, Task centered, Team building, Therapeutic Touch, Theraplay, Trauma specific, Transactional Analysis, Transference, Traumatic Incident Reduction, Twelve step recovery support, Validation, Wellness oriented, Whole Hearted Healing
Most frequently reported interventions were cognitive behavioral therapy (42.3%); psychodynamic (20.5%); solution focused (16.9%); cognitive therapy (17.5%); behavior modification (13.6%); and family systems (11.5%). Other interventions named are listed in Table 4, in descending order of frequency. Interventions participants identified from a list as having used within the past year (with any frequency), or used in the past and discontinued are presented in Table 5.
Table 5. Interventions and assessment procedures respondents reported currently using in any frequency within the past year and in the past/discontinued
Currently Use Used in Interventions (total N = 367) (within past year) Past/Discontinued N % N % Cognitive Behavioral Therapy 279 76.0 4 1.1 Anxiety Management Training 254 69.2 7 1.9 Solution Focused Therapy 225 61.3 6 1.6 Cognitive Therapy 215 58.6 8 2.2 Behavior Modification/Therapy 213 58.0 11 3.0 Interpersonal Therapy 188 51.2 3 0.8 Social Skills Training 171 46.6 16 4.4 Relaxation for PTSD 167 45.5 6 1.6 Insight Oriented Marital Therapy 160 43.6 8 2.2 Mindfulness Based Stress Reduction 154 42.0 3 0.8 Genogram 133 36.2 17 4.6 Thought Stopping 123 33.5 5 1.4 Social Problem Solving 116 31.6 7 1.9
47 Table 5 Continued Currently Use Used in Interventions (total N = 367) (within past year) Past/Discontinued N % N % Dream Interpretation 110 30.0 9 2.5 Emotionally Focused Couples Therapy 100 27.2 4 1.1 Motivational Interviewing 99 27.0 3 0.8 Attachment Therapy 97 26.4 8 2.2 Play Therapy 93 25.3 26 7.1 Critical Incident Stress Debriefing 89 24.3 22 6.0 Dialectical Behavior Therapy 83 22.6 8 2.2 Critical Incident Stress Management 82 22.3 13 3.5 Body centered Psychotherapy 78 21.3 4 1.1 Acceptance and Commitment Therapy 77 21.0 5 1.4 Imago Relationship Therapy 62 16.9 7 1.9 Exposure therapy for phobias, OCD, panic 60 16.3 15 4.1 EMDR for trauma/PTSD 59 16.1 12 3.3 EMDR for other conditions 54 14.7 10 2.7 Systematic Desensitization 53 14.4 9 2.5 Psychoanalysis 47 12.8 7 1.9 Psychodrama 46 12.5 13 3.5 Hypnosis 45 12.3 9 2.5 Love and Logic 38 10.4 7 1.9 Applied Behavior Analysis 38 10.4 8 2.2 Task Centered Practice 38 10.4 4 1.1 Reparenting 36 9.8 3 0.8 Exposure therapy for PTSD 35 9.5 7 1.9 Traumatic Incident Reduction 36 9.8 2 0.5 Myers Briggs Type Indicator 32 8.7 15 4.1 Age Regression (for sexual abuse) 28 7.6 10 2.7 Assertive Community Treatment 18 4.9 3 0.8 Emotional Freedom Techniques 19 5.2 2 0.5 Jungian Sandtray Therapy 19 5.2 6 1.6 Neurolinguistic Programming 19 5.2 6 1.6 Supported Employment Therapy 16 4.4 1 0.3 Stress Innoculation 15 4.1 1 0.3 Therapeutic Touch 15 4.1 1 0.3 Healing Touch 14 3.8 2 0.5 Biofeedback (other than EEG) 14 3.8 4 1.1 Lucid Dreaming 12 3.3 2 0.5 Sensory Motor Integration 11 3.0 3 0.8 Bioenergetic Therapy 10 2.7 4 1.1 Eneagram 10 2.7 10 2.7 Thought Field Therapy 10 2.7 4 1.1 Past Lives Therapy 9 2.5 0 0 Reiki 9 2.5 3 0.8 Biofeedback – EEG (Neurofeedback) 8 2.2 7 1.9 Facilitated Communication 7 1.9 2 0.5 Holotropic Breathwork 7 1.9 3 0.8 Qigong 7 1.9 1 0.3
48 Table 5 Continued Currently Use Used in Interventions (total N = 367) (within past year) Past/Discontinued N % N % Applied Kinesiology (emotional problems) 6 1.6 2 0.5 Psychosynthesis 6 1.6 2 0.5 DARE Programs 5 1.4 4 1.1 Tapas Accupressure Technique 5 1.4 1 0.3 Applied Kinesiology (for allergies) 4 1.1 1 0.3 Holding Therapy 4 1.1 3 0.8 Sexual Reorientation/Reparative for 4 1.1 1 0.3 Gays/Lesbians Scared Straight 3 0.8 3 0.8 Rebirthing Therapy 2 0.5 1 0.3 Primal Therapy 2 0.5 2 0.5 Seemorg Matrix Work 0 0 0 0 Radionics 0 0 0 0
Again, cognitive behavioral therapy was the most frequent intervention reported currently used (76.0%), followed by anxiety management training (69.2%), solution focused therapy (61.3%), cognitive therapy (58.6%), behavior modification (58.0%), and interpersonal therapy (51.2%). Even though a relatively high percentage of participants reported using behavioral approaches, only 16.3% reported using exposure based therapies for phobias, panic and OCD and only 9.5% reported using exposure based therapy for trauma, which is the therapy shown to have the most empirical support for PTSD (Institute of Medicine, 2007). However, 16.1% reported using Eye Movement Desensitization and Reprocessing (EMDR) and Traumatic Incident Reduction (9.8%), which some have argued work through the mechanism of exposure, rather than other claimed mechanisms of action such as eye movements (Herbert et al., 2000). Critical Incident Stress Debriefing was used by 24.3% of our sample. The most reported therapy for PTSD was relaxation (45.5%).
4.6 Research Question 3
What percentage of the sample is using NUTS, CUTs, and ESTs?
Percentages of the sample using CUTs, NUTs, CNUTs, and ESTs and their average numbers are displayed in Table 6.
49 Table 6. Usage of NUTs, CUTs, CNUTs, and ESTs
Total N N %
Percentage using: 367 NUTs 276 75.2 CUTs 221 60.2 CNUTs 317 86.3 ESTs 358 97.5
Number of: 367 Mean (s.d.) Range NUTs 2.34 (2.45) 0 – 15 CUTs 0.92 (0.92) 0 – 4 CNUTs 3.26 (2.87) 0 17 ESTs 6.41 (3.20) 0 16
Three quarters (75.2%) of respondents reported using at least one NUT, with an average of 2.34 NUTs (SD=2.45). Percentage using CUTs was 60.2% with an average of .92 (SD=.92) and 86.3% reported using CNUTs, with an average of 3.26 (SD=2.87). Nearly all of the sample
(97.5%) reported using at least one EST with an average number of 6.41 (SD=3.20).
4.7 Research Question 4
What reasons do the respondents give for selecting interventions?
The most highly rated (on a scale of 1 to 7) reason for choosing an intervention was “Clinical experience with positive results that held up over time” (M=6.50, SD=.88). This was followed by “Compatibility with your theoretical orientation” (M=5.65, SD=1.38); “Compatibility with your personality” (M=5.63, SD=1.38); “Clinical experience of fast, positive results with clients” (M=5.45, SD=1.56); “Intervention emotionally resonated for you” (M=5.20, SD=1.66); “Endorsement by respected professional” (M=5.01, SD=1.41); “Your intuition” (M=4.95, SD=1.64) and “Colleagues’ reports of success” (M=4.84, SD=1.45). “Favorable research in peer reviewed journals (M=4.74, SD=1.54) was rated lower than all of the above listed reasons, although it was rated more highly than “Clients (other than your own) reports of successes” (M=4.49, SD=1.77); “The intervention helped you personally” (M=4.23, SD=2.03); “Website articles” (M=3.41, SD=1.50) and “Magazine articles” (M=3.34, SD=1.45).
50 4.8 Research Question 5
What attitudes to respondents have towards evidence-based practice?
Stratified alpha for the entire EBPAS was .82. Alphas for the subscales were as follows: Appeal (.66); Requirements (.85); Openness (.79) and Divergence (.63). These alphas are similar to those reported by Aarons (2004). Although the stratified alpha for the entire scale was acceptable at .82, two of the subscales (Divergence and Appeal) had unacceptably low alphas. The EBPAS has a theoretical range of 15 75. The range for the present sample was 30 70, with an average score of 54.08 (SD=7.15). Thus, respondents were, on average, above the neutral point of 45. This indicates that our average respondent had a somewhat positive attitude toward evidence based practice, as measured by the EBPAS.
4.9 Research Question 6
How are the use of NUTs, CUTs, and ESTs related to demographics and practice characteristics? The relationship between NUTs, CUTs, CNUTs, and ESTs to demographics is displayed in Tables 7.
Table 7. Relationship between Demographics and Number of NUTs, CUTs, CNUTs, and ESTs
N NUTs CUTs CNUTs ESTs Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.) Gender 346 Female 268 2.56(2.59) .97 (.95) 3.53(3.02) 6.43(2.75) Male 78 1.72(1.95) .73 (.77) 2.45(2.18) 6.63(3.30) t=.3.12** d=.37 t=2.01* d=.28 t=3.51** d=.54 t=.50 Religion 334
Christian 144 2.27(2.18)a b .94(1.05) 3.22(2.76) a b 6.78(3.12)
Eastern/New Age 32 3.56(3.12)a c e 1.03(.90) 4.59(3.44) a c e 6.59(3.38)
Jewish 80 1.71(2.01)c d .93(.82) 2.64(2.38) c d 6.01(3.27)
Nondenominational/ 34 3.68(3.47)b d f 1.03(.76) 4.71(3.76) b d f 6.18(2.72) Spiritual
Atheist/Agnostic/ 44 1.73(1.58)e f .82(.76) 2.55(1.78) e f 6.48(3.39) None
51
Table 7 Continued F(4,329)=7.17** F(4,329) =0.36 F(4,329)=5.96** F(4,329) =.84 η2=.08 η2=.07
N NUTs CUTs CNUTs ESTs Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.) Geographic region 366 Northeast 159 2.04(2.43) .98(.91) 3.02(2.86) 6.02(3.14)a South 74 2.78(2.40) 1.00(1.02) 3.78(3.04) 6.50(3.03) Midwest 71 2.68(2.69) .80(.82) 3.48(2.95) 7.31(3.05)a b West 62 2.18(2.19) .74(.85) 2.92(2.47) 6.18(3.51)b F(3,362)=2.17 F(3,362)=1.60 F(3,362)=1.64 F(3,362)=2.85* η2=.02
Age 367 r=.08 r= .07 r=.05 r= .09
Note: Means in the same column that share subscript letters differ at the .05 level in the Fisher least significant difference (LSD) comparison.
*p<.05 **p<.01
The relationship between demographics and usage of NUTs, CUTs, and CNUTs (dichotomized versions) is displayed in Table 8.
Table 8. Relationship between Demographics and Usage of NUTs, CUTs, and CNUTs (dichotomized)
NUTs CUTs CNUTs Total N N % N % N % Gender 346 Female 268 211 78.7 167 62.3 236 88.1 Male 78 49 62.8 42 53.8 65 83.3 X2=8.19** Ф=.15 X2=1.81 X2=1.19
Religion 334 Christian 144 110 76.4 80 55.6 123 85.4 Eastern/New Age 32 28 87.5 21 65.6 31 96.9 Jewish 80 53 66.3 52 65.0 68 85.0 Nondenominational/ 34 29 85.3 26 76.5 33 97.1 Spiritual Atheist/Agnostic/ 44 34 77.3 28 63.6 40 90.9 None X2=8.16 X2=6.09 X2=7.11 Geographic region 366 Northeast 159 112 70.4 100 62.9 135 84.9 South 74 63 85.1 45 60.8 67 90.5 Midwest 71 53 74.6 41 57.7 61 85.9 West 62 47 75.8 34 54.8 53 85.5 X2=5.86 X2=1.41 X2=1.43
52 Table 8 Continued N Mean (s.d.) N Mean (s.d.) N Mean (s.d.) Age 340 NUTs CUTs CNUTs Total N N % N % N % Used 257 53.42 (9.88) 208 52.97(10.06) 297 52.72(10.22) Not used 83 51.93 (11.43) 132 54.67(11.80) 43 53.59(10.40) t= 1.15 t=.42 t=.76
**p<.01
Bivariate analyses on the dichotomized version of the EST variable were not conducted due to the fact that 97% of our sample reported using at least one EST. The relationship between female gender and NUTs, CUTs, and CNUTs was found to be significant and will be discussed further in the section entitled Hypothesis 1. The relationship between number of NUTs and religion was also found to be significant and will be discussed further in the section entitled Hypothesis 2. Additionally, the number of CNUTs and religion was found to be significant, with post hoc testing showing the same differences that were found with NUTs. Also, an ANOVA revealed a significant relationship between geographic region and number of ESTs. Post hoc testing using Fishers Least Significant Difference (LSD) test revealed significant differences, with participants from the Midwest using a higher number of ESTs than participants from the Northeast or West, although the effect size was small. Relationships between practice characteristics and NUTS, CUTs, CNUTs and ESTs are displayed in Tables 9 and 10.
Table 9. Relationship between Practice Characteristics and Number of NUTs, CUTs, CNUTs, and ESTs
N NUTs CUTs CNUTs ESTs Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.)
Private practice 313 2.47(2.56) .97(.93) 3.44(2.97) 6.46(3.29) Not in private practice 50 1.62(1.47) .60(.78) 2.22(1.88) 6.36(2.45) t=3.36** d=.41 t=2.70** d=.43 t=3.90**d=.49 t=.26
Large city 186 2.30(2.32) .89(.89) 3.19(2.71) 6.08(3.07) Not large city 179 2.39(2.59) .95(.94) 3.34(3.04) 6.78(3.31) t=.37 t=.60 t=.51 t= 2.10* d= .22 Theoretical Orientation CBT/Cognitive/ 110 1.83(1.96) .77(.94) 2.60(2.50) 7.10(2.94) Behavioral Other orientations 253 2.58(2.61) .99(.91) 3.57(2.08) 6.16(3.26)
53 Table 9 Continued N NUTs CUTs CNUTs ESTs Mean (s.d.) Mean (s.d.) Mean (s.d.) Mean (s.d.) t= 3.03** d= .32 t= 2.06* d= .24 t= 2.99** d= .42 t=2.60** d=.30
Eclectic 106 2.56(2.34) .92(.93) 3.47(2.79) 6.75(3.39) Other orientations 257 2.27(2.50) .93(.92) 3.19(2.91) 6.32(3.10) t=1.02 t=.10 t=.84 t=1.15 Trauma Indicated specialty 136 3.17(2.86) 1.07(.99) 4.24(3.30) 6.77(3.17) Not indicated 229 1.85(2.03) .83(.86) 2.68(2.41) 6.21(3.17) t=4.71** d=.53 t=2.47** d=.26 t=4.81** d=.54 t=1.63 Mood disorders Indicated specialty 102 2.24(2.31) .78(.84) 3.02(2.60) 6.36(2.98) Not indicated 263 2.38(2.51) .97(.94) 3.36(2.97) 6.44(3.29) t= .52 t= 1.77 t= 1.01 t=.21 Marital/family issues Indicated specialty 93 2.56(2.40) .86(.86) 3.42(2.80) 6.71(3.14) Not indicated 272 2.27(2.47) .94(.94) 3.21(2.90) 6.32(3.22) t=.99 t= .73 t=.61 t=1.01 Anxiety disorders Indicated specialty 74 2.36(2.74) .84(.81) 3.20(3.08 6.43(3.05) Not indicated 291 2.34(2.38) .94(.94) 3.28(2.82) 6.42(3.24) t=.08 t= .87 t=..20 t=.04
Number of years in 364 r= .03 r= .10 r= .06 r= .10 practice
Year graduated MSW 347 r= .02 r=.13* r2=.02 r=.03 r=.12* r2=.01
*p<.05 **p<.01
Table 10. Relationship between Practice Characteristics and Usage of NUTs, CUTs, and CNUTs (dichotomized)
NUTs CUTs CNUTs Total N N % N % N % 363 Private practice 313 236 75.4 197 62.9 274 87.5 Not in private practice 50 37 74.0 23 46.0 40 80.0 X2=.05 X2=5.18* Ф=.12 X2=2.10 365 Large city 186 135 72.6 112 60.2 161 86.6 Not large city 179 139 77.7 109 60.9 154 86.0 X2=1.25 X2=.02 X2=.02
Theoretical Orientation 363 CBT/Cognitive/ 110 77 70.0 54 49.1 87 79.1 Behavioral Other orientations 253 196 77.5 166 65.6 227 89.7 X2=2.30 X2=8.77* Ф=.16 X2=7.42** Ф=.14
Eclectic 106 82 77.4 63 59.4 91 85.8
54 Table 10 Continued NUTs CUTs CNUTs Total N N % N % N % Other orientations 257 191 74.3 157 61.1 223 86.8 X2=.37 X2=.09 X2=.06 Trauma 365 Indicated specialty 136 118 86.8 91 66.9 125 91.9 Not indicated 229 156 68.1 130 56.8 190 83.0 X2=15.85** Ф=.21 X2=3.68 X2=5.77* Ф=.13 Mood disorders 365 Indicated specialty 102 76 74.5 56 54.9 86 84.3 Not indicated 263 198 75.3 165 62.7 229 87.1 X2=.02 X2=1.89 X2=.47 Marital/family issues 365 Indicated specialty 93 74 79.6 57 61.3 86 92.5 Not indicated 272 200 73.5 164 60.3 229 84.2 X2=1.35 X2=.03 X2=4.02* Ф=.11 Anxiety disorders 365 Indicated specialty 74 52 70.3 44 59.5 62 83.8 Not indicated 291 222 76.3 177 60.8 253 86.9 X2=1.14 X2=.05 X2=.50
N Mean (s.d.) N Mean (s.d.) N Mean (s.d.) Years in practice 364 Used 274 18.69(9.74) 221 18.55(10.00) 315 18.77(9.86) Not used 90 19.06(11.18) 143 19.15(10.27) 49 18.88(11.66) t= .30 t=.55 t=.07 Year graduated MSW Used 262 1988(11.33) 210 1988(10.26) 302 1988(10.12) Not used 85 1987(10.17) 137 1987(10.75) 45 1986(12.54) t=.54 t=.94 t=.73
*p<.05 **p<.01
The relationship between number of NUTs, CUTS, and CNUTS and being in private practice was statistically significant. That is, participants in private practice were more likely to use a higher number of these therapies. However, the relationship between number of ESTs and being in private practice was not significant. Participants not living in a large city used a significantly higher number of ESTs. Also, participants in private practice were found to be significantly more likely to use any CUTs (dichotomized version). Having a theoretical orientation other than CBT was also found to be significantly related to using higher numbers of NUTs, CUTs, CNUTs, and ESTS (see Table 10) and the dichotomized version of CUTs and CNUTs (see Table 11). Additionally, as presented in Table 10, those participants who indicated a specialization in trauma used a statistically significantly higher number of NUTs, CUTS, and CNUTs, but not a higher number of ESTs. A statistically
55 significant relationship was also found between the dichotomized versions of NUTs and CNUTs and specialization in trauma (see Table 10). The three other most frequently cited areas of specialization (mood disorders, marital/family issues, and anxiety disorders) were not significantly related to use of NUTs, CUTs, or ESTS, nor were number of years in practice, or year of graduation with MSW. However, a significant relationship was found between the dichotomized version of CNUTs and a specialization in marital and family issues, although the effect size was small. 4.10 Research Question 7
Are attitudes towards evidence-based practice statistically significantly related to the use of NUTs, CUTs, CNUTs, or ESTs? The relationship between NUTs, CUTs, CNUTs, and ESTs and EBPAS scores is presented in Table 11.
Table 11. Relationship of NUTs, CUTs, CNUTs and ESTs and Theoretical Orientation to EBPAS Scores
EBPAS Total Score Divergence Subscale N r N r
Number of NUTs 336 .22** r2=.05 354 .06
Number of CUTs 336 .07 n.s. 354 .03
Number of CNUTs 336 .21** r2=.04 354 .06
Number of ESTs 336 .22** r2=.05 354 .12* r2=.01
N Mean(s.d.) N Mean(s.d.)
Used NUTs 254 54.68(6.91) 268 9.65(2.71) Did not use NUTs 82 52.30(7.64) 86 9.72(3.01) t=2.64** d=.32 t= .22
Used CUTs 203 54.56(7.21) 214 9.64(2.82) Did not use CUTs 133 53.40(7.03) 140 9.71(2.73) t=1.45 n.s. t= .24 n.s.
Used CNUTs 292 54.22(7.13) 309 9.71(2.75) Did not use CNUTs 44 53.30(7.30) 45 9.33(3.01) t=.80 n.s. t=.85 n.s. ESTS (N/A, 97.5% of sample used at least one EST)
Theoretical orientation
56 Table 11 Continued EBPAS Total Score Divergence Subscale N r N r CBT/cognitive/behavioral 99 55.58(6.87) 105 9.15(2.55) Other orientations 238 53.49(7.21) 250 9.92(2.86) t=2.46* d=.30 t= 2.37* d= .28
*p<.05 **p<.01
A significant positive correlation was found between EBPAS scores and number of NUTs, CNUTs, and ESTS. That is, people who used higher numbers of NUTs, CNUTs, or ESTs were more likely to have a positive attitude towards evidence based practice as measured by the EBPAS. Additionally, people who used any NUT (dichotomized version) had significantly higher scores on the EBPAS.
4.11 Research Question 8
Are attitudes towards evidence-based practice statistically significantly related to theoretical orientation? Results of this analysis are displayed in Table 11. Those who indicated a theoretical orientation of CBT scored significantly higher on the EBPAS than those of other theoretical orientations. This indicates that those with a CBT theoretical orientation had a more positive attitude towards evidence based practice, according to the EBPAS.
4.12 Hypothesis 1
Hypothesis 1 states that females will be statistically significantly more likely than males to use NUTs, CUTs and CNUTs and will use a higher number of NUTs, CUTs and CNUTs. The results, presented in Table 7, indicate that this hypothesis was supported for the relationship between female gender and number of NUTs, CUTs, and CNUTs. That is, independent samples t testing revealed that females used a significantly higher number of NUTs, CUTs, and CNUTs than males. The hypothesis that females will be more likely than males to use NUTs (dichotomized) was also supported, with the results presented in Table 8. However, females were not more likely than males to use CUTs or CNUTs, and thus, that part of the hypothesis was not supported.
57
4.13 Hypothesis 2
Hypothesis 2 states that respondents who report affiliation with eastern/new age religions and nondenominational/spiritual will be statistically significantly more likely to use NUTs and will use a higher number of NUTs than those who report other religious affiliation or no affiliation. Results of the ANOVA examining the relationship between religion and number of NUTs are displayed in Table 7 and indicate that this hypothesis is supported. Fisher’s Least Significant Difference (LSD) test revealed significant differences between Eastern/New Age and Christian; Nondenominational/spiritual and Christian; Eastern/New Age and Jewish; Nondenominational/spiritual and Jewish; Eastern/New Age and Atheist/Agnostic/None; Nondenominational/spiritual and Atheist/Agnostic/None. Thus, people who report eastern/new age and nondenominational/spiritual religious orientations were more likely to use NUTs than Christians, Jews, or those who report being atheists/agnostics/no religion. The results of the chi square analysis examining the relationship between use of NUTs and religion is displayed in Table 8. The results of this chi square are not significant and thus, the hypothesis that respondents reporting an affiliation with eastern/new age or nondenominational/spiritual would be more likely to use NUTs (dichotomized) than those reporting other religious affiliations was not supported.
4.14 Hypothesis 3
Hypothesis 3 states that clinical experience will be a statistically significantly more highly rated influence on choice of therapies than empirical evidence (i.e. studies published in peer reviewed journals) for the entire sample. A split plot ANOVA with the comparison of reasons as the within subjects variable (for Hypothesis 3) and CBT theoretical orientation as the between subjects variable (see Hypothesis 4) was conducted and is presented in Table 12.
58 Table 12. Relationship of reasons for choosing interventions to CBT theoretical orientation
Reason Total CBT Non CBT (rated on a scale of 1 7 where 1=not at all Mean Mean Mean important and 7=very important) (s.d.) (s.d.) (s.d.)
Research vs. Clinical Experience with fast positive results (N=342)
Between subjects (CBT theoretical F(1,340)=25.83** orientation) η=.07
Favorable research published in peer 4.76 5.20 4.57 reviewed journals (1.53) (1.54) (1.49) Within subjects Between subjects Wilks’ λ =.91 t=3.51** F(1,340)=34.40** d=.42 d=.42 Clinical experience of fast, positive 5.42 5.96 5.20 results with clients (1.58) (1.29) (1.64) Between subjects t=4.17** d=.52 Research vs. Clinical experience with results that hold up (N=344)
Between subjects (CBT theoretical F(1,342)=8.80* orientation) η=.03
Favorable research published in peer 4.77 5.22 4.58 reviewed journals (1.52) (1.51) (1.48) Within subjects Between subjects Wilks’ λ =.54 t=3.62** F(1,342)=291.08** d=.43 d=1.39
Clinical experience of positive results 6.50 6.51 6.50 that hold up over time (.88) (.83) (.90) Between subjects t=.134 n.s.
*p<.01 **p<.001
59 The results of the repeated measures, within subjects ANOVA reveals a statistically significant difference with a medium effect size (d=.42) was found between “Clinical experience with fast positive results” and “Favorable research in peer reviewed journals.” Additionally, a statistically significant difference with a very large effect size (d=1.39) was found between “Clinical experience of positive results that hold up over time” and “Favorable research in peer reviewed journals.” In both cases, clinical experience was rated significantly more highly than research in peer reviewed journals. Thus, this hypothesis is supported.
4.15 Hypothesis 4
Hypothesis 4 states that LCSWs who report a theoretical orientation of CBT will rate empirical evidence as statistically significantly more influential in choice of therapy than those who report other theoretical orientations. The statistical results of the between subjects ANOVA is presented in Table 12 and demonstrates that this hypothesis is supported. That is, participants who reported a theoretical orientation of CBT rated the reason for choosing an intervention “Favorable research in peer reviewed journals” significantly higher than those who reported other theoretical orientations. However, although not part of this hypothesis, it is worth noting that participants of both CBT and other orientations rated the clinical experience items higher than “Favorable research in peer reviewed journals.”
4.16 Hypothesis 5
Hypothesis 5 states that LCSWs who use NUTs, CUTs, and/or CNUTs will score statistically significantly higher on the Divergence subscale of the EBPAS than those who do not (note that a high score on this subscale means a belief that EBP diverges from their actual practice). The results of the correlation between number of NUTs, CUTs, and CNUTs, and the Divergence subscale of the EBPAS, as well as the t test between NUTs, CUTs, and CNUTs and the Divergence subscale of the EBPAS are displayed in Table 11. No significant differences were found and thus, this hypothesis was not supported. However, it is relevant to note that the Divergence subscale of the EBPAS was found to have a poor alpha of .63. Although not part of
60 this hypothesis, it is interesting to note that there was a weak, but significant negative correlation between number of ESTs and the Divergence subscale of the EBPAS.
61 CHAPTER 5
CONCLUSIONS AND IMPLICATIONS FOR SOCIAL WORK PRACTICE
5.1 Key Findings
Descriptive Findings The sample from the present study was drawn from a population of LCSWs who advertised their services over the Internet and examined their choices of interventions. The sample was consistent with NASW’s membership in being predominantly white and female. The present sample was older than NASW’s membership (NASW, 2003) and the analysis of early versus late responders revealed that non respondents may have been younger than those who responded. The present sample has a disproportionately high number of Jewish respondents (23%) and a lower number of Christian respondents (43%) than the general population (Kosmin et al., 2001). This is probably due to the fact that there are a high concentration of NASW members from the New York City area (NASW, n.d.), which has a higher percentage of Jewish people than the general population and the vast majority of the present sample are members of NASW. The theoretical orientations reported by respondents were consistent with the pilot study (Pignotti & Thyer, 2009). The finding of Cognitive Behavioral orientation being the most frequently reported single orientation reported by 29.7% of respondents (second only to the 31.5% who reported “eclectic”) represents a change from earlier social work surveys where psychoanalytic or neo Freudian orientations (Saltman et al., 1993; Strom, 1994) or family therapy (Cocozelli & Constable, 1985) were predominant. In the present study, only 12% of respondents reported family therapy and 11% of respondents reported psychodynamic/neo Freudian as their theoretical orientation, which would suggest that these orientations may be declining in favor of cognitive behavioral theories. This is also consistent with the pattern observed with practicing clinical psychologists, where psychodynamic orientations are also reported to be declining and cognitive behavioral orientations increasing (Norcross, Karpiak & Santoro, 2005).
62 Again, consistent with the pilot data (Pignotti & Thyer, 2009) the intervention respondents reported using most often and the most frequently reported intervention being used (see Tables 4 and 5) was CBT. This is also consistent with surveys of clinical psychologists and other mental health professionals (Sharp et al., 2005; Sharp et al., in press; vonRanson & Robinson, 2006). It would seem that these findings, taken together, would indicate that in recent years CBT is the predominant intervention of choice among mental health professionals. However, the second intervention respondents reported using was psychodynamic therapy with 20.5% of respondents naming this intervention. Although this was less than half the number of respondents reporting CBT, this is more than the 11% who reported psychodynamic as their theoretical orientation. Thus, it appears that even though a smaller percentage consider psychodynamic to be their theoretical orientation, approximately an additional 10% appear to be using psychodynamic based interventions in their practice. This is an indication that what interventions respondents report practicing may be different from their reported theoretical orientations. Although the majority of respondents reported using interventions that had empirical support, many of the interventions that respondents reported using lacked such support and some, such as Critical Incident Stress Debriefing, reported by nearly a quarter of our sample, have been shown in some studies to be potentially harmful (Lilienfeld, 2007). Other therapies of concern such as age regression for sexual abuse, holding therapy, reparative therapy for gays and lesbians, and rebirthing were reported by only a small percentage of our sample. However, the use of such therapies is nevertheless of concern. If our sample is in any way representative of other LCSWs, even a small percentage in our sample would indicate that hundreds LCSWs may possibly be using these interventions and this warrants further investigation. It is also possible that the usage of some of these interventions might be under reported due to the negative reputation of some of these interventions have acquired. Also noteworthy is the relatively low percentage of our sample that reported using exposure therapy for PTSD (9.5%) and for phobias, panic and OCD (16%). In spite of the fact that exposure therapy has the strongest support for treating people with these conditions, consistent with the findings of surveys of clinical psychologists (Becker et al., 2004), a relatively low percentage of clinicians report using exposure therapy. As Becker et al. found, this may be due to lack of training, resistance to using a manualized intervention, or concerns that the client
63 may decompensate. Even though the concern regarding decompensation has been shown to be without basis (Cahill, Foa, Hembree, Marshall, & Nacash, 2006), if practitioners believe this to be the case, this could be a barrier to their adopting exposure therapy as a practice. Nearly the entire sample in the present study (97.5%) reported using at least one therapy that was classified as an EST. However, three quarters of our respondents also reported using at least one NUT and 86.3% reported using at least one CUT or a NUT. This indicates that although respondents are using interventions with empirical support, an overwhelming majority are also using interventions that lack such support. Although we do not know specifics about how these interventions were employed, the reasons respondents gave for selecting interventions can provide us with some insight into this matter. The most highly rated reasons for selecting interventions were reasons based on clinical experience. As indicated in the results section, clinical experience with fast results, with results that hold up over time, compatibility with theoretical orientation, personality, intuition, endorsement by respected professionals, and colleagues reports of success were all rated more highly than favorable results in peer reviewed journals. Although our respondents clearly were not averse to using interventions with empirical support, as evidenced by their scoring above the neutral point on the EBPAS, the fact that an intervention has such support does not appear to be a top criteria in selection of an intervention. Relationship between demographics, practice characteristics and use of NUTs, CUTs, and CNUTs Consistent with Pignotti and Thyer (2009), the hypothesis of the present study that females are more likely to use NUTs and use a higher number of NUTs than males was supported. However, the hypothesis that females use more CUTs and CNUTs than males and use them in higher numbers, was not supported. Thus, it seems that although females are more likely to use novel therapies that lack empirical support, males are just as likely as females to use conventionally accepted treatments that lack empirical support. The reason for this is unknown at this time and no data in the present study would suggest a reason. Although the relationship between the use of NUTs, CUTs and CNUTs and religion was not significant in the earlier pilot study (Pignotti & Thyer 2009) with the larger sample size of the present study, the relationship between NUTs and religion became significant, although the relationship between CUTs, CNUTs and religion remained not significant. Post hoc testing of
64 the ANOVA showed that the study hypothesis that participants reporting affiliation with eastern/new age religions and nondenominational/spiritual were indeed more likely to use NUTs than those reporting other religious affiliations or no religious affiliation. Perhaps the difference is related to the fact that many of the eastern/new age religions and nondenominational/spiritual affiliations tended to be associated with unconventional approaches to religion. Thus, participants were open to becoming involved with unconventional religions may also have been more open to studying and practicing unconventional interventions. While this does not necessarily mean that being affiliated with an unconventional religion caused participants to choose unconventional interventions, the choice of both might be due to other factors that warrant further investigation, variables such as personality traits or belief systems. With regard to the research question on the relationship between practice characteristics and NUTs, CUTs, and CNUTs, an interesting finding is that participants who indicated a specialization in trauma used a significantly higher number of these types of interventions, when compared to participants who did not report a specialization in trauma and were also more likely to use such interventions (i.e. the dichotomized versions of NUTs and CUTs with trauma orientation was also significant). Although mental health professionals who specialized in trauma have been believed to be more prone to using such interventions (Gist, Woodall & Magenheimer, 1999) this is the first time data have been produced that directly compare trauma specialists to those reporting no such specialty and support this notion. This may be partly due to the fact that some of the interventions classified as NUTs were originally designed specifically to address trauma (e.g. CISD) although this was not the case for most of the therapies classified as NUTs. Relationship between reasons for choosing interventions and theoretical orientation As hypothesized, our sample as a whole rated clinical experience with success significantly more highly than studies published in peer reviewed journals as a reason for selecting an intervention, with a d of 1.39, indicating a robust effect size for the comparison between clinical experience of results that hold up over time with favorable research in peer reviewed journals. Moreover, therapists who reported a cognitive behavioral theoretical orientation rated studies published in peer reviewed journals significantly more highly as a reason for choosing an intervention than those reporting other theoretical orientation rated this same reason with medium effect sizes. However, therapists of cognitive behavioral orientation still rated clinical experience significantly more highly than research published in peer reviewed
65 journals, indicating that clinical experience is a more compelling reason for selecting an intervention than research, even for those with a cognitive behavioral orientation. It would seem that based on these results, clinical experience is very highly valued by LCSWs, regardless of their theoretical orientation. Thus, it may be the case that if a clinician was faced with a conflict between research evidence and their own clinical experience, a decision might be made in favor of clinical experience over research. This is an issue that deserves further investigation. Relationship between EBPAS and use of NUTs, CUT, CNUTs and ESTs Surprisingly, a respondent’s use of NUTs, CUTs, or CNUTs were not related to their EBPAS scores, nor were these variables related to their Divergence subscale scores. The overall EBPAS score was related to the number of ESTs used by respondents, but use of NUTs, CUTs, or CNUTs did not seem to have an influence on respondents’ attitudes towards evidence based practice., which, on average, was above the midpoint on the scale and therefore, positive. Apparently, a positive attitude towards evidence based practice does not preclude the decision to also use interventions that do not have such support.
5.2 Study Limitations
The present study had a number of limitations that need to be taken into account. The sample consisted of LCSWs who had publicly available e mail addresses who advertised their services over the internet and were mostly in private practice. Thus, the present sample is not necessarily representative of LCSWs who do not publicly provide their e mail addresses, do not advertise their services on the internet, or do not engage in private practice. Moreover, the present sample was predominantly Caucasian and had fewer racial and ethnic minorities than NASW (2003). This is probably due to the predominance of private practitioners, given that a previous survey of clinical social workers in private practice (Strom, 1994) reported an even higher percentage of Caucasian participants (97%) than the present sample (94%). LCSWs working for agencies might be faced with more restrictions against using NUTs. Moreover, Aarons (2004) in his studies of agency based samples found that such service providers might not use empirically supported therapies due to resistance to changing the conventional approaches they use that may be lacking in empirical support. Thus, agency based
66 service providers, including LCSWs, based on Aarons findings, might be found to use more CUTs, than NUTs or ESTs. Additionally, it is possible that therapists who advertise services on the internet might be more likely to use NUTs than those who do not, as their presence and time spent on the internet might give them more access to advertisements for such approaches and opportunity to network with other therapists who participate in online discussions and report success with such approaches. This may motivate such therapists to train and practice such approaches, whereas therapists who are not online as much, if at all, may not learn about such approaches as frequently. However, Specht and Courtney (1994) noted even before the internet was widely used that social workers in private practice were using and advertising such therapies and thus, the possibility of therapists not online using such therapies cannot be dismissed entirely. Another obvious limitation of the present study is that as with most survey research, we had to rely on the self reports of LCSWs rather than direct observation of what they actually do in practice. It is also possible that since the invitations were sent via electronic mail, people other than the intended recipient may have filled out the questionnaire. This is a problem that is present with any survey delivered by a method other than in person administration, such as mailed surveys. There were also limitations presented by the EBPAS. The alphas on some of the subscales were unacceptably low and thus the results need to be interpreted with caution. It is also important to note that the EBPAS tends to focus on attitudes towards ESTs and does not measure all three components of Sackett et al’s (2000) definition of EBP. A more comprehensive measure of EBP might have produced different results.
5.3 Recommendations for Future Research
The results of the present study indicate a number of possible directions for future research as well as further analysis of the existing data. An analysis could be conducted of the existing data to determine the relationship between theoretical orientation and the interventions LCSWs listed as using in their practices, similar to Sharp et al.’s (2005) examination of the practices of clinical psychologists, in order to determine whether self reported interventions are
67 consistent with their self reported theoretical orientation. Additional analyses could also be conducted on the educational and continuing education data, to determine if a relationship exists between these data, choice of intervention, theoretical orientation, and attitude towards evidence based practice. Also, given that 141 of our participants indicated that they specialized in trauma and that subset was more likely to use NUTs than those who did not specialize in trauma, conducting further data analysis on that subset of respondents, their intervention choices, reasons, and attitudes towards evidence based practice would be of interest. Additionally, a content analysis for those from the entire sample who answered the question, could be conducted on the open ended question regarding reasons for discontinuing an intervention. Since the present study did not distinguish between manualized forms of therapies that have empirical support and other forms that might not have manuals and support, future research could address this issue. For example, a therapist might be practicing a form of CBT that was manualized and adhering to a well supported protocol for a particular condition being addressed such as PTSD. On the other hand, a therapist might be using the term CBT more loosely and using it to address a condition for which it does not have empirical support, such as a personality disorder. Thus, even though nearly our entire sample reported using interventions that had empirical support, we do not know if what they were actually doing with clients in their practice had empirical support. More detailed questions would be necessary in future research, to operationalize interventions such as CBT more specifically. Given that nearly a third of the present sample identified their theoretical orientation as eclectic, additional questions on eclecticism would also be helpful, similar to those asked of clinical psychologists (Norcross, Karpiak, & Lister, 2005) to determine what they meant by “eclectic.” Were they intentionally integrating different approaches to be consistent with a theoretical orientation, were they being pragmatic and selecting therapies that appeared to be working, were they choosing therapies to fit the client’s needs, or were the therapies being selected in a more haphazard manner? Future research could investigate all of these possibilities. Future research could also broaden the investigation of LCSWs use of EBP. Clearly, EBP, by Sackett et al.’s (2000) definition involves more than simply choosing to use interventions that have empirical support. The present study focused primarily on the first part, the selection of an intervention based on available evidence. However, we do not know from the results of the present study whether these LCSWs formulated questions about their clients and searched
68 databases appropriately for the best possible evidence. We also do not know the extent to which they employed their clinical expertise or utilized client values in making their decisions. If a client was unwilling to do a particular intervention that had empirical support, if such an intervention had been tried and not worked, or if no empirically supported interventions existed for the condition being addressed, then it might have been defensible for the therapist to choose an intervention that lacked empirical support, if the client was provided with proper informed consent. We also do not know if these particular LCSWs made claims about the NUTs they were using that went beyond the evidence or if they properly informed their clients that the interventions were experimental. Survey questions in future research could explore these possibilities and elicit more details on how LCSWs conduct their practices. Since the present study focused on LCSWs in private practice, future research could focus on the practices of LCSWs who are working in settings other than private practice such as hospitals, schools and other social service agencies. Would such practitioners and their supervisors be more likely to use conventional therapies that lack support and be more resistant to learning any new intervention, regardless of whether the new therapy had evidence? Based on Aarons’ (2004) findings from his agency samples, some of the practitioners in agencies and their supervisors were resistant to learning the newer evidence based approaches. Future research could investigate whether this is the case in agency settings where social workers are employed. Another focus for future research could be the relationship between an LCSWs acceptance of third party reimbursement and their use of empirically supported therapies. Since most of the present sample were found to be using both supported and unsupported interventions, the question arises of how this would be dealt with by managed care, to the extent practitioners are requesting such reimbursements. Third party payers have been described as “the fuels for the psychotherapy engine” (Thyer, 1995, p.96). As Thyer pointed out, both private insurers and public programs have been known to reimburse for interventions that lack empirical support and thus, more rigorous practice standards based on evidence have been recommended. In more recent years, with financial constraints, this may be changing and interventions that lack support might not be so easily reimbursable. What third party payers will reimburse for may have an influence on interventions selected by those LCSWs who accept third party payments and an investigation on the extent of their influence would be a valuable part of future research.
69
5.4 Implications for Social Work Practice
Participants in the present study collectively listed over 100 interventions used in practice. On average, they used six ESTs and three novel or conventional unsupported interventions. That is, participants used on average twice as many ESTS as they did novel or conventional unsupported interventions. An overwhelming majority, 97.5% of participants reported using at least one EST. In light of Flexner’s (1915/2001) criterion that a discipline must base practice on a scientific body of knowledge to be considered a profession, these results, at least where the present sample is concerned, are indicative that the social work profession may be meeting that criterion. Although the results of the present study cannot be generalized to other LCSWs, and need to be replicated with other samples of LCSWs, there is no reason to believe that the present sample would be more rigorous in their choice of ESTs than other LCSWs. Hence, these results are encouraging even if not conclusive at this point in time. Even though the assumption cannot be made that all who report using ESTs are using specific manualized empirically supported interventions, 97.5% of participants in the present study report that they are using interventions that at the very least, have some theoretical support. Nevertheless, some trends from the past appear to still be in place. It appears that although LCSWs today are using a number of interventions different from those used 30 years ago, the trend towards eclecticism of the 1970s (Jayaratne, 1978) appears not to have changed. Nearly a third of our sample defined their orientation as “eclectic” and even others who did not define themselves as “eclectic” listed multiple interventions. Clinical experience, the most highly rated criterion for selection of an intervention, appears to be an important factor in determining which interventions clinicians select. Although, according to EBPAS scores, our sample displayed a positive attitude towards EBP, they nevertheless rated their clinical experience as more important. Today, some schools of social work are putting more emphasis on evidence based practice and are teaching interventions with empirical support, so practices may be changing with more recent graduates of social work programs. However, many students are still practicing
70 in field placements settings that may not be considering the empirical support of interventions being used and that may be reducing the impact of emphasizing EBP in the classroom. Additionally, social workers today who spend time on the internet are bombarded with advertisements and testimonials for various novel interventions. Although many such interventions lack empirical support, they offer workshops and certification programs accompanied by unsupported claims for efficacy, often based on nothing more than testimonials and anecdotes. Social work students, as well as currently practicing LCSWs could benefit from learning to critically evaluate such claims, rather than relying upon word of mouth from colleagues or what seems to be working in their practice. Such judgments can be subject to biases such as expectancy and confirmation bias (Lilienfeld, Lynn & Lohr, 2003), that no human beings, including social workers, are immune to. Moreover, many mental health professionals greatly overestimate their ability to learn from experience and may be unaware of the large body of evidence that supports the superiority of actuarial judgment to clinical judgment (Dawes et al., 1989; Garb & Boyle, 2003). Dawes and his colleagues’ review demonstrated that “individuals may have considerable difficulty distinguishing valid and invalid variables and commonly develop false beliefs in associations between variables” (p. 1671). Additionally, these authors point out that clinical judgments in the absence of empirical evidence can lead to self fulfilling prophecies. That is, “prediction of an outcome often leads to decisions that influence or bias that outcome” (p. 1671). Also, predictions based on clinical judgment can be remembered as more consistent than they actually were. Another problem with clinical judgment is that the samples clinicians are exposed to may not necessarily be representative of the population as a whole and thus a given problem might become over pathologized when the clinician sees only people who are seeking help, and would not be likely to see people who were able to resolve the problem on their own. The present study results suggest that clinical social workers may be overvaluing clinical experience, while viewing research evidence as less valuable in making decisions regarding selection of interventions. While the experience of seasoned clinicians claiming various areas of expertise does have value and ought not to be dismissed entirely, years of experience is no substitute for critical thinking nor should it give the expert carte blanche to make unsupported assertions immune from challenge. Critical questioning and evaluation of claims made by
71 experts who are considered authorities in various specialties is also necessary. Clinical social workers need to learn how to evaluate such claims and research. Not all novel interventions are pseudoscientific and not all make bogus claims in the absence of evidence. The goal would be for social workers to have the ability to be open to legitimate investigations of novel interventions and yet carry out critical evaluation of such interventions. In the words of Carl Sagan: At the heart of science is an essential tension between two seemingly contradictory attitudes an openness to new ideas, no matter how bizarre or counterintuitive they may be, and the most ruthless skeptical scrutiny of all ideas, old and new. This is how deep truths are winnowed from deep nonsense. The collective enterprise of creative thinking and skeptical thinking together keeps the field on track (Sagan, 1996, p. 304). The social workers who learn discernment will be the social workers who will best be able to utilize their skills, talents, creativity and idealism to serve their clients, at the micro, mezzo and macro levels.
72 APPENDIX A
NOVEL UNSUPPORTED PRACTICES ON THE INTERNET
Table 13. Examples of novel unsupported practices promoted by LCSWs on the worldwide web
Name of website/ Services Web address/ Offered/ Products sold and Location cost (if listed) Claims Made Basis for Claims
Sandra Radomski, ND, Seminars Allergy elimination Testimonials, LCSW Private sessions (allergies claimed to be uncontrolled http://www.allergyantidotes.c Allergy elimination connected to ADD, unpublished case om/ through energy therapies autism, asthma, anxiety, studies, non peer Connecticut Devices sold: arthritis, brain fog, reviewed articles Eagle Guardian (a depression, panic homeopathic device) $795; attacks, chronic cough, Manuals and DVDs chronic fatigue, digestive $10 $80; Energy frequency problems, unexplained tubes $90 $150 symptoms) Lasers for stimulation of acupressure points $50 $195
Suzanne Connolly, LCSW, Thought Field Therapy Success in treating wide Testimonials LMFT (tapping on acupressure variety of psychological Personal experience http://suzanneconnolly.com/ points) problems Professional Sedona, Arizona, seminars Training seminars $300 endorsements offered throughout the US 350 Book by the website and internationally owner Uncontrolled studies and case reports
Center for Integrative Energy Psychology Superior to “talk Unsubstantiated Psychotherapy (Mary Sise, including: therapy” for trauma conclusions from LCSW) Thought Field Therapy treatment neuroscience theories http://www.integrativepsy.co Be Set Free Fast and brain scans m/ Seemorg Matrix Work Correctly notes the Includes names of 17 other Tapas Acupressure lack of research LCSWs doing these practices Technique Albany, NY DVDs and books: $15 $34.95
Attracting Abundance Workshops and teleclasses ability to earn more Testimonials Dr. Carol Look LCSW Combines Emotional money and achieve (doctorate in clinical Freedom Technique with personal and hypnotherapy) The Secret (law of professional success http://www.attractingabundan attraction) ce.com/ New York City
Matthew Engel, LCSW Past life regressions Communication with Anecdotal http://www.matthewengel.co Individual $160 deceased m/pastliferegressionsf.html Group $50 Predict the future San Francisco, CA Hypnotherapy
73 Table 13 – Continued
Name of website/ Services Web address/ Offered/ Products sold and Location cost (if listed) Claims Made Basis for Claims
Psychic intuitive Psychic medium Astrology and tarot
Regina Perlmutter, LCSW Reiki, Hand writing Indirect claims through Testimonials http://lightonlove.com/healin analysis, Rebirthing, Feng testimonials: claim skin g/ Shui, Psychic/ Medical cancer gone, help with Encino, CA and via telephone intuitive, Tantra, anxiety and depression, Emotional Freedom stop smoking Technique, Animal communication, theta healing, past life regressions
Carla Mullin, LCSW Reiki, Chakra healing, finding a soul mate, self Testimonials http://mindbodyspirithealing. hands on healing, esteem enhancement, net/ Neuroemotional spiritual growth Lake Park, FL Technique, inner child, psychodrama, channeling, muscle testing
Sharon Stein, LCSW Dream work Increased understanding Reference to http://www.sharonstein.com/ Past life regression and awareness authority Aurora, CO Individuals $120 Couples $125
Joyce Meyers, LCSW Neurolinguistic Release of trauma, Testimonials http://www.heartandsoulthera Programming, Past life anxiety, finding root py.com/index.html regression, inner child causes through past lives New York City bonding, paranormal experiences, Spirit release therapy
Deborah Mitnick, LCSW Critical Incident Stress Eliminate negative Testimonials http://www.trauma Debriefing effects of trauma Reference to tir.com/index.htm Tapas Acupressure EFT “often works when authority Maryland Technique nothing else will” Uncontrolled case Emotional Freedom reports Technique Traumatic Incident Reduction
Debbie Vajda, LCSW Allergy antidotes (see anxiety, bipolar disorder, Assertions http://www.the4dgroup.com/ Radomski); energy chronic pain, depression, DebbyVajda/default.htm therapies medical problems, OCD, Oregon better and faster than “talk therapy”
74 Table 13 – Continued
Name of website/ Services Web address/ Offered/ Products sold and Location cost (if listed) Claims Made Basis for Claims
Lynn Lyon, LCSW Theraplay, Holding superiority to traditional Assertions http://www.attachmenttherap Therapy, Dyadic therapy for child ynj.com/ Developmental behavioral and New Jersey Psychotherapy “attachment” problems
Rochelle Sparrow, LCSW, Psychic trance channeling Channels information Claims to have Spirit Whisperer Psychic development from guides to help with received information http://www.rochellesparrow.c course $20 plus free e spiritual and emotional from spiritual om/ book problems “guides” Phoenix, AZ Claims JFK is still alive Testimonials and channels him
Gena Wilson, LCSW Psychic, medium, angel Inspired by angels, Assertions http://inspiredbyangels.com/ messenger, animal telepathic Greenbelt, MD communicator and healer communication with Reiki animals Intuitive readings via telephone or in person Past life regression
Cynthia Lee Shelton, LCSW Angel messages, archangel Traditional therapy is Assertions, http://www.cynthialeeshelton. visits, psychic intuitive “limiting” testimonials com/ therapy, energy work, Austin, TX Reiki, Remote Viewing groups Individual $80 per hr Groups $55 $333
Roberta Colasanti, LICSW Alien encounters Help UFO Assertions http://www.johnemackinstitut Collaborated with Dr. John “experiencers” integrate e.org/passport/integratingextr Mack by interviewing and their experience aordinary.html working with individuals Boston, MA who reported anomalous experiences.
Mitch Smith, LCSW Hypnosis for trauma, “Hypnosis is without Assertions http://mentalperformance.net/ sports performance, equal when it comes to Testimonials Baltimore, MD smoking cessation, uncovering and healing overeating psychological trauma such as rape, car accidents or childhood abuse”
75
APPENDIX B
SYSTEMATIC LITERATURE REVIEW
Table 14. Summary of Studies Reviewed on Theoretical Orientation, Therapy Choice, and Attitudes towards EBP or ESTs (for abbreviations, see key at end of table)
Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
Saltman et al., 1993 225 MSW NASW Mail survey Demographics TO learned in school: 65% neo Freudian; 58% members from 42 Descriptive Perceived knowledge of human psychoanalytic; 40% cognitive; 36% states Systematic random behavior theory systems; 23% existential; 9% social learning; sampling Reported TOs learned in MSW 8% ecological; 3% symbolic interaction 45% response rate programs (named up to three) Most influential theorists: Erikson (88); Rogers and in practice (54); Freud (53); Maslow (30); Piaget (29); Most influential human behavior Beck (23); Minuchin (22); Bowen and Satir theorists (21) TO current practice: 26% systems; 21% neo Freudian; 12% existential; 11% psychoanalytic; 11% cognitive; 5% social learning; 2% ecological Earlier graduates more likely to report TO psychoanalytic or neo Freudian; more recent graduates more likely to report systems and cognitive
Strom, 1994 157 NASW Mail survey Demographics TO (could name more than one): members in private Exploratory, descriptive Practice characteristics PD 83%; cognitive behavioral 62%; systemic, practice Random sampling TO originally trained in 53%; ego psychology 52%; task centered Response rate: 29% TO in practice 48%; behavioral 37%; gestalt 30%;
76
Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
humanistic 28%; ecological 11%; other named by respondents: transactional analysis, solution focused, imagery, hypnotherapy, existential, function, chemical dependency disease model, psychodrama, neurolinguistic programming Theories gaining most adherents (based on change from what trained in): cognitive behavioral and task centered
Timberlake et al., 1997 N=2640 advanced Mail survey Demographics Respondents used an average of 8 theories practitioners of Random sample of Theories used 84% psychosocial; 70% family systems; 65% clinical social work board certified Modality (e.g. individual, cognitive; 61% ego psychology; 59% diplomate (BCD) social couples, family) lifespan development; 59% object relations; workers 51% self psychology; 49% psychoanalytic; 53% response rate 47% crisis; 43% behavioral; 39% role theory
Orlinsky, Ambühl et al., N=3800 therapists Mail survey Demographics TO: Salient (rated 4 or higher on scale of 1 5): 1999 from USA and 11 Retrospective, and Practice characteristics Analytic/PD 59%; Humanistic 31%; other countries projective TO (rated each orientation on a Systemic 19%; Cognitive 19%; Behavioral Psychologists 47% Mixed sampling scale of 0 5) 13%; Other 13% Psychiatrists or methods: Perceived past, present and 0 salient orientations: 12% other MDs 36% Convenience, and future development as 1 salient orientation: 46% Social Workers 8% snowball sampling; therapists 2 salient orientations: 26% Nurses 3% purposive sampling 3 or more salient orientations: 15% Lay practitioners from various 5% professional organizations
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
Orlinsky, Ronnestad et al., N=3958 therapists As described above Likert scale questions on Social workers rated perceived level of 1999 (as above) therapists’ self report on their therapeutic mastery lower than psychologists psychologists 62%; perceived mastery, or psychiatrists psychiatrists 24%; experienced growth, and its Perceived mastery positively related to years of social workers 6%; relationship to length of time experience other 8% in practice (level of No correlation between currently experienced experience) growth and years of experience
Orlinsky et al., 2001 N=4,923 As described above Self report of influences on Most highly rated influence was direct clinical psychologists 57%; therapist development, rated experience with patients, followed by (in psychiatrists 28%; by Likert scale questions order of importance) formal supervision, social workers 6%; getting personal therapy; personal life other 19% outside of therapy; informal case discussions with colleagues; taking courses; reading relevant books or journals; giving formal supervision to others. Doing research and teaching courses were not rated as important influences. CBT therapists rated personal therapy lower than the other TOs did
Henderson, 2000 N=321 NASW Mail survey Knowledge of alternative 33% eclectic; 13% systems; 13% behaviorist; clinical social Descriptive therapies 9% psychosocial; 7% cognitive; 6% workers Systematic random Use or referral for specific biopsychosocial; 5% Freudian or neo sampling alternative therapies Freudian Response rate 36% TO 30% indicated great knowledge or expertise in alternative techniques; 50% moderate Mind body and community based were the best known types (average of 14.6 clients per year referred for mind body)
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
75% indicated little or no knowledge of parapsychology
Mussell et al., 2000 N=271 practicing Mail survey Demographics For eating disorders TO: 39% CBT; 28% licensed Random sampling TO and techniques used by those eclectic; 10% family systems; 5% psychologists from Descriptive and who worked with eating psychodynamic; 3% IPT, rest were “other” a Midwestern state exploratory disorders Most reported CBT techniques: cognitive 55% response rate restructuring 72%; self monitoring 68%; relapse prevention 55%; homework 50% 70% indicated using ESTs 78% reported no training in CBT ESTs for eating disorders
Ball et al., 2002 N=66 clinicians Survey Demographics Few reported one dominant therapy from community Descriptive, Practice characteristics Males more likely to endorse CBT substance abuse correlational TO Masters level more likely to endorse PD treatment programs Convenience sample Personal recovery Below masters more likely favor 12 step learning MI Counseling/therapy techniques social workers 21% Beliefs about treatment certified drug/alcohol 50% other 7%
Hays et al., 2002 N= 138 APA Mail survey Amount of time spent training in 19% spent little or no time training in ESTs; accredited Random sampling ESTs 28% spent more than 15 hours internship training Exploratory Types of ESTS used in training Most endorsed ESTS were: CT for depression directors 29% response rate and supervision (54%) and panic disorder (39%); CBT for GAD (34%); chronic pain (33%); applied relaxation for GAD (29%); DBT for BPD
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
(22%); IPT for depression (17%)
Sheldon & Chilvers, 2002 N=1226 social Survey Demographics 5% had regular research discussions in service workers in Descriptive Extent research findings supervision; 35% occasionally the UK Stratified random discussed in supervision and 52% reported research “often” or “sometimes” (social workers, sampling meetings discussed in meetings team leaders, case Response rate 54% Reading habits and preferences 75% reported access to publications managers, Familiarity with research 5% read controlled trials; 36% client opinions; occupational Knowledge of research issues 43% evaluation (but only small percentage therapists) Attitudes towards EBP able to describe a study) 90% saw research as relevant to practice
Poznanski & McLennan, N=103 Melborne Interviews plus mail NEO Five Factor Inventory TO: PD 31%; CB 27%; Family systemic 23%; 2003 psychologists survey Therapeutic Orientation Measure Experiential 18% Purposive sampling Demographics CB therapists younger; PD older from various Open ended interview questions: CB more strictly adhered to TO organizations family stress while growing up PD higher neuroticism than CB Response rate NR CB lower on openness to experience CB lower family origin stress and more positive than PD or experiential CB reported university training more important influence; >50% experiential therapists reported it has no influence All experiential and 90% PD participated in personal therapy; 36% CB never sought personal therapy; CB said personal therapy no influence on TO
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
Aarons, 2004 N=322 San Diego Survey (in person) EBPAS EFA produced 4 factor solution: Appeal, California service Psychometric analysis Provider characteristics Requirements, Openness, Divergence providers in 49 (sample divided for Organizational characteristics Overall alpha .77 public mental EFA and CFA) Subscale alphas: health agencies Convenience sample .59 (divergence); .80 (appeal); .78 providing services Response rate unknown (openness); .90 (requirements) to youth and CFA fit indices: families X2 =144.92 (df=84); Of professionals: CFI=93; TLI=.92; RMSEA=.067; SRMR=.077 social workers 32% Fit was good; alpha on divergence subscale Of interns: below acceptable level social workers Regression analysis results: 25% Appeal scores: associated with higher (rest were educational attainment; case management psychologists, providers scored lower than outpatient psychiatrists, providers; those working in agencies with MFTs and other) written practice policies scored higher Openness scores: positive association with higher intern status, low bureaucracy programs and written practice policies Requirements scores: day treatment providers scored higher than outpatient providers; low bureaucracy scored higher Divergence: interns scored lower (indicating a more positive attitude toward EBP) Total EBPAS: interns, wraparound providers and low bureaucracy scored higher
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
Aarons, 2005 same as above same as above same as above Provided a summary of reliability and validity findings of EBPAS as above Discussed the role of openness to innovation and its relationship to willingness to adopt EBP
Aarons, 2006 N=303 same as above EBPAS Transactional and transformational leadership same as above Multifactor Leadership styles positively associated with EBPAS. Questionnaire Transformational negatively associated with Divergence subscale (this subscale is reverse scored when included in the total EBPAS)
Aarons & Sawitzky, 2006 N=301 same as above EBPAS Hierarchical Regression analysis showed same as above Children’s Services Survey (to constructive organizational culture positively assess organizational culture associated with EBPAS Appeal, Openness, and climate) and Total scores and negatively associated with Divergence subscale score Provider education level positively associated with Appeal subscale Age and job tenure negatively associated with Openness subscale Age positively associated with Divergence subscale score
Aarons et al., 2007 N=221 Internet survey EBPAS CFA showed good fit: Mental health Psychometric study X2 =183.51 (df=92); service providers (CFA) CFI=92; TLI=.90; RMSEA=.07; SRMR=.07 working for Snowball sampling Alpha=.79 agencies in US 41% response rate Subscale alphas ranged from .66 to .93
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
from 17 states Note: this was a different sample from the one 34% social used in the studies described above workers; others included psychologists, counselors, MFTs, nurses Becker et al., 2004 N=207 Mail survey TO TO: Eclectic 37%; PD 28%; CBT 21%; psychologists from Descriptive study Utilization of exposure therapy Cognitive 9% New England and Random sampling for PTSD and perceived barriers 28.5% reported training in imaginal exposure; Texas Response rate 27% 27% for in vivo exposure; 12.5% in exposure for anxiety disorders 72% reported not at all comfortable with exposure therapy 17% reported using imaginal exposure for PTSD and only 9% with 50% or more of their PTSD patients 37% reported other interventions for PTSD including psychodynamic trauma focused; other CBT strategies; EMDR; hypnosis
Coleman, 2004 N=130 Psychometric analysis Theoretical Evaluation Self Test EFA identified six subscales: psychoanalytic, NASW members mail or in person (TEST) scale cognitive behavioral, family therapy, working in Random sampling for Respondents also asked which ecosystems, cultural, pragmatic, biological (a agencies (n=19) NASW members; TOs used in practice seventh, “humanistic” retained for theoretical Masters and Purposive sampling for reasons) doctoral level others Average alpha reported: .65 clinicians from 20% response rate for Reported TOs: agencies (n=55) NASW members Eclectic 31%; PD 15%; Humanistic 15%;
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
MSW students Cognitive 12% (n=56) TEST able to discriminate proponents of PD and 72% social workers cognitive 28% other mental health professions
Coleman, 2007 N=178 Psychometric analysis TEST scale EFA with N=178 EFA on pooled data N=308 MSW students (replication of replicated five of the original six subscales (n=146) Coleman, 2004) CFA pooled data indicated four factors a better Practicing Convenience sample fit (behavioral health, PD, ecocultural, family clinicians (n=32) therapy) These data were Alpha range on 5 subscales: .72 to .54, with pooled with average of .64 Coleman, 2004 for Goodness of fit statistics acceptable range a total N of 308
Freiheit et al. 2004 N=189 Mail survey Demographics More than two thirds were using CBT but only psychologists in Descriptive Practice characteristics 12 37% used exposure based therapies Minnesota Random sampling from Therapies used for treating A minority reported using EMDR (18%) and list of Minnesota anxiety disorders (OCD, Panic energy therapies (8%) psychologists disorder, social anxiety disorder) 43% response rate
Karekla, Lundgren & N=172 graduate Internet survey Demographics TO (graduate program, self described) Forsyth, 2004 psychology Descriptive study TO (self described and graduate CBT (62%, 51%); Eclectic (33%, 36%); students from 60 List serv invitations, program) PD/humanistic (3%, 11%) APA accredited response rate unknown Knowledge of ESTs, manuals 65% had not read publications about ESTs; CBT doctoral programs Didactic and practical more likely to read EST experience with ESTs 71% correctly identified ESTs
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
31% reported no courses devoted (whole or in part) to ESTs; 51% had no courses covering treatment manuals; 31% no clinical training with treatment manuals 57% planned to use ESTs in future “all the time”; 24% planned to use manuals “all the time” 77% planned to seek additional training in ESTs
McClure et al., 2005 N=279 Texas Mail survey Demographics 56% LPCs and 70% psychologists indicated therapists Descriptive TO (if “eclectic”, asked which negative impact of managed care 122 LPCs Random sampling from type) 1% of LPCs and no psychologists provided 157 Psychologists professional directories Attitudes on managed care and internet counseling; 59% rated it negatively in Texas internet therapy Most reported TOs for LPCs, psychologists: Response rate 35% Eclectic (30%; 31%); CB (22%; 27%); Multiple (31%; 17%); Psychoanalytic (.8%; 6%) Unsystematic eclecticism (30%; 19%); Therapeutic eclecticism (22%; 44%); Technical eclecticism (47%; 37%) 36% LPCs and 24% psychologists indicated changing their TO (related to length in practice)
Norcross, Karpiak & N=187 Division 12 Mail Survey Eclecticism 59% preferred the term “integrative” Lister, 2005 APA reporting Descriptive Previous adherence to a TO 85% considered eclecticism a broader TO Eclectic TO Random sampling Asked if preferred term Types of eclecticism Response rate 44% “eclectic” or “integrative” Theoretical integration 27.5% Whether they considered eclectic Common factors 27.5%
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
an absence of a TO Assimilative integration 26% Type of eclecticism Technical 19% How often used various TOs Most frequent combinations: Behavioral and Cognitive 16%; Cognitive and Humanistic 7%; Cognitive and psychoanalytic 7%; Cognitive and interpersonal 6%; Humanistic and Interpersonal 5%
Norcross, Karpiak & N=654 Same as above Demographics Percentage of women increased from 16% in Santoro, 2005 Division 12 APA Practice characteristics 1960 to 34% present study Psychologists from TO (primary and secondary) Ethnic minorities increased from 3% in 1981 to the 48 states Training and career experiences 7% present study compared to earlier Most reported TO: Eclectic 29%; Cognitive surveys 28%; PD 15%; Behavioral 10% PD and humanistic declined Cognitive doubled each year Eclectic consistently most reported
Sharp et al., 2005 N=123 Psychometric Demographics CBT 62%; PD 39%; DBT 11% Philadelphia Descriptive Therapeutic strategies Factor analysis PCA of strategies showed 7 clinical Random sampling TO factors: CBT (3 different factors: directive, psychologists who Mail survey non directive and behavioral); PD; treat BPD Response rate 47% Adjunctive; DBT; Humanistic Logistic regression showed specific techniques were related to reported TO
Bates, 2006 N=4 Canadian Qualitative study Open ended questions on The author and participants appear to be school social Interviews opinions and experiences confusing EBP with ESTs. Attitude was workers Convenience sample with evidence based practice generally favorable although participants (and
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
the author) saw clinical expertise and client values as conflicting with EBP. Participants stated that EBP gave them certainty and respect as professionals
Boisvert & Faust, 2006 N 181 APA Mail survey Knowledge of research findings Underestimated strong research support for practicing Descriptive on general therapy (compared to positive findings psychologists Random sampling expert opinions on research Underestimated advantage of treatment vs. no 36% response rate findings) treatment groups in research Incorrect about relative benefit of specific vs nonspecific treatment factors
Lucock et al., 2006 N=154 Mail survey TO TO: CBT 20%; PD 12%; Eclectic/integrative 95 qualified Descriptive Questionnaire on Influencing 16%; others included person centered/gestalt/ psychotherapists Convenience sample Factors on Clinical Practice humanistic; systemic, and group analytic and 69 trainee (one agency did mainly including EBP Highest rated influences for qualified therapists: psychologists in CBT for anxiety current supervision; client characteristics, the UK who disorders) client feedback, psychological formulation; worked for Response rate 77% intuition/judgment; professional training; post agencies qualification training Highest rated influences for trainees: current supervision; past supervision; client characteristics; client feedback; psychological forumulation; professional training Literature, manuals and evidence based guidelines not rated highly by either group CBT TO rated EBP items higher than other therapists; CBT rated personal therapy, client characteristics, spirituality, major life events,
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Table 14 Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
alternative therapies, and TV and films lower than other therapists did
Upton & Upton, 2006 N=666 health Mail survey Demographics Psychologists and physiotherapists rated science Random sampling from Self perceived knowledge and themselves higher in skills and knowledge professionals lists of hospital use of CE and EBP (based on than other professions (e.g. podiatrists, speech working in personnel Sackett et al, 1997 steps) therapists, dental technicians) hospitals (included 66% response rate Likelihood of acting on evidence Most reported sources of evidence for psychologists) Descriptive study from various sources psychologists were colleagues, journal Barriers to EBP articles, and own practice Most reported barriers were money, time and organizational structure; psychologists found obtaining money easier than other professions von Ranson & Robinson, N=52 Telephone interviews TO Most common TO: Eclectic 50%; CBT 33% 2006 Clinicians in Descriptive Asked to indicate if they used 10 Eclectic therapies reported: CBT, IPT, EMDR, Calgary, Canada Convenience and specified therapies or others SFT, addiction based therapy, spirituality, who work with snowball sample Reasons for using interventions psychoeducation, self disclosure, and play eating disorder Response rate 74% therapy clients CBT techniques: relapse prevention, cognitive Counseling restructuring, self monitoring, stimulus psychology 39% control techniques, formal problem solving, Clinical homework, distracting activities psychology 21% Reasons for choosing: supported by research Social work 19% 39%; recommended by others 4%; consistent Nursing 4% with orientation 39%; compatible with clinical style 12%; experience indicates effective 60%; trained in approach 23%; flexible 27%; worked for self 10%
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
CBT clinicians more likely to use because supported by research; IPT or addiction based more likely to use because of personal clinical experience
Caldwell et al., 2007 85 recent graduates Mail survey Demographics 96% viewed research as very or fairly relevant from 3 London Descriptive Educational training in EBP to practice universities (≤2 Random sample from 3 Skills training in EBP 95% reported receiving research methods yrs. clinical university databases Access to databases courses; 41% had shared teachings with experience) Response rate 43% Attitudes towards EBP colleagues social workers Confidence in EBP 88% did research project during training 31%; rest were 76% believed greater emphasis should be placed occupational on research informing practice therapists, nurses 22% reported research findings frequently and discussed at work; 55% occasionally physiotherapists 42% able to think of example of professional practice changing because of research 40% reported never using databases to search literature during previous year Discrepancy exists between positive attitudes towards EBP and reported usage of research resources
Gioia, 2007 N=15 mental Longitudinal Impact of training in EBP (once EBPAS scores showed little change (were fairly health practitioners Described as a week for 21 months) high even on first interview) from agency (7 had experimental but no Interviews and EBPAS at Masters in control group inception, 6, 12, and 18 months counseling or Semi structured (no control group) social work) interviews, plus pencil
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
and paper survey
Gray et al., 2007 N=461 trauma Internet survey Demographics Age negatively related to positive attitudes professionals from Descriptive and Practice characteristics towards EBP ISTSS plus internet correlational TO On average, sample had positive attitudes list serv members Response rate <24% EBPAS towards EBP (above the midpoint on EBPAS) psychologists 58%; (exact rate unknown Evidence based practice CBT TO had more positive attitudes (EBPAS social workers because additional questionnaire (EBPQ) and EBPQ) towards EBP than PD, eclectic, or 13%; psychiatrists participants recruited Trauma treatments used in other 9%; counselors 8% from list serv practice Most endorsed non EB interventions were: plus other MH invitations) bioenergetics, nutritional, somatic professionals experiencing therapy, body psychotherapy, sensorimotor therapy Most frequently reported barrier to EBP was access (time and expense)
Hatfield & Ogles, 2007 N=874 APA Mail survey TO Most reported TOs: clinical Descriptive Demographics Eclectic 30%; Cognitive 29%; psychologists Psychometric Practice characteristics Psychoanalytic/PD 20%; Behavioral 8%; Random sampling from Likert rating questions on why Interpersonal 6% APA clinical clinicians use or do not use 3 factors for reasons to use: treatment aid, psychologists outcome measures in practice business requirement, payer required Response rate 44% 3 factors for reasons not to use: utility (not helpful, interferes with autonomy, fear of misuse, confidentiality violations); practical (too much paperwork, time or money); Know how (lack of knowledge in how to do)
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
Henggeler et al., 2007 N=432 substance Survey (in person) DV: Interest in learning EBP equated with ESTs (by authors) abuse counselors Descriptive evidence based approaches 80% chose to attend from 50 agencies in Correlational measured by voluntary Leadership in 88% of organizations supported South Carolina HLM Analysis attendance at workshop on attendance at EBP workshop social workers 35% Convenience sample EBP Practitioners with higher percentages of child or Others included Demographics adolescent clients more likely to attend were psychologists, Practice characteristics No other practitioner characteristics significant counselors, Organizational characteristics Organizational readiness to change associated certified AOD EBPAS with attendance Organizational Readiness for More favorable organizational climates more Change scale likely to attend (CEUs were also offered for Reasons given more for interest and desire to attendance) help clients than CEUs or free lunch Reasons for attendance EBPAS and treatment approaches not predictors Usefulness ratings of therapies for workshop attendance
Luebbe et al., 2007 N=1195 clinical Internet survey Demographics 81% only included research component of the psychology Descriptive study Knowledge of definition of EBP EBP definition; only 3.7% contained all three graduate students Convenience sample (students were asked to write components; 18% equated EBP with EST from scientist (students from 168 their definition of EBP) Students reported more exposure to EBP in practitioner or graduate programs Experience and attitudes towards classes than practica clinical science invited via e mail to EBP Mean levels of reported EBP influence clinical model programs participate) and research “a little” and “somewhat” Response rate unknown Most students agreed with EBP principles Most highly related factor of influence on treatment planning was advice from supervisor and patient specific factors; research evidence less frequent
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
Riley et al., 2007 N=239 practicing Internet survey Practice influences and attitudes Most highly rated influential factor on practice psychologists from Descriptive study about EST was clinical experience state psychology Random sampling 64% reported using ESTs for the conditions they licensing board list 12% response rate treat Limited time and resources most reported barrier to ESTs 26% monitored client progress and outcomes with quantitative measures
Schottenbauer, Glass & N=171 Internet survey TO TO: CBT 36%; PD 36%; Integrative/eclectic Arnkoff, 2007 Psychologists 54% Descriptive Presented with vignette of 10%; EMDR 7%; Humanistic 5% Social Work 10% Convenience sample trauma client and asked what If client not responding, majority recommended Counseling invited from electronic would do if client not reassessment of client motivation, Psychology 10% list servs responding to what therapist environment or therapist conceptualization. Psychiatrists 9% Response rate unknown usually did Most did not recommend any specific Other 17% technique
Simons et al., 2007 N=20 graduate and Quasi experimental Demographics Experimental group showed increase in positive undergraduate Repeated measures Attitude towards manuals attitude towards treatment manuals community MANOVA Research self efficacy Males more positive attitude towards ESTs counseling students Descriptive Research Training Environment African Americans less favorable attitudes from a Catholic Convenience sample Scale towards treatment manuals teaching university Protocol Implementation (note the very low sample size, however) Questionnaire
Sprang & Craig, 2007 N=888 Mail survey Trauma Practices Questionnaire EFA identified seven dimensions of trauma Mental health Psychometric analysis (TPQ) practices: CBT; Rational Emotive therapy; professionals from Convenience sample Eclectic therapy; EMDR; PD therapy; one southern state 15% response rate Psychopharmacology; SFT
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
Sprang et al., 2008 N=888 (as above) Same as above Demographics Dimensions identified: CBT, RET, Eclectic, Social workers Trauma specific training EMDR, PD, Psychopharmacological, 49%; Psychologists TPQ Solution focused 17%; Professional 2 open ended questions: Exposure infrequently reported as preferred counselors 13%; 1) what assessment tools for treatment MFT 8; alcohol trauma they used and Trauma trained more likely to use EMDR and and drug 4%; 2) What their treatment approach less likely to have no identified treatment and nurse practitioners of choice was for trauma assessment approach 2% 55% did not identify any assessment strategy 22% used non trauma specific assessments MANOVA with TPQ dimensions: females higher use of eclectic; Males more likely to use psychopharmacology; interaction between gender and discipline. When gender controlled for, differences between social workers and MD’s significant
Stewart & Chambless, N=591 APA Mail survey TO TO: CB 45%; PD 22%; Eclectic 20%; 2007 Psychologists in Correlational plus Demographics Humanistic 4%; Family systems 4%; other private practice Experimental with Practice decision influences 5% random assignment EBPAS Overall mild agreement that EST research has Random sampling from Esteem for Research Utilization practice relevance APA clinical practice Scale (developed by these Clinical experience rated more important than Response rate: 23% authors) combined with EBPAS outcome research, discussions with divergence subscale colleagues and personal therapy Vignette case study of patient Greatest source to increase therapy skills and with panic disorder effectiveness is past experience with clients, Experimental group received more important than research EST information for panic CBT more positive towards research than PD
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
disorder vs. control group that and eclectic did not CBT had more graduate training emphasizing outcome research than PD For experiment, those receiving research summary more likely to report they would use the EST (86%) than control group (78%) but effect size small
Stewart & Chambless, Same as above Same as above TO PD TO took longer to conclude client lack of 2008 Demographics progress than CBT or eclectic Practice characteristics CBT more positive attitude towards research, EBPAS Divergence subscale more likely to utilize research findings and Esteem for Research Utilization treatment manuals than PD Scale (developed by these Negative correlation between number of authors) sessions taken to conclude failure and positive Number of sessions before attitudes towards research failure to make progress was Controlling for positive attitudes toward concluded research, CBT therapists still treated clients How clinicians proceed when less time before concluding failure clients do not progress After concluding failure 76% reported the relied on clinical experience and what worked for them to decide what to do next 41.6% reported consulting treatment manuals informed by research
Topolinski & Hertel, 2007 N=184 Mail survey TO of therapists’ education SN, Openness and NFC positively related to psychotherapists Descriptive TO of practice insight TO in current practice (physicians and Correlational Demographics (psychoanalytic) and subsequent training but psychologists) Convenience sample Sensing Intuition (SN) subscale not to initial training
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
from German Response rates: 90% of MBTI (short German version) Physicians more likely than psychologists to health insurance from insurance Openness to experience (from choose insight oriented training directory and directory; hospital Big 5) Higher age associated with insight TO clinicians from 63 response rate unknown Need for cognition (NFC) Measures did not predict self rated insight TO German psychiatric hospitals
Varlami & Bayne, 2007 N=84 counseling Mail survey Demographics MBTI SJ type associated with CBT psychology Descriptive Keirsey Temperament Sorter (a Intuition, Intuition Judging and Extroversion trainees in Surrey, Correlational modification of the MBTI) Intuition and ENFJ type associated with PD UK Convenience sample Open ended questions re TO; 3 TO 46% response rate types identified: CBT, person centered, PD
Wilson & White, 2007 N=163 Internet survey Demographics 41% had used CATs personally within past 12 undergraduate and Psychometric study Complementary and alternative months graduate Convenience sample therapy (CAT) personal usage EFA identified 3 factors for PATCAT: psychology Response rate unknown PATCAT scale to measure Knowledge, Risk and Integration students in attitudes toward CAT Alpha=.89 Subscales: .90, .80, .70 Australia Overall, participants indicated knowledge dissemination of CAT was important and should be integrated into psychological practice; respondents also aware of risks
Nelson & Steele, 2008 N=206 mental Internet survey Demographics Items with highest percentage agreement were health practitioners Convenience sample Attitudes and influences on treatment flexibility (80%); empirical support from 15 states Participants recruited treatment selection including in studies with “real world” clinical social workers 17% from list servs so research and evidence based conditions (78%, rated higher than support Rest were doctoral response rate unknown practice from highly controlled studies); treatment
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Table 14 – Continued Type of Study/ N/Population(s) Analyses/Sampling and Authors/Year Studied Response Rate Variables and Measures Relevant Findings
psychologists, or Relative importance of such appealing to clients (69%) masters level influences Lowest agreement focus on therapeutic clinicians TO relationship as main mechanism of change (20%) CBT rated highly controlled studies as more important than other TOs No significant differences between masters and doctoral level practitioners Treatment flexibility, research support in clinical study, colleague endorsement, and previous success were most highly ranked items
Sharp et al., in press N=79 clinical Mail survey Demographics TO: CBT 29%; Eclectic 29%; PD 25%; psychologists from Exploratory study Critical Thinking scale (CTQ) Existential/Humanistic 10%; PETs 4%; APA (63) and Random sample from TO Radical/applied behavioral 3% ACEP (15) APA Treatment Approaches Graduates of scientist practitioner model 15% response rate Questionnaire (therapies used in programs had higher critical thinking scores practice including novel energy (approached significance p<.10) therapies referred to as PETs) Professional model graduates more likely to endorse PETs (approached significance p<.06) APA had higher critical thinking scores than ACEP on deduction and interpretation subscales (p<.05) with moderate effect sizes PET TO negatively correlated with critical thinking total score CBT had higher critical thinking scores
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Table 14 – Continued
Key for abbreviations: ACEP=Association for Comprehensive Energy Psychology LCSW=Licensed clinical social worker AOD=Alcohol and drug LPC = Licensed professional counselor APA=American Psychological Association MBTI=Myers Briggs Type Indicator BPD=Borderline personality disorder MI=Motivational interviewing CB=Cognitive behavioral MSW = Masters in social work CAT=Complementary and alternative therapies NASW = National Association of Social Workers CBT=Cognitive behavioral therapy NFJ=Intuitive feeling judging on MBTI CE=Clinical effectiveness NFP=Intuitive feeling perceiving on MBTI CFA=Confirmatory Factor Analysis NR=not reported CFI=Comparative fit index (for CFA) PATCAT=Psychologist Attitudes Towards Complementary and Alternative DBT=Dialectical Behavior Therapy Therapies df = Degrees of freedom PCA=Principle components analysis DV=Dependent variable PD=psychodynamic orientation EBP=Evidence based practice PETs=Power Energy Therapies EBPAS=Evidence based practice attitudes scale RET=Rational Emotive Therapy EFA=Exploratory Factor Analysis RMSEA=Root Mean Square Error of Approximation (for CFA) ENFJ=MBTI type Extraverted, Intuition, Feeling, Judging SFT=Solution focused therapy EMDR=Eye movement desensitization and reprocessing SJ=sensing judging type on MBTI ESTs=Empirically Supported Treatments or Therapies SRMR=Standard Root Mean Square Residual (for CFA) GAD=Generalized Anxiety Disorder TLI=Tucker Lewis index (for CFA) HLM=Hierarchical Linear Modeling TO = Theoretical orientation IPT=Interpersonal therapy X2 = chi square statistic ISTSS=International Society for Traumatic Stress Studies
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APPENDIX C
DATA COLLECTION INSTRUMENT
LCSW Interventions Survey
Thank you for participating in this survey. There are five sections. In this section, you will be asked to tell us about your practice.
Please type “X” next to the answer in the multiple choice questions or type in the answer, as appropriate.
1. Are you a Licensed Clinical Social Worker? Yes ____ No ____
2. In what state do you practice?
Name of state: ______
3. In what type of area do you practice?
Large City (population over 100,000) ______Small City or Town (under 100,000) ______Suburban ______Rural ______Other (please specify)
4. How many years have you been practicing? ____ years
5. Do you consider yourself a specialist in the treatment of any specific disorders/issues? If so, please list up to three areas you specialize in:
1. 2. 3.
6. Please indicate the approximate percentage of your practice in the following areas (please type in percentage - should sum to 100%):
Older Adults (65+) _____ % Adults (18 64) _____ % Adolescents (13 17) _____ % School Age (6 12) _____ % Pre School Age (3 5) _____ % Infants/Toddlers (0 2) _____ %
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7. Which one best describes your primary therapeutic orientation? (put an —X“ by only one choice)
Behavioral Cognitive Cognitive Behavioral Eclectic Energy Psychology Existential Family Systems Humanistic/Client Centered Interpersonal Psychoanalytic Psychodynamic/Neo Freudian Positive Psychology Other (please specify)
8. In what type of setting do you practice? (put an —X“ next to all that apply)
Private Practice Residential Treatment Community Mental Health Center Outpatient Clinic Mental Hospital General Hospital Developmental Disabilities Center Prison University Other (please specify)
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Section 2: Interventions Used in Practice
9. Please list the three interventions you have used most frequently within the past year, beginning with the one you used most frequently
Most Frequent:
Second Most Frequent:
Third Most Frequent:
10. Below is a list of interventions and assessment techniques. We do not expect you to be familiar with all of them. Please just indicate which you have used in your practice (with individuals, families or groups) within the past year by putting an —X“ in the appropriate box and column (first column, if you have used it within the past year and second column if you previously used but discontinued).
Currently use Used but Intervention (within past year) Discontinued
Acceptance and Commitment Therapy Age regression methods for adults sexually abused as children Anxiety Management Training Applied Behavior Analysis Applied Kinesiology for allergy or food sensitivity Applied Kinesiology for emotional diagnosis Assertive Community Treatment Attachment Therapy Behavior Modification/Behavior Therapy Bioenergetic Therapy Biofeedback (EEG Neurofeedback) Biofeedback ( Non EEG) Body Centered Psychotherapy Cognitive Behavioral Therapy Cognitive Therapy Critical incident Stress Debriefing Critical Incident Stress Management DARE Programs Dialectical Behavioral Therapy Dream Interpretation Emotional Freedom Technique (EFT) Emotionally Focused Couples Therapy Eneagram for Personality Assessment
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Exposure Therapy for phobias, OCD, or panic disorder Exposure Therapy for PTSD Eye Movement Desensitization and Reprocessing for Trauma/PTSD Eye Movement Desensitization and Reprocessing for Other Conditions Facilitated Communication for Autism Genogram Healing Touch Holding Therapy Holotropic Breathwork Hypnosis Imago Relationship Therapy Insight Oriented Marital Therapy Interpersonal Therapy Jungian Sandtray Therapy Love and Logic Lucid Dreaming as Therapeutic Technique Mindfulness Based Stress Reduction Motivational Interviewing Myers Briggs Type Indicator Neuro linguistic Programming Past Lives Therapy Play Therapy Primal Therapy Psychoanalysis Psychodrama Psychosynthesis Qigong Radionics Rebirthing Therapy Reiki Relaxation Training for PTSD Reparenting Therapy Scared Straight Seemorg Matrix Work Sensory Motor Integration Therapy Sexual Reorientation/Reparative Therapy (for gays/lesbians) Social Problem SolvingTherapy Social Skills Training Solution Focused Therapy Stress Innoculation
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Supported Employment Therapy Systematic Desensitization Tapas Acupressure Technique Task Centered Practice Therapeutic Touch Thought Field Therapy Thought stopping procedures Traumatic Incident Reduction
11. Please list any interventions not included on the list that you have used within the past year.
12. What is the most important source of information for interventions you currently use in your practice? (please type an —X“ next to only one of the following choices):
Faculty member in a class in an MSW program Field placement supervisor in an MSW program Faculty member in other program Verbal recommendation from colleague Conference Continuing Education course Journal Article Magazine Article Advertisement in a magazine Internet website Internet list serv discussion Other (please specify)
13. How important on a scale of 1 to 7 are each of the following reasons in selecting interventions in your practice (please type a number next to each item on a scale of 1 to 7 where 1 is not at all important and 7 is very important).
Rating (1-7)
Clinical experience of fast, positive results with clients Clinical experience of positive results that hold up over time The intervention helped you personally Your intuition Colleagues’ reports of clinical successes Endorsement by respected professional Clients (other than your own) reports of success Website articles Magazine articles Favorable research published in peer reviewed journal
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Compatibility with your theoretical orientation Compatibility with your personality Intervention emotionally resonated for you
14. Are there other reasons that are important for you in selecting an intervention? If so, please describe below:
15. If there were interventions you used in the past, please list each one and explain why you decided to discontinue using each of them, including any that were not on the list.
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Section 3: Opinions about Interventions
The following questions ask about your feelings about using new types of therapy, interventions, or treatments. Manualized therapy, treatment, or intervention refers to any intervention that has specific guidelines and/or components that are outlined in a manual and/or that are to be followed in a structured or predetermined way.
16. Please indicate the extent to which you agree with each item, using the following scale, typing in the appropriate number next to the item.
0 = Not at all 1 = To a slight extent 2 = To a moderate extent 3 = To a great extent 4 = To a very great extent
Rating (1 4) I like to use new types of therapy/interventions to help my clients
I am willing to try new types of therapy/interventions even if I have to follow a treatment manual
I know better than academic researchers how to care for my clients
I am willing to use new and different types of therapy/interventions developed by researchers
Research based treatments/interventions are not clinically useful
Clinical experience is more important than manualized therapy/interventions
I would not use manualized therapy/interventions
I would try a new therapy/intervention even if it were very different from what I am used to doing
17. For the following questions: If you received training in a therapy or intervention that was new to you, how likely would you be to adopt it if:
Please type appropriate number next to each item as above (for questions pertaining to agency or supervisor, type —N/A“ if you have no agency or supervisor)
It was intuitively appealing
It made sense to you
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It was required by your supervisor
It was required by your agency
It was required by your state
It was being used by colleagues who were happy with it
You felt you had enough training to use it correctly
Section 4: Educational Background and Continuing Education
18. From where and when did you obtain your MSW?
Name of Institution: ______
Year: ______
19. What, if any, other graduate degrees do you hold?
DSW Ph.D. Social Work Other (please specify)
20. Please list any continuing education seminars, workshops or certification training you have taken within the past two years
21. Please indicate how important each of these reasons are for you in choosing the seminars and workshops you attend on a scale of 1 to 7 where 1 is not at all important and 7 is extremely important (type number next to each item):
Ability to obtain CE credits Hearing or reading about a colleague’s success Endorsement from a university faculty member Endorsement from other recognized authority in subject area Hearing or reading about clients’ successes Favorable peer reviewed research Reading an article in magazine Reading an article on website Internet list serv discussion
22. Are there other reasons that are important to you in deciding whether to attend workshops, seminars or certification trainings? If so, please describe.
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23. Are you a member of any of the following organizations (put an —X“ next to all that apply):
National Association for Social Workers (NASW) Society for Social Work Research (SSWR) Other (please specify)
Section 5: Please tell us about yourself
24. What is your gender?
Male Female
25. What is your age? ______
26. What is your race/ethnicity?
African American/Black Hispanic/Latino Asian/Pacific Islander Caucasian/White, non Hispanic Other (please specify)
27. What is your religious preference?
Catholic Protestant Jewish Muslim Buddhist Atheist Agnostic Other (please specify)
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APPENDIX D
IRB APPROVAL LETTER
From: Human Subjects [mailto:[email protected]] Sent: Wednesday, August 29, 2007 9:13 AM To: [email protected] Subject: Use of Human Subjects in Research - Approval Memorandum
Office of the Vice President For Research Human Subjects Committee Tallahassee, Florida 32306-2742 (850) 644-8673 . FAX (850) 644-4392
APPROVAL MEMORANDUM Date: 8/29/2007 To: Bruce Thyer
Address: College of Social Work, University Center Building C, M/C 2570 Dept.: SOCIAL WORK
From: Thomas L. Jacobson, Chair
Re: Use of Human Subjects in Research The use of Novel Unvalidated Therapies versus Empirically Supported Therapies among Licensed Clinical Social Workers
The application that you submitted to this office in regard to the use of human subjects in the proposal referenced above have been reviewed by the Secretary, the Chair, and two members of the Human Subjects Committee. Your project is determined to be Expedited per 45 CFR § 46.110(7) and has been approved by an expedited review process.
The Human Subjects Committee has not evaluated your proposal for scientific merit, except to weigh the risk to the human participants and the aspects of the proposal related to potential risk and benefit. This approval does not replace any departmental or other approvals, which may be required.
If you submitted a proposed consent form with your application, the approved stamped consent form is attached to this approval notice. Only the stamped version of the consent form may be used in recruiting research subjects.
If the project has not been completed by 8/22/2008 you must request a renewal of approval for continuation of the project. As a courtesy, a renewal notice will be sent to you prior to your expiration date; however, it is your responsibility as the Principal Investigator to timely request renewal of your approval from the Committee.
You are advised that any change in protocol for this project must be reviewed and approved by the Committee prior to implementation of the proposed change in the protocol. A protocol change/amendment form is required to be submitted for approval by the Committee. In addition, federal regulations require that the Principal Investigator promptly report, in writing any unanticipated problems or adverse events involving risks to research subjects or others.
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By copy of this memorandum, the Chair of your department and/or your major professor is reminded that he/she is responsible for being informed concerning research projects involving human subjects in the department, and should review protocols as often as needed to insure that the project is being conducted in compliance with our institution and with DHHS regulations.
This institution has an Assurance on file with the Office for Human Research Protection. The Assurance Number is IRB00000446.
Cc: Bruce Thyer, Advisor HSC No. 2007.633
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REFERENCES
Aarons, G. A. (2004). Mental health provider attitudes toward adoption of evidence based practice: The evidence based practice scale (EBPAS). Mental Health Services Research, 6, 61 74.
Aarons, G. A. (2005). Measuring provider attitudes toward adoption of evidence based practice: Considerations of organizational context and individual differences. Child and Adolescent Psychiatric Clinics of North America, 14, 255 271.
Aarons, G. A. (2006). Transformational and transactional leadership: Association with attitudes toward evidence based practice. Psychiatric Services, 57, 1162 1169.
Aarons, G. A., & Sawitzky, A. C. (2006). Organizational culture and climate and mental health provider attitudes toward evidence based practice. Psychological Services, 3, 61 72.
Aarons, G. A., McDonald, E. J., Sheehan, A. K., & Walrath Greene, C. M. (2007). Confirmatory factor analysis of the evidence based practice attitude scale (EBPAS) in a geographically diverse sample of community mental health providers. Adminstration and Policy in Mental Health and Mental Health Services Research, 34, 465 469.
Arkowitz, H., Westra, H. A., Miller, W. R. & Rollnick, S. (2008). Motivational interviewing in the treatment of psychological problems. New York: The Guilford Press.
Ball, S., Bachrach, K., DeCarlo, J., Farentinos, C., Keen, M., McSherry, T., et al. (2002). Characteristics, beliefs and practices of community clinicians trained to provide manual guided therapy for substance abusers. Journal of Substance Abuse Treatment, 23, 309 318.
Bates, M. (2006). A critically reflective approach to evidence based practice: A sample of school social workers. Canadian Social Work Review, 23, 95 109.
Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42, 277 292.
Beyerstein, B. L. (2001). Fringe psychotherapies: The public at risk. The Scientific Review of Alternative Medicine, 5, 70 79.
Bloom, M., Fischer, J., & Orme, J. G. (2006). Evaluation practice: Guidelines for the accountable professional (5th ed.). Boston: Allyn and Bacon.
109
Boisvert, C.M. & Faust, D. (2006). Practicing psychologists’ knowledge of general psychotherapy research findings: Implications for science practice relations. Professional Psychology: Research and Practice, 37, 708 716.
Bunge, M. (1998). Philosophy of science: From problem to theory, Volume One (Revised Edition). New Brunswick, NJ: Transaction Publishers.
Cahill, S. P., Foa, E. B., Hembree, E. A., Marshall, R. D., & Nacash, N. (2006). Dissemination of exposure therapy in the treatment of posttraumatic stress disorder. Journal of Traumatic Stress, 19, 597 610.
Caldwell, K., Coleman, K., Copp, G., Bell, L., & Ghazi, F. (2007). Preparing for professional practice: How well does professional training equip health and social care practitioners to engage in evidence based practice? Nurse Education Today, 27, 518 528.
Callahan, R.J. & Trubo, R. (2001). Tapping the Healer Within. Chicago: Contemporary Books.
Centre for Evidence Based Medicine (2001). Levels of Evidence. Oxford, UK: Author. Retrieved on July 28, 2008 from http://www.cebm.net/index.aspx?o=1025 .
Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., & Zeanah, C. et al. (2006). Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child maltreatment, 11, 76 89.
Chambless, D. L., Baker, M.J., Baucom, D.H., Beutler, L.E., Calhoun, K.S., Crits Christoph, P. et al. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51, 3 16.
Cocozelli, C. (1985). A psychometric study of the theoretical orientations of clinical social workers. Journal of Social Service Research, 9(2/3), 47 70.
Cocozzelli, C. (1987). Testing typological hypotheses about clinical social work practice theory. Journal of Social Work Education, 23, 6 15.
Cocozzelli, C. & Constable, R. T. (1985). An empirical analysis of the relationship between theory and practice in clinical social work. Journal of Social Service Research, 9(1), 47 64.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates.
Coleman, D. (2004). Theoretical Evaluation Self Test (TEST): A preliminary validation study. Social Work Research, 28, 117 127.
Coleman, D. (2007). Further factorial validity of a scale of therapist theoretical orientation. Research on Social Work Practice,17, 474 481.
110
Collins (2006). Frequently asked questions on medical intuition. Retrieved on May 15, 2008 from http://www.medical intuition.com/faq.htm .
Devilly, G. (2002). Eye movement desensitization and reprocessing: A chronology of its development and scientific standing. The Scientific Review of Mental Health Practice, 1, 113 138.
Dawes, R. (1994). House of cards: Psychology and psychotherapy built on myth. New York: The Free Press.
Dawes, R. M., Faust, D. & Meehl, P. E. (1989). Clinical versus actuarial judgment. Science, 243, 1668 1674.
Dillman (2007). Mail and Internet Surveys: The Tailored Design Method. Hoboken, NJ: John Wiley & Sons.
Ferguson, M. (1980). The Aquarian conspiracy. Los Angeles, CA: J.P. Tarcher.
Flexner, A. (1915). Is social work a profession? Is social work a profession? In National Conference of Charities and Correction, Proceedings of the National Conference of Charities and Correction at the 42nd annual session held in Baltimore, Maryland, May 12 19. Chicago: Hildmann. Reprinted in Research on Social Work Practice (2001), 11, 152-165.
Freiheit, S. R., Vye, C., Swan, R., & Cady, M. (2004). Cognitive behavioral therapy for anxiety: Is dissemination working? The Behavior Therapist, 27, 25 32.
Gambrill, E. (1999). Evidence based practice: An alternative to authority based practice. Families in Society, 80, 341 350.
Gambrill, E. (2005). Critical thinking in clinical practice: Improving the quality of judgments and decisions (Second Edition). Hoboken, NJ: John Wiley & Sons.
Gambrill, E. (2006). Evidence based practice and policy: Choices ahead. Research on Social Work Practice, 16, 338 357.
Gaudiano, B. A., & Herbert, J. D. (2000, July/August). Can we really tap our problems away?: A critical analysis of Thought Field Therapy. Skeptical Inquirer, 24, 29 36.
Gioia, D. (2007). Using an organizational change model to qualitatively understand practitioner adoption of evidence based practice in community mental health. Best Practices in Mental Health: An International Journal, 3, 1 15.
Gist, R., Woodall, S. J. & Magenheimer, L. K. (1999). “And then you do the hokey pokey and you turn yourself around. . .” In R. Gist & B. Lubin (Eds) Response to disaster: Psychosocial, community, and ecological approaches (pp. 269 290). Philadelphia, PA: Bruner/Mazel.
111
Gray, M. J., Elhai, J. D. & Schmidt, L. O. (2007). Trauma professionals’ attitudes toward and utilization of evidence based practices. Behavior Modification, 31, 732 768.
Hartston, H. (2008). The state of psychotherapy in the United States. Journal of Psychotherapy Integration, 18, 87 102.
Hatfield, D. R., & Ogles, B. M. (2007). Why some clinicians use outcome measures and others do not. Administration and Policy in Mental Health and Mental Health Services Research, 34, 283 291.
Hays, K. A., Rardin, D. K., Jarvis, P. A., Taylor, N. M., Moorman, A. S., & Armstead, C. D. (2002). An exploratory survey on empirically supported treatments: Implications for internship training. Professional Psychology: Research and Practice, 33, 207 211.
Helppro (n.d.). National Social Worker Finder. Retrieved on July 28, 2008 from http://www.helppro.com.
Henderson, L. (2000). The knowledge and use of alternative therapeutic techniques by social work practitioners: A descriptive study. Social Work in Health Care, 30, 55 71.
Henggeler, S. W., Chapman, J. E., Rowland, M. D., Halliday Boykins, C. A., Randall, J., Shackelford, J., et al. (2007). If you build it, they will come: Statewide practitioner interest in contingency management for youths. Journal of Substance Abuse Treatment, 32, 121 131.
Herbert, J. D. (2003a). The concept of pseudoscience as a pedagogical heuristic. The Scientific Review of Mental Health Practice, 2, 102 104.
Herbert, J. D. (2003b). The science and practice of empirically supported treatments. Behavior Modification, 27, 412 430.
Herbert, J. D. & Gaudiano, B. A. (2005). Moving from empirically supported treatment lists to practice guidelines in psychotherapy: The role of the placebo concept. Journal of Clinical Psychology, 61, 893 908.
Herbert, J. D., Lilienfeld, S. O., Lohr, J. M., Montgomery, R. W., O'Donohue, W. T., & Rosen, G. M., et al..(2000). Science and pseudoscience in the development of eye movement desensitization and reprocessing: Implications for clinical psychology. Clinical Psychology Review, 20, 945 971.
Howard, M. O., McMillen, C. J., & Pollio, D. E. (2003). Teaching evidence based practice: Toward a new paradigm for social work education. Research on Social Work Practice, 13, 234 259. Howell, D. C. (2002). Statistical methods for psychology (Fifth edition). Pacific Grove, CA: Wadsworth Group.
112
Jayaratne, S. (1978). A study of clinical eclecticism. Social Service Review, 52, 621 631.
Kosmin, B. A., Mayer, E. & Keysar, A. (2001). American Religious Identification Survey. New York: The Graduate Center of the City University of New York. Retrived on July 18, 2008 from http://www.gc.cuny.edu/faculty/research_briefs/aris/aris_index.htm .
Karekla, M., Lundgren, J. D., & Forsyth, J. P. (2004). A survey of graduate training in empirically supported and manualized treatments: A preliminary report. Cognitive and Behavioral Practice, 11, 230 242.
Kazdin, A. (2008). Evidence based treatment and practice. American Psychologist, 63, 146 159.
Klonsky, D. (2008). Website on research supported psychological treatments. Retrieved June 14, 2008 from Society of Clinical Psychology American Association of Clinical Psychology, Division 12 site: http://www.psychology.sunysb.edu/eklonsky /division12/ .
Lazarus, A. A. & Beutler, L. (1993). On technical eclecticism. Journal of Counseling and Development, 71, 381 385.
Lilienfeld, S. O. (1998). Pseudoscience in contemporary clinical psychology: What it is and what we can do about it. The Clinical Psychologist, 51, 3–9.
Lilienfeld, S. O. (2002). The Scientific Review of Mental Health Practice: Our raison d’etre, The Scientific Review of Mental Health Practice, 1, 5 10.
Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53 70.
Lilienfeld, S.O., Fowler, K.A., Lohr, J.M., & Lynn, S.J. (2005). Pseudoscience, nonscience, and nonsense in clinical psychology: Dangers and remedies. In R.H. Wright & N.A. Cummings (Eds.), Destructive trends in mental health: The well-intentioned path to harm (pp. 187 218). New York: Routledge.
Lilienfeld, S. O., Lohr, J. M., & Morier, D. (2001). The teaching of courses in the science and pseudoscience of psychology: Useful resources. Teaching of Psychology, 28, 182 191.
Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (2003a). Science and pseudoscience in clinical psychology: Initial thoughts, reflections, and considerations. In S. O. Lilienfeld, S. J. Lynn & J. M. Lohr (Eds.), Science and pseudoscience in clinical psychology (pp. 1 14). New York: Guilford Press.
Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (2003b). Pseudoscience is alive and well. The Scientific Review of Mental Health Practice, 2, 107 110. Lohr, J. M. (2008, May). Open-minded skepticism: Experimental analysis for the informed clinician-in-training. Paper presented at annual convention of the Association for Psychological Science, Chicago, IL.
113
Lucock, M. P., Hall, P., & Noble, R. (2006). A survey of influences on the practice of psychotherapists and clinical psychologists in training in the UK. Clinical Psychology & Psychotherapy, 13, 123 130.
Luebbe, A. M., Radcliffe, A. M., Callands, T. A., Green, D., & Thorn, B. E. (2007). Evidence based practice in psychology: Perceptions of graduate students in scientist practitioner programs. Journal of Clinical Psychology, 63, 643 655.
McClure, R. F., Livingston, R. B., Livingston, K. H., & Gage, R. (2005). A survey of practicing psychotherapists. Journal of Professional Counseling: Practice, Theory, & Research, 33, 35 46.
McNally, R. J. (2003). The demise of pseudoscience. The Scientific Review of Mental Health Practice, 2, 97 101.
McNally, R. J. (2004). Has clinical psychology gone astray? A review of Science and Pseudoscience in Clinical Psychology. Contemporary Psychology: APA Review of Books, 49, 555 557.
McTaggart, L. (2002). The field: The quest for the secret force of the universe. New York: HarperCollins Publishers Inc.
Meinert, R. T. (1998). Consequences for professional social work under conditions of postmodernity. In R. G. Meinert, J. T. Pardeck, J. W. Murphy (eds.), Postmodernism, Religion and the Future of Social Work (pp. 41 54). Binghamton, NY: The Haworth Pastoral Press.
Meinert, R. T., Pardeck, J. T., & Kreuger, L. T. (2000). Social Work: Seeking relevancy in the twenty-first century. Binghamton, NY: The Haworth Press, Inc.
Mercer, J. (2002). Attachment therapy: A treatment without empirical support. Scientific Review of Mental Health Practice, 1, 105 112.
Mercer, J. & Pignotti, M. (2007). Shortcuts cause errors in systematic research synthesis: Rethinking evaluation of mental health interventions. The Scientific Review of Mental Health Practice, 5, 59 77.
Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment therapy on trial: The torture and death of Candace Newmaker. Westport, CT: Praeger Publishers/Greenwood Publishing Group, Inc.
Mussell, M. P., Crosby, R. D., Crow, S. J., Knopke, A. J., Peterson, C. B., Wonderlich, S. A., et al. (2000). Utilization of empirically supported psychotherapy treatments for individuals with eating disorders: A survey of psychologists. The International Journal of Eating Disorders, 27, 230 237.
114
National Association of Social Workers (1996). Code of ethics. Revised and adopted by the Delegate Assembly of the National Association of Social Workers. Washington, DC: NASW Press.
National Association of Social Workers. (2003). Demographics. Practice Research Network.. Retrieved on December 30, 2007, from https://www.socialworkers.org/naswprn/surveyTwo/Datagram2.pdf
National Association of Social Workers (2005, Aug. 7). NASW anti restraint resolution. Retrieved on Sept. 10, 2006 from http://www.childrenintherapy.org/library/documents/nasw.html.
National Association of Social Workers (n.d.). Membership map. Retrieved December 30, 2007 from http://www.naswdc.org/images/new_look/membershipMap.gif .
Nelson, T. D., & Steele, R. G. (2008). Influences on practitioner treatment selection: Best research evidence and other considerations. The Journal of Behavioral Health.Services & Research, 35, 170 178.
Norcross, J. C., Garofalo, A., & Koocher, G. P. (2006). Discredited psychological treatments and tests: A Delphi poll. Professional Psychology: (?) Research and Practice, 37, 515 522.
Norcross, J. C., Karpiak, C. P., & Lister, K. M. (2005). What's an integrationist? A study of self identified integrative and (occasionally) eclectic psychologists. Journal of Clinical Psychology, 61, 1587 1594.
Norcross, J. C., Karpiak, C. P., & Santoro, S. O. (2005). Clinical psychologists across the years: The division of clinical psychology from 1960 to 2003. Journal of Clinical Psychology, 61, 1467 1483.
Olatunji, B. O., Parker, L. M. & Lohr, J. M. (2005). Pseudoscience in contemporary psychology: Professional issues and implications. The Scientific Review of Mental Health Practice, 4, 19 36.
Orlinsky, D., Ambühl, H., Ronnestad, M. H., Davis, J., Gerin, P., Davis, M., et al. (1999). Development of psychotherapists: Concepts, questions, and methods of a collaborative international study. Psychotherapy Research, 9, 127 153.
Orlinsky, D., Ronnestad, M. H., Ambühl, H., Willutzki, U., Botersman, J., Cierpka, M., et al. (1999). Psychotherapists' assessments of their development at different career levels. Psychotherapy: Theory, Research, Practice, Training, 36, 203 215. Orlinsky, D. E., Botermans, J., & Ronnestad, M. H. (2001). Towards an empirically grounded model of psychotherapy training: Four thousand therapists rate influences on their development. Australian Psychologist.Special Issue: Training in Clinical and Counseling Psychology, 36, 139 148.
115
Pignotti, M. (2005). Thought Field Therapy in the media: A critical analysis of one exemplar. The Scientific Review of Mental Health Practice, 3, 60 66.
Pignotti, M. (2007). Thought Field Therapy: A former insider’s experience. Research on Social Work Practice, 17, 392 407.
Pignotti, M. & Thyer, B. A. (2009). The use of novel unsupported and empirically supported therapies by licensed clinical social workers. Social Work Research, 33, 5 17.
Pittenger, D. J. (2005). Cautionary comments regarding the Myers Briggs Type Indicator. Consulting Psychology Journal: Practice and Research, 57, 210 221.
Popper, K. R. (1979). Objective knowledge: An evolutionary approach (revised edition). Oxford, England: Oxford University Press.
Poznanski, J. J., & Mclennan, J. (2003). Becoming a psychologist with a particular theoretical orientation to counseling practice. Australian Psychologist, 38, 223 226.
Riley, W. T., Schumann, M. F., Forman Hoffman, V. L., Mihm, P., Applegate, B. W., & Asif, O. (2007). Responses of practicing psychologists to a web site developed to promote empirically supported treatments. Professional Psychology: Research and Practice, 38, 44 53.
Rosen, G.M., & Davison, G.C. (2003). Psychology should list empirically supported principles of change (ESPs) and not credential trademarked therapies or other treatment packages. Behavior Modification, 27 , 300 312.
Sackett, D. L., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (1997). Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingstone.
Sackett, D. L., Straus, S. E., Richardson, W. C., Rosenberg, W., & Haynes, R. M. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). New York: Churchill Livingstone.
Sagan, C. (1996). The demon-haunted world: Science as a candle in the dark. New York: Ballantine Books.
Saltman, J. E. E., & Greene, R. R. (1993). Social workers' perceived knowledge and use of human behavior theory. Journal of Social Work Education, 29, 88 98.
Schottenbauer, M. A., Glass, C. R., & Arnkoff, D. B. (2007). Decision making and psychotherapy integration: Theoretical considerations, preliminary data, and implications for future research. Journal of Psychotherapy Integration, 17, 225 250
116
Sharp, I. R., Henriques, G. R., Chapman, J. E., Jeglic, E. L., Brown, G. K., & Beck, A. T. (2005). Strategies used in the treatment of borderline personality disorder: A survey of practicing psychologists. Journal of Contemporary Psychotherapy, 35, 359 368.
Sharp, I. R., Herbert, J. D. & Redding, R.E. (in press). The role of critical thinking in practicing psychologists’ choice of intervention techniques. The Scientific Review of Mental Health Practice.
Sheldon, B., & Chilvers, R. (2002). An empirical study of the obstacles to evidence based practice. Social Work and Social Sciences Review. Special Issue: Evidence-Based Practice--I, 10, 6 26.
Shermer, M. (1997). Why People Believe Weird Things: Pseudoscience, Superstition and Bogus Notions of our Time. New York: MJF Books.
Siebert, D. C. & Siebert, C. F. (2007). Help seeking among helping professionals: A role identity perspective. American Journal of Orthopsychiatry, 77, 49 55.
Simons, L., Giorgio, T., Houston, H., & Jacobucci, R. (2007). An exploration of students' perceptions of empirically supported treatments: The significance of gender and ethnicity. Journal of Alcohol and Drug Education, 51, 63 85.
Singer, M.T., Lalich, J. (1996). Crazy therapies: What are they? How do they work? San Francisco: Jossey Bass Publishers.
Singer, M. T. & Nievod, A. (2003). New Age Therapies. In S.O. Lilienfeld, S.J. Lynn, & J. M. Lohr (Eds.) Science and pseudoscience in clinical psychology (pp. 176 204). New York: Guilford Press.
Specht, H., & Courtney, M. E. (1994). Unfaithful angels: How social work has abandoned its mission. New York: Free Press.
Sprang, G., & Craig, C. (2007). An exploratory factor analysis of the trauma practices questionnaire. Best Practices in Mental Health: An International Journal, 3, 9 20.
Sprang, G., Craig, C. & Clark, J. (2008). Factors impacting trauma treatment practice patterns: The convergence/divergence of science and practice. Anxiety Disorders, 22, 162 174.
Springer, D. W., Abell, N., & Hudson, W. W. (2002). Creating and validating rapid assessment instruments for practice and research: Part 1. Research on Social Work Practice, 12, 408 439.
Stewart, R. E. & Chambless, D. L. (2007). Does psychotherapy research determine treatment decisions in private practice? Journal of Clinical Psychology, 63, 267 281.
117
Stewart, R. E., & Chambless, D. L. (2008). Treatment failures in private practice: How do psychologists proceed? Professional Psychology: Research and Practice, 39, 176 181.
Strom, K. (1994). Social workers in private practice: An update. Clinical Social Work Journal, 22, 73 89.
Thyer, B. A. (1995). Promoting an empiricist agenda within the human services: An ethical and humanistic imperative. Journal of Behavior Therapy and Experimental Psychiatry, 26, 93 98.
Thyer, B. A. (2004). What is evidence based practice? Brief Treatment and Crisis Intervention, 4, 167 176.
Thyer, B. A. (2007). Social work education and clinical learning: Towards evidence based practice? Clinical Social Work Journal, 35, 25 32.
Thyer, B. A. & Pignotti, M. (in press). Science and pseudoscience in clinical assessment. In C. Jordan & C. Franklin (Eds.). Clinical assessment for social workers: Quantitative and qualitative approaches (third edition). Chicago, IL: Lyceum Press.
Timberlake, E. M., Sabatino, C. A. & Martin, J. A. (1997). Advanced practitioners in clinical social work: A profile. Social Work, 42, 374 385.
Topolinski, S. & Hertel, G. (2007). The role of personality in psychotherapists’ careers: Relationships between personality traits, therapeutic schools and job satisfaction. Psychotherapy Research, 17, 365 375.
Trinkoff, A. M. & Storr, C. (1997). Collecting substance use data with an anonymous mailed survey. Drug and Alcohol Dependence, 48, 1 8.
Upton, D., & Upton, P. (2006). Knowledge and use of evidence based practice by allied health and health science professionals in the United Kingdom. Journal of Allied Health, 35, 127 133.
Varlami, E., & Bayne, R. (2007). Psychological type and counselling psychology trainees' choice of counselling orientation. Counselling Psychology Quarterly, 20, 361 373.
Von Ranson, K. M., & Robinson, K. E. (2006). Who is providing what type of psychotherapy to eating disorder clients? A survey. International Journal of Eating Disorders, 39, 27 34.
Weick, A. & Saleebey, D. (1998). Postmodern perspectives for social work. In R. G. Meinert, J. T. Pardeck, J. W. Murphy (eds.), Postmodernism, Religion and the Future of Social Work (pp. 21 40). Binghamton, NY: The Haworth Pastoral Press. Wilson, L. & White, K. M. (2007). Development of an attitudes towards complementary therapies scale for psychologists. Clinical Psychologist, 11, 37 44.
118
Witkin, S. (1999). Constructing our future. Social Work, 44, 5 8.
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BIOGRAPHICAL SKETCH
Monica Pignotti received her B.A. from the University of Michigan in 1980 and her Masters in Social Work from the Fordham University Graduate School of Social Services in 1996. She has ten years of clinical experience working with a diverse population of both children and adults, as well as five years of post master’s research experience, working at Saint Vincents Hospital in New York City and as a research consultant for the National Multiple Sclerosis Society. The following are some key peer reviewed first authored publications: Pignotti, M. & Thyer, B. A. (2009). The use of novel unsupported and empirically supported therapies by licensed clinical social workers. Social Work Research, 33, 5 17.
Pignotti, M. & Abell, N. (2009). The negative stereotyping of single persons scale: Initial psychometric development. Research on Social Work Practice, 19, 639 652.
Pignotti, M. & Thyer, B. A. (2009). Some Comments on "Energy Psychology: A Review of the Evidence": Premature Conclusions Based on Incomplete Evidence? Psychotherapy, 46, 257 261.
Pignotti, M. (in press). Reactive attachment disorder and international adoption: A systematic research synthesis. The Scientific Review of Mental Health Practice.
Pignotti, M. (2005). Thought Field Therapy Voice Technology vs. random meridian point sequences: a single blind controlled experiment. The Scientific Review of Mental Health Practice, 4(1), 72 81.
Pignotti, M. (2005, Fall/Winter). Thought Field Therapy in the media: a critical analysis of one exemplar. The Scientific Review of Mental Health Practice, 3(2) p. 60 66.
Additionally, she is co author on the following book, currently under contract with Oxford University Press as part of a series on evidence based practice: Thyer, B. A.& Pignotti, M. Science and Pseudoscience in Social Work.
Dr. Pignotti serves on the Editorial Board of the journal, Research on Social Work Practice.
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