Enhancing Information Pertaining to Client Characteristics to Facilitate Evidence-Based Practice

Jennifer L. Callahan,1 Christopher J. Heath,1 Nicki L. Aubuchon-Endsley,2 Frank L. Collins Jr.,1 and Gregory L. Herbert1
1 2

University of North Texas Alpert Medical School of Brown University

Objective: Evidence-based practice (EBP) includes utilization of empirically supported treatments, application of clinical expertise, and consideration of client characteristics. The following brief report aims to elucidate barriers in the study and dissemination of research regarding these client characteristics. Design: Authors examined empirical papers cited on psychologicaltreatments.org (N = 338) and categorized each according to efcacy evidence available pertaining to gender, race/ethnicity, and socioeconomic status (SES). Results: Gender was most commonly considered (7% of studies), with less than 2% of studies analyzing efcacy in relation to race/ethnicity or SES. Conclusions: Available ndings are summarized according to disorder. Researchers are encouraged to attend to client variables in efcacy studies and suggestions are offered for training students to include client variables in EBP . C 2013 Wiley Periodicals, Inc. J. Clin. Psychol. 00:125, 2013.
Keywords: evidence-based practice; client variables; psychological treatments; dissemination

The evidence-based practice (EBP) movement dominates health care today and unites practitioners and clinical scientists in a range of health care disciplines. Psychologists have identied evidence-based psychological practice (EBPP) as the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences (American Psychological Association [APA], 2005, p. 1). This approach sets a high bar for competent practice of professional psychology that serves to protect the public. The EBP movement is relatively recent, rooted in trends toward increasing accountability for medical outcomes in the United Kingdom (Wampold & Bhati, 2004). In the United States, EBP in psychotherapy rst became salient during the 1990s with APAs Division 12 (Society of Clinical Psychology) Task Force on Promotion and Dissemination of Psychological Procedures (APA, 1993). The task force outlined the importance of identifying and utilizing Empirically Validated Psychological Treatments in addition to the effect of these treatments on clinician training and third-party payers. Though recent, the EBP movement is complicated and expansive. Thus, a comprehensive outline of its history is beyond the scope of the current article. However, the current article does address existing problems with dissemination of research on EBP (Addis, Wade & Hatgis, 2006; Gallo & Barlow, 2012; Kendall & Beidas, 2007) specically related to client variables within EBP. The facilitation of widespread application of EBP can be achieved only by careful management of evidence dissemination (McCabe, 2004), and many professional organizations are working towards this goal (McHugh & Barlow, 2010). Both the Substance Abuse and Mental Health Services Administration (SAMSHA) and Centers for Disease Control and Prevention (CDC) provide extensive information about their funded treatment projects. However, these sites are limited by not considering unfunded research. Further, the CDC website (http://www.cdc.gov/DiseasesConditions/) contains little information of use for mental health evidence dissemination, while the use of the Diagnostic and
Please address correspondence to: Jennifer L. Callahan, Department of Psychology, University of North Texas, 1155 Union Circle #311280, Denton TX 76203-5017. E-mail: Jennifer.Callahan@unt.edu
* Posthumous.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 00(00), 125 (2013) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).

C 2013 Wiley Periodicals, Inc. DOI: 10.1002/jclp.21995

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Figure 1. The intersecting roles of research evidence, patient characteristics, and practitioner expertise in forming clinical decisions that characterize evidence-based practice within a given context (adapted from Spring, B., Walker, B., Brownson, R., Mullen, E., Newhousc, R., et al. [July, 2008]. Denition and competencies for evidence-based behavioral practice (EBBP). Retrieved from http://ebbp.org/ documents/EBBP_Competcncies.pdf)

Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) diagnostic labels is limited on the SAMSHA website (http://www.nrepp.samhsa.gov/nd.asp). The site allows for advanced search by client characteristics, which is commendable. APAs Division 12 has also organized evidence for dissemination on psychologicaltreatments.org. This website is organized by diagnosis, citing hundreds of efcacy studies. It serves to identify the best available research evidence for common psychological disorders and explicitly reminds users that this evidence will necessarily be combined with clinician expertise and client values and characteristics in determining optimum approaches to treatment. However, accomplishing this integration of effective treatments, expertise, and client variables is challenging. Research consumers must decide what to read and whether ndings should change their practice (Gross & Johnston, 2009; Stewart, Chambless, & Baron, 2012). Following these decisions, practitioners must use their clinical expertise to determine if evidence presented is relevant for particular individuals (Mazzucchelli & Sanders, 2010). As in Figure 1, EBP requires that clinical decisions incorporate the best available research evidence with client/population characteristics, state, needs, values, and preferences, and resources, including practitioner expertise. Therefore, to move toward EBP, we must also consider the relationship of client characteristics to treatment efcacy. In particular, prevalence rates for various mental health issues (e.g., Axis II disorders; Golomb, Fava, Abraham, & Rosenbaum, 1995) may be a function of gender. Psychopathology may also vary as a function of socioeconomic status (SES), ethnicity, and a range of other individual variables (Dohrenwend et al., 1992; Nguyen, Huang, Arganza, & Liao, 2007). A risk to successful delivery of EBP is to become focused on empirically supported treatments (ESTs) to an extent that important components of EBP are neglected. Although ESTs are important, they contribute only one component of EBP. The current article attempts to gather ndings regarding individual differences and their effects on psychotherapy outcomes. Although knowing the answers to these questions would not address all components of EBP, it would move the discussion beyond a focus on treatment evidence towards comprehensive foreground questions that inform clinical practice with individuals. This review examined accessible empirical studies cited on psychologicaltreatments.org to assist practitioners in responding to such foreground questions. Each study was considered with respect to gender, race/ethnicity, and SES, and those providing supporting evidence for treatment efcacy were summarized. insufcient (not reported) informaEach study was examined to determine if there was: tion regarding client diversity; insufcient diversity (<10% of reported N) in the sample; sufcient representation of client diversity (>10% of reported N) but no corresponding efcacy

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analyses; inclusion of diversity in efcacy analyses with a nding of signicant differences by group; or evidence that the treatment was equally effective (no signicant group differences) for diverse clients. See Appendices for summary.

Overall Patterns Observed in the Cited Studies

Fully 93% (N = 315) of studies did not examine gender differences. Disorders that contained no cited gender difference studies included borderline personality disorder (BPD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and specic phobia. Cited studies for BPD included only women. Citations for the remaining disorders described adequate gender representation to examine differences. The few studies examining differential treatment efcacy by gender report no signicant differences (see Table A1). However, multicomponent cognitivebehavioral therapy for rheumatologic pain (Keefe et al., 1990a, 1990b) and reminiscence/life review therapy for depression (Fry, 1983) were more effective for women. Five studies addressed treatment efcacy as a function of race/ethnicity (1.5%; see Table A2). The Robinson-Wheelan et al. (2007) study results revealed that self-management/self-control therapy for depression was effective across groups. Similarly, efcacy of behavior therapy/behavior activation treatment of depression was found to be independent of race/ethnicity (Arean et al., 2005). With respect to schizophrenia, race/ethnicity did not signicantly co-vary with treatment efcacy of cognitive adaptation training (Velligan et al., 2000; Velligan et al., 2002). Finally, Davidson and colleagues (2004) reported no differences in efcacy between Caucasian and racial/ethnic minority clients for cognitive and behavioral therapy for social phobia. Few studies (N = 4; 1.2%), evaluated SES differences in treatment efcacy (see Table A3). No differences were found in family-focused therapy for bipolar disorder (Miklowitz, George, Richards, Simoneau, & Suddath, 2003), self-management / self-control therapy for depression (Robinson-Whelen, Hughes, Taylor, Hall, & Rehm, 2007), behavioral weight loss treatment for obesity and pediatric overweight (Israel, Silverman, & Solotar, 1986), or eye movement desensitization and reprocessing for posttraumatic stress disorder (PTSD; Wilson, Becker, & Tinker, 1995). Most studies were noted as containing insufcient information. Although many recent studies included information about education or employment status, this was not sufcient for characterizing SES.

Disorder Specic Findings

Tables A4 thru A16 provide details on all empirical studies cited on the Division 12 website, clustered into tables by disorder. Several listed disorders did not inform foreground questions. However, eight disorders included one or more treatment(s) that evaluated client characteristics, which are summarized below. Regarding bipolar disorder, differential prevalence rates have not been established based on race, ethnicity, or gender although gender may play a role in the number, type, and onset of manic and major depressive episodes (American Psychiatric Association, 2000). Prevalence, however, does vary by age (6% of U.S. adults aged 1829 years, 5% aged 3044 years, 5% aged 4559 years, and 1% aged 60+ years; Kessler et al., 2005). Three studies from the website showed support of treatment efcacy independent of gender, including family-focused therapy (Miklowitz et al., 2003; Rea et al., 2003) and interpersonal and social rhythm therapy (Frank et al., 2005). Most studies (18 of 21 studies; 86%) failed to examine gender differences, examined one gender, or provided insufcient information in the methods to provide support. One study showed support independent of SES (family-focused therapy; Miklowitz et al., 2003) and no studies addressed race/ethnicity. Depression prevalence varies by gender (70% more likely in women), race (40% more likely in White, non-Hispanic individuals than Black, non-Hispanic individuals), and age (9% of U.S. adults aged 1825 years, 7% aged 2649 years, and 5% aged 50+ years; Kessler et al., 2005). Several studies found support for treatment of Depression independent of gender, including behavior therapy/behavioral activation (Arean et al., 2005; Hopko, Lejuez, Lepage, Hokpo, & McNeil, 2003), cognitive behavioral analysis system of psychotherapy (Klein et al., 2004;

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Manber et al., 2003), interpersonal therapy (Reynolds et al., 1999), problem-solving therapy (Reynolds et al., 1999), self-management/self-control therapy (Rokke, Tomhave, & Jocic, 2000), and behavioral couple therapy (Christensen, Atkins, Yi, Baucom, & George, 2006). As noted above, reminiscence/life review therapy found greater efcacy for women. Only two treatments, behavior therapy/behavior activation (Arean et al., 2005) and self-management/selfcontrol therapy (Robinson-Whelen et al., 2007) examined race/ethnicity inuences on treatment efcacy. Both studies found treatment to be equally effective for Caucasian and ethnic minority clients. Self-management/self-control therapy (Robinson-Whelen et al., 2007) was also found to be equally effective regardless of SES. Eating disorder prevalence varies by demographic characteristics depending on the specic disorder. Prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder is two to three times greater in women and more likely in industrialized societies (Hudson, Hiripi, Pope, & Kessler, 2007). Although the incidence of anorexia nervosa does not appear to vary by age, those younger than 60 years of age are signicantly more to develop bulimia nervosa and binge eating disorder compared with other age groups (Hudson et al., 2007). Studies supported behavioral weight loss for obesity and pediatric overweight as equally effective across gender (Tuomilehto et al., 2001; Wing, Blair, Marcus, Epstein, Harvey, 1994) and not differentially inuenced by parental SES (Israel et al., 1986). EMG biofeedback was found to be equally effective for insomnia in women and men (Barrowsky, Moskowitz, & Zweig, 1990), despite a greater prevalence of the disorder in women. Psychoanalytic treatment for panic disorder was also equally effective for both women and men, though there is a greater incidence of diagnosis in women (Milrod et al., 2007). Eye movement desensitization and reprocessing therapy for PTSD was equally effective across gender and SES categories (Wilson et al., 1995). Cognitive adaptation training for schizophrenia was equally effective for men and women, independent of race/ethnicity (Velligan et al., 2000; Velligan et al., 2002), although it is manifested differently by gender. Treatment effects were independent of gender and race/ethnicity for cognitive and behavioral therapy for social phobia (Davidson et al., 2004) and independent of gender for cognitive therapy (Clark et al., 2003), even though Social Phobia is more common in women.

Discussion
The goal of the current study was to assist practitioners as they aim to provide high quality EBP. However, as we carried out the study, we came to more fully appreciate the frequent lack of consideration of client characteristics by researchers studying treatment efcacy. Overall, evidence for treatment efcacy rarely addresses foreground questions of gender, race/ethnicity, or SES. This is unfortunate as client variables reect a range of factors contributing to individual uniqueness. Such variables may include the clients presenting problems (e.g., variations in etiology, symptoms, behavior, etc.), views of treatment (e.g., readiness to change, preferences, expectations, etc.), sociocultural and familial factors (e.g., religion, values, beliefs, etc.), environmental factors (e.g., employment, major life events, etc.), or other factors like age or development level (APA, 2006). While research indicates that client characteristics play an important role in treatment outcomes (see Clarkin & Levy, 2004; Zane, Sue, Young, Nunez, & Hall, 2004) and should be incorporated in EBP to treat individuals (Beutler, Forrester, Gallagher-Thompson, Thompson, & Tomlins, 2012), the tables provided in Appendices support that client variables are frequently overlooked in research. It is not possible to determine from these data whether practitioners also overlook these variables. In the absence of such information, it may be helpful for practitioners to keep in mind a few easily recalled ndings from broad psychotherapy literature that are not evident from studies considered in this review.

Client Variables in the Broad Literature Age and gender. Consideration of client characteristics reveals that, among adults, age is not strongly related to treatment retention or outcome in the broad psychotherapy literature

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(Dubrin & Zastowny, 1988; Sledge, Moras, Hartley, & Levine, 1990). Although, more recently it has been reported that younger individuals are more likely to have used mental health services and report greater likelihood of using such services in the future (Smith, Peck, & McGovern 2004). Similarly, research generally reveals no gender differences in therapy outcome in adults (Gareld, 1994; Petry, Tennen, & Afeck, 2000), with some exceptions pertaining to treatment for depression (Thase, Frank, Kornstein, & Yonkers, 2000) or substance abuse disorders (Blood & Cornwall, 1994; Rivers, Greenbaum, & Goldberg, 2001). Recent reports do indicate that gender may inuence clients willingness to initiate treatment and evaluation of treatment options (Green, Polen, Dickinson, Lynch, & Bennett, 2002; Smith, Peck, & McGovern, 2004).

Race and ethnicity. For racial and ethnic minority clients, research suggests that the working alliance (connection between client and practitioner with respect to goals, tasks, and bond; Gelso & Hayes, 1998) may be especially important in fostering positive outcomes, and some approaches may foster more positive alliances (e.g., Duan & Wang, 2000; Ortega & Alegr a, 2002; Wong, Kim, & Zane, 2003). Other research suggests that the impact of therapist attitude on treatment outcomes might be related to SES, rather than ethnicity (Lerner, 1972). Demeanor. Beyond demographics, it is also important in EBP to consider client variables like demeanor and preferences. Thornton et al. (2003) reported that behaviorally oriented, structured treatments worked better with clients who had a helpless demeanor, while a less structured, facilitative treatment milieu was found to be more efcacious for others. Preferences. Swift and Callahan (2009) conducted a meta-analytic review summarizing data from 26 studies including 2,300 clients and found that those who received preferred treatment were half as likely to drop out and had a 58% chance of showing greater improvement. They also found that study design served as a moderator, causing partially randomized preference trials to likely underestimate the effect of client treatment preferences. A subsequent meta-analysis (Swift, Callahan, & Vollmer, 2011) replicated this nding. Meta-regression of this data found that client preferences are important to all clients, regardless of age, gender, ethnicity, educational level, or marital status (Swift, Callahan, Ivanovic, & Kominiak, 2013). The current article illustrates the dearth of research related to the inuence of client variables on treatment outcomes. The information presented is often characterized by false dichotomies (e.g., ethnicity treated as Caucasian/not Caucasian). Additionally, gender is presented as dichotomous despite evidence that this construct may not accurately reect gender identity (Lorber, 1995). These dichotomies prevent a nuanced understanding of the literature and reect difculties in collecting representative samples. Increased understanding of these non-dichotomous constructs will allow for more clinically applicable ndings in research. The efcacy of a psychological treatment with any given individual is even far more complicated. The requirement of clinical expertise in true EBP underscores the challenge in competently bridging the nomothetic-idiographic divide when engaged in professional practice. Although consideration of clinical expertise variables in EBP is beyond the scope of this review (though we encourage this to complement the existing Division 12 website and the current study tables in appendices), we wish to conclude by offering a few suggestions on training of students in EBP. Promoting Client Variables During Training in EBP
Training students to integrate client variables into EBP can be challenging because they often are highly desirous of learning ESTs and are prone to mistakenly conclude that using an EST is EBP. The lack of attention to client variables in the cited studies on the psychologicaltreatments.org website may inadvertently reinforce the mistaken perception by students that use of an EST is EBP. This lack of distinction between EST and EBP may not be unique to students. A number of studies and literature reviews substitute the term evidence-based practice with other terms (e.g., Chambless & Ollendick, 2001), thereby possibly adding to denitional confusion. Westen and colleagues (Westen, Novotnoy & Thompson-Brenner, 2004; Westen & Bradley, 2005) highlight that although ESTs are often seen as the fundamental basis of EBP, they comprise only one component of EBP. This ignores other aspects of psychotherapy practice and

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research that contribute to EBP such as common factors (Wampold & Bhati, 2004) and client treatment preferences (Swift & Callahan, 2009). True adherence to EBP guidelines must account for these and other research/factors in treatment provision, which should also be incorporated into training (Spring, 2007). Aside from encouraging a range of practicum experiences that bring students into contact with a variety of clients from diverse backgrounds, characteristics, values, and preferences, we suggest formal instruction in shared decision-making in clinical practice (Adams & Drake, 2006). A collaborative interaction between therapist and client should be emphasized with both inuencing treatment decisions (Beutler et al., 2012; Ford, Schoeld, & Hope, 2003). Four components are inherent to successful application of the shared decision-making model: (a) two parties are involved, (b) both share information, (c) both discuss preferences for treatment, and (d) an agreement is reached as to implement treatment (Charles, Whelan, Gafni, Willan, & Farrell, 2003). The use of a shared decision-making model coupled with diverse practicum experiences may further trainee development in EBP. Practicum supervisors are strongly encouraged to routinely discuss client and trainee values, preferences, goals, plans, progress, etc., during supervision, especially when treatment decisions are considered. In contrast, supervisors are discouraged from simply monitoring treatment adherence (an important part of effective EST supervision) as the sole indicator of EBP.

Promoting Client Variables With Lifelong Learning in EBP

EBP also requires lifelong learning via consumption of research (Spring, 2007). To facilitate this, we suggest that practitioners specically attend to client characteristics information as research consumers. Lifelong learning could be promoted by encouraging future research regarding EPBs at the division, professional societies, and other levels. Additionally, dissemination of updates to research in EBPs should be encouraged at conferences in addition to associated clinical trainings. It is also vital to recognize that publication bias limits dissemination of psychotherapy research (Song et al., 2010), suggesting that greater emphasis on null or unpublished ndings may be particularly helpful. In particular, research consumers and reviewers should encourage investigators to publish their broad range of ndings. Finally, with respect to dissemination efforts, organizations should include pertinent client information (e.g., Division 12 could add a section to each disorders page) or create dynamic websites that allow for searching according to client characteristics or embed within sites the necessary programming code to open and simultaneously search other databases. In sum, the lack of research addressing the effect of client variables currently prevents reliably generalizable conclusions being drawn from papers reviewed. The dearth of investigation into these variables is therefore identied as a vital area for growth within the larger sphere of psychotherapy research.

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Appendix

Table A1
Gender
Bipolar disorder BDP Chronic pain Depression Eating disorders GAD Insomnia OCD Panic PTSD Schizophrenia Social phobia Specic phobia 3 0 0 8 2 0 1 0 1 1 2 2 0 0 0 2 1 0 0 0 0 0 0 0 0 0 16 0 11 35 30 9 16 6 5 2 26 18 19 1 8 2 10 58 0 1 0 0 12 5 1 6 1 0 0 1 7 1 0 1 0 0 2 2 3

Notes. N = 338; Evidence for each group; Analyzed subgroups; Sufcient N, no analysis; Insufcient information reported. Insufcient N, < 10%; BPD = borderline personality disorder; GAD = generalized anxiety disorder; OCD = obsessive-compulsive disorder; PTSD = posttraumatic stress disorder.

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Table A2
Race/Ethnicity
Bipolar disorder BDP Chronic pain Depression Eating disorders GAD Insomnia OCD Panic PTSD Schizophrenia Social phobia Specic phobia 0 0 0 2 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 3 1 19 30 1 3 0 2 9 16 3 2 4 1 1 13 16 2 2 1 1 2 2 2 1 11 4 13 21 51 7 13 6 3 4 15 17 25

Notes. N = 338; Evidence for each group; Analyzed subgroups; Sufcient N, no analysis; Insufcient information reported. Insufcient N, < 10%; BPD = borderline personality disorder; GAD = generalized anxiety disorder; OCD = obsessive-compulsive disorder; PTSD = posttraumatic stress disorder.

Table A3
SES
Bipolar disorder BDP Chronic pain Depression Eating disorders GAD Insomnia OCD Panic PTSD Schizophrenia Social phobia Specic phobia 1 0 0 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 2 1 3 9 0 0 0 0 6 3 2 2 0 0 0 2 0 0 0 0 0 0 4 0 0 15 6 14 49 87 10 18 7 6 8 28 21 26

Notes. N = 338; Evidence for each group; Analyzed subgroups; Sufcient N, no analysis; Insufcient information reported. Insufcient N, < 10%; BPD = borderline personality disorder; GAD = generalized anxiety disorder; OCD = obsessive-compulsive disorder; PTSD = posttraumatic stress disorder.