The following answer was co-written by my co-authors, Dr. Bumni Olatunji (https://psychwire.com/ask/profiles/112wjlh/bunmi-o-olatunji), Director of Clinical Training in the Department of Psychology at Vanderbilt University, and Dr. Bethany Teachman (https://psychwire.com/ask/profiles/1rh6d9/bethany-teachman), Director of Clinical Training in the Department of Psychology at the University of Virginia.

Given the co-occurrence of personality disorders with other forms of psychopathology, they naturally lend themselves to being conceptualized dimensionally rather than categorically. (Categorization of psychological disorders attempts to “carve nature at its joints,” but a growing body of research suggests that it is not clear that such “joints” exist between disorders.) The dimensional approach suggests that symptoms of psychopathology exist on a continuum from normal to severely ill. Application of a dimensional approach to conceptualizing how personality disorders may relate to other forms of psychopathology represents an important opportunity to move the field forward. The Hierarchical Taxonomy of Psychopathology (HiTOP) provides an example of a new dimensional classification system which is based on state-of-the art scientific evidence and can be applied to a wide range of problems, including personality disorders. In the HiTOP system, personality disorders should be viewed as a spectrum because applying an artificial boundary to distinguish what is a healthy personality versus mental illness results in unstable diagnoses. This dimensional approach also has important implications for treatment as reflected in the emergence of evidence-based transdiagnostic/unified approaches to the treatment of psychopathology, including personality disorders.

For more information about HiTOP, visit https://www.apa.org/pubs/journals/features/abn-abn0000258.pdf and https://www.sciencedirect.com/science/article/abs/pii/S1077722914000960

Here are some valuable resources for learning more about the gap between what we know from clinical psychological science and what happens in practice, about why it can be challenging to implement evidence-based approaches in community health care, and about some creative solutions to the problem:

Barnett, M. L., Lau, A. S., & Miranda, J. (2018). Lay health worker involvement in evidence-based treatment delivery: A conceptual model to address disparities in care. Annual Review of Clinical Psychology, 14, 185-208. https://doi.org/10.1146/annurev-clinpsy-050817-084825

Clark, D. M. (2018). Realizing the mass public benefit of evidence-based psychological therapies: The IAPT program. Annual Review of Clinical Psychology, 14, 159-183. https://doi.org/10.1146/annurev-clinpsy-050817-084833

Kazdin, A. E. (2017). Addressing the treatment gap: A key challenge for extending evidence-based psychosocial interventions. Behaviour Research and Therapy, 88, 7-18. https://doi.org/10.1016/j.brat.2016.06.004

Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37. https://doi.org/10.1177/1745691610393527

Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2013). Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies. Clinical Psychology Review, 33(7), 883-900. https://doi.org/10.1016/j.cpr.2012.09.008

Siev, J., Huppert, J. D., & Chambless, D. L. (2009). The Dodo Bird, treatment technique, and disseminating empirically supported treatments. The Behavior Therapist, 32, 69-76. https://psycnet.apa.org/record/2009-16244-001

The following answer was written by my co-author, Dr. Bethany Teachman (https://psychwire.com/ask/profiles/1rh6d9/bethany-teachman), Director of Clinical Training in the Department of Psychology at the University of Virginia.

It can be challenging to share personal information in group settings, especially when talking about personal experiences with mental health struggles that are new, and you don’t feel sure how others will react. This natural hesitancy is valuable information to share with the group leader so they can help to make the space one that feels supportive and in which it feels safe to open up. Of course, we can’t fully control how others react and disclosing personal information takes courage, but fortunately, in group treatment settings the other group members are typically having some similar struggles and it can be powerful to realize one is not alone in these difficult experiences. Also, group members often have great ideas about what might be helpful given their own personal experiences with managing mental health issues. One trick to build comfort when disclosing in groups is to increase how much one discloses over time, so try sharing one tough piece of information in the first couple sessions, then aim to share two pieces by session 3, and so on.

Evidence-based practice (EBP) in clinical psychology was endorsed as official APA policy largely because there is little doubt that clinical psychologists should base their practice decisions on a combination of (a) the best available scientific evidence, (b) personal judgment and experience, and (c) the characteristics and preferences and needs of clients. The main misconception about EBP is that it forces clinicians to base clinical decisions entirely on the results of empirical research. Indeed, if EBP requires anything, it is that clinicians should combine information from the three sources listed above. Suppose, for example, that an empirical study shows Treatment A to have a statistically significant advantage over Treatment B when both were administered under laboratory conditions by therapists who used therapy manuals with volunteer clients who were all about the same age and who all displayed the same type of disorder, such as mild depression. Would Treatment A work just as well with clients of varying ages or ethnic backgrounds, who have somewhat more severe disorders, and who are seen in a private practitioner’s office? It might, but it might not. Clinicians must remember that the value of scientific evidence depends not only on the quality of the research designs that generated it (its internal validity) but also on the broader applicability of the evidence (its external validity). So, a clinician who employs EBP in family therapy would want to stay in touch with high-quality scientific evidence regarding effective family therapy methods but must also consider how useful that evidence is for guiding decisions regarding a particular family.

For more information about evidence-based practice, visit https://www.apa.org/practice/resources/evidence

It is often the case that clients, like students, hope for simple, easy answers to complicated questions, but clinicians have an obligation to help those clients understand the importance of critical thinking about the treatment of psychological disorders. It may be useful (using language appropriate to each client’s level of scientific sophistication to ask clients to consider the following five-questions about the disorders and treatments of interest to them:

1. What am I being asked to believe? (e.g., that Treatment A is better than Treatment B.)
2. What kind of evidence is available to support the claim? (e.g., that a controlled laboratory experiment showed Treatment A to work better than Treatment B with a particular type of client and disorder.)
3. Are there alternative ways to interpret the evidence? (Perhaps Treatment A was just more impressive to clients than Treatment B. Maybe the therapists had more confidence in Treatment A and therefore conducted it more carefully. Would the results be different for clients with different kinds of disorders? Was the statistically significant superiority of A over B large enough to be clinically significant—that is, to make a noticeable difference in clients’ lives?)
4. What additional evidence would help evaluate the alternatives? (Additional studies with a wider range of clients and disorders in real clinical settings, along with information about what treatments a given client has tried previously, what treatment the client prefers, and the feasibility of offering Treatment A given the clinician’s setting and experience.)
5. What conclusions are most reasonable given the kind of evidence available? (It is important to pay close attention to the research evidence for treatment A relative to B and to share that information with the client, but also to recognize your own comfort level in administering various treatments and of course to listen carefully to the client’s preferences and evidence of ‘fit’ of each treatment for that client within the client’s community and culture and within the current treatment setting. Clinicians always have to remember that evidence-based practice is not a “one size fits all” model.)

I am no longer teaching graduate students, but during the decades that I did so I tried to point out that, ideally, psychotherapy should be based on methods that clinical psychological science tells us are most likely to benefit particular clients with particular problems, but that we do not yet have enough empirical evidence available to make it so in relation to every disorder and every client. I also lamented the fact that too many training programs lead clinicians to deliver psychotherapy mainly as an art, that is, in ways that are shaped not by empirical evidence but by less-than-scientific beliefs. I pointed out that those choices are often driven not only by training experiences but by the clinicians’ personalities, philosophies of life, and other personal characteristics. In short, psychotherapy can be taught mainly as an art or mainly as a science. I prefer a mainly science-oriented approach in which clinical decisions are guided by the principles of evidence-based practice.

For more information about the training of students in scientific clinical psychology, visit the website of the Academy of Psychological Clinical Science at https://www.acadpsychclinicalscience.org/

Clinicians who care about the quality of the services they provide to their clients should stay abreast of current developments in their field, including research published in scientific journals. But rather than trying to read everything, consider subscribing to tables of contents from all the main clinical psychology journals so that you can be aware of what is being published in each of them. Doing so makes it easier to identify and focus on reading research that is most relevant to your own practice.

Many clinical psychologists favor an approach in which it is acceptable, and even desirable, to employ techniques from a variety of therapy “schools” rather than sticking to just one—as long as the choices are based on evidence-based principles of change. This approach reflects technical eclecticism because it allows a clinician to use one primary theoretical approach to explain the origins of disorder, identifying important change processes, and developing a treatment plan, but also to draw on useful techniques from multiple therapeutic models to achieve treatment goals. Theoretical eclecticism refers to holding no clear or coherent theoretical orientation to guide one’s view of disorder and being willing to draw on various techniques based on whatever seems interesting or convenient. To clinical scientists, technical eclecticism is the far more desirable option.

Psychotherapy integration—the systematic combination of elements of various clinical psychology theories—also makes sense to me. If assessment and therapy techniques are tools, it is easy to see that possessing a wide range of tools, and the knowledge of when and how to use them, makes for an effective psychotherapist. I am not alone in this view, as you can see by looking at the Journal of Psychotherapy Integration, which is devoted to integrating various therapy approaches (https://www.apa.org/pubs/journals/int).

However, technical eclecticism and psychotherapy integration are not easy to achieve. Clinicians have to ask themselves how varying theories and techniques can best be combined, and clinical training programs have to assure that their students will integrate clinical techniques in a thoughtful rather than a capricious manner. Further, it can be difficult for trainees to gain in-depth knowledge of all theoretical approaches, and the effort to do so might be more confusing than enlightening. As noted above, I think that clinicians might be better off trying to understand clients' problems within one reasonably coherent theoretical orientation rather than by trying to employ multiple orientations, some of which may be based on conflicting assumptions. For example, a psychoanalytic approach to treating a young woman’s eating disorder might focus on her early childhood experiences, whereas a cognitive-behavioral approach would focus on what she is telling herself about her self-worth and on factors that are currently reinforcing her problematic eating patterns.

Still, many clinical psychologists and clinical psychology training programs today are looking for ways to integrate what various theoretical approaches have to offer, searching for common elements in the causes of disorders (transdiagnostic mechanisms) and in the effectiveness of treatments (principles of change). I think that these trends will be good for clinical psychology in the long run.