BASIC RESEARCH AND PSYCHOLOGICAL TREATMENT

Running head: BASIC RESEARCH AND PSYCHOLOGICAL TREATMENT

This is an unedited manuscript accepted for publication at Clinical Psychology Review. The published version of the paper is available under the following link:

https://doi.org/10.1016/j.cpr.2022.102163

(When and How) Does Basic Research in Clinical Psychology Lead to More Effective

Psychological Treatment for Mental Disorders?

Thomas Ehring

Karina Limburg

Anna E. Kunze

Charlotte E. Wittekind

Gabriela G. Werner

Larissa Wolkenstein

Melike Guzey

Barbara Cludius

Department of Psychology, LMU Munich, Germany

Correspondence should be addressed to: Thomas Ehring, PhD, Department of Psychology, LMU

Munich, Leopoldstr. 13, D-80802 Munich, tel: +49-89-2180 5172, e-mail:

[email protected]

Melike Guzey is now at the Department of Psychology, Ankara University, Turkey

Declarations of interest: none

BASIC RESEARCH AND PSYCHOLOGICAL TREATMENT 2

Abstract

An important aim of basic research in Clinical Psychology is to improve clinical practice

(e.g., by developing novel interventions or improving the efficacy of existing ones) based on an

improved understanding of key mechanisms involved in psychopathology. In the first part of this

article, we examine how frequently this translation has happened in the past by reviewing all 40

evidence-based psychological interventions recommended in current clinical guidelines for five

important (groups of) mental disorders. Results show that only 23% of treatments showed a very

strong link between basic research and the development of the intervention, and further 20%

showed a strong link. These findings thus suggest that the route from basic research to clinical

innovation may not be as strong historically as is commonly assumed. Important challenges for

translational research in clinical psychology are reviewed, leading to the introduction of a new

framework, and a discussion of possible solutions to overcome these challenges. Suggestions

include increased attention to robust and replicable research findings, a stronger focus on

experimental psychopathology research to establish causality of psychopathological

mechanisms, a more systematic structural integration of basic and applied research in clinical

psychology, a stronger emphasis on mechanisms of change and moderators of clinical

interventions, increased attention to clinical subgroups, and emphasizing improvements to

existing interventions over the development of novel interventions.

Keywords: Experimental Psychopathology; Clinical Interventions; Translational Research


1. Introduction

The standard narrative of current clinical psychology states that in order to develop

innovative psychological interventions and/or further improve existing evidence-based

treatments for mental disorders, it is necessary to conduct basic research investigating the

processes underlying the development and maintenance of psychopathology (Clark & Fairburn,

1997; Davey, 2014; Kring et al., 2017; Oltmanns & Canstonguay, 2013). Past decades have seen

extensive basic research in clinical psychology. Without any doubt, this approach has been very

successful in that it has led to a refinement of theoretical models, and has increased knowledge

on processes that are associated with and/or causally linked to psychopathology. However, has

basic research in clinical psychology so far also upheld its promise to lead to new and/or more

effective treatments? In other words: How well does the translation of basic research into clinical

treatments work?

The aims of the current paper are to (1) critically examine evidence for basic research

leading to more effective psychological treatments for mental disorders, (2) review obstacles for

the translation of basic research findings into clinical innovation, and (3) discuss possible

solutions to the translational gap1.

The manuscript draws heavily on general concepts of translational research in clinical

psychology and psychiatry (e.g., Fulford et al., 2014; Machado-Vieira, 2012), and on ideas

presented in earlier reviews on similar topics (e.g., Clark, 2004; Forsyth & Zvolensky, 2001;

Kindt, 2018; Salkovskis, 2002; van den Hout et al., 2017; Vervliet & Raes, 2013; Waters et al.,

2016). However, it provides a novel integration of these issues, leading to specific suggestions.

1 The current manuscript focuses on the challenges of translating basic research findings into the development of psychological interventions. There are additional challenges related to the dissemination and implementation of evidence-based treatments in clinical practice as well as providing broad and affordable access to these treatments. However, these topics are beyond the scope of the current manuscript. Interested readers are referred to scholarly reviews on this issue (e.g., Clark, 2012; Lilienfeld et al., 2013; McNally & McNally, 2016).


2. Definitions

In order to examine whether, how often, and under which circumstances basic research

leads to the improvement of psychological treatment for mental disorders, it is necessary to first

define these terms. For the purpose of this review, we define basic research in clinical

psychology broadly as any type of psychological research investigating processes that are

involved in the development and/or maintenance of psychopathology across any level of

explanation (e.g., biological, cognitive, behavioral). Basic research can be correlational or

experimental, based on self-report data and/or include more objective measures. Importantly, for

the purpose of the current article, basic research is not defined by any particular method used,

but instead by the research questions that are addressed. This broad definition appears adequate

in order to prevent any preconception on which types of mechanisms or methods are relevant

here.

Based on a suggestion by Norcross (1990), we defined psychological treatment for

mental disorders as any intervention that has been developed to treat mental disorders, is based

on a psychological theory, and uses psychological methods to modify individuals’ behaviors,

cognitions, emotions, and/or other personal characteristics.

Whereas the definitions of both basic research and psychological treatment are

reasonably straightforward, finding criteria that can be used to judge when basic research has led

to more effective psychological treatment appears more challenging. For the purpose of this

review, this aspect is operationalized as the development of new evidence-based treatments

and/or the substantial further development and improvement of existing evidence-based

treatments based on the results of basic research in clinical psychology. In order to identify these

new or improved evidence-based treatments, we will rely on two sources that are both based on

agreed standards for evidence-based or empirically-supported treatments. First, about 25 years

ago a Task Force of the Division 12 of the American Psychological Association (APA)

developed criteria to determine whether a particular psychological treatment for a specified


disorder has been shown to be efficacious in controlled research (Chambless & Hollon, 1998;

Chambless & Ollendick, 2001). Depending on the available evidence, the strength of the

research support for a particular treatment can then be rated as strong (equivalent to the earlier

term well-established treatments), modest, or controversial. Our first source thus consists of a list

of psychological treatments that have been examined according to these criteria, and that are

continuously published online by the APA’s Division 12 (Society of Clinical Psychology, 2021,

Nov 16). Our second source will be clinical guidelines that are developed following a systematic

and transparent approach examining the research base supporting the efficacy and effectiveness

of psychological treatments, namely the guidelines developed by the UK-based National Institute

for Health and Care Excellence (NICE) (https://www.nice.org.uk/). Although there has been

some controversy in the literature regarding the exact criteria for establishing empirically-

supported treatments (Chambless, 2015; Rosen & Davison, 2003; Tolin et al., 2015), the corpus

of empirically-supported treatments represented by our two sources, the APA’s Division 12 list

and the clinical NICE guidelines, can be regarded as the field’s current consensus on which

treatments have been shown to be efficacious in treating a particular mental disorder.

In the following section, we will use these definitions to address the first aim of our

review. The two sources to identify effective treatments will thereby be used in a complementary

way so that interventions included in at least one of the two sources will be considered.

3. Does Basic Research lead to Improvements in Psychological Treatments?

As stated above, the standard narrative of clinical psychology posits that basic research

into processes involved in the development and/or maintenance of psychopathology can bring

about more effective psychological treatment for mental disorders. In this section, we will

examine whether there is historical evidence for this claim. To this end, we selected the five

groups of mental disorders that, according to the Global Burden of Disease Study, are associated

with the highest disease burden; these are major depression, anxiety disorders, drug use

disorders, alcohol use disorders, and schizophrenia (Murray et al., 2012). For these disorders, we


first consulted the list provided by Division 12 of the APA (Society of Clinical Psychology,

2021, Nov 16) to identify treatments showing either strong or moderate research support for each

particular disorder according to the criteria put forward by Chambless and Hollon (1998). For

each psychological treatment identified in this way, we then examined whether the development

of this treatment was based on or influenced by basic research as defined in the earlier section.

We applied the following criteria to rate the strength of the link between basic research and

treatment development (note that our criteria allowed for situations, in which basic science and

treatment development was conducted by the same researchers, as well as situations, in which

basic research conducted by others was used):

1. Very strong: systematic testing of underlying theory2 conducted prior to treatment

development AND treatment principles or interventions developed or refined in basic

research before application;

2. Strong: one of the two criteria for “very strong” present and conducted prior to

development of intervention;

3. Moderate: some testing of theoretical model or intervention principles prior to or parallel

to treatment development, but not in a systematic or extensive way;

4. Weak: no basic research directly underlying treatment3.

In a second step, we checked whether any additional psychological interventions not

included in the APA Division 12 list were recommended as evidence-based treatments in current

NICE treatment guidelines for the same disorders, namely depression (NICE, 2018), generalized

anxiety disorder (NICE, 2011b), social anxiety disorder (NICE, 2013), drug use disorder (NICE,

2008), alcohol use disorder (NICE, 2011a), and schizophrenia (NICE, 2014). These treatments

were then examined in the same way as described above. In the following, we summarize our

2 Note that we did not rate the quality of the theoretical models underlying treatment development. 3 There were cases, in which treatment developers made some reference to basic research findings, but it was not clear how exactly basic research findings were linked to treatment development. Those cases were rated as “Weak – moderate”.


findings for the five disorder groups. Detailed results for each intervention, including the source

it was taken from (APA list and/or NICE guideline), can be found in the Supplementary Material

(Table A).

3.1 Psychological Treatments Showing a Very Strong Link to Basic Research

We reviewed a total of 40 treatments for depression, anxiety disorders, alcohol or drug

use disorders, and schizophrenia, all of which had been rated with modest or strong research

support in the APA Division 12 list (Society of Clinical Psychology, 2021, Nov 16) and/or are

recommended according to the NICE guidelines (NICE, 2008, 2011a, 2011b, 2013, 2014, 2018).

Out of these 40 treatments, nine can be rated as having a very strong link between basic research

and treatment development, namely Behavioral Activation for Depression, Cognitive

Remediation for Schizophrenia, Social Learning/Token Economy Programs for Schizophrenia,

Social Skills Training for Schizophrenia, Applied Relaxation for Generalized Anxiety Disorder

and Panic Disorder, Cognitive Behavioral Therapy for Panic Disorder, Exposure Therapy for

Specific Phobias, and Prize-based Contingency Management for Substance Use Disorders (for

details see Table A in the Supplementary Material). All nine treatments (1) are based on a theory

that has been tested using basic research and (2) use principles or interventions that were

developed and/or refined in basic research. With the exception of Cognitive Remediation based

on the model of neuroplasticity (Eack et al., 2010), all interventions with a very strong link to

basic research are based on research that has existed for more than 40 years (e.g., social learning

theory: Bandura, 1986; reciprocal inhibition: Lazarus, 1963; Wolpe, 1958; operant learning:

Sherman & Baer, 1969); similarly, the interventions in this category were all developed more

than 20 years ago. Thus, more recent developments of novel interventions based on basic

research are largely lacking.

3.2 Psychological Treatments With a Strong Link to Basic Research

Of the remaining 31 treatments, eight were rated as showing a strong link to basic

research, which means that either the underlying model was tested using basic research prior to


treatment development or treatment principles were assessed using basic research prior to

treatment development. This group of treatments includes Acceptance and Commitment Therapy

(ACT) for Depression, Schizophrenia, and Mixed Anxiety Conditions, Mindfulness-Based

Cognitive Therapy (MBCT) for Depression, Cognitive Behavioral Therapy (CBT) for Social

Anxiety Disorder and Generalized Anxiety Disorder, Moderate Drinking for Alcohol Use

Disorders, and Behavioral Treatment for Alcohol Use Disorders (for details, see Table A in the

Supplementary Material). Some of these treatments are based on early conditioning theories and

are thus grounded in research dating back more than 40 years (e.g., Wikler, 1965). Exceptions

are ACT and MBCT, where treatment targets (processes) were selected based on more recent

theoretical models that have been tested in basic research prior to treatment development, further

supporting our conclusion above that there are only a few recent examples of novel effective

interventions being developed based on basic research.

3.3. Psychological Treatments With a Modest or Weak Link to Basic Research

The remaining 23 treatments only show a modest to weak link to basic research, or even

no link to basic research at all. Many of these interventions are purely based on models derived

from clinical experience (e.g., Assertive Community Therapy for Schizophrenia: Stein & Test,

1980; Friends Care for Mixed Substance Abuse: Brown et al., 2001), whereas others are either

partly predicated on theory based on findings from basic research (Problem Solving Therapy for

Depression, D’Zurilla & Goldfried, 1971) or use some principles which originated through basic

research (Illness Management and Recovery for Schizophrenia, Kopelowicz, Liberman, &

Zarate, 2006). More recent examples from this are the Cognitive Behavioral Analysis System of

Psychotherapy for Depression (CBASP; McCullough, 2006), or Emotion-Focused Therapy for

Depression (Greenberg, 2004).

3.4 Conclusion

For the five (groups of) disorders with the highest disease burden, we closely examined

evidence-based treatments either listed by the APA’s Division 12 as interventions with modest to


strong research to support them (Society of Clinical Psychology, 2021, Nov 16) or recommended

by recent NICE guidelines. Results showed that the majority of evidence-based treatments with

strong or very strong research support fall into one of two groups. The first group comprises

CBT-based interventions that heavily rely on basic research conducted over 40 years ago, such

as basic learning theory or cognitive models of psychopathology. The second group is made up

of treatments that are only moderately or weakly based on basic research. Only very few

treatments have been developed and/or modified based on more recent basic research. These

notable exceptions include MBCT for relapse prevention in depression (Segal et al., 2013), ACT

(Hayes et al., 2013), and cognitive remediation for schizophrenia (Bowie et al., 2020).

Taking into account the extensive basic research literature on these five (groups of)

disorders, we conclude that translation of basic research findings into the development of new

evidence-based interventions or substantial further development and improvement of existing

psychological treatment approaches has – at least in recent years – not been the rule, with only

23% of treatments showing a very strong link between basic research and the development of the

intervention, and further 20% showing a strong link. When interpreting these findings, it should

be considered that some of our criteria for classification of the link between basic research and

intervention development were challenging to assess, for example, whether basic research was

conducted prior to treatment development. We therefore cannot rule out that we overestimated

the strength of the link in some cases. Nevertheless, it can be argued that our findings challenge

the standard narrative of clinical psychology. Of course, this does not necessarily mean that

translation of basic research findings into clinical innovation is not possible or not promising to

pursue. However, it shows that translation does not appear to be occurring as regularly as is

commonly assumed. In the remainder of this article, we will review challenges that may

contribute to a low level of translation of basic research findings into clinical interventions, and

discuss possible solutions to overcome these challenges.


4. A Framework for Translational Research in Clinical Psychology

4.1 Why Do We Need a Model of Translational Research?

Within the field of clinical psychological science, basic and applied research typically

represent two rather separate scientific disciplines, which differ with regard to the research

questions they address as well as standards used in the research process regarding designs,

methods and settings (Forsyth & Zvolensky, 2001; Waters et al., 2016; Zvolensky et al., 2001).

Both fields are highly specialized and adhere to domain-specific methodological standards.

Specifically, there is extensive high-quality basic research leading to the discovery and

understanding of important processes involved in psychopathology. In addition, there is also

extensive clinical trials research that tests traditional, novel or refined psychological

interventions, and follows clinical trial technology (e.g., Guidi et al., 2018).

A number of authors have highlighted that there is a lack of integration and

communication between these two research areas within clinical psychology and that this

contributes to the translational gap (Milton & Holmes, 2018; Sheeran et al., 2017; Waters et al.,

2016; Zvolensky et al., 2001). Of note, systematic research bridging the gap between the basic

research results and testing of interventions targeting these processes is comparatively sparse. In

addition, although there are explicit universally accepted methodological standards for both basic

and applied research in clinical psychology, these do not exist to a similar degree for

translational research aiming to empirically study how knowledge of processes involved in the

development and/or maintenance of psychopathology can be transformed into novel and/or

improved interventions that can then be tested using standard clinical trial technology. In order to

examine the challenges of translational research as well as possible solutions in more detail, we

will therefore first propose a framework for translational research in clinical psychology that is

heavily based on the experimental medicine approach (Riddle et al., 2015; Sheeran et al., 2017).

In the context of the current manuscript, the framework serves two main functions. First, from

our analysis of the literature in Chapter 3, we have concluded that basic research only rarely


leads to clinical innovation. In Chapter 5, we will discuss why this may be the case, and will

argue that translational research in clinical psychology poses a number of non-trivial challenges

that may explain the low rate of successful translation. The framework will guide this discussion

by providing a prototypical sequence of research designs and aims, on the basis of which

challenges related to each of the steps in this sequence can be discussed in more depth. Second,

the framework will be used to delineate possible solutions to these challenges. For example, we

will argue that developing an explicit framework for translational research will aid future

research in this area.

4.2 A Framework for Translational Research in Clinical Psychology

Our framework for translational research in clinical psychology aims to integrate and

extend earlier conceptualizations (Clark, 2004; Ehring et al., 2011; Forsyth & Zvolensky, 2001;

Kraemer, 2016; Kraemer et al., 2002; Onken et al., 2014; Riddle & Group, 2015; Sheeran et al.,

2017; van den Hout et al., 2017; Vervliet & Raes, 2013; Zvolensky et al., 2001). We suggest that

translational research typically involves a sequence of steps (for an overview, see Figure 1),

whereby each step is characterized by specific goals as well as specific methods and designs that

distinguish this step form the other ones. The steps are presented in a sequential order as each

subsequent step is based on the results of the earlier ones. Importantly, however, the different

steps are thought to be inter-related in more complex ways (see dotted lines within the figure),

with, for example, results from clinical studies raising novel basic research questions (see also

Waters et al., 2016). Importantly, research in all areas is suggested to be heavily based on

underlying theoretical models on the etiology of the clinical phenomenon under investigation as

well as theoretical models on the assumed mechanisms and principles of change.

Step 1. The first step consists of identifying processes involved in the development and

maintenance of psychopathology that can serve as potential intervention targets. It can be

expected that the majority of basic research in clinical psychology falls within this area. Typical

designs include correlational studies linking psychological or biological processes to continuous


measures of psychopathology or studies comparing a diagnosed clinical group to one or several

(non-)clinical control groups with regard to a certain process. Putative processes for this type of

research are typically selected based on theory, exploratory findings, and/or phenomenological

observations (Clark, 2004; Ehring et al., 2011). More refined designs include longitudinal studies

testing whether a process predicts future development or maintenance of psychopathology.

Although conclusions that can be drawn from longitudinal data exceed that of cross-sectional

studies since temporal precedence of a process can be tested, it should be noted that these are

still correlational, thereby belonging to Step 1 of our model (van den Hout et al., 2017).

Step 2. Once a process has reliably been shown to be associated with psychopathology,

the next step consists of establishing causality via Experimental Psychopathology (EPP)

Research (for reviews, see Forsyth & Zvolensky, 2001; van den Hout et al., 2017; Zvolensky et

al., 2001). An important characteristic of EPP research is that the psychological process serves as

the independent variable and is thus experimentally manipulated in order to investigate its effect

on psychopathological signs or symptoms as dependent variables. For example, if Y is some

feature of psychopathology (e.g., OCD symptoms) and X may be a pathogenic process (e.g.,

inflated responsibility interpretation), then inducing X should lead to Y, while not inducing X

should not lead to Y. If this is the case, we can infer that X is sufficient for Y to occur (van den

Hout et al., 2017). Within this general framework, different research questions and designs are

possible (for a systematic overview, see Forsyth & Zvolensky, 2001). As a whole, EPP research

aims to elucidate whether, how, when, and why specific processes result in maladaptive

behavior(s) or other psychopathological symptoms using an experimental approach whereby the

putative causal process is manipulated. Possibly the most important distinction in EPP designs

concerns the question of whether non-clinical participants or individuals suffering from (sub-

)clinical levels of psychopathology are included. Following terminology proposed by Forsyth


and Zvolensky (2001)4, Type-I EPP research is a design to test the causal role of a defined

process for the development of defined symptoms, whereas Type-II EPP research designs give

an indication of the modulation of already existing symptoms. In both EPP research designs, a

process of interest is manipulated and its effect on symptoms is tested; however, they differ with

regard to the groups included. Type-I EPP research requires including individuals who currently

do not suffer from the tested symptoms. For ethical and practical reasons, these studies need to

focus on transient symptoms of low severity as dependent variables, which raises important

questions regarding external validity (see Section 5.3 below for a more detailed discussion).

Type-II EPP research, on the other hand, includes individuals currently suffering from

psychopathological symptoms or disorders. Thus, Type-II research allows somewhat different

conclusions from Type-I research: The causality of a certain process on the modulation of

already existing symptoms can be tested, namely, how are certain symptoms maintained or

increased, as well as what leads to a reduction of these symptoms. However, concluding from the

results of a Type-II experiment how certain symptoms develop would be similar to an ex-

juvantibus argument, that is, assuming that the effects of a cure for a certain condition (e.g.,

Aspirin for headaches) would tell us something about the cause of the condition (e.g., lack of

Aspirin causing headaches), which is a logical fallacy (see van den Hout et al., 2017).

Step 3. Once EPP research has shown that a certain process is causally linked to

psychopathology (Type-I EPP research) and/or its maintenance or modulation (Type-II EPP

research), this process can be regarded as a promising treatment target. The next step then aims

to develop and refine intervention strategies to modify this process. In contrast to EPP research,

the psychological process is now the dependent variable, and the interventions are

experimentally induced to change the process. According to several authors, this is a crucial step

for the translation of basic research findings to clinical interventions that often requires

4 Note that Forsyth and Zovelensky (2001) include two additional types of research (Type III and Type IV) in their classification. However, as these do not use an experimental design, they do not qualify as EPP research in a more narrow sense, and would thus rather fall within Step 1 of our framework.


systematic research efforts and an iterative process leading to the sequential refinement of

intervention strategies and best ways of delivery (Clark, 2004; Salkovskis, 2002; Waters et al.,

2016). This step often combines experimental analogue studies in non-clinical or sub-clinical

populations (Waters et al., 2016) with “therapy experiments” in (sub-)clinical samples (Clark,

2004).

Despite its high potential, this step is arguably the least frequently used in current clinical

psychology. We will therefore provide an example to illustrate this type of research. In their

cognitive model of social phobia, Clark and Wells (1995) suggest (1) negative self-processing

during social situations that is mainly focused on internal information, and (2) engagement in

safety behaviors, as two key factors maintaining social anxiety. Based on their model, the

authors have developed a cognitive therapy program for social phobia that has been shown to be

highly effective (Clark et al., 2006). Importantly, in the process of developing the treatment,

Clark and colleagues have conducted therapy experiments in sub-clinical populations to test

whether interventions aimed at modifying the key processes indeed show the intended effect,

and/or how these interventions can best be delivered to change the target processes. For example,

Clark and Wells (1995) suggested that video feedback may be an effective strategy to reduce

negative self-processing and negative appraisals regarding the self by providing external

information about one’s performance in social situations that may counteract the strong focus on

internal information. However, it remained unclear how video feedback could best be

implemented to achieve this aim. Harvey et al. (2000) therefore conducted a therapy experiment

testing whether the effects of video feedback could be improved by a cognitive preparation. The

cognitive preparation first focuses on the patients’ prediction of how they will appear in the

video and forms a vivid image of themselves giving the speech and then contrasts this prediction

with the video. Results showed that video feedback was most effective in reducing negative self-

evaluation in combination with this cognitive preparation.


Step 4. Based on results from Step 3, on theoretical ideas regarding mechanisms and

principles of change, as well as on clinical expertise, new or improved interventions are then

developed and tested using clinical trial methodology. One important research question in this

step concerns the efficacy of novel or improved interventions (Step 4.1), with randomized

controlled trials (RCTs) typically being regarded as the gold standard research design (Guidi et

al., 2018). In these studies, the effect of an intervention on psychopathological outcome(s) is

investigated using an experimental design. However, there is also a renewed interest in

alternative designs. Those designs include open trials and multiple-baseline single case studies,

at least as a first step before conducting time- and resource-intensive RCTs (Kazdin, 2016), or

adaptive rolling designs testing multiple treatment options simultaneously and using Bayesian

statistics to remove and/or add treatment arms while the study is ongoing (Blackwell et al.,

2019).

Another important issue in this step is focused on the question of which processes

mediate treatment effects (Kraemer et al., 2002), including those that can be considered

mechanisms of change (Kazdin, 2007) (Step 4.2). Additionally, it is important to identify which

treatment works best for a specific group of patients (i.e., moderation) (Kazdin, 2007), how

treatment non-response can be predicted (e.g., De Carlo et al., 2016; Taylor et al., 2012), and

what are predictors of dropout (Swift & Greenberg, 2012) (Step 4.3), with the aim of further

improving acceptability and efficacy for a broad range of patients. A final very crucial aspect

that we would like to subsume in this step is testing the effectiveness of interventions, that is,

whether results found in controlled RCT research can be replicated in routine clinical settings

with non-selective patient populations and therapists with typical training, supervision, and case

loads. Step 4 can of course further be subdivided into different stages with the aim to optimize

both efficacy and implementability of interventions. For example, the NIH stage model suggests

a sequence ranging from intervention development and refinement (Stage I; roughly equivalent


to Step 3 in our model) via efficacy research in research setting (Stage II) followed by efficacy in

community settings (Stage III) to effectiveness trials (Stage IV) (Onken et al., 2014).

Step 5. Interventions that have been shown to be efficacious and effective in Step 4 then

need to be disseminated and implemented in clinical practice. As described in Section 2 of this

article, clinical guidelines as well as other compilations of empirically-supported treatments

(e.g., the APA Division 12 list) play an important role in disseminating results from controlled

clinical research conducted in Step 4 to clinical practice. Clinical guidelines are typically based

on a systematic review of the available empirical evidence that is then translated into

recommendations for clinical practice in a structured consensus process.

Step 6. On the basis of results of clinical trial research that is summarized in clinical

guidelines, empirically-supported interventions then need to be disseminated to a large number

of clinicians and implemented in clinical practice. This step also requires systematic research on

how to optimize this process (for a review, see Lilienfeld et al., 2013).

4.3 Summary and Conclusion

In sum, our framework suggests that improving psychological treatment for mental

disorders based on basic research requires a number of different steps, whereby each step is

characterized by unique goals and specific research methods and designs. When looking through

the lens of this framework, we can conclude that current basic research in clinical psychology is

mostly focused on Step 1. Applied clinical research, on the other hand, mainly focuses on

establishing a causal effect of the intervention on the outcome (Step 4.1) with a much less strong

emphasis on the mechanisms of change. One reason for the low rate of translation of basic

research findings into clinical innovation may therefore be the relative paucity of studies

focusing on Steps 2, 3, and 4.2 (see also Sheeran et al., 2017; Waters et al., 2016). However, at

each step of the translational process a number of additional challenges are conceivable that may

ultimately lead to a low rate of innovation in clinical interventions based on basic research.


5. Challenges and Possible Solutions

5.1 Introduction

In Section 3, we concluded that translation of basic research findings into improvement

of clinical practice does not happen as frequently as assumed by the standard narrative of clinical

psychology. In Section 4, we suggested that one of the main reasons for the lack of successful

translation may be the gap between basic and applied research in clinical psychological science.

Based on earlier concepts, we proposed a framework for translational research consisting of a

sequence of inter-related steps, whereby each step is defined by different goals, research

methods, and designs. In this section, we will move from this bird’s eye view to zooming in on

more specific challenges to conducting translational research following this framework (see

Table 1 for a summary). Some of these challenges are related to many (if not all) of the steps

outlined in our framework, whereas others are more specifically tied to specific steps.

- Insert Table 1 about here -

5.2 General Challenges

5.2.1 Division Between Basic Research and Clinical Interventions Research

One reason for the apparent gap between basic and applied research may be that studies

bridging the gap (e.g., Step 3) require considerable expertise in both basic research as well as

know-how on clinical intervention principles. Given the high level of specialization in the field,

not all research groups in clinical psychology may currently possess the expertise and resources

to perform all steps in the translational chain, including lab-based and clinic-based studies,

studies with non-clinical and clinical participants, and studies using experimental vs. mediational

designs (see also Waters et al., 2016). Furthermore, even in research groups with expertise across

the translational chain, studies linking basic research with applied research is rare, which may

suggest that basic vs. applied research are often separate strains of research within the field or

even within research groups. Importantly, however, a number of authors have argued for an

integrated approach with strong structural links between basic research and treatment


development. For example, Clark (2004) emphasizes the need for an interplay between theory,

basic experimental research, and treatment development, which should ideally be conducted

within one research group or institute. Similarly, Kindt (2018) highlights a need for bi-

directional translation where basic research findings on important treatment targets and/or

intervention principles inform the development of novel interventions, experiences and data on

the efficacy and working mechanisms of these interventions in a clinical context, then in turn

feed back into further theoretical development and advanced additional basic research (see also

Holmes et al., 2014). The potential advantages of such an integrated research approach are

immediately apparent. However, such an approach requires a solid structural basis where

resources and expertise for both basic and clinical research are present within one organizational

unit focusing on certain disorders and/or processes across the whole range of designs and

research questions outlined in Figure 1 (see also Forsyth & Zvolensky, 2001, who suggest

creating Translational Research Centers for this purpose). As highlighted by Hayes (1987), there

is also a language gap between basic research focusing on precise models that are not necessarily

broad in scope, and clinical application favoring concepts that are often broad but tend to be

technically imprecise. He calls for a mutual interest model where basic researchers, clinically-

oriented researchers, and practitioners collaborate and communicate in areas of overlapping

interests. However, this arguably needs a solid structural basis, and not just a declaration of

interest. There are some examples for research centers built around this idea that have been

successful in developing novel interventions. For example, Clark (2004) has attributed his

research group’s success in improving treatments for anxiety disorders to the deliberate interplay

between basic research, clinical observations, and systematic translational research.

5.2.2 Limited Resources and Funding

An additional and related reason why a research program spanning basic as well as

applied research is rarely realized is the fact that it is both time-consuming and expensive. A

number of authors have highlighted that across the globe, mental health research receives a lower


proportion of health funding than other areas, especially when regarded relative to health burden

(Christensen et al., 2011; Hazo et al., 2017; van der Feltz-Cornelis et al., 2014; Wykes et al.,

2015). Therefore, there is an urgent need to increase funding in this area.

5.3 Challenges (Mainly) Related to Steps 1-3

We will now turn to challenges that primarily concern the early steps in the translational

change that are focused on identifying potential targets for interventions and developing novel

intervention strategies. Although this manuscript specifically focuses on one function of basic

research in clinical psychology, namely to provide the basis for the development of new and/or

improved psychological interventions, it is important to note that this is by far not the only aim

of this type of research. Instead, curiosity-driven research aiming to better understand basic

psychological mechanisms or mechanisms involved in the development and maintenance of

psychopathology without any direct applied implications is valuable and worthwhile in itself. In

addition, it is not always possible to predict which basic research findings will ultimately be

useful for any applied purpose, which underlines the importance of posing any restrictions on the

topics that are investigated in basic science (see e.g., Deutsch, 2011). Importantly, our following

discussion of challenges and possible recommendations for the early stages in the translational

process is compatible with the view that basic science serves many purposes and should not be

restricted too early on. However, we will specifically focus on the conditions that hinder or

promote later translation of basic research findings into clinical practice.

5.3.1 Stability and Replicability of Basic Research Findings

From a translational perspective, basic research in clinical psychology (Step 1 of our

framework) is crucial to identify processes related to the development and/or maintenance of

psychopathology that may serve as potential treatment targets. However, the success of

translating knowledge on key processes driving psychopathology into novel or improved

psychological interventions depends on the stability and replicability of the effects identified in

basic research. There is emerging evidence showing that basic research findings in psychology in


general (Shrout & Rodgers, 2018) as well as clinical psychology specifically (Tackett et al.,

2019) are less stable and replicable than traditionally assumed. A number of potential reasons for

this have been highlighted.

First, the lack of stability of basic research findings may be related to poor reliability of

measures typically used in basic research (LeBel & Paunonen, 2011). Paradigms derived from

experimental psychology (e.g., the Stroop task) produce robust experimental effects due to low

between-participant variance. However, because of this low between-participant variance these

tasks show low reliability when focusing on individual differences (Hedge et al., 2018). For

example, when reviewing psychometric properties of commonly used measures of attentional

biases, van Bockstaele et al. (2014) found that all of them either show unacceptably low

reliability or have never been tested for reliability. In general, psychometric properties of

behavioral or biological measures used in basic psychological research are rarely tested and

reported (Parsons et al., 2019). Crucially, there is evidence that low reliability of measures used

as dependent variables is related to replication failure (LeBel & Paunonen, 2011). As a

consequence, when applying behavioral measures alternative metrics may be needed for tasks

assessing clinically relevant individual differences (McNally, 2019), including modeling

approaches (see e.g., Takano et al., 2021).

Second, a large number of studies in psychological research have been found to be

under-powered (Shrout & Rodgers, 2018; Szucs & Ioannidis, 2017). For example, Bakker et al.

(2012) estimated that the average power in psychological studies is around .35 in a two

independent samples comparison. Reardon et al. (2019) recently examined the statistical power

of studies published in two leading journals within clinical psychology (Journal of Abnormal

Psychology; Journal of Consulting and Clinical Psychology). Reassuringly, the average power

was considerably higher than typically reported for other fields of psychology, with average

power to detect a medium effect size of just below .80. Of note, however, even in these two


high-impact journals most studies were not adequately powered to detect small effect sizes that

are typical for basic research in clinical psychology.

Although the combination of lack of statistical power and small effect sizes should lead

to a large number of non-significant findings, it has been shown that the vast majority of

publications in psychology (typically > 80%) report significant findings supporting the

hypotheses (Bakker et al., 2012; Shrout & Rodgers, 2018). It has been suggested that this is the

result of widespread publication bias, which means that significant findings have a higher

likelihood of being published than non-significant ones (Bakker et al., 2012; Kühberger et al.,

2014).

Finally, there is evidence that the stability and replicability of published findings is

further reduced by the use of questionable research practices resulting in inflated false positive

error rates in the psychological literature (Bakker et al., 2012; Simmons et al., 2011;

Wagenmakers et al., 2012). Questionable research practices need to be clearly distinguished

from outright fraud, but refer to research practices that are rather widespread and have often been

encouraged by policies related to job prospects, grant funding, and publication in peer-reviewed

journals (Nosek et al., 2012). Questionable research practices that have frequently been

highlighted in the literature include the lack of a clear distinction between exploratory and

confirmatory research, selective reporting of results on different dependent variables, making the

end of data collection dependent on results of interim data analyses, conducting multiple

analyses with slight variations (e.g., entering covariates, dropping conditions or groups, deleting

participants), and incorrect reporting of statistical findings (Bakker & Wicherts, 2011; Shrout &

Rodgers, 2018; Simmons et al., 2011).

In sum, there is evidence for a lack of replicability and stability of research findings in

psychology in general, but also basic research in clinical psychology, specifically. However, it is

conceivable that the translation of basic research findings into novel or improved clinical

interventions requires the identification of processes that can be assessed in a reliable and valid


way, and that show a stable and substantial relationship with psychopathology. In other words,

the research principle laid out in the standard narrative of clinical psychology – that is, leading

from understanding basic processes involved in psychopathology to developing effective

interventions by directly targeting these processes – can only be successful if basic research

indeed leads to stable and replicable findings on the nature and characteristics of these processes.

The methodological challenges described above may therefore provide one explanation for the

apparent translational gap. This also means that in order to increase the potential of basic

research to lead to clinical innovation, a first step would involve attempts at improving stability

and replicability of basic research findings. A number of important remedies have been

suggested in the literature to address the methodological challenges described above (for detailed

reviews of these measures, see Ioannidis, 2014; Krypotos et al., 2019; Parsons et al., 2019;

Shrout & Rodgers, 2018; Tackett et al., 2019). These include:

a stronger focus on the reliability of basic research measurements, including standard

reporting;

increasing research transparency and collaboration by open science practices including

study preregistration and data sharing;

putting greater emphasis on the need for systematic replication;

use of improved statistical tools, including refined power analyses, and use of Bayesian

analyses;

incentivizing good scientific practices and open science.

According to a recent audit study, open science practices are not routinely enforced in the

field of clinical psychology to date (Nutu et al., 2019). Thus, there is considerable potential for

implementing these procedures in our field.

5.3.2 Lack of Basic Studies Establishing Causality and Investigating Change Procedures

Several authors have highlighted that the vast majority of studies within basic research in

clinical psychology fall within Step 1 (correlational research identifying processes related to


psychopathology); the identification of potential treatment targets is then usually more or less

directly followed up by applied research testing the effects of (novel or modified) interventions

targeting these processes on psychopathological outcomes (i.e., Step 4.1) (Sheeran et al., 2017;

Waters et al., 2016). From a translational perspective, there are two crucial problems with this

strategy. First, a novel intervention can be expected to be most effective if the process has a

causal effect on the development and/or maintenance of psychopathology. However, neither Step

1 nor Step 4.1 is suitable to test causality. Step 1 typically does not include experimental

methodology; although Step 4.1 typically uses an experimental design, it is aimed at establishing

a causal relationship between an intervention and psychopathology, but not the causal effect of

manipulating the process on psychopathological outcome (see also Figure 2 for an illustration).

Therefore, EPP research (Step 2) is needed to establish this causal relationship. Of note, while

the experiment is the undisputed gold standard to establish causality, there are instances where

true experiments are not possible for ethical or practical reasons. In these cases, alternative

approaches based on observational data have been suggested in recent years (Rohrer, 2018).

The second problem related to jumping from Step 1 (identification of potential treatment

targets) – or even Step 2 – directly to Step 4.1 is the fact that even if we know that we should

target a certain process in treatment, it is still an empirical question to investigate how this

process can best be modified. Clark (2004) highlighted the fact that this may have been less

important in early behavior therapy where intervention procedures could be taken directly from

basic science. More recent cognitive models, on the other hand, are less focused on specific

intervention procedures, but rather specify processes as treatment targets, which makes it

necessary to independently investigate which intervention procedures are best suited to modify

these processes. Using an example from the cognitive bias modification literature, MacLeod and

Grafton (2016) similarly highlight the importance of distinguishing between processes and

intervention procedures. To illustrate, MacLeod and Grafton (2016) refer to the process of

modifying attentional biases to threat. The corresponding procedure would, for example, be an


attentional probe task with contingencies designed to modify rather than assess attentional

biases. MacLeod and Grafton (2016) illustrate serious consequences of failing to maintain the

distinction between process and procedure. For example, if a certain procedure fails to reliably

produce the intended effect (e.g., the attentional probe task does not lead to a reduction of

symptoms of anxiety), it is important to establish why it failed to do so. It could be due to the

lack of causality of the underlying process (e.g., attentional bias modification is not causally

linked to changes in symptoms of anxiety). Or it could be due to a failure of the intervention

procedure used to reliably change the underlying process (e.g., the attentional probe task does

not lead to a modification of attentional biases to threat). Importantly, these two possible

explanations cannot be distinguished when using a design where the intervention is the

independent variable and symptomatology the dependent one (e.g., testing the effect of the

attentional probe task on symptoms of anxiety). Instead, it appears important to independently

test the effect of the intervention on changing the process (e.g., testing the effect of the

attentional probe task on the modification of attentional biases to threat) as well as the effect of

change of process on symptom change (e.g., the effect of modification of attentional biases to

threat on changes in symptoms of anxiety).

In sum, in order to improve translation of basic research findings into clinical innovation,

it appears important to put a much stronger focus on experimental studies testing the effects

manipulating the process on psychopathological outcome (Step 2) and testing the effects of

interventions on changing the process (Step 3) before conducting RCTs that are focused on the

effect of interventions on outcome (Step 4).

5.3.3 External Validity of Basic and Translational Research

EPP research (Step 2) and research developing and refining intervention strategies (Step

3) often uses analogue designs with non-clinical participants as well as other reductionist design

features (e.g., interventions of low intensity and/or duration; short time interval between

intervention and outcome) to establish causality between process and outcome or intervention


and process, respectively (van den Hout, 1999; van den Hout et al., 2017). This raises important

questions regarding the external validity of these studies, specifically, whether results on causal

mechanisms identified in EPP research (Steps 2 and 3) allow for drawing conclusions for

mechanisms involved in clinical populations and settings. There is probably not a single EPP

paper that does not dutifully state in the Limitations section that the use of non-clinical samples

or other reductionist features is a limitation and that results need to be replicated in clinical

samples before any firm conclusions can be drawn. However, the field lacks universally accepted

criteria that could be used to define, ensure, and appraise external validity of EPP research

findings. The lack of nuanced, operationalized, and specific criteria for external validity may

thus be an additional challenge for the successful translation of basic research findings to clinical

innovation. Developing, validating, and using such a framework may, on the other hand, be an

important step forward.

In this context, two criteria often used when evaluating the external validity of EPP

findings may in fact be much less valid than commonly assumed. First, the use of non-clinical or

analogue samples is not per se less valid than studying clinical samples. As discussed in Section

4.2, in order to establish the causality of a candidate process for the emergence of symptoms of

psychopathology, Type-I EPP research on non-clinical participants appears optimal and even

superior to running the same experiment in clinical samples (see also van den Hout, 1999; van

den Hout et al., 2017). However, with low symptom severity, the validity of experimentally

manipulating different intervention strategies with the aim of refining those interventions can be

reduced. It therefore depends on the research question to determine which population and which

degree of reduction is optimal. Second, the discussion of external validity of Type-I EPP

research often focuses on issues of face validity. Examples include: Do the precise procedures,

instructions, or dosages used resemble clinical interventions in the wild? And does the behavior

studied as the dependent variable in the experiment resemble behavior of clinical populations?

Logically, however, face validity is neither necessary nor sufficient for the validity of an


experimental model (for a detailed discussion, see Scheveneels et al., 2016; Vervliet & Raes,

2013). Vervliet et al. have suggested a number of alternative criteria that merit a more explicit

consideration when planning and evaluating EPP studies (Scheveneels et al., 2016; Vervliet &

Raes, 2013). The first is construct validity, which requires a clear theoretical rationale (ideally

also supported by empirical evidence) suggesting why processes that drive behavior or behavior

change in the analogue situation are the same as those in the clinical context. The second is

predictive validity, which refers to how well individual differences in the basic model predict

individual differences in clinical treatment responses. An example of predictive validity would

be whether individual differences in extinction performance in fear conditioning paradigms are

related to the outcome of exposure treatment in patients with anxiety disorders. A strong

relationship would support the validity of using fear conditioning extinction models as analogue

models of exposure treatment (see Scheveneels et al., 2016).

In sum, the success of using basic research findings to develop and refine clinical

interventions can be expected to be substantially dependent on the external validity of basic

research. Developing and using explicit models and operationalized criteria for external validity

of reductionist research should thus improve the chance of identifying processes in Steps 1 to 3

that can indeed be used as targets for novel or improved clinical interventions. On a cautionary

note, it is conceivable that not all relevant processes for the development and maintenance of

psychopathology can be modeled equally well in the laboratory. Similarly, it is unlikely that it is

possible to develop externally valid analogue paradigms modeling all processes involved in a

particular disorder. For example, the trauma film paradigm is an established EPP analogue

paradigm to study processes involved in an individual’s response to traumatic experiences as

well as PTSD symptoms (James et al., 2016). However, not all processes involved in PTSD can

be modeled equally well in this paradigm, based on the criteria of construct and predictive

validity; whereas some memory processes leading to the development of intrusive memories can

be assumed to be similar in the experimental analogue as well as the response to real-life trauma,


this may be true to a much lower degree for other processes (e.g., development of a negative

self-concept).

5.3.4 Fat-Handed Interventions and Easy-To-Vary Theories

The experimental method and focus on causality in EPP research has been developed in

parallel to and inspired by biological and medical sciences, where this has – without any doubt –

been a highly successful strategy (Forsyth & Zvolensky, 2001; van den Hout et al., 2017).

However, discovering causation using the experimental method may be systematically harder in

psychology than in other sciences. Referring to formalized philosophical theories of causation,

Eronen (2020) highlights a number of obstacles that hinder the success of causal discovery in

psychology because of the nature of its subject, that is, internal processes. This includes the fact

that interventions in psychology experiments that aim to manipulate a particular process (see

Steps 2 and 3 of our proposed framework) are typically fat-handed. This means that instead of

surgically manipulating only one defined process, they typically impact on several variables

simultaneously, limiting conclusions regarding causality. In addition, Eronen (2020) highlights

the systematic problem of measuring target processes in order to establish whether a certain

manipulation or intervention has indeed changed this process and only this process. Of note,

whereas these obstacles are thought to be ubiquitous in psychology as a discipline, the degree to

which they apply to a specific research topic or experiment may vary. For example, manipulating

non-psychological variables in an individual’s environment is considerably less fat-handed than

manipulating internal psychological processes (e.g., thoughts, emotions, attentional processes,

etc.). This may be a reason why in Section 3 in our review of interventions based on basic

research, many positive examples for successful translational research were based on early

behavior therapy, where basic learning principles studied in the laboratory were applied to

clinical interventions: These interventions explicitly manipulated non-psychological variables in

the environment (e.g., external reinforcement of certain behaviors in operant interventions;


repeated exposure to threat-related stimuli in exposure treatment) to study their effects on

observable behavior.

A number of important conclusions can be drawn from this observation. First, it is

important to acknowledge that establishing causality in psychology is hard, and systematically

harder than in other fields. Second, this does not mean, however, that establishing causality is not

possible, but it may require a somewhat different strategy than, for example, those used in

biology or medical sciences.

In addition, several authors have pointed out that psychological theories often lack

precision and falsifiability, thus hindering scientific progress (Eronen & Bringmann, 2021;

Oberauer & Lewandowsky, 2019; Robinaugh et al., 2021). According to Deutsch (2011),

theories with high explanatory power are hard to vary, which means that they entail specific

details that are related in a way that changing any detail would affect the whole theory.

Psychological theories, on the other hand, are often rather easy to vary, which in combination

with fat-handed experimental interventions hinders the identification of robust phenomena.

There is an ongoing discussion about how theory formation in psychology could be improved,

with some authors calling for an increased formalization of theories (Oberauer & Lewandowsky,

2019; Robinaugh et al., 2021), making them hard to vary (but see also Yarkoni, 2020, for a

critical view on formalization and a plea for prediction over explanation). Others suggest that

more attention should be given to improving and validating psychological constructs in iterative

processes, with a focus on better understanding robust empirical findings (Eronen & Bringmann,

2021).

5.4 Challenges Related to Clinical Trials (Step 4) and Clinical Guidelines (Step 5)

After having reviewed challenges related to basic and translational research in the early

stages of our framework (see Figure 1), we now turn to challenges and possible remedies in the

later stages of the translational chain, namely, evaluating and disseminating clinical

interventions.


Applied research in clinical psychology has a strong focus on research investigating the

efficacy of manualized interventions using RCT designs (see Figure 1, Step 4.1). There are a

number of good reasons for this focus as RCTs are the gold standard for establishing the efficacy

of treatments and therefore one of the most important criteria for evidence-based interventions

recommended in clinical guidelines and lists of empirically supported treatments (e.g., Society of

Clinical Psychology, 2021, Nov 16). However, it has sometimes been argued that the exclusive

focus on RCT-based research in Clinical Psychology has come at the cost of other research

questions and designs that may be instrumental to improving psychological treatment for mental

disorders.

5.4.1 Lack of Research on Mediators and Mechanisms of Change

Several authors have highlighted that in order to improve psychological interventions, we

need to understand not only whether treatments work, but especially also why and how they work

(Kazdin, 2007; Kraemer, 2016; Lemmens et al., 2016). This can be done by studying mediators

as well as mechanisms of change related to interventions. Whereas RCTs designed to mainly test

the efficacy of interventions can be re-analyzed to test certain aspects of mediation (Kraemer et

al., Guidi et al., 2018; 2002), a complete understanding of why and how treatments work

realistically requires a whole research program using a number of different designs to study

different sub-aspects of this research question. Importantly, although the commonly used

mediation analysis can provide useful information in this context, it has been highlighted that it

is often not used and interpreted in an appropriate way (Fiedler et al., 2011). The influential and

very useful framework by Kazdin (2007), on the other hand, includes a set of eight criteria for

establishing mechanisms of change (see Table 2), only some of which can be studied using

traditional RCT designs. For example, an important criterion for a process to qualify as a

mechanism of change is that changes in the process during treatment precede changes in

symptoms. This requires designs with multiple assessments of both mechanisms and symptoms

during the course of treatment (Lemmens et al., 2016). In addition, designs already discussed for


Steps 2 and 3 are additionally needed to test causality, namely, experimentally manipulating a

putative mechanism of change, and testing its effect on clinical outcome as well as testing the

effects of clinical interventions on putative mechanisms of change. In sum, understanding causal

mechanisms should not be restricted to the early steps in the translational process, but remains

equally important when efficacious interventions have been developed in order to better

understand how and why they work. Of note, understanding why and how treatments work is not

only important to further refine standardized treatment packages but can also directly feed into

clinical practice. For example, Salkovskis (2002) highlights that effective clinical practice is not

only based on knowledge about evidence-based treatment procedures but should be directly

informed by empirically supported treatment principles that are in turn rooted in a theory of the

maintenance of psychopathology as well as mechanisms of change.

- Insert Table 2 about here -

5.4.2 Sparsity of Research on Moderators and Predictors of Treatment Outcome

The main analyses applied to studies using an RCT design focus on testing differences

between different conditions participants have been randomized to. This allows for drawing

conclusions at a group level, that is, whether a certain treatment is on average more efficacious

than a second one. However, there is, of course, considerable variability within groups regarding

responses to treatment, and information on this variability may be highly informative both on

practical as well as theoretical grounds. Therefore, several authors have called for analyses of

moderators and predictors of treatment response to be included in RCT research (e.g., Kraemer

et al., 2002). Recent years have seen a large rise in conceptual and methodological approaches to

studying individual differences in treatment response (Buckman et al., in press; DeRubeis et al.,

2014; Passos & Mwangi, 2020). A challenge to conducting this type of research, however, is that

it requires larger sample sizes than those typically found in RCTs on psychological treatment of

mental disorders (Lutz et al., 2021).

5.4.3 Improving Existing Interventions by Combining Basic and Clinical Research


A detailed description of conceptual, methodological, and statistical approaches to testing

mediation, mechanisms of change, and moderation is beyond the scope of this manuscript (for

more information on these issues see e.g., Crits-Christoph & Gibbons, 2021; Kazdin, 2007;

Lemmens et al., 2016). However, there are a number of important implications that are relevant

for our discussion of challenges to the improvement of psychological treatment by basic science.

First, in order to improve psychological interventions, we need a stronger focus on

mediators, mechanisms of change, and moderators, that is, on understanding why, how, and when

existing treatments work, as this may provide important clues on how to further improve these

treatments. Second, understanding mechanisms of change requires a close interaction between

basic and clinical research (see also Section 5.2.1 for a more detailed description of this issue).

Finally, our framework introduced in Section 4 describes the process of developing interventions

grounded in basic science as a chronological process that suggests developing novel

interventions based on a thorough knowledge of causal processes and optimized intervention

strategies targeting these processes. Whereas we suggest that this is indeed a promising sequence

for translational research, it is not likely that the accumulation of knowledge only happens in one

direction. Instead, the dotted backward arrows shown in Figure 1 suggest that each subsequent

step in the sequence will ideally also inform earlier steps, sometimes also termed back-

translation (e.g., Kindt, 2018). Specifically, when a certain treatment has been found to be

efficacious (Step 4.1) along with first information on possible mediators, moderators, and

predictors of response (Steps 4.2 and 4.3), this typically raises new research questions, at least

some of which require going back to earlier steps in the translational chain. This includes

studying mechanisms of change, refining and testing theoretical assumptions underlying the

intervention, and systematic testing of how the intervention techniques can be improved and/or

adapted for subgroups of patients who do not yet respond to a sufficient degree.

There are several examples in the literature showing that using a combination of basic

and applied research to better understand how, why, and when psychological treatments work,


and then using this knowledge to further improve these interventions, may be a very promising

strategy. For example, exposure in vivo is an empirically-supported treatment for anxiety

disorders, based very strongly on basic research in clinical psychology, namely early learning

theory (see Section 3). However, exposure in vivo as currently used in clinical practice has

evolved from its predecessor, Systematic Desensibilization, through a long series of basic

experimental as well as clinical studies, including dismantling research aimed at understanding

why and how the treatment works, as well as pre-clinical and clinical research that tests optimal

conditions for exposure treatment to be efficacious (Hamm, 2014). In recent decades, basic

research has focused on further unraveling the mechanisms of change in exposure therapy

showing that instead of erasing the threat-meaning of the stimulus, an additional – inhibitory –

meaning (conditioned stimulus + no unconditioned stimulus) is learned (Craske et al., 2008).

Based on this inhibitory learning theory approach, there has been systematic research

investigating how exposure treatment can be implemented to foster the development of new non-

threat associations, to enhance the retrieval of those newly learned associations, and to inhibit

activation of old threat associations (Craske et al., 2014). The mediating role of these strategies

has been tested in various settings and has shown some promising results (for an overview see

Weisman & Rodebaugh, 2018). In sum, exposure treatment for anxiety disorders is an example

of a highly efficacious intervention that was originally developed based on basic research (as

examined in Section 3), and can also serve as an example of the promise of using a combination

of basic and applied research to further improve existing treatments5.

Exposure treatment is just one example where a combination of basic and applied

research has helped to refine treatments. In fact, it is quite common in disorder-specific

cognitive-behavioral therapy (CBT) approaches that existing interventions are modified and/or

complemented by add-on interventions to increase efficacy. Further examples of efficacious

5 On a side note, this is an interesting example of a case where the development of a highly effective intervention was strongly based on theory and basic research, but later scrutiny showed that the theoretical basis was not correct. This emphasizes the need for studying mechanism of change and engaging in back-translation.


modifications of existing treatments are the development of new versions of CBT for social

anxiety disorder and PTSD by Clark and Ehlers based on basic research (Clark, 2004; Ehlers &

Clark, 2008), the improvement of behavioral activation for depression based on results from

working mechanisms (Martell et al., 2001), the development of enhanced CBT-I for insomnia

based on experimental research on cognitive factors involved in insomnia (Harvey et al., 2005),

and the development of rumination-focused CBT for depression based on research into working

mechanisms (Watkins, 2016). Examples of add-on interventions include meta-cognitive training

as an intervention specific for patients with positive symptoms of psychosis based on basic

research on cognitive biases in psychosis (Moritz & Woodward, 2007), or approach bias

modification as an add-on to interventions for alcohol use disorders (Wiers et al., 2011).

Importantly, however, these types of clinical innovation based on basic research are mostly not

reflected in current clinical guidelines, and therefore possibly do not reach clinical practice at a

large scale. One reason for this is that there is a considerable time lag between the discovery of a

new treatment (principle) and its inclusion in the clinical guidelines, due to the time needed to

conduct a sufficient number of high quality randomized controlled trials to reach the minimum

level of evidence needed for a treatment to be recommended for clinical practice. Moreover,

guidelines are only updated once every few years.

In addition, we argue that there are systematic obstacles to treatment innovation based on

basic research entering clinical guidelines. We will turn to this issue in the next section.

5.4.4 Clinical Innovation Does Not Always Show Up in Clinical Guidelines

Current clinical guidelines and compilations of evidence-based treatments (e.g., Society

of Clinical Psychology, 2021, Nov 16) have a number of important characteristics that make it

unlikely for most of the innovations described above to be represented in these guidelines.

First, in line with the dominant disorder-focused approach in clinical psychology and

psychiatry (Dalgleish et al., 2020) and current criteria for empirically-supported treatments

(Chambless & Ollendick, 2001), guidelines focus on treatments for disorders according to DSM


criteria. If a novel or improved treatment approach is of particular use for a certain subgroup of

individuals within a disorder category, for example, defined by a certain risk factor or process

and/or works particularly well in targeting a key process, this is typically not represented in the

guidelines.

Second, guidelines typically reduce complexity by clustering similar treatments, thereby

obscuring variability – or information on differential efficacy – within these clusters. In this way,

guidelines typically favor new “trademarked” treatments over improvements to existing ones.

In other words, a treatment approach that is presented as a new treatment with a separate name

(e.g., ACT, CBASP, schema therapy), is more likely to be examined and described separately

within the guidelines than if an existing treatment is modified, even if this modification is quite

substantial and/or leads to changes in efficacy. For example, within the APA Division 12 list’s

section on anxiety disorders, it is quite broadly stated that the best evidence exists for CBT

including exposure treatments. However, no specific recommendations on how to conduct

exposure treatment are provided, nor does the list differentiate between exposure treatment

following a habituation rationale vs. a version of the same treatment aimed at optimizing

inhibition learning vs. cognitive variants of CBT for anxiety disorders. However, most examples

provided in Section 5.4.3 showing that basic research can lead – and has led – to improved

clinical interventions, represent (sometimes quite substantial) improvements to existing

treatments rather than the development of entirely new types of treatment.

To conclude, clinical guidelines play a crucial and undoubtedly valuable role in the

dissemination and implementation of evidence-based interventions. In order to provide clear

recommendations and be easily accessible to the intended readership, they necessarily need to

reduce complexity. However, a drawback of this key requirement may be that current clinical

guidelines are not designed to effectively represent the cumulative and sometimes subtle

improvements to clinical interventions or to pick up on improvements for subgroups of patients

within a diagnostic category. Therefore, our analysis in Section 3, which was based on


recommendations in current clinical guidelines, may have underestimated the degree to which

basic research has improved psychological treatment for mental disorders. Although this does

not substantially change our evaluation that improvement of psychological treatment by basic

research is currently an exception rather the norm, it may nevertheless lead to a more optimistic

description of the current status of translational research in clinical psychology.

However, regardless of whether the current situation is described as the glass being half

full or half empty, it appears important to consider possible improvements regarding the way that

innovation in psychological treatment can be represented in clinical guidelines. First, it appears

necessary for guidelines to become more specific both in defining the population a certain

recommendation is made for, as well as regarding the intervention that is suggested for this

population. Looking at the population aspect, clinical research as well as clinical guidelines may

need to pay more attention to subgroups of patients suffering from a certain diagnosis. Whereas

only few differences in efficacy between active treatments can typically be found when looking

at the level of diagnostic categories, there may be more room to improve efficacy for certain

subgroups of patients through the use of novel interventions (see also Section 5.4.2 on studying

moderators). This is also in line with recent calls for higher personalization of treatment in

research and clinical practice (Cohen et al., 2021; Fisher & Boswell, 2016).

When looking at the recommended interventions, clinical guidelines may need to revise

how these are classified and described. Whereas guidelines often include very broad categories

(e.g., CBT for anxiety disorders) and/or trademarked treatments, it appears important to pay

more attention to subtle differences between treatment approaches within a certain category, as

long as these are related to differences in efficacy.

Reflecting on how current developments in psychological treatments find their way into

clinical guidelines also raises more fundamental questions for both basic and translational

research, as well as their implementation in clinical practice. First, whereas the track record of

basic research to lead to truly novel interventions that ultimately fulfill criteria for empirically-


supported treatments seems modest, the potential of basic research to substantially improve

existing interventions appears to be rather high. Using basic and translational research

approaches to (a) unravel mechanisms of change, (b) systematically test how interventions can

be tailored to more specifically target these mechanisms of change, and (c) identify processes

responsible for non-response or reduced responding, and develop interventions targeting these

processes may have a higher potential to improve psychological treatments in the short-term than

developing completely novel interventions based on basic science, at least for disorders where

highly efficacious and effective treatments already exist.

Second, whereas the recommendations made so far can be accommodated within the

current disorder-focused approach to classifying evidence-based interventions, some authors are

calling for a more radical paradigm shift regarding how psychological treatment for mental

disorders should be conceptualized and organized. Specifically, this view suggests that it is

promising to adopt a transdiagnostic or process-based approach to understanding and treating

psychopathology (Dalgleish et al., 2020; Hayes, Hofmann, & Ciarrochi, 2020). The jury is still

out as to whether this novel paradigm leads to more efficacious treatments than the traditional

disorder-focused approach. From a conceptual perspective, however, this paradigm may be

better suited to improve translation from basic research findings to clinical interventions since

focusing on processes instead of disorders as the main unit of analysis fits very well with the

translational framework described in this manuscript (for a recent review of the promises and

challenges of transdiagnostic approaches, see Dalgleish et al., 2020).

6. Conclusions and Future Perspectives

Basic research in clinical psychology serves different purposes. However, arguably one

of the most important aims is to ultimately improve clinical practice. It therefore appears

important to critically evaluate the track record of basic research to achieve this aim. In our

review of the literature, we found clear evidence for a translational gap in that only some


evidence-based treatments are indeed rooted in basic research. In other words, historically

successful translation does not appear to be the rule. However, there are different ways that this

key conclusion of our review can be interpreted.

First, one could quite rightly argue that our analysis of current clinical guidelines and the

list of empirically-supported treatments provided by the Division 12 of the APA is rather

conservative and does not do justice to the clinical innovation that has happened in recent years

based on basic research. Indeed, as discussed in Section 5.4, there are systematic reasons why

improvements to existing treatments based on basic research often do not show up in clinical

guidelines. In addition, we had to make decisions regarding the interventions included in our

analyses (focusing on five groups of disorders only), as well as the operationalization of criteria

to score the link between basic research and treatment development; results may have been

different with different inclusion criteria and/or criteria. Furthermore, a large number of novel

treatment targets and treatment principles developed in recent decades have been based on basic

research, including cognitive bias modification (Jones & Sharpe, 2017), neurofeedback

(Trambaiolli et al., 2021), reconsolidation-based interventions (Elsey & Kindt, 2017), and

cognitive control training (Koster et al., 2017). Although none of these treatments meet the

criteria for empirically-supported interventions, yet, nor have they demonstrated superiority over

existing evidence-based interventions, it may be a matter of time before these – and other – novel

approaches reach clinical practice.

In contrast to this first view, one could alternatively conclude that basic research aiming

to understand mechanisms underlying psychopathology may not be a very promising avenue to

improve clinical practice. For example, network theorists have suggested to mainly focus on the

structure and dynamics of symptom networks rather than trying to understand mechanisms

underlying syndromes (Borsboom, 2017; note, however, that network theory and experimental

psychopathology are not necessarily antagonistic but often also regarded as complementary, e.g.,

Fried & Cramer, 2017; McNally, 2016). From a more pragmatic perspective, it appears


noteworthy that there have been a number of novel and improved clinical interventions

introduced into the field in recent decades (see Table A, Supplementary Material) but that most

of these have come out of clinical practice and/or applied research rather than being translated

from basic research. Translation based on basic research is therefore clearly not the only source

of clinical innovation (Emmelkamp et al., 2010).

In our own opinion, none of these radical interpretations are currently justified. Instead,

examples of both early behavior therapy – where basic laboratory-based research led to the

development of highly efficacious interventions – as well as of promising novel treatment targets

and intervention principles developed in recent decades show that translational research is

promising and worth pursuing. However, the translational path from basic research to clinical

innovation does not appear to happen automatically or easily. Instead, it is complicated by a

number of serious challenges, each of which appears to reduce the likelihood that identifying a

promising target process for psychological interventions ultimately leads to interventions that

improve clinical practice. Therefore, the most important conclusion appears to be that as a field,

clinical psychology needs to more explicitly discuss and develop strategies to improve

translation.


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Table 1. Challenges to Translational Research in Clinical Psychology and Possible Solutions

Challenge Possible solutions Article section

Lack of integration and communication

between basic and applied research within

clinical psychological science

Follow framework for Translational Research systematically linking basic and applied

research

Improve structural basis for collaboration between basic and applied researchers

5.2.1

Limited resources and funding Increase funding for (translational) mental health research 5.2.2

Lack of stability and replicability of basic

research findings

Stronger focus on reliability of measurements

Increasing research transparency and collaboration (e.g., preregistration; data sharing)

Strong emphasis on replication

Improved statistical tools (e.g., refined power analyses; Bayesian statistics)

Incentivize good scientific practice and open science

5.3.1

Lack of basic studies establishing causality

before moving from Step 1 (identification of

treatment target) to Step 4 (testing complex

clinical intervention)

More frequent use of experimental research in Step 2 (process → outcome) and Step 3

(intervention → process)

5.3.2


Challenge Possible solutions Article section

Unclear external validity of basic and

translational research

Developing commonly agreed criteria for external validity of EPP research (e.g.,

focusing on predictive, construct, and diagnostic validity), and designing and

evaluating studies accordingly

5.3.3

Fat-handed interventions and easy-to-vary

theories

Focus on robust empirical findings; searching for multiple sources of evidence

Improving theory building (e.g., via formalization), and focusing on construct validity

5.3.4

Imbalance between research focused on

efficacy compared to research on mediators,

mechanisms of change, and moderators

More emphasis on studying mediators and mechanisms of change in applied Clinical

Psychology

Integration of basic research (Steps 2 and 3) and applied research (Step 4.2) when

investigating mechanisms of change

Using basic research to further improve existing psychological interventions is a

promising strategy

5.4.1 – 5.4.3

Clinical innovation does not always show up in

clinical guidelines

Guidelines should pay more attention to subgroups, add-on interventions, and

variations within broad treatment groups

Development of interventions for processes instead of disorders

5.4.4


Table 2. Criteria for Mechanisms of Change According to Kazdin (2007)

1. Strong association between intervention and mechanism

2. Strong association between mechanisms and therapeutic change

3. Specificity of the association between intervention, mechanism, and outcome

4. Relationships are consistent and replicated across studies

5. Experimental manipulation of mechanisms changes outcome

6. Change of mechanism precedes change in outcome

7. Dose-response relationship between mechanism and outcome found

8. Plausible and theoretically coherent explanation for mechanism found

Figure 1: Title and Caption

Figure 1. Framework for Translational Research in Clinical Psychology

Note. The figure shows a conceptual model for translational research, which involves a number of sequential steps, whereby each subsequent step is based on the results of the earlier ones. Within [the parentheses] in Steps 2, 3 and 4.1, we name the manipulated variable followed by the dependent variable. The dotted arrows symbolize that later steps also influence earlier steps.

Figure by Ehring et al. (2022), available at https://doi.org/10.31234/osf.io/7cvh6, under a CC-BY4.0 license.

Clinical trials III• moderators• non-response• dropout• effectiveness

in routine care

Clinical trials II• mediators• mechanisms

of change

4.2

Development and maintenance of

psychopathology

Mechanisms and principles of

change

Establishing causality of the process

Identification of processes

(potential treatment targets)

Clinical guidelines Dissemination & Implementation

Clinical trials IEfficacy1.

[process → outcome]

2.

4.1

4.2

4.3

5. 6.

Theory

[intervention → outcome]

[intervention → process]

Developing/refining intervention strategies to modify the process

3.

[intervention → process]

Figure 2 Relationship between Intervention, Process, and Psychopathological Outcome Note. Step 2, Step 3, Step 4.1 and Step 4.2 refer to our Framework for Translational Research in Clinical Psychology. Step 2: Establishing causality of the process, Step 3: Developing or refining intervention strategies to modify the process, Step 4.1: Clinical trials I (test of efficacy), Step 4.2: Clinical trials II (test of mediators and mechanisms of change).

Mediation (Step 4.2)

Step 2 Step 3

Intervention

Process (treatment target)

Psychopathology Step 4.1

Supplementary Material

Ehring, T., Limburg, K., Kunze, A.E., Wittekind, C.E., Werner, G.G., Wolkenstein, L.,

Guzey, M., & Cludius, B. (2022). (When and How) Does Basic Research in Clinical Psychology Lead to Improvements in Psychological Treatment for Mental Disorders. Clinical Psychology Review, 94: 102163. https://doi.org/10.1016/j.cpr.2022.102163

Table A. Overview of Empirically-Supported Treatments and Their Link to Basic Research

Disorder(s) Treatment Strength of research support according to APA Div 12 list

Recommen- dation by NICE

Underlying theoretical model(s)

Empirical testing of theoretical model in basic research prior to treatment development?

Key treatment targets identified in basic research AND/OR intervention principles/techniques developed in basic research?

Strength of link between basic research and treatment development1

Summary of link between basic research and treatment development

Depression Acceptance and Commitment Therapy (ACT)

Modest Not reviewed Relational Frame Theory; Contextual Behavioral Science (Hayes et al., 2013)

Yes

Yes

Strong Acceptance and Commitment Therapy was developed based on a theoretical model and empirical testing of this model (Hayes et al., 2013). The theory and basic research findings have led to the identification of treatment targets (e.g., cognitive fusion, experiential avoidance; Hayes, 2004). The techniques and intervention principles were not directly developed in basic research.

Depression Behavioral Activation

Strong Recommended Operant learning theory; behavioral model of depression (Lewinsohn, 1974)

Yes

Yes

Strong Behavioral Activation was developed based on early learning theory (operant conditioning) that has been studied extensively in basic research before being applied to treat depression (Staddon & Cerutti, 2003). In addition, it was based on basic research into the role of (lack of) positive reinforcement in depression (Lewinsohn, 1974). The principles of intervention were, however, not based on basic research,

1 Very strong: systematic testing of underlying theory conducted prior to treatment development AND treatment principles/interventions developed or refined in basic research before application (example: exposure treatment). Strong: one of the two criteria for “very strong” present and conducted prior to development of intervention Moderate: some testing of theoretical model or intervention principles prior to or parallel to treatment development, but not in a systematic or extensive way Weak: no basic research directly underlying treatment

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but rather on clinical experiences (Dimidjian et al., 2011).

Depression Cognitive Behavioral Analysis System of Psychotherapy

Strong Not reviewed No formal theoretical model, but reference to developmental origins of chronic depression, role of preoperational thinking, interpersonal processes, and learning principles (McCullough, 2006)

No No Weak Cognitive Behavioral Analysis System of Psychotherapy is not based on a formal theoretical model but the developer makes reference to different models from clinical psychology and proposes hypotheses on the processes involved in the development and maintenance of chronic depression (McCullough, 2006). However, these hypotheses have not been systematically tested in basic research prior to treatment development. Intervention principles and techniques are based on existing behavioral and psychodynamic treatments or were developed based on clinical models, but not developed in basic research.

Depression Cognitive therapy

Strong Recommended Cognitive theory of depression (Aaron T. Beck, 1967)

Partly Partly Moderate to Strong

Cognitive therapy was developed based on a clinical model of depression (Aaron T. Beck, 1967). Treatment principles are mainly based on this clinical model and were not developed in basic research. However, basic research on the role of negative appraisals and cognitive errors in depression took place in parallel as well as subsequent to treatment development (Ingram et al., 1998).

Depression Emotion-focused therapy

Modest Not reviewed Dialectical-constructivist model of human functioning (Greenberg, 2004)

No No Weak - Moderate

Emotion-focused therapy was developed based on a clinical model on the role of emotion in psychopathology with roots in humanistic approaches to

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psychological treatment (Greenberg, 2004). The developers make some reference to basic emotion theory and research, but key assumptions underlying the treatment have not been tested in basic research prior to treatment development. In addition, techniques were not developed based on basic research.

Depression Interpersonal Psychotherapy

Strong Recommended No formal theoretical model but reference to psychodynamic and attachment models of depression and empirical findings on psychosocial aspects of depression (Markowitz & Weissman, 2012)

No Partly Weak - Moderate

Interpersonal Psychotherapy is not based on a formal theoretical model, but authors make some reference to empirically-supported theoretical models (e.g., attachment theory) and empirical findings (e.g., on the role of psychosocial aspects of depression; Markowitz & Weissman, 2012). Treatment targets partly derived from this empirical evidence, but rather loose connection.

Depression Mindfulness-Based Cognitive Therapy (MBCT)

Strong Recommended for relapse prevention

Differential activation hypothesis (Teasdale, 1988); theories on the role of rumination in depression vulnerability (e.g., Response Style Theory; Nolen-Hoeksema, 2004)

Yes

Yes Strong Mindfulness-Based Cognitive Therapy was developed specifically for relapse prevention and is based on basic research that had identified cognitive reactivity and a ruminative response style as key vulnerability factors for depression relapse (Segal et al., 2013). The principles and techniques targeting these processes were not directly derived from basic research but combined existing CBT strategies and mindfulness-based intervention (e.g., meditation, yoga) developed independent of basic research.

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Depression Self-Management/ Self-Control Therapy for depression

Strong Not reviewed Model of self-control (Kanfer, 1970); Self-control model of depression (Rehm, 1977)


Self-Management/ Self-Control Therapy was developed based on a theoretical model (Kanfer, 1970; Rehm, 1977). However, key assumptions of this model were not tested in basic research prior to the development of the intervention. Treatment principles were loosely related basic research findings (e.g., basic learning principles).

Depression Problem-Solving Therapy

Strong Not recommended

Problem-solving theory (D'Zurilla & Goldfried, 1971; D'Zurilla & Nezu, 2007)

Yes Yes Moderate Problem-Solving Therapy was based on a theoretical model highlighting the role of (social) problem solving in depression (D'Zurilla & Nezu, 2007). The model has been tested in basic research in parallel and subsequent to treatment development. The treatment target (problem-solving) was partly identified in basic research. Intervention principles and techniques were not developed in basic research.

Depression Rational Emotive Behavioral Therapy

Modest Not recommended

(Ir-)rational belief model (Ellis, 1995)

No No Weak Rational Emotive Behavioral Therapy was developed based on a clinical model on the role of beliefs in psychopathology (Ellis, 1995). The model was not systematically tested prior to treatment development. Similarly, intervention principles and techniques are not based on basic research.

Depression Reminiscence/ Life review therapy for depression

Modest Not reviewed Heterogeneous approaches with some reference to theories of developmental stages and their specific

Partly Partly Weak - Moderate

Several variants of this treatment approach exist, with reference to different theoretical models (e.g., Arean et al., 1993; Serrano et al.,

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goals (Eriksen et al., 1986) and theories on autobiographical memory in depression (Williams et al., 2007)

2004). Development of one version (Serrano et al., 2004) is based on basic research findings on difficulties remembering specific autobiographical memories in depression and strategies to improve this factor. However, overall only weak to moderate basis in basic research findings.

Depression Self-System Therapy for depression

Modest Not reviewed Regulatory focus theory (Higgins, 1987)

Yes Partly Moderate Self-System Therapy for Depression is based on a self-regulation model stating deficits in self-regulation in depression (especially high discrepancy between actual and ideal selves and high incentive motivation) (Higgins, 1987). Some aspects of the theory have been tested prior to and in parallel with treatment development (Mason et al., 2019). Intervention principles are mainly taken from existing CBT treatments.

Depression Short-Term Psychodynamic Therapy for depression


Heterogeneous approaches based on different psychodynamic models

No No Weak Short-Term Psychodynamic Therapy for depression are heterogenous approaches based on psychodynamic theories with no connection to basic research (for an overview, see Leichsenring & Schauenburg, 2014).

Schizophrenia Acceptance and Commitment Therapy (ACT)


Yes

Yes

Strong Acceptance and Commitment Therapy was developed based on a theoretical model and empirical testing of this model (Hayes et al., 2013). The theory and basic research findings have led to the identification of treatment targets (e.g., cognitive fusion, experiential avoidance, Hayes, 2004). The

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techniques and intervention principles were not directly developed in basic research.

Schizophrenia Assertive Community Treatment

Strong Not reviewed Model is based on clinical experience and intervention studies (Stein & Test, 1980).

No No Weak Assertive Community Treatment was developed to support patients with a high risk for hospitalization with medication management, rehabilitation and social services. The treatment is not based on a formal theoretical model. Clinical experience was used to reduce hospitalization. The developed community treatments were then studied and improved (Rosenheck & Dennis, 2001; Stein & Test, 1980).

Schizophrenia Cognitive Adaptation Training (CAT)

Modest Not reviewed No formal theoretical model (D.I. Velligan et al., 2013)

No Yes Moderate Cognitive adaption training supports patients with schizophrenia to improve everyday functioning by teaching strategies to compensate for cognitive deficits. Treatment is not based on a formal theoretical model, however, treatment principles regarding cognitive impairment in schizophrenia are based on findings from basic research (Velligan et al., 2002).

Schizophrenia Cognitive Behavioral Therapy (CBT)

Strong Recommended Heterogenous group of interventions of which some are based on cognitive models conditioning theory (for an overview, see Dickerson, 2000)

Partly Partly Moderate - Strong

Cognitive Behavioral Therapy for schizophrenia comprises different interventions based on models that are either derived from clinical experience or basic research (e.g., conditioning theory, Dickerson, 2000). Whereas some aspects of the treatment development are based on basic research (e.g., reality testing, relaxation techniques) others are not (e.g.,

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standard cognitive techniques like reattribution).

Schizophrenia Cognitive Remediation


Based on the model of neuroplasticity to restore cognitive functions (Eack et al., 2010)

Yes

Yes Very Strong Basic research has led to the realization of neuroplasticity and the life-long ability to restore cognitive functions (Eack et al., 2010). Basic research has also identified cognitive deficits in schizophrenia (including memory problems, attention deficits, and problems in executive functioning; Heinrichs, 2005) and has established that those can be reduced or compensated by training. Cognitive Remediation is thus based and was adapted based on findings from basic research (see e.g., Medalia & Richardson, 2005)

Schizophrenia Family Psychoedu-cation

Strong Recommended Models are based on clinical experiences (McFarlane et al., 2003)

No No Weak Family psychoeducation is based on clinical experiences which recognized that the family can support the patient’s recovery. To help family members to do so, family psychoeducation gives information, clinical guidance and support to the family members (McFarlane et al., 2003). Neither the model nor the treatment targets are based on findings from basic research.

Schizophrenia Illness Management and Recovery (IMR)

Modest Not reviewed Transtheoretical Model (Prochaska et al., 1982) and stress-vulnerability (Zubin & Spring, 1977)


Illness Management and Recovery is based on clinical models and uses different interventions for the management of psychotic symptoms. Those interventions include psychoeducation, cognitive behavioral approaches to medication adherence,

9








relapse prevention plans, social skills and coping skills training (Mueser et al., 2006). Some interventions (e.g., social skills training) are based on findings from basic research (for an overview, see Kopelowicz et al., 2006).

Schizophrenia Social Learning/Token Economy Programs

Strong Not reviewed Operant conditioning (Sherman & Baer, 1969)

Yes Yes Very Strong Token Economy programs are based on early theories of operant conditioning (Sherman & Baer, 1969). Target behaviors are rewarded with tokens. Those tokens can be exchanged at pre-determined times for rewards (for an overview, see Kazdin & Bootzin, 1972). Both the underlying theory of operant conditioning as well as the development of the intervention is based on basic research (Doll et al., 2013; Kazdin, 1982)

Schizophrenia Social Skills Training


Based on behavioral and social learning theories (for an overview, see Kopelowicz et al., 2006)

Yes Yes Very Strong Social skills trainings are based on early theories of operant conditioning and social learning, which are based on finding from basic research. Social skills training also use techniques such as modeling or prompting, which stem from basic research (for an overview, see Kopelowicz et al., 2006).

Schizophrenia Supported Employment

Strong Not reviewed No formal theoretical model (Drake et al., 1999)

No No Weak The aim of Supported Employment is to help patients with a rapid and individualized placement in a regular job and grants a time-unlimited follow-along support. Supported Employment was developed based on clinical experiences (see Drake et al., 1999).

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Panic Disorder

Applied Relaxation for Panic Disorder

Modest Not reviewed Based on the model of reciprocal inhibition (Lazarus, 1963; Wolpe, 1958)

Yes Yes Very Strong Applied Relaxation is based on the model of reciprocal inhibition (Lazarus, 1963; Wolpe, 1958), according to which relaxation and anxiety are incompatible. Relaxation is taught using Progressive Muscle Relaxation, which is based on early experimental work conducted by Jacobsen (for an overview, see McGuigan & Lehrer, 2007).Wolpe developed a condensed version, which was also tested in experimental research (Bernstein et al., 2007).

Panic Disorder

Cognitive Behavioral Therapy for Panic Disorder

Strong Recommended Conditioning theory (Mowrer, 1960) and cognitive theories of panic disorder (Aaron T. Beck et al., 1985; D. M. Clark, 1986)

Yes Yes Very Strong Treatment is based on early learning theory (classical & operant conditioning) that has been studied extensively in basic research before being applied to treat anxiety disorders as well as on the cognitive model of panic disorder that has been tested in basic research (for an overview, see Moscovitch et al., 2009)

Panic Disorder

Psychoanalytic treatment for panic disorder

Modest/ controversial

Not reviewed Psychodynamic theories on unconscious processes and psychodynamic conflicts (Milrod et al., 1997)

No No Weak Treatment is based on a clinical psychodynamic model. No systematic basic research testing the theory was conducted, nor are intervention strategies/techniques based on basic research (Milrod et al., 1997).

Social Anxiety Disorder

Cognitive Behavioral Therapy for Social Anxiety Disorder

Strong Recommended Conditioning theory (Mowrer, 1960) and cognitive models of social anxiety disorder (Clark & Wells, 1995; Rapee & Heimberg, 1997)

Yes Partly Strong Several variants of CBT for social anxiety disorder exist. They differ in their relative focus on behavioral and/or cognitive strategies. Exposure-based treatment is based on basic learning theory (classical and operant

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conditioning) and stems from extensive basic research testing the basic theories as well as developing and refining treatment principles (Weisman & Rodebaugh, 2018). More recent CBT treatments with a stronger focus on cognitive factors are based on some basic research findings (e.g., the role of attentional processes or intrusive imagery in the maintenance of social anxiety; Weisman & Rodebaugh, 2018). Much of this research has been conducted in parallel or subsequent to treatment development.

Specific Phobias

Exposure Therapy

Strong not reviewed Conditioning theory (Mowrer, 1960)

Yes Yes Very Strong Exposure-based treatment is based on basic learning theory (classical and operant conditioning). Both the basic theories as well as developing and refining treatment principles was based on extensive basic research (Weisman & Rodebaugh, 2018).

Generalized Anxiety Disorder

Cognitive and Behavioral Therapies

Strong Recommended Avoidance theory of worry and generalized anxiety disorder (Borkovec et al., 2004), Intolerance of Uncertainty Model (Dugas et al., 1998); Cognitive theory of anxiety disorders (Aaron T. Beck et al., 1985)

Yes Partly Strong Several variants of CBT for GAD exist, differing in their relative focus on behavioral and/or cognitive strategies. Behavioral interventions are partly based on basic learning theory (e.g., stimulus control techniques), and partly based on a disorder-specific learning theory model of GAD (Borkovec et al., 2004). Cognitive interventions are partly based on general cognitive theory (Aaron T. Beck et al., 1985) and partly on basic research into specific cognitive factors

12








involved in GAD (e.g., intolerance of uncertainty, Dugas et al., 1998).

Generalized Anxiety Disorder

Applied Relaxation

not reviewed Recommended Based on the model of reciprocal inhibition (Lazarus, 1963; Wolpe, 1958)

Yes Yes Very Strong Applied Relaxation is based on the model of reciprocal inhibition (Lazarus, 1963; Wolpe, 1958) according to which relaxation and anxiety are incompatible. Relaxation is taught using Progressive Muscle Relaxation, which is based on early experimental work conducted by Jacobsen (for an overview, see McGuigan & Lehrer, 2007).Wolpe developed a condensed version, which was also tested in experimental research (Bernstein et al., 2007).

Mixed Anxiety Conditions

Acceptance and Commitment Therapy


Yes

Yes

Strong Acceptance and Commitment Therapy was developed based on a theoretical model and empirical testing of this model (Hayes et al., 2013). The theory and basic research findings have led to the identification of treatment targets (e.g., cognitive fusion, experiential avoidance, Hayes, 2004). The techniques and intervention principles were not directly developed in basic research.

Alcohol Use Disorders

Behavioral Couples Therapy

Strong Recommended Based on a cognitive-behavioral treatment model (McCrady et al., 2016)

Partly Partly Moderate The cognitive-behavioral treatment model for alcohol use disorders includes elements that are based on operant conditioning. This principle had been in basic research before being applied to treatment. However, including the spouse in the treatment is based on clinical experiences and not

13








directly linked to basic research (McCrady et al., 2016).


Moderate Drinking for Alcohol Use Disorders

Modest Recommended Based on operant conditioning (see e.g. Strickler et al., 1975)

Yes Yes Strong The Moderate Drinking approach is based on basic learning theory (especially operant conditioning) and was tested using experimental research (starting in the 1970s) before being transferred to clinical practice (see Strickler et al., 1976).

Alcohol Use disorders / Substance misuse

Cognitive Behavioral Therapy

not included Recommended Cognitive model of substance misuse (Beck et al., 1993), conditioning theory, and cognitive-behavioral model of relapse (Marlatt & Donovan, 2005)


Cognitive Behavioral Therapy for substance use disorders typically comprises elements of cognitive therapy, motivational interviewing, and behavioral therapy. Thus, interventions are partly based on clinical models (e.g., cognitive therapy; Beck et al., 1993) whereas other models were developed based on basic research (e.g., conditioning theory). Some treatment principles, such as cue exposure, are based on basic research (Drummond et al., 1990)


Behavioral treatment

not included Recommended Conditioning theory (Drummond et al., 1990; Wikler, 1965)

Yes Yes Strong Behavioral treatment is a generic term that includes a range of interventions such as cue exposure or behavioral self-control. These interventions are based on early conditioning theory and results from basic research (Drummond et al., 1990; Hester, 1995).

Mixed Substance Abuse/Dependence

Motivational Interviewing / Motivational Enhancement Therapy

Strong Recommended for all patients with alcohol-related disorders

Transtheoretical Model of Change (Prochaska et al., 1982)

No Partly Moderate This method was developed by (William R. Miller, 1983) after interviewing individuals with substance abuse. It includes relationship-building principles of non-

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directive therapy (Rogers, 1961) and active behavioral strategies, which are chosen according to the stage of the transtheoretical model of change, that the patient is in (Prochaska et al., 1982). Even though systematic research was done to understand the mechanisms of change and improve motivational interviewing later-on, the development of the intervention was not explicitly based on basic research (Miller & Rose, 2009).


Friends Care Modest Not reviewed Based on a clinical model No No Weak Friends care is an after-care program which includes elements such as supportive counseling, crisis intervention and skills building for relapse prevention. The program is based on clinical experiences (Brown et al., 2001).


Guided Self-Change


Guided Self-Change Model of Treatment Transtheoretical Model of Change (Prochaska et al., 1982); Social Learning Theory (Bandura, 1986)


Guided Self-Change incorporates elements of motivational interviewing, cognitive-behavioral therapy, and relapse prevention. Therefore, some of the methods are based on models that are based from results of basic research (e.g., Bandura, 1986). The program itself was developed on both results from basic research as well as clinical experiences (Sobell et al., 1995).


Prize-Based Contingency Management

Strong not recommended for Alcohol Use disorders/

Operant Conditioning (Sherman & Baer, 1969)

Yes Yes Very strong Prize-based contingency management evolved from basic behavioral research (operant conditioning). The token is a chance to win a prize. The chances increase the longer the abstinence. In

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Recommended for Drug use

comparison to contingency management it is an intermittent reinforcement procedure (Peirce et al., 2006). Systematic basic research has been conducted to enhance the effect of the intervention while lowering the costs (Petry et al., 2017).


Seeking Safety Strong (for adults)

Not reviewed Based on a clinical model according to which safety is the most important tenant in the treatment of comorbid substance abuse and posttraumatic stress disorder (Najavits, 2003).

Partly Partly Moderate Seeking Safety was developed for individuals with both substance abuse and posttraumatic stress disorder (Najavits, 2003). It incorporates elements of, for example, cognitive-behavioral substance abuse treatment, and thus draws upon models and methods which were developed using basic research. However, the program itself was developed based on clinical experiences.

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