Novel Unsupported and Empirically Supported ...

Behavioural and Cognitive Psychotherapy: page 1 of 19 doi:10.1017/S135246581100052X

Novel Unsupported and Empirically Supported Therapies: Patterns of Usage Among Licensed Clinical Social Workers Monica Pignotti and Bruce A. Thyer Florida State University, Tallahassee, USA

Background: While considerable attention has been focused in recent years on evidencebased practice, less attention has been placed on clinical social workers’ choice to use ineffective or harmful interventions, referred to in the present paper as Novel Unsupported Therapies (NUSTs). Method: The present study surveyed 400 Licensed Clinical Social Workers (LCSWs) across the United States in order to determine the extent of their usage of NUSTs, as well as their usage of conventional therapies that lacked support and empirically supported therapies (ESTs). Reasons for selecting interventions were also assessed. Results: While the vast majority (97.5%) reported using some form of EST, 75% of our sample also reported using at least one NUST. Logistic regression analysis revealed that NUST usage was related to female gender and trauma specialization. A split plot ANOVA revealed that respondents rated positive clinical experience higher than published research as a reason for selecting an intervention. LCSWs with a CBT theoretical orientation rated research evidence more highly than those of other theoretical orientations. However, even within the group of LCSWs with a CBT orientation, clinical experience was rated more highly than research evidence. Conclusions: Implications for practice are discussed. Keywords: Evidence based practice, pseudoscience, iatrogenic effects, psychotherapy, cognitive behavioral therapy, therapeutic interventions, empirically supported treatments.

Introduction The majority of psychotherapy providers in the United States are clinical social workers, who outnumber both psychiatrists and psychologists (Hartston, 2008). Over the past decade, considerable attention has been focused on the implementation of evidence-based practice (EBP) in social work and other mental health professions. As mental health professionals, clinical social workers are held accountable to their clients to select interventions most likely to help them and to accurately represent the extent of such evidence or lack thereof (National Association of Social Workers, 1999; Gambrill, 2006; Myers and Thyer, 1997). Consequently, increasing attention is being placed on the importance of properly training social workers in the use of EBP (Parrish and Rubin, 2011; Rubin and Parrish, 2007). EBP has been defined by its developers as the “integration of the best research evidence with clinical expertise and [client] values” (Sackett, Straus, Richardson, Rosenberg and Haynes, 2000, p.1). Clinical expertise refers to relationship skills, past clinical experience,

Reprint requests to Monica Pignotti, Florida State University, Social Work, c/o Bruce Thyer, 296 Champions Way, Tallahassee 32306-2024, USA. E-mail: [email protected]; [email protected] © British Association for Behavioural and Cognitive Psychotherapies 2011

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M. Pignotti and B. A. Thyer

and identifying unique client circumstances, individual risks and benefits, and client values refer to “unique preferences, concerns, and expectations each client brings to the encounter” (p.1). EBP is “not a static state of knowledge but rather represents a constantly evolving state of information” (Thyer, 2004, p. 168). The present study focuses on the first part of the definition, selection of interventions that have the best research evidence for the client’s problems, as well as its opposite, the selection of interventions that lack such evidentiary support and possible reasons for such choices. While a great deal of effort has been spent in identifying interventions that have empirical support, until recently little attention has been focused on interventions that lack empirical support, make unsupported claims, and in worst case scenarios may even do more harm than good. For a few exceptions illustrating social workers exposing ineffective or harmful interventions see Stocks (1998), Sarnoff (2001), Pignotti and Thyer (2009a) and Thyer and Pignotti (2010). Lilienfeld (2007) discussed a number of reasons why it is important to identify ineffective or harmful interventions, even if those being harmed are in the minority. A primary principle included in all mental health and health professional codes of ethics is primum non nocere, which means “First, do no harm” (American Psychological Association, 2002; National Association of Social Workers, 1999). Lilienfeld points out that even though clients, on average, benefit from various forms of psychotherapy, some treatments “can produce harm in a nontrivial number of individuals” (p. 54). Lilienfeld’s concerns have been elaborated upon recently by others who share his concerns (Barlow, 2010; Castonguay, Boswell, Constantino, Goldfried and Hill, 2010; Dimidjian and Hollon, 2010). Dimidjian and Hollon indicated that interventions can do harm in a number of ways, directly or indirectly. Even interventions that, in and of themselves, appear to do no harm may result in opportunity cost (Lilienfeld, 1998, 2002). That is, such interventions might waste an individual’s or an organization’s time and money. Moreover, if such interventions are opted for in lieu of interventions that have empirical support, the client could be indirectly harmed by being deprived of an intervention from which he or she could benefit or at least could prevent the client from further deterioration that may occur with an intervention that lacks support. Interventions that lack adequate empirical support and yet make unsupported claims for their efficacy will hereafter be referred to as Novel Unsupported Therapies (NUST). New interventions that are in the process of being properly researched that do not make claims beyond the data would be excluded from the category of NUSTs, by the definition used in the present study. An example of a NUST would be Thought Field Therapy, a novel therapy that employs finger tapping on purported acupressure points on the body in specified sequences, which claims to cure a variety of psychological and medical problems in minutes and makes unsupported claims of superiority to existing empirically supported interventions (Callahan and Trubo, 2001). Conversely, not all interventions that lack empirical support are necessarily new. Conventional interventions and assessment methods that are widely accepted can nevertheless lack empirical support. Such interventions will, in the present study, be referred to as Conventional Unsupported Therapies (CUST). An example of a CUST would be dream interpretation, a common practice used in conventional therapy that nevertheless lacks credible empirical support. Before social work professionals can attempt to change the practices of clinicians by providing them with the knowledge, the skills and the motivation to select the best practices for their clients, we must first determine the extent to which the problem of the use of

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interventions that lack empirical support exists. In an exploratory study, which was a survey of 191 licensed clinical social workers throughout the US, Pignotti and Thyer (2009b) found that 75% of those who responded to the survey reported having used at least one NUST within the past year. The study did not classify or specifically identify Empirically Supported Therapies (ESTs). The most commonly-used NUSTs included Attachment Therapy (26.5%), Critical Incident Stress Debriefing (22.9%), Critical Incident Stress Management (21.2%), Body-Centered Psychotherapy (21.8%), and EMDR for conditions other than PTSD (15.9%). Although the first three are interventions classified as directly potentially harmful (Lilienfeld, 2007), a caveat to keep in mind is that specifics on what clinicians actually did with their clients was not reported, hence not all of what was reported was necessarily harmful. In addition to identifying what interventions clinicians are choosing, it is important and relevant to understand their reasons for selecting interventions in order to determine the extent to which clinicians value research findings in making such choices. Several surveys of mental health professionals have found that clinicians usually value clinical experience over empirical evidence in selecting interventions (Lucock, Hall and Noble, 2006; Orlinsky, Botermans and Ronnestad, 2001; Riley et al., 2007; Stewart and Chambless, 2007; von Ranson and Robinson, 2006). Orlinsky et al. included a minority of clinical social workers and a variety of mental health professionals, but the other samples were comprised of clinical psychologists. Cook, Schnurr, Biyanova and Coyne (2009) conducted a web-based survey of 2607 Canadian and US psychotherapists to determine influences on their practice choices. They found that the factors most highly influential on current practice were significant mentors, books, training in graduate school, and discussions with colleagues and that “empirical evidence had little influence on the practice of mental health providers” (p. 671). A qualitative study on school social workers suggested that some participants appeared to see evidence-based practice and the practical necessities of clinical experience as being in conflict (Bates, 2006). The present study expands upon our pilot study (Pignotti and Thyer, 2009b), by adding to the sample size and employing an expert review for the classification of therapies as NUSTs and CUSTs and by adding a new category, Empirically Supported Therapies (ESTs), which was not a variable included in the previous study (Pignotti and Thyer, 2009b). Participants in the present survey were also asked to rate how important various reasons (i.e. positive clinical experiences, research) were in the selection of interventions in their practices, data not included in the previous report. Based on prior studies, we hypothesized that LCSWs would rate clinical experience as more important than evidence from research in selecting interventions. We also examined the relationship between sociodemographic characteristics and practice characteristics with the use of novel unsupported and empirically supported therapies and conducted a logistic regression analysis on variables found to be significant in an exploratory bivariate analysis.

Method Data collection and participants Permission was obtained for this study from Florida State University’s Institutional Review Board (IRB). The current sample was comprised of data from 191 participants in an earlier pilot study (Pignotti and Thyer, 2009b) hereinafter referred to as round one. These data were combined with data collected from 209 additional participants (round two), resulting in a total

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of 400 participants from both rounds, with the combined data reported in the present report. Dillman’s (2007) methods were used for invitations to participate, which included an e-mailed pre-letter informing participants about the survey, an initial invitation, and three follow-up requests sent to nonrespondents. Participants were assured that their responses would be anonymous and that data would only be reported as summaries in which no individual’s response could be identified. Both rounds of data collection consisted of study participants who were LCSWs located across the US who advertised their services on the Internet and published their electronic mail addresses on the website www.helppro.com. This database of LCSWs is linked to the National Association of Social Workers’ (NASW) website. This website, described as “the most comprehensive, user-friendly National Social Worker finder” (Helppro, n.d., para 1), was selected as appropriate for this study because LCSWs from a wide variety of specialties listed e-mail addresses that were publicly accessible. Approximately 25% of LCSWs in that database did not have published e-mail addresses and thus had to be excluded. Because the addresses were accessible only through a search by zip code, the database was first searched by randomly selected zip codes. Our goal was to obtain as complete a list as possible, so we concluded the search by zip code when we were no longer getting any new names (after 2000 randomly selected zip codes). The resulting list consisted of 2200 potential participants. For round one, 400 participants were randomly selected from the aforementioned list of 2200 LCSWs and invited, via e-mail, to participate. However, 26 of the 400 e-mail addresses were returned as undeliverable, resulting in 374 participants who presumably received an invitation to participate, of whom 191 responded. For round two, an additional 600 randomly selected participants from the original compiled list were invited to participate. Of those invitations, 80 were undeliverable, leaving a total of 520 participants who presumably received the invitation to participate, with 209 responding; thus the response rate for the combined samples was 45%. A total of 33 of the 400 respondents completed only the first page of the survey. The first page contained the following variables: licensure, state, theoretical orientation, years in practice, area of specialty, practice setting, and age group of clients. Thus, analyses that contained variables that were not on the first page of the survey will have missing data, as indicated by the lower numbers reported in the tables on these analyses. The variables beyond the first page of the survey included demographics, interventions used in practice, and reasons for using the interventions. Analysis of the completers versus the noncompleters revealed no significant differences on the first page variables, with the exception of practice setting. Completers were more likely to be in private practice than noncompleters (see Pignotti and Thyer, 2009b for a full report of this analysis).

Sample description Demographics for the present study (round one and round two participants combined) are presented in Table 1. As expected with surveys of social workers, 77% of the respondents were female. Participants ranged in age from 27 to 82 years old, with an average age of 53 years (SD = 10). It is noteworthy that 15% were over 62 years, a considerably higher percentage than the 5% reported by an NASW practitioner survey (National Association of Social Workers, 2003). Consistent with earlier surveys of clinical social workers in private practice (Strom, 1994), 94% were Caucasian. Respondents practiced in 39 different states,

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Table 1. Sample description Total N Sex Female Male Geographic region Northeast South Midwest West US Military overseas Race/ethnicity White/Caucasian African-American/Black Hispanic/Latino Asian/Pacific Islander Other Religion Christian Eastern/New Age Jewish Nondenominational/spiritual Atheist/agnostic/none Age (according to NASW categories) Under age 33 33–42 43–52 53–62 Over age 62 Mean (SD) Median Range

N

%

271 79

77.4 22.6

175 82 75 67 1

43.8 20.5 18.8 16.8 0.3

327 9 7 3 3

93.7 2.6 2.0 0.9 0.9

146 32 82 34 44

43.2 9.5 24.3 10.1 13.0

350

399

349

338

Study Sample % (n = 344) N % 11 3.2 48 14.0 83 24.1 149 43.3 53 15.4 53.13 (10.28) 54 27–82

NASW (2003) % (n = 1560) 7.0 17.0 34.0 34.0 5.0 Not reported 50 Not reported

plus one respondent who was in the military practicing overseas. The largest percentage of participants were from the Northeast (44%). Measures Survey instrument. The survey instrument included questions on demographics (age, sex, race, religion, geographic location, education); practice characteristics (years in practice, area of specialization, region, type of practice setting, age group of clients, and theoretical orientation); therapies used in practice; and reasons for choosing interventions. Participants were asked in two different ways about therapies used in practice. First, they were asked to name the three interventions they use most in their practices. Next, participants were

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presented with a list of commonly used interventions and asked to indicate whether they had used them within the past year. The interventions presented were selected on the basis of being cited in the social work and other professional literatures, mention of commonly used unorthodox therapies (derived from Lilienfeld, 2007; Lilienfeld, Lynn and Lohr, 2003; Norcross, Garofalo and Koocher, 2006) and selected therapies advertised by LCSWs on the internet on the website www.helppro.com. Three assessment procedures used by LCSWs (Myers-Briggs Type Indicator, Eneagram and Genogram) were also included. In order to determine reasons for using interventions, participants were presented with a list of possible reasons and asked to rate their importance on a scale of 1 to7, where 1 is “not at all important” and 7 is “very important.” A copy of our survey instrument is available from the senior author. Creation of categories for types of interventions and expert review. Composite variables were created for Novel Unsupported Therapies (NUSTs), Conventional Unsupported Therapies (CUSTs), combined NUSTs and CUSTs (CNUSTs), and Empirically Supported Therapies (ESTs) by summing the affirmative responses for each therapy that fall into those categories. Both continuous (number used) and dichotomous (used or did not use) versions of each of these variables were created. The following definitions were used: ESTs: Therapies that meet the Division 12 of the American Psychological Association criteria (Chambless et al., 1998) for empirically supported therapies for either a probably or a well established treatment and does not have key proponents who make claims that go beyond the evidence. NUSTs: Therapies that are relatively new, not widely accepted and or widely taught in graduate programs, have not met the American Psychological Association’s Division 12 criteria as an EST, and have major proponents who are making claims based only on anecdotes, uncontrolled case reports, and/or testimonials that go beyond the evidence. Therapies that do meet the Division 12 criteria as an EST for certain conditions, but make claims that go beyond the evidence, were also considered NUSTs (e.g. a therapy that meets the EST criteria for PTSD but makes claims for being successful with other conditions that are unsupported). CUSTs: Therapies that are conventionally accepted and taught, and yet do not meet the criteria for ESTs. These are therapies that are accepted, based on favorable clinical experience or authority but lack published clinical trials to support their efficacy. Categorization of therapies for the present study was determined by an expert review, as based on recommendations by Springer, Abell and Hudson (2002). A panel of two expert reviewers in addition to one of the present authors (Thyer) was presented with the list of therapies used in the survey, accompanied by the above definition of NUSTs, CUSTs, and ESTs. The two expert reviewers were selected because they are considered experts in the area of science and pseudoscience in mental health practice, having published extensively in that area. The expert reviewers indicated, by placing an “X” in the appropriate column, whether they thought the therapy fit the construct. The option of “not familiar with this therapy” was also offered. Inter-rater agreement was calculated by summing the number of agreements and dividing that by the number of agreements plus disagreements and then multiplying this by 100 to obtain the percentage (Bloom, Fischer and Orme, 2006). This calculation was made between each of the two reviewers with one another and with Thyer. Inter-rater agreement ranged from 95–98% for ESTs; 84–94% for NUSTs; and 84–92% for CUSTs. Therapies that received at least two votes for a particular category were classified in that category. In some

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Table 2. Expert review classification of interventions and assessment procedures ESTs: Acceptance and Commitment Therapy, Anxiety Management Training, Assertive Community Treatment, Behavior Modification/Behavior Therapy, Cognitive Behavioral Therapy, Cognitive Therapy, Dialectical Behavior Therapy, Emotionally Focused Couples Therapy, Exposure Therapy for Phobias, OCD, or Panic Disorder, Exposure Therapy for PTSD/Trauma, EMDR for PTSD/Trauma, Interpersonal Therapy, Motivational Interviewing, Social Problem Solving Therapy, Social Skills Training, Solution Focused Therapy, Stress Inoculation, Supported Employment Therapy, Systematic Desensitization, Task Centered Practice NUSTs: Age regression methods for adults sexually abused as children, Applied Kinesiology (for allergy/food sensitivity or for emotional problems), Attachment Therapy, Bioenergetic Therapy, EEG Biofeedback (Neurofeedback), Body Centered Psychotherapy, Critical Incident Stress Debriefing, Critical Incident Stress Management, DARE programs, Emotional Freedom Technique, Eneagram, EMDR for conditions other than PTSD, Facilitated Communication for autism, Healing Touch, Holding Therapy, Holotropic Breathwork, Imago Relationship Therapy, Jungian Sandtray Therapy, Love and Logic, Lucid Dreaming, Myers-Briggs Type Indicator, Neuro-linguistic programming, Past Lives Therapy, Psychosynthesis, Primal Therapy, QiGong, Radionics, Rebirthing Therapy, Reiki, Reparenting Therapy, Scared Straight, Seemorg Matrix, Sensory-Motor Integration, Sexual Reorientation/Reparative therapy for gays/lesbians, Tapas Acupressure Technique, Therapeutic Touch, Thought Field Therapy, Traumatic Incident Reduction CUSTs: Dream interpretation, Psychoanalysis, Psychodrama, Genogram Unclassified: The following interventions did not receive enough votes from the expert review panel to be classified into any of those categories: Biofeedback (non-EEG), Hypnosis, Insight Oriented Marital Therapy, Mindfulness Based Stress Reduction, Play Therapy, Relaxation training for PTSD, and Thought Stopping Procedures.

cases, due to one of the reviewers not being familiar with a particular therapy, there were ties. The ties were resolved through the present authors forming a rationale and reaching consensus. The resulting classifications of NUSTs, CUSTS, and ESTs are presented in Table 2. Results Practice characteristics Practice characteristics for the sample are presented in Table 3 and areas of specialization are presented in Table 4. Most commonly reported interventions Interventions used within the past year and the most frequently used interventions (respondents were asked to name three), as reported by respondents, are presented in

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M. Pignotti and B. A. Thyer Table 3. Practice characteristics Description

Total N ∗

Practice setting Private practice Outpatient clinic School Community mental health General hospital Other (Included: university, mental hospital, residential treatment facility, nursing home, military and prison) Theoretical orientation Eclectic or specified combinations Cognitive, Behavioral, or Cognitive-Behavioral Family Systems/Interpersonal Humanistic/client centered/transpersonal/Gestalt/TA/positive Psychodynamic//analytic/neo Freudian Energy or body oriented Other theoretical orientations written in (Included: Child-centered, Dyadic DevelopmentalPsychotherapy, EMDR, Equine AssistedPsychotherapy, Instinctual Trauma ResponseModel, Mindfulness, Narrative, Neurofeedback,Prevention, Solution focused) Type of area of practice∗ Large city (>100,000) Suburban Small city/town Rural

Years in practice Year graduated with MSW Practice age group percentage Older adults (age 65+) Adults (age 18–64) Adolescents School age children Pre-school children Infants

N

%

336 39 24 23 17 41

85.7 9.9 6.1 5.9 4.3 6.7

123 116 48 40

31.5 29.7 12.3 10.2

43 9

11.0 2.3

12

3.1

204 119 107 34

51.3 29.9 26.9 8.5

392

391

398

N

Mean (SD)

Range

394 351 389

18.85 (10.20) 1987 (10.54)

1–56 1949–2007

11.17 (20.23) 64.85 (29.85) 14.68 (20.56) 7.24 (13.15) 1.82 (6.47) 0.35 (2.75)

0–100 0–100 0–100 0–72 0–50 0–35

Table 5. For interventions used within the past year, the top five ESTs and NUST are listed, along with the four CUSTs. The top 10 interventions written in by participants as most frequently used are also reported. These interventions were not reported by category because the expert review panel only classified the prepared list of interventions, not the ones participants wrote in as most frequently used. A complete list of all interventions reported and their frequency is available from the first author upon request.

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Table 4. Areas of specialization named by participants∗ Total N = 396 Trauma/PTSD/abuse/loss Depression/bipolar/mood disorders Marital/relationship/family issues Anxiety disorders (other than PTSD) Addictions/codependency Geriatric/older adult issues Disabilities/chronic illness/pain Eating disorders ADHD/learning disabilities Gay, bisexual, lesbian, transgender (GBLT) issues Women’s issues Co-occurring disorders, severe mental illness Transitional issues Sexual problems Divorce/mediation/custody Parenting issues Stress management Adoption/foster care Attachment disorders Child conduct/behavioral disorders Personality disorders (unspecified) Spiritual/existential issues Caregivers Anger management Borderline/self injury Employee assistance Men’s issues Pre/perinatal/postpartum Infant mental health issues Autism/Pervasive developmental disorders Hospice/end of life issues Criminal/juvenile justice

N

%

141 110 99 79 64 29 28 21 17 17 16 13 12 10 9 8 8 7 7 7 7 7 5 4 4 4 4 4 3 2 1 1

35.6 27.8 25.0 19.9 16.2 7.3 7.1 5.3 4.3 4.3 4.0 3.3 3.0 2.5 2.3 2.0 1.0 1.8 1.8 1.8 1.8 1.8 1.3 1.0 1.0 1.0 1.0 1.0 0.8 0.5 0.3 0.3

∗

Total percentages add up to >100% because some respondents were allowed to name more than one area.

Participant prevalence of usage of ESTs, NUSTs, CUSTs, and combined novel and conventional unsupported therapies (CNUSTs) are presented in Table 6. An overwhelming majority (97.5%) of participants reported using at least one intervention classified as an EST. However three-quarters of respondents also reported using at least one NUST and 86% reported having used at least one NUST or CUST within the past year.

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M. Pignotti and B. A. Thyer Table 5. Most commonly reported interventions used within past year Intervention Used within past year Empirically Supported (top five) Cognitive-Behavioral Therapy Anxiety Management Training Solution Focused Therapy Cognitive Therapy Behavior Modification/Therapy Novel Unsupported (top five) Attachment therapy Critical Incident Stress Debriefing Critical Incident Stress Management Body-centered Psychotherapy Imago Relationship Therapy Conventional Unsupported Therapies or Assessment Genogram Dream Interpretation Psychoanalysis Psychodrama Top Ten Most Frequently Used Named By Respondents Cognitive-Behavioral Therapy Psychodynamic Solution Focused Cognitive Therapy/Restructuring Behavior Modification/Evaluation Family Systems/Interventions EMDR Interpersonal Therapy Anxiety Management Training Mindfulness

N

%

279 254 225 215 213

76.0 69.2 61.3 58.6 58.0

97 89 82 78 62

26.4 24.3 22.3 21.3 16.9

133 110 47 46

36.2 30.0 12.8 12.5

140 68 56 58 45 38 32 28 21 18

42.3 20.5 16.9 17.5 13.6 11.5 9.7 8.5 6.3 5.4

Table 6. Participant usage of ESTs, NUSTs, and CUSTs Total N Percentage using: NUSTs CUTs CNUSTs ESTs Number of: NUSTs CUSTs CNUSTs ESTs

N

%

367

367

276 221 317 358

75.2 60.2 86.3 97.5

Mean (SD) 2.34 (2.45) 0.92 (0.92) 3.26 (2.87) 6.41 (3.20)

Range 0–15 0–4 0–17 0–16

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Table 7. Reasons for selecting interventions Reasons listed from most to least highly rated (rated on a scale of 1 to 7 where 1 = not at all important and 7 = very important

Mean (SD)

Clinical experience with positive results held up over time Compatibility with theoretical orientation Compatibility with your (therapist’s) personality Clinical experience of fast, positive results with clients Intervention emotionally resonated for you (therapist) Endorsement by respected professional Intuition Colleagues’ reports of success Favorable research in peer reviewed journals Clients’ (other than your own) reports of success Intervention helped the therapist personally Website articles Magazine articles

6.50 (0.88) 5.65 (1.38) 5.63 (1.38) 5.45 (1.56) 5.20 (1.66) 5.01 (1.41) 4.95 (1.64) 4.84 (1.45) 4.74 (1.54) 4.49 (1.77) 4.23 (2.03) 3.41 (1.50) 3.34 (1.45)

Reasons for selecting interventions and relationship to CBT theoretical orientation The participant ratings of reasons for selecting interventions reported by respondents are presented in Table 7. The split plot ANOVA (similar to that conducted by Stewart and Chambless, 2007) of the relationship between reasons (clinical experience and favorable research in peer reviewed journals) by CBT theoretical orientation is presented in Table 8. Given that CBT-oriented interventions are, in general, more widely researched than those of other orientations (although there are exceptions), the purpose of this analysis was to determine whether CBT oriented practitioners would consider research findings more important than those of other theoretical orientations. The within subject variables were reasons for selecting interventions and the between subject variable was CBT theoretical orientation. The hypothesis that clinical experience would be more highly rated than peer reviewed research was supported. Both clinical experience with results that held up over time and clinical experience with fast, positive results were rated significantly more highly than favorable research in peer reviewed journals as reasons for selecting interventions. Participants with a CBT theoretical orientation rated favorable research more highly than those of other orientations. However, within the group of participants with a CBT orientation, they too rated clinical experience more highly than favorable research. Relationship between demographic/practice characteristics and usage of NUSTs Bivariate analyses were conducted on dichotomized usage of NUSTs with each demographic and practice characteristic. Chi square analysis indicated that females were more likely than males to use NUSTs (X2 = 8.19 = .15 p < .01) and that participants who indicated subscribing to a new age, spiritual or nondenominational religion were more likely to use NUSTs than those of other religions (X2 = 4.81 = .12 p < .05). Additionally, participants who indicated a specialization in trauma were more likely to use NUSTs than those who

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M. Pignotti and B. A. Thyer Table 8. Relationship between reasons for choosing interventions to theoretical orientation

Reason (rated on a scale of 1–7 where 1 = not at all important and 7 = very important) Research vs. clinical experience with fast positive results (N = 342) Between subjects (CBT theoretical orientation) Favorable research published in peerReviewed journals

Total CBT Non-CBT Mean (SD) Mean (SD) Mean (SD)

F(1,340) = 25.83∗∗ η = .07 4.76 (1.53) Within subjects Wilks’ λ = .91 F(1,340) = 34.40∗∗ d = .42

Clinical experience of fast, positive results with clients

5.20 4.57 (1.54) (1.49) Between subjects t = 3.51∗∗ d = .42

5.42 (1.58) 5.96 (1.29) 5.20 (1.64) Between subjects t = 4.17∗∗ d = .52

Research vs. clinical experience with results that hold up (N = 344) Between subjects (CBT theoreticalorientation) Favorable research published in peer-reviewed journals

F(1,342) = 8.80∗ η = .03 4.77 (1.52) 5.22 (1.51) 4.58 (1.48) Within subjects Wilks’ λ = .54 F(1,342) = 291.08∗∗ d = 1.39

Clinical experience of positive results that hold up over time

Between subjects t = 3.62∗∗ d = .43

6.50 (.88)

6.51 (.83)

6.50 (.90)

Between subjects t = .134 n.s. ∗

p < .01; ∗∗ p < .001

did not indicate a specialization in trauma ((X2 = 15.85 = .21 p