Clinical Psychology Review 95 (2022) 102163

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Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

(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 1, Barbara Cludius
Department of Psychology, LMU Munich, Munich, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: An important aim of basic research in Clinical Psychology is to improve clinical practice (e.g., by developing
Experimental psychopathology novel interventions or improving the efficacy of existing ones) based on an improved understanding of key
Clinical interventions mechanisms involved in psychopathology. In the first part of this article, we examine how frequently this
Translational research
translation has happened in the past by reviewing all 40 evidence-based psychological interventions recom­
mended 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 psycho­
pathological 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.

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 under­
lying the development and maintenance of psychopathology (Clark &
Fairburn, 1997; Davey, 2014; Kring, Johnson, Davison, & Neale, 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 so­
lutions to the translational gap.2
The manuscript draws heavily on general concepts of translational
research in clinical psychology and psychiatry (e.g., Fulford, Bortolotti,
& Broome, 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, Engelhard, &

* Corresponding author at: Department of Psychology, LMU Munich, Leopoldstr. 13, D-80802 Munich, Germany.
E-mail address: thomas.ehring@lmu.de (T. Ehring).
1
Melike Guzey is now at the Department of Psychology, Ankara University, Turkey.
2
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).

https://doi.org/10.1016/j.cpr.2022.102163
Received 5 January 2022; Received in revised form 29 April 2022; Accepted 12 May 2022
Available online 17 May 2022
0272-7358/© 2022 Elsevier Ltd. All rights reserved.
T. Ehring et al.
McNally, 2017; Vervliet & Raes, 2013; Waters, LeBeau, & Craske, 2016).
However, it provides a novel integration of these issues, leading to
specific suggestions.
2. Definitions
In order to examine whether, how often, and under which circum­
stances 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 experi­
mental, based on self-report data and/or include more objective mea­
sures. 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, cog­
nitions, 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 psycho­
logical treatment appears more challenging. For the purpose of this re­
view, 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 Di­
vision 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 Psy­
chology, 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, McKay, Forman, Klonsky, & Thombs, 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.
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Clinical Psychology Review 95 (2022) 102163
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 psy­
chological 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 disor­
ders, 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 treat­
ments 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 situa­
tions, in which basic research conducted by others was used):
1. Very strong: systematic testing of underlying theory3 conducted
prior to treatment development AND treatment principles or in­
terventions developed or refined in basic research before application;
2. Strong: one of the two criteria for “very strong” present and con­
ducted prior to development of intervention;
3. Moderate: some testing of theoretical model or intervention prin­
ciples prior to or parallel to treatment development, but not in a
systematic or extensive way;
4. Weak: no basic research directly underlying treatment.4
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 schizo­
phrenia (NICE, 2014). These treatments were then examined in the same
way as described above. In the following, we summarize our 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 disor­
ders, 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 rec­
ommended 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
3
Note that we did not rate the quality of the theoretical models underlying
treatment development.
4
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”.
T. Ehring et al.
Programs for Schizophrenia, Social Skills Training for Schizophrenia,
Applied Relaxation for Generalized Anxiety Disorder and Panic Disor­
der, 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 treat­
ment 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 Dis­
orders (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 (pro­
cesses) 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 ex­
amples 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 experi­
ence (e.g., Assertive Community Therapy for Schizophrenia: Stein &
Test, 1980; Friends Care for Mixed Substance Abuse: Brown, O’Grady,
Battjes, Farrell, Smith, & Nurco, 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 Man­
agement 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 Jr., 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
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Clinical Psychology Review 95 (2022) 102163
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, Williams, & Teasdale, 2013), ACT (Hayes, Levin, Plumb-
Vilardaga, Villatte, & Pistorello, 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 psycho­
logical 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,
Lejuez, Stuart, & Curtin, 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 tradi­
tional, 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 inte­
gration and communication between these two research areas within
clinical psychology and that this contributes to the translational gap
(Milton & Holmes, 2018; Sheeran, Klein, & Rothman, 2017; Waters
et al., 2016; Zvolensky et al., 2001). Of note, systematic research
bridging the gap between the basic research results and testing of in­
terventions targeting these processes is comparatively sparse. In addi­
tion, 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 devel­
opment 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 & Group, 2015; Sheeran et al., 2017). In the context of
the current manuscript, the framework serves two main functions. First,
T. Ehring et al.
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. Sec­
ond, 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,
Kleim, & Ehlers, 2011; Forsyth & Zvolensky, 2001; Kraemer, 2016;
Kraemer, Wilson, Fairburn, & Agras, 2002; Onken, Carroll, Shoham,
Cuthbert, & Riddle, 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 Fig. 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 de­
signs 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 psy­
chopathology. Although conclusions that can be drawn from longitu­
dinal 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 (see also,
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 For­
syth & Zvolensky, 2001; van den Hout et al., 2017; Zvolensky et al.,
2001). An important characteristic of EPP research is that the psycho­
logical process serves as the independent variable and is thus experi­
mentally 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 inter­
pretation), 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
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Clinical Psychology Review 95 (2022) 102163
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),5Type-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 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 con­
ducted 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) sug­
gested that video feedback may be an effective strategy to reduce
negative self-processing and negative appraisals regarding the self by
5
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.
T. Ehring et al.
Theory
Development and Mechanisms and
maintenance of principles of
psychopathology change
1. 2. 3.
Identification of Establishing causality Developing/refining
processes intervention strategies
of the process
(potential treatment to modify the process
targets) [process → outcome] [intervention → process]
Fig. 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, Limburg, Kunze, Wittekind, Werner, & Cludius. (2022), available at https://doi.org/10.31234/osf.io/7cvh6, under a CC-BY4.0 license.
providing external information about one’s performance in social situ­
ations 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, Clark, Ehlers, and Rapee
(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. These 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, Woud, Margraf, & Schönbrodt, 2019).
Another important issue in this step is focused on the question of
which processes mediate treatment effects (Kraemer et al., 2002),
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Clinical Psychology Review 95 (2022) 102163
4.1
Clinical trials I
Efficacy 5. 6.
[intervention → outcome]
Dissemination &
Clinical guidelines
Implementation
4.2
4.2
Clinical trials II
• mediators
• mechanisms
of change
4.3
Clinical trials III
• moderators
• non-response
• dropout
• effectiveness
in routine care
including those that can be considered mechanisms of change (Kazdin,
2007) (Step 4.2). Additionally, it is important to identify which treat­
ment works best for a specific group of patients (i.e., moderation) (Kaz­
din, 2007), how treatment non-response can be predicted (e.g., De Carlo,
Calati, & Serretti, 2016; Taylor, Abramowitz, & McKay, 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 effi­
cacy 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 ef­
ficacy 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 sys­
tematic review of the available empirical evidence that is then translated
into recommendations for clinical practice in a structured consensus
T. Ehring et al. Clinical Psychology Review 95 (2022) 102163

process. Table 1
Step 6. On the basis of results of clinical trial research that is sum­ Challenges to translational research in clinical psychology and possible
marized in clinical guidelines, empirically-supported interventions then solutions.
need to be disseminated to a large number of clinicians and imple­ Challenge Possible solutions Article
mented in clinical practice. This step also requires systematic research section
on how to optimize this process (for a review, see Lilienfeld, Ritschel, Lack of integration and • Follow framework for 5.2.1
Lynn, Cautin, & Latzman, 2013). communication between Translational Research
basic and applied research systematically linking basic
within clinical psychological and applied research
4.3. Summary and conclusion
science • Improve structural basis for
collaboration between basic
In sum, our framework suggests that improving psychological and applied researchers
treatment for mental disorders based on basic research requires a Limited resources and funding • Increase funding for 5.2.2
number of different steps, whereby each step is characterized by unique (translational) mental health
research
goals and specific research methods and designs. When looking through Lack of stability and • Stronger focus on reliability of 5.3.1
the lens of this framework, we can conclude that current basic research replicability of basic research measurements
in clinical psychology is mostly focused on Step 1. Applied clinical findings • Increasing research
research, on the other hand, mainly focuses on establishing a causal transparency and collaboration
(e.g., preregistration; data
effect of the intervention on the outcome (Step 4.1) with a much less
sharing)
strong emphasis on the mechanisms of change. One reason for the low • Strong emphasis on replication
rate of translation of basic research findings into clinical innovation may • Improved statistical tools (e.g.,
therefore be the relative paucity of studies focusing on Steps 2, 3, and 4.2 refined power analyses;
(see also Sheeran et al., 2017; Waters et al., 2016). In addition, at each Bayesian statistics)
• Incentivize good scientific
step of the translational process a number of additional challenges are practice and open science
conceivable that may ultimately lead to a low rate of innovation in Lack of basic studies • More frequent use of 5.3.2
clinical interventions based on basic research. establishing causality before experimental research in Step
moving from Step 1 2 (process → outcome) and
(identification of treatment Step 3 (intervention →
5. Challenges and possible solutions
target) to Step 4 (testing process)
complex clinical
5.1. Introduction intervention)
Unclear external validity of • Developing commonly agreed 5.3.3
In Section 3, we concluded that translation of basic research findings basic and translational criteria for external validity of
research EPP research (e.g., focusing on
into improvement of clinical practice does not happen as frequently as predictive, construct, and
assumed by the standard narrative of clinical psychology. In Section 4, diagnostic validity), and
we suggested that one of the main reasons for the lack of successful designing and evaluating
translation may be the gap between basic and applied research in clin­ studies accordingly
Fat-handed interventions and • Focus on robust empirical 5.3.4
ical psychological science. Based on earlier concepts, we proposed a
easy-to-vary theories findings; searching for multiple
framework for translational research consisting of a sequence of inter- sources of evidence
related steps, whereby each step is defined by different goals, research • Improving theory building (e.
methods, and designs. In this section, we will move from this bird’s eye g., via formalization), and
view to zooming in on more specific challenges to conducting trans­ focusing on construct validity
Imbalance between research • More emphasis on studying 5.4.1–5.4.3
lational research following this framework (see Table 1 for a summary). focused on efficacy compared mediators and mechanisms of
Some of these challenges are related to many (if not all) of the steps to research on mediators, change in applied Clinical
outlined in our framework, whereas others are more specifically tied to mechanisms of change, and Psychology
specific steps. moderators • Integration of basic research
(Steps 2 and 3) and applied
research (Step 4.2) when
5.2. General challenges investigating mechanisms of
change
5.2.1. Division between basic research and clinical interventions research • Using basic research to further
One reason for the apparent gap between basic and applied research improve existing psychological
interventions is a promising
may be that studies bridging the gap (e.g., Step 3) require considerable strategy
expertise in both basic research as well as know-how on clinical inter­ Clinical innovation does not • Guidelines should pay more 5.4.4
vention principles. Given the high level of specialization in the field, not always show up in clinical attention to subgroups, add-on
all research groups in clinical psychology may currently possess the guidelines interventions, and variations
within broad treatment groups
expertise and resources to perform all steps in the translational chain,
• Development of interventions
including lab-based and clinic-based studies, studies with non-clinical for processes instead of
and clinical participants, and studies using experimental vs. media­ disorders
tional 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 are rare, which may suggest Similarly, Kindt (2018) highlights a need for bi-directional translation
that basic vs. applied research are often separate strains of research where basic research findings on important treatment targets and/or
within the field or even within research groups. Importantly, however, a intervention principles inform the development of novel interventions;
number of authors have argued for an integrated approach with strong on the other hand, experiences and data on the efficacy and working
structural links between basic research and treatment development. For mechanisms of these interventions in a clinical context then in turn feed
example, Clark (2004) emphasizes the need for an interplay between back into further theoretical development and advanced additional
theory, basic experimental research, and treatment development, which basic research (see also Holmes, Craske, & Graybiel, 2014). The poten­
should ideally be conducted within one research group or institute. tial advantages of such an integrated research approach are immediately

6
T. Ehring et al.
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 ques­
tions outlined in Fig. 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 collabo­
rate 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 trans­
lational 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 high­
lighted 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 chain focused on identifying potential targets for in­
terventions 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 mainte­
nance of psychopathology without any direct applied applications 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; this underlines the importance of not posing any re­
strictions on the topics that are investigated in basic science
(see e.g., Deutsch, 2011). Importantly, our following discussion of chal­
lenges and possible recommendations for the early stages in the trans­
lational 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 psychol­
ogy (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, Brandes, King, & Markon, 2019) are less stable and replicable
than traditionally assumed. A number of potential reasons for this have
been highlighted.
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Clinical Psychology Review 95 (2022) 102163
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, Powell, & Sumner, 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 biolog­
ical measures used in basic psychological research are rarely tested and
reported (Parsons, Kruijt, & Fox, 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, Taylor, Wit­
tekind, Sakamoto, & Ehring, 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, van Dijk, and Wicherts (2012)
estimated that the average power in psychological studies is around 0.35
in a two independent samples comparison. Reardon, Smack, Herzhoff,
and Tackett (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 0.80. 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 (typi­
cally >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 sig­
nificant findings have a higher likelihood of being published than non-
significant ones (Bakker et al., 2012; Kühberger, Fritz, & Scherndl,
2014).
Finally, there is evidence that the stability and replicability of pub­
lished findings is further reduced by the use of questionable research
practices resulting in inflated false positive error rates in the psycho­
logical literature (Bakker et al., 2012; Simmons, Nelson, & Simonsohn,
2011; Wagenmakers, Wetzels, Borsboom, van der Maas, & Kievit, 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, Spies,
& Motyl, 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
T. Ehring et al.
substantial relationship with psychopathology. In other words, the
research principle laid out in the standard narrative of clinical psy­
chology – 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 char­
acteristics of these processes. The methodological challenges described
above may therefore provide one explanation for the apparent trans­
lational 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 find­
ings. 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,
Klugkist, Mertens, & Engelhard, 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,
Gentili, Naudet, & Cristea, 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 (correla­
tional 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
Mediation (Step 4.2)
Process (treatment
target)
Step 3 Step 2
Intervention Psychopathology
Step 4.1
Fig. 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 Trans­
lational 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).
8
Clinical Psychology Review 95 (2022) 102163
test causality. Step 1 typically does not include experimental method­
ology; 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 Fig. 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 experi­
ments 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 inter­
vention procedures, but rather specify processes as treatment targets,
which makes it necessary to independently investigate which interven­
tion 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 expla­
nations cannot be distinguished when using a design where the inter­
vention 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 in­
terventions 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 inter­
vention strategies (Step 3) often uses analogue designs with non-clinical
participants as well as other reductionist design features (e.g., in­
terventions of low intensity and/or duration; short time interval be­
tween 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
T. Ehring et al.
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 con­
clusions can be drawn. However, the field lacks universally accepted
criteria that could be used to define, ensure, and appraise external val­
idity 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, Boddez, Vervliet, & Hermans,
2016; Vervliet & Raes, 2013). Vervliet et al. have suggested a number of
alternative criteria that merit a more explicit consideration when plan­
ning and evaluating EPP studies (Scheveneels et al., 2016; Vervliet &
Raes, 2013). The first is construct validity, which requires a clear theo­
retical rationale (ideally also supported by empirical evidence) sug­
gesting 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 differ­
ences 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 con­
ditioning 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 depen­
dent 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. Simi­
larly, 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
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Clinical Psychology Review 95 (2022) 102163
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). How­
ever, 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) high­
lights a number of obstacles that hinder the success of causal discovery
in psychology because of the nature of its subject, that is, internal pro­
cesses. This includes the fact that interventions in psychology experi­
ments 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 typi­
cally impact on several variables simultaneously, limiting conclusions
regarding causality. In addition, Eronen (2020) highlights the system­
atic 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 environ­
ment is considerably less fat-handed than manipulating internal psy­
chological processes (e.g., thoughts, emotions, attentional processes,
etc.). This may be a reason why in our review of interventions based on
basic research in Section 3, 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 reinforce­
ment 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 obser­
vation. 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, Haslbeck, Ryan, Fried, & Waldorp, 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 sug­
gest 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 Fig. 1), we now turn to
challenges and possible remedies in the later stages of the translational
T. Ehring et al.
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 Fig. 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 Psy­
chology, 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 instru­
mental 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 psycho­
logical interventions, we need to understand not only whether treatments
work, but especially also why and how they work (Kazdin, 2007;
Kraemer, 2016; Lemmens, Müller, Arntz, & Huibers, 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 in­
terventions can be re-analyzed to test certain aspects of mediation
(Guidi et al., 2018; Kraemer et al., 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, Schott, & Meiser, 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 (Lem­
mens 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 mecha­
nisms 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.
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
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
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Clinical Psychology Review 95 (2022) 102163
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 vari­
ability may be highly informative both on practical as well as theoretical
grounds. Therefore, several authors have called for analyses of moder­
ators 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., 2021; 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, de Jong, Rubel, & Jaime, 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 modera­
tion 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 im­
plications 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 frame­
work introduced in Section 4 describes the process of developing in­
terventions 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 Fig. 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 theoret­
ical 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;
this included 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 –
T. Ehring et al.
inhibitory – meaning (conditioned stimulus + no unconditioned stim­
ulus) 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, Treanor, Conway, Zbozinek, & Vervliet, 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 treatments.6
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) ap­
proaches that existing interventions are modified and/or complemented
by add-on interventions to increase efficacy. Further examples of effi­
cacious 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, Addis, & Jacobsen, 2001), the
development of enhanced CBT-I for insomnia based on experimental
research on cognitive factors involved in insomnia (Harvey, Tang, &
Browning, 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 symp­
toms of psychosis based on basic research on cognitive biases in psy­
chosis (Moritz & Woodward, 2007), or approach bias modification as an
add-on to interventions for alcohol use disorders (Wiers, Eberl, Rinck,
Becker, & Lindenmeyer, 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 recom­
mended 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, Black, Johnston, & Bevan, 2020)
and current criteria for empirically-supported treatments (Chambless &
Ollendick, 2001), guidelines focus on treatments for disorders accord­
ing 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
6 efficacy.
On a side note, this is an interesting example of a case where the devel­
opment 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.
11
Clinical Psychology Review 95 (2022) 102163
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 differen­
tial 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 guide­
lines 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 psy­
chological treatment for mental disorders. Although this does not sub­
stantially 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 psycho­
logical treatment can be represented in clinical guidelines. First, it ap­
pears 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, Delgadillo, & DeRubeis, 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
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
T. Ehring et al.
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 in­
terventions 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 effec­
tive treatments already exist.
Second, whereas the recommendations made so far can be accom­
modated 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 in­
terventions 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,
Kohl, Linden, & Mehler, 2021), reconsolidation-based interventions
(Elsey & Kindt, 2017), and cognitive control training (Koster, Hoor­
elbeke, Onraedt, Owens, & Derakshan, 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 psycho­
pathology may not be a very promising avenue to improve clinical
practice. For example, network theorists have suggested to mainly focus
12
Clinical Psychology Review 95 (2022) 102163
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 complemen­
tary, e.g., Fried & Cramer, 2017; McNally, 2016). From a more prag­
matic 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, Ehring, & Powers, 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 tar­
gets 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.
Role of funding sources
The authors received no external funding for the writing of this
article or the underlying literature searches.
Contributors
TE, KL, AEK, CEW, GGW, MG, and BC developed the key ideas for
this manuscript, its conceptual basis and structure, and each co-author
provided first drafts of one or more chapters. BC and TE conducted
the literature searches, analyzed the NICE guidelines and APA lists of
empirically supported treatments, and summarized the findings. TE and
BC wrote the first draft of the whole manuscript, and all authors
contributed to and have approved the final manuscript.
Declaration of Competing Interest
All authors declare that they have no conflicts of interest.
Data availability
No data was used for the research described in the article.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.cpr.2022.102163.
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