Psychopathology Review

PR Volume 4 (2017), Issue 2, 112-128

ISSN 2051-8315 / DOI:10.5127/pr.038015

Experimental Psychopathology and Clinical Psychology:

An Integrative Model to Guide Clinical Science and Practice

Allison M. Waters, PhDa, Richard T. LeBeau, PhDb, & Michelle G. Craske, PhDb
a School of Applied Psychology, Griffith University, Mt Gravatt campus, QLD, Australia.
b Department of Psychology, UCLA, Los Angeles, CA.

Abstract
Experimental psychopathology has elucidated mechanisms underlying various forms of psychopathology and has
contributed to the continuous updating and generation of mechanistically-focused and evidence-based psychological
treatments. Clinical psychology is an applied field of psychology concerned with the assessment and treatment of
psychological disorders and behavioral problems. Despite the notable commonality in their focus upon psychological
dysfunction, conceptual frameworks that guide their integration are surprisingly scarce. Clinical science and practice
would benefit greatly from the combined strengths of each discipline. In this review, we begin by defining experimental
psychopathology and clinical psychology, we present arguments for greater integration between them, and we
propose a model to guide the integration of experimental psychopathology-informed science into clinical practice,
illustrating the relevance of the model by drawing upon the seminal research on fear conditioning and extinction and
other experimental paradigms.
© Copyright 2017 Textrum Ltd. All rights reserved.
Keywords: Experimental psychopathology, Clinical psychology, Science, Practice
Correspondence to: Allison M. Waters School of Applied Psychology, Griffith University, Mt Gravatt campus, QLD,
Australia, 4122, email: a.waters@griffith.edu.au
Received 19-Mar-2015; received in revised form 30-Dec-2015; accepted 12-Jan-2016
 Psychopathology Review, Volume 4 (2017), Issue 2, 112-128 113

Table of Contents
Introduction 
Value of integration between experimental psychopathology and clinical psychology 
Value of experimental psychopathology for clinical psychology 
Value of clinical psychology for experimental psychopathology 
An experimental psychopathology-influenced model of clinical science and practice 
(1) Experimental psychopathology research 
(2) Translational experimental psychopathology research 
Expectancy learning. 
Safety learning. 
(3a) Dissemination to the clinical science community 
(4a) Theory integration and refinement 
(3b) Dissemination into the clinical practice community 
(4b) Clinical practice integration and refinement 
Challenges, Important Issues and Future Considerations 
Challenges facing experimental psychopathology research and translational research 
Challenges facing dissemination to the clinical science community 
Challenges facing dissemination to the clinical practice community 
Future Directions 
Conclusion 
References 

Introduction
Approaches to psychological research can be conceptualized along a continuum. At one end, basic psychological
research examines fundamental behavioral, cognitive, physiological, neurobiological and other processes
independently of their relevance to psychopathology. At the other end are applied forms of psychological research
such as clinical psychology (CP), defined as the integration of science, theory, and practice to understand, predict,
and alleviate maladjustment, disability, and discomfort as well as to promote human adaptation, adjustment, and
personal development (Society of Clinical Psychology of the American Psychological Association, n.d.). As such, CP
researchers are most interested in answers to pressing public-health problems and the development of assessments
and interventions with functional utility than basic psychology researchers (Zvolensky, Lejuez, Stuart, & Curtin, 2001).
In order to achieve these goals, CP research investigates individuals with psychological problems in settings where
the problems are most likely to manifest (Zvolensky et al., 2001).
Experimental psychopathology (EP) is a domain of psychological research that bridges the gap between basic
psychological research and applied fields of psychology such as CP. EP involves “laboratory-based research with
humans, nonhuman animals, or both types of participants, directly aimed at discovering and explaining the etiology
and maintenance of psychopathological processes” (Zvolensky et al., 2001, p. 371). Experimental
psychopathologists use experimental methodology and laboratory models to systematically evaluate fundamental
psychological processes that underlie maladaptive behaviour (Vervliet & Raes, 2013). In essence, EP addresses the
generalizability of the basic science of functional psychological processes to dysfunctional psychological processes
in highly controlled conditions. Traditionally, EP has drawn upon learning theory and cognitive science to inform
experimental methods, with dependent variables ranging from self-report to behavioural observations, performance
on cognitive tasks, and psychophysiological measurement. Neuroscience has expanded the tool box for experimental
psychopathologists as it has begun to elucidate brain regions associated with specific dysfunctions in cognitions,
affect and behavior (Kazdin, 2014).
In this paper, our aim is to consider the value and challenges of greater integration of EP research with the discipline
of CP. Although review papers exist that summarise the utility of EP for advancing CP (Zvolensky, Forsyth, &
Johnson, 2013), or apply experimental principles to specific disorders (Vervliet & Raes, 2013), there are surprisingly
few models that guide the integration of EP and CP. By highlighting the opportunities and challenges that arise for
 Psychopathology Review, Volume 4 (2017), Issue 2, 112-128 114

each discipline area through their greater integration, we argue that the time is ripe for an integrative model that can
facilitate the advancement of EP research and its dissemination and integration into the clinical science and clinical
practice communities, with the ultimate goals of advancing scientific knowledge and patient care. We identify specific
challenges and opportunities in advancing such an EP-informed model of clinical science and practice and
recommend that greater intra- and inter-disciplinary collaboration across the clinical science and practice sectors is
needed to achieve these goals.

Value of integration between experimental psychopathology and clinical

psychology

Value of experimental psychopathology for clinical psychology

One of the major contributions that EP can make to CP is mechanistic research that leads to new and improved
treatments. Such research examines the processes or events that are responsible for change in a particular variable.
This is of paramount importance, since although psychological treatments can achieve effect sizes that approach or
exceed 1.0 (as is the case for cognitive behavioral therapy for anxiety disorders; Bandelow et al., 2015), the percent
of individuals who achieve remission hovers around 50% (Loerinc et al., 2015; Ginsburg et al., 2014). Moreover,
beyond the anxiety disorders, there are several diagnoses that lack strongly empirically supported
nonpharmacological treatments at all (http://www.div12.org/psychological-treatments/disorders/).
Therefore, outcomes from CP treatments leave substantial room for improvement and are likely to benefit from
greater integration of mechanistically-focused EP research. By addressing mechanisms that underlie
psychopathology, EP can provide evidence of causal relations that can inform theory development (Kazdin, 2007).
Theory-driven models of psychopathology are essential since they generate testable hypotheses and results that
lead to further conceptual refinements and more effective treatments. Furthermore, by explaining the etiology and
maintenance of psychological dysfunctions in terms of distinct underlying mechanisms that cut across disorders as
traditionally defined, EP informs treatments that target specific dysfunctions (e.g., MacLeod & Clarke, 2015).
Examples of specific dysfunctions include: over-general memory which has been linked to depression (Sumner et
al., 2010), eating disorders (Ridout, Matharu, Sanders, & Wallis, 2015) and posttraumatic stress disorder (Ono,
Devilly & Shum, 2015); biases in attention to and appraisal of negative information that have been linked with anxiety
and depression (MacLeod & Mathews, 2012) and disordered eating (Brooks, Prince, Stahl, Campbell, & Treasure,
2011); over-reliance on habit responding systems that are linked to obsessive compulsive disorder (Gillan et al.,
2011), eating disorders (Park, Godier, & Cowdrey, 2014) and substance use disorders (Everitt & Robbins, 2005);
and dysregulation in reward responding that occurs within depression, schizophrenia and substance use disorders
(Thomsen, Whybrow & Kringelbach, 2015). Treatments that target specific dysfunctions such as these are likely to
improve outcomes.
The EP approach can also identify and explain the active ingredients associated with treatment change (Kraemer,
Wilson, Fairburn & Agras, 2002), teasing apart specific from nonspecific factors. Furthermore, active components of
treatment can be improved upon whereas inactive elements can be removed, and specific components of treatments
can be combined in ways that prove synergistic rather than antagonistic and thereby improve treatment outcomes
(Kraemer et al., 2002). Focusing on skills and material that are necessary for improved outcomes would result in
more efficient use of clinician time. Eventually, change scores on identified mediators early in treatment can be used
to guide decision-making about continuation of treatment or switching to alternative treatments. An EP approach can
also identify for whom one particular treatment works better than another treatment (Kraemer et al., 2002; Kazdin,
2014). To date, we have little understanding of why certain client characteristics (e.g., age, gender, race) moderate
treatment outcome (Kazdin, 2014). However, linking moderators to psychophysiological, neural, affective, cognitive
or behavioral mechanisms could elucidate key features of psychological disturbances that explain response to
treatment. Not only would this permit an evidence-based system of matching individuals to treatments, which
presumably will improve outcomes, but knowledge of mechanistic moderators could also inform treatments that are
more closely targeted at those mechanisms (Kazdin, 2014).
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In addition to the benefits that derive from a mechanistic approach, EP also provides methods and tools that may
enhance the therapeutic process. Examples include virtual reality technologies for exposure therapy (Diemer,
Mühlberger, Pauli, & Zwanzger, 2014), pharmacological agents such as d-cycloserine to augment exposure therapy
(Rodrigues et al., 2014), and cognitive bias modification training (Clarke, Notebaert & McLeod, 2014), all of which
evolved from EP research and larger interdisciplinary collaborations. Finally, EP provides a science-driven model for
conducting clinical research, as well as clinical assessment and treatment at the patient level (Zvolensky et al., 2013).
The EP approach directly encourages the clinician to use the research literature to guide treatment choice, to consider
potential mechanisms underlying a given clinical presentation and to tailor treatment accordingly, and to collect
patient data regularly in order to evaluate effectiveness and need for treatment tailoring.

Value of clinical psychology for experimental psychopathology

EP research can be and has been directly informed by clinical observations. Many highly regarded and influential
theories and treatments of psychological disorders have emanated from clinical observations of patients during
routine clinical care. For example, Beck (1963) first began to formulate his cognitive theory of depression in the 1950s
based on careful clinical observations about the negative content of patients’ thoughts regarding the self, the
environment and the future. Ellis’s (1957) seminal work on irrational beliefs in neurosis and Meichenbaum’s (1977)
self-instructional training represent formative examples of how CP observations contributed to the development of
cognitive science and systematic empirical research using laboratory models and experimental methods (see Clark
& Beck, 2010). A more recent example is Barlow’s careful observations of the way in which clients with panic disorder
responded to imagery of bodily sensations that led to interest in interoceptive conditioning as a conceptual model for
experimental investigation (see Bouton, Mineka, & Barlow, 2001).
Clinical psychology investigation of patients who do not respond well to treatments is another valuable source for
EP. For example, cognitive behavioural therapies for depression are relatively ineffective for symptoms of anhedonia,
or low levels of positive affect (Dichter et al., 2009; Dunn, German, Hollon, & DeRubeis, in preparation). EP
researchers have suggested that this ‘anhedonia-nonresponse’ may be explained by dysregulation within the reward
responding system, including the anticipation of reward, consumption of reward and learning of reward (Thomsen,
et al., 2015). The body of EP research that is currently investigating the neural, psychophysiological, cognitive and
behavioural features of deficits in reward sensitivity in relation to anhedonia may eventually inform new treatments
for anhedonia (e.g., Ubl et al., 2015; Treadway, Bossaller, Shelton, & Zald, 2012; Yang et al., 2014; Wacker Dillon,
& Pizzagalli, 2009; Pizagalli, Losifescu, Hallett, Ratner, & Fava, 2008).
Cognitive behavioural therapy for bulimia nervosa is another example. This treatment was first developed, tested and
refined in the 1980s (Fairburn, 1981, 1985; Fairburn, Cooper, & Cooper, 1986), a detailed treatment manual was
published and revised in the 1990s (Fairburn, Marcus, & Wilson, 1993; Wilson, Fairburn, & Agras, 1997), the theory
was subsequently elaborated at the same time (Fairburn, 1997), and tested in a series of treatment trials (e.g., Agras,
Crow, et al., 2000; Agras, Walsh, Fairburn, Wilson, & Kraemer 2000; Fairburn et al., 1993). However, based on
observations that several individual client factors were associated with limited response to the original treatment, the
theoretical model and associated treatment were revised to include the role of low self-esteem, perfectionism, and
mood intolerance (Cooper & Fairburn, 2011). These clinically-derived modifications now provide fodder for
experimental paradigms to investigate their contribution as mediators of treatment for eating disorders. Dialectical
behaviour therapy for Borderline Personality Disorder provides yet another example, as it emerged from the
frustration of clinicians working with chronically parasuicidal patients who were not responding to traditional cognitive
interventions (Linehan, 1987). The success of the therapy for parasuicidal patients with Borderline Personality
Disorder led to a proliferation of research into the etioloy, phenomenology, and course of the disorder, which in turn
led to refined and improved treatments (Linehan & Wilks, 2015). Thus, rich data derived from patients who do not
respond to evidence-based practices can be utilised to guide further experimental investigations of underlying
mechanisms, associated theoretical refinement and further research on modified treatments.
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An experimental psychopathology-influenced model of clinical science and

practice
Figure 1 presents a model describing how EP research can inform both clinical science and clinical practice through
a cyclical process involving five stages. The model begins with (1) fundamental experimental psychopathology
research focused on theory-driven, laboratory-based experimental investigation of psychological processes.
Knowledge derived from the first stage is then utilized in (2) translational experimental psychopathology research,
whereby processes and mechanisms underlying dysfunction are tested as moderators and mediators of treatment
outcome, novel treatments targeting such mechanisms are tested, and ongoing treatment refinement is undertaken
through controlled trials. Next, knowledge arising from EP translational studies is disseminated into (3a) the clinical
science community (upper panel), which in turn informs ongoing (4a) theory refinement and development (upper
panel), and is also disseminated into (3b) the clinical practice community (lower panel) which in turn gives rise to (4b)
clinical practice integration and refinement (lower panel). Together, ongoing refinement and development of theory
and practice ultimately inspires further fundamental EP research and the continuation of an EP-informed model of
clinical science and practice in an ongoing, cyclical manner. We describe each stage in more detail below and
illustrate it with an example applied to the fear conditioning and extinction model of anxiety and its treatment.

Figure 1: An experimental psychopathology-informed model of clinical science and practice

(1) Experimental psychopathology research

Several key tenets of EP can be identified. It is theory-driven and laboratory-based, it utilizes validated experimental
models and methods primarily with non-clinical samples, and it involves a systematic progression of studies
addressing research findings as they emerge (Vervliet & Raes, 2013; Zvolensky et al., 2001). EP research that is
based on models of Pavlovian fear conditioning and extinction has added substantially to our understanding of
possible etiological pathways, maintaining factors and treatments for dysregulation in fear and anxiety. Fear
conditioning involves pairing a neutral stimulus (e.g. a shape) with an innately aversive or threatening stimulus (e.g.
an electrical shock). This produces conditional fear of the shape (increased heart rate, skin conductance activity,
startle eye blink activity, avoidance), akin to clinical anxiety symptoms. Moreover, fear extinction is modelled by
 Psychopathology Review, Volume 4 (2017), Issue 2, 112-128 117

repeated presentations of the shape in the absence of the aversive stimulus, which typically produces a decline in
conditional fear, akin to the reduction in clinical anxiety symptoms observed with exposure-based treatments.
By way of example, EP research has shown that anxious individuals display elevated acquisition of fear conditioning
(in simple conditioning paradigms; see Duits et al., 2015 & Lissek et al., 2005 for reviews); elevated generalization
of fear conditioning (Lissek et al., 2010; Lissek et al., 2014); weakened extinction, especially at test of extinction
retrieval (e.g., Craske, Waters, Bergman, Naliboff, Lipp, Negoro, & Ornitz, 2008; Lau et al., 2008; Lissek et al., 2009;
Waters, Henry, & Neumann, 2009); and deficits in transfer of safety (Jovanovic et al., 2005; Jovanovic et al., 2009,
Jovanovic et al., 2010). Moreover, EP research has shown that some of these features are already present in healthy
children who are at risk for anxiety disorders by virtue of parental anxiety disorders (Craske, et al., 2008; Waters,
Peters, Forrest, & Zimmer-Gembeck, 2014).

(2) Translational experimental psychopathology research

Studies that focus on the translation of fundamental EP research into clinical practice address mediators and
moderators of current treatments, strategies and tools to enhance outcomes based on treatments derived from EP
research, and the development of novel treatments that specifically target key mechanisms identified through EP
research. Such translational questions are often addressed through randomized controlled trials (RCTs) of treatment
efficacy.
Exposure-based treatments for anxiety disorders, which are founded upon principles of extinction learning, have
been subjected to numerous RCTs in comparison with waitlist control groups and other active interventions and have
been shown to produce moderate to large effect sizes (see Rapee, Schniering, & Hudson, 2009 for review of child
samples and Hofmann & Smits, 2008 for a review of adult samples). Nevertheless, approximately 40-50% of anxious
patients are classified as ‘non-responders’, meaning that they do not achieve full remission (Rapee et al., 2009;
Loerinc et al., 2015) and almost half of those who do respond relapse over the ensuing years after treatment
(Ginsburg et al., 2014). Therefore, researchers espousing an EP approach have focused on integrating new
knowledge derived from ongoing laboratory-based research on underlying mechanisms of extinction learning into
contemporary learning models of anxiety disorders (e.g., Craske et al., 2008; Craske, Treanor, Conway, Zbozinek,
& Vervliet, 2014) and clinical practice research in order to enhance outcomes. We review two such strategies below.

Expectancy learning.
Error correction models of extinction learning posit that learning is enhanced by the mismatch between high
expectancy for the aversive stimulus and its absence (Rescorla & Wagner, 1972). In accord, exposure therapy may
be best designed to violate expectancies regarding the frequency or intensity of aversive outcomes. Thus, for a client
with panic disorder who predicts that elevated heart rate is likely to lead to a heart attack, exposures may be best
designed to repeatedly violate this expectancy through inducing increased heart rate under conditions in which heart
attacks are expected to be most likely to occur, and reducing safety behaviors or other forms of avoidance. This
approach to exposure therapy has been supported in clinical trials (Baker et al., 2010; Deacon et al., 2013).
Furthermore, the associative strength of multiple conditional stimuli summate or combine to “over-predict” the
occurrence of the unconditional stimulus. Hence, when the unconditional stimulus does not occur in the presence of
multiple conditional stimuli, the discrepancy between what was predicted and what actually occurred is enhanced.
Studies in animals and humans have found that this “deepened extinction” enhances learning (Culver, Vervliet, &
Craske, 2014; Rescorla, 2006). Thus, exposure may be enhanced by initial exposure to individual predictors of a
feared outcome followed by their combination (such as exposure to hyperventilation, and then combining
hyperventilation with exposure to heat for the individual who fears loss of consciousness from lightheadedness and
heat).

Safety learning.
The presence of inhibitory stimuli can negatively impact extinction. Conditioned inhibitors, or “safety signals”, are
stimuli that predict the non-occurrence of the unconditional stimulus and therefore reduce the expectation that it will
occur. Numerous studies in both animal and human samples have demonstrated the deleterious effects of safety
 Psychopathology Review, Volume 4 (2017), Issue 2, 112-128 118

signals on extinction learning (Lovibond, 2004). Clinically relevant examples of safety signals include anxiolytic
medication, cell phones, or the presence of another person. A number of clinical studies demonstrate a negative
impact of safety signals on outcomes from exposure therapy (e.g., Sloan & Telch, 2002). Although others have failed
to replicate the deleterious effect of engaging in safety behaviors during exposure in claustrophobic fear (Deacon,
Sy, Lickel & Nelson, 2010), this may be a function of the ratio of inhibition and excitation in a given trial and warrants
further EP examination.

(3a) Dissemination to the clinical science community

Distribution of EP research currently occurs primarily through the publication of research findings in EP, CP, and
psychiatry-related journals, websites of professional associations devoted to EP topics, and related conferences.
However, more could be done. For example, funding of clinical science research that embraces an EP approach
would advance the integration of these two fields, and indeed the National Institutes of Mental Health Strategic Plan
for Research (2015) announced a priority for psychotherapy trials that seek to identify mechanisms. Furthermore,
experimental scientists and clinical scientists could benefit from more frequent joint meetings, as has been advocated
and implemented by the MQ: Transforming Mental Health Foundation (see Holmes, Craske, & Graybiel, 2014).
Annual meetings of special interest groups, such as Annual European Meeting on Human Fear Conditioning, can
bring together experimental psychopathologists and clinical scientists. More could be done to attach EP special
interest groups to professional meetings that target clinical scientists (e.g., Association for Psychological Science,
Association for Behavioral and Cognitive Therapy) and devotion of annual meetings to the integration of these two
fields. Furthermore, greater collaboration between EP researcher and neuroscientists, cognitive psychologists, and
social psychologists could provide new ideas and improved methodologies.

(4a) Theory integration and refinement

Knowledge arising from EP research once circulated amongst the scientific community continues to inform theory
refinement and development. A considerable body of research exists demonstrating the cyclical process of basic EP-
informed research on fear learning and extinction leading to theory refinements such as models of panic disorder
(Bouton et al., 2001), anxiety disorders more generally (Mineka & Zinbarg, 2006) and models of learning through
exposure therapy (Craske et al., 2014). Similarly, new theory developments inspire innovative EP-informed laboratory
research. For example, inhibitory retrieval models of extinction that have been translated into models for exposure
therapy have raised the important question of generalization stimuli during extinction. That is, typical Pavlovian
conditioning experiments in rodents and humans involve fear acquisition and extinction to simple conditional stimuli
(CS), such as a shape of brief duration. Aversive experiences in humans rarely involve simple cues but rather are
associated with complex, multi-sensory stimuli (e.g., auditory, visual, tactile, olfactory) that persist more than a few
seconds and are embedded within an array of stimuli that form the background context. In addition, Pavlovian
experiments typically replicate the exact CS across acquisition, extinction and retest. However, exposure therapy
usually targets stimuli that only resemble the original CS, with some features overlapping and others that differ.
Moreover, given pervasive generalization of fear, the intended effects of exposure therapy are for an array of complex
stimuli that extend beyond those targeted in exposure. Some EP researchers have begun to evaluate the
mechanisms underlying acquisition of fear of complex, multi-sensory stimuli, and the effects of variation in elements
of complex conditional stimuli upon extinction and renewal of fear (e.g., Barry, Griffith, Vervliet, & Hermans, 2015;
see Boddez, Baeyens, Hermans, & Beckers, 2013 for a review). A greater understanding of these mechanisms may
elucidate methods for augmenting exposure therapy.

(3b) Dissemination into the clinical practice community

Methods for disseminating EP-informed research findings into the clinical community requires strong links between
EP researchers and professional organizations committed to psychological science and practice, the provision of
clinical training, and mental health service delivery. The joint goal will be for principles of EP to become increasingly
integrated into clinical training, ongoing professional development, and eventually clinical practice.
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The foundation for a mental health workforce competent in EP-informed research and practice methods requires
clinical training and ongoing professional development that emphasises therapy and research knowledge (Engelhard,
2012; Schurman & Gayes, 2014). Such a focus is of fundamental importance given that experimentally-informed
treatments are under-utilized in clinical practice. For example, the most commonly reported reasons for not utilizing
exposure therapy in the case of post-traumatic stress disorder (PTSD) is a lack of training and experience (e.g.,
Black Becker, Zayfert, & Anderson, 2004). This highlights the need for greater involvement of EP researchers in
graduate clinical training programs, perhaps via dedicated classes within existing courses focused on EP research
methods and procedures, the use of EP textbooks and online teaching resources to demonstrate EP principles, the
provision of short-term placement opportunities with EP researchers as apart of ongoing practicum training, or in
established EP research departments, the provision of dedicated courses or summer school programs focused on
EP. Greater involvement of EP researchers in ongoing professional development initiatives is also important, and
might include workshop series, webinars, and the provision of EP-informed resources via websites of the professional
bodies that target the clinical community (e.g., American Psychological Association, Australian Psychological Society,
British Psychological Association).
Another avenue for greater dissemination into clinical practice is through stakeholder partnerships between EP
researchers and mental health services. Large-scale dissemination projects focused on therapist training in evidence-
based practices (components of which were established and refined based on EP research e.g., exposure therapy
and cognitive therapy) illustrate such an approach (e.g., Clark et al., 2009 Southam-Gerow et al., 2014). Another
avenue is through partnerships between EP researchers, clinical psychology training programs, and community
stakeholders (e.g., schools) in order to reach clients ‘where they are’. For example, one such partnership project
between a local school, a university clinical training program and EP researchers examined the mechanisms of
threat-based cognitive biases as predictors or moderators of change following a cognitive-behavioural intervention
delivered to primary school-age children via provisionally-registered clinical psychology interns practicing under
supervision as part of their graduate-level clinical training (Waters, Groth, Sanders, O’Brien, & Zimmer-Gembeck,
2015). Such partnerships also have the potential to increase EP researchers’ understanding of real world variables
they may not account for in the laboratory and clinicians’ appreciation for the relevance of EP to their practice by
enabling them to see firsthand the practical application of the findings from EP research to the problems and
populations they work with.

(4b) Clinical practice integration and refinement

With the dissemination of more EP-informed research into clinical settings and training programs, strategies are
required that ensure continued research integration and refinement in clinical practice. Such strategies might include
novel assessment and treatment delivery approaches of evidence-based treatments derived from EP-research, the
provision of clinical-science positions, fellowships and grant funding opportunities within mental health workplaces,
as well as routine reporting of n = 1 case series and case studies derived from EP-informed clinical practice to inform
EP researchers and the broader clinical science community.
Novel EP-informed assessment and treatment delivery that is sustainable within workplaces and accessible to clients
is of critical importance. Examples include the use of online and e-mental health strategies derived from EP research
and delivered in primary care, such as computer-based modular CBT programs for anxiety and depressive disorders
(Craske et al., 2009; Hadjistavropoulos, et al., 2014), internet-based cognitive bias modification programs (e.g.,
Blackwell et al., 2015; Williams et al., 2015; Salemink, Kindt, Rienties, & van den Hout, 2014), and automated data
collection methods that minimise patient burden (e.g., Carlbring et al., 2012). These initiatives require clinical
research to be based in clinically relevant settings, rather than requiring subsequent evaluation of the generalizability
of treatment effects to such settings. Relatedly, the CONSORT flow diagrams of many efficacy RCTs that target
mechanisms derived from EP research demonstrate by necessity the high rates of patient exclusion (e.g., Carlbring
et al., 2012; Eldar et al., 2012; Waters et al., 2014). Therefore, subsequent effectiveness trials with broader inclusion
criteria that are based in clinical settings would be more persuasive for therapists (e.g., Wergeland et al., 2014).
Furthermore, a number of rigorous RCTs have not demonstrated the expected support for the comparative
effectiveness of evidence-based treatments (e.g., that include EP-based principles such as exposure therapy)
against usual care in various community service contexts (e.g., Southam-Gerow et al., 2010). Similarly, despite the
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strong evidence base for exposure therapy, as well as its acceptability and preferability to clients (Olatunji, Deacon,
& Abramowitz, 2009), this treatment is rarely used by clinicians (Black Becker et al., 2004; Van Minnen, Hendriks, &
Olff, 2010). Therefore, another approach has been to design evidence-based protocols in a modular format that can
be adapted for use across multiple disorders, address comorbidity or treatment interference, and adapted in response
to poor progress through ongoing patient evaluation (Chorpita & Daleiden, 2009; Weisz & Chorpita, 2012). This work
has emphasized the testing of new treatment designs to coordinate existing clinical procedures with evidence-based
practices (Chorpita, Bernstein, & Daleiden, 2011). Such approaches have yielded significantly steeper trajectories of
improvement and better diagnostic outcomes at post-treatment and 2 year follow-up relative to standard evidence-
based practices and usual care with community patients (Chorpita et al., 2013; Weisz & Chorpita, 2012).
However, all of these initiatives require supportive workplaces, managers and supervisors who embrace research-
related activities within clinician workloads (Ollendick, 2014). As the disciplines of EP and CP become increasingly
specialized and the knowledge base grows, it will become less possible for clinicians to remain current and sufficiently
expert in multiple areas. Numerous initiatives have been proposed to address these problems, including an increased
role of academic researchers in mental health care settings (Engelhard, 2012), an increased presence of clinicians
working in university research centres (Shapiro, 2002), and the development and uptake of clinical practice guidelines
in both settings that to some extent, incorporate key EP research principles (Ollendick, 2014; Hollon et al., 2014).
At the individual clinical practice level, EP shares numerous principles with the scientist-practitioner model which
advocates for clinical psychologists working as research-informed applied scientists (Shapiro, 2002). Indeed, both
approaches share core competencies such as utilizing assessment and intervention procedures in accordance with
protocols, accessing and integrating ongoing research findings to guide patient care (at either the patient or laboratory
level), framing and testing hypotheses (either n = 1 case designs or laboratory methodology or RCTs), ongoing
evaluation through the use of dependent measures across modalities (e.g., self-report, behavioral observations,
physiology), modifying treatment or laboratory approaches based on data, building and maintaining multi-disciplinary
teams of professionals committed to applied science approaches, and ensuring adequate provision of training in
practice-based evidence and evidence-based practice (Engelhard, 2012; Schurman & Gayes, 2014; Shapiro, 2002).
Moreover, clinical practice provides the opportunity to study rare or complex cases in real-world settings through
case study research that might otherwise be excluded from laboratory studies and tightly controlled RCTs. Case
study research has great potential as one mechanism for bridging the scientist-practitioner gap (Ollendick, 2014).
Clinical case studies provide an in-depth description of an individual patient or group of patients within the unique
context and characteristics of the case (Kazdin, 2011). This in turn can stimulate innovative research questions that
can be tested through EP research and contribute to psychological theory or therapy development (Drotar, 2011).
Single-case designs (which are distinct from illustrative case studies due to repeated measurement within an
individual across time, and ideally across different conditions) can also serve as evidence of treatment efficacy and
are particularly useful in CP when studying rare conditions and when large samples are difficult to obtain (e.g., Cohen,
Feinstein, Masuda, & Vowles, 2014; Oar, Farrell, Waters, Conlon, & Ollendick, 2015; Ollendick & King, 2012;). Thus,
single-case research conducted within a scientist-practitioner model of clinical practice shares numerous qualities
and characteristics with EP by involving rigorous scientific standards and high internal validity (Kratochwill et al.,
2013). Greater adoption of single-case designs in clinical settings could be an avenue by which EP research
principles can be embedded in clinical practice. Moreover, encouraging scientist-practitioners who implement EP-
informed approaches into their clinical work (such as single-case research studies) to communicate the results and
logistical challenges of their work to the scientific and clinical community via professional practice websites and
practitioner-focused journal outlets and conferences, will enable greater integration of CP and EP research.

Challenges, Important Issues and Future Considerations

EP has made significant contributions by systematically applying laboratory-based models and experimental
methods to identify mechanisms that underlie psychological problems and disorders. Through this knowledge, EP
has laid the foundation for the development and refinement of science-based treatments based on the continued
evaluation of mechanisms as well as predictors and moderators of treatment outcomes. At the interface with clinical
psychological practice, EP shares much in common with the principles and assumptions of a scientist-practitioner
model of clinical practice and single-case design research. Despite enormous advancement in both knowledge and
 Psychopathology Review, Volume 4 (2017), Issue 2, 112-128 121

application, significant challenges remain for ensuring that EP research continues to play a dominant role in the
advancement of psychological knowledge and the development of evidence-based treatment approaches and clinical
practice (Sloan, 2014). By considering the major steps in the model proposed in Figure 1, we summarize some of
the key issues, challenges and opportunities facing the discipline of EP and its integration with the clinical science
community and the clinical practice community.

Challenges facing experimental psychopathology research and translational

research
There are numerous opportunities and challenges facing researchers within the field of EP research. With a greater
emphasis placed on conceptualizing psychopathology in terms of broad underlying mechanisms that cut across
diagnoses as traditionally defined (e.g., the Research Domains Criteria; RDoC) (Sanislow et al., 2010), a key issue
for EP research relates to the psychometric properties of laboratory methods that are typically used to assess such
mechanisms. As many of the experimental paradigms derived from EP research form the basis of construct
measurement, there is a need to advance research on the psychometric properties of experimental measures, such
as the test-retest reliability of the visual probe task and other measures assessing attention biases (e.g., Brown et
al., 2014; Price et al., 2015; Staugaard, 2009). This is critical for moving towards a dimensional approach based on
underlying neurological, cognitive, biological, and behavioural constructs that are defined by such measures, and if
such measures are to be used for evaluating treatment response.
Another issue relates to whether standardized measurement tools, or at least a core set of measurement
recommendations, should be utilized. Similar to the way in which traditional symptom clusters are measured with
well-validated and highly utilized self-report measures (e.g., the Beck Depression Inventory), it will be important for
EP researchers to consider whether their measurement tools should similarly become standardized. Ways in which
this has already advanced is through the use of technology, such as virtual reality methodology (see Coelho, Waters,
Hine, & Wallis, 2009); the availability of online tools (see Wiers, Rinck, Kordts, Houben, & Strack, 2010); and making
methodology available for use by other research groups to allow for standardization of measurement (e.g., Abend,
Pine & Bar-Haim, 2014). However, wide variation continues to exist in the experimental design (e.g., fear-potentiation
protocols versus Pavlovian conditioning and extinction tasks), the stimuli utilized (e.g., word versus picture stimuli),
and the task parameters employed by EP researchers (e.g., number of trials, stimulus exposure durations) even
though the same EP-derived theoretical constructs are being studied.
EP researchers will also need to consider whether definitions of response should be determined for measures derived
from EP. For example, in the area of psychophysiology, published guidelines exist for measuring, scoring and
analyzing startle eye blink responses (Blumenthal et al., 2005). Similarly agreed upon guidelines for other EP
measures that involve more varied data management procedures might be useful. One example relates to guidelines
for defining successful fear extinction when assessed across multiple self-report and physiological measures.
Another example relates to cognitive biases in terms of guidelines for the measurement and scoring of attention and
interpretation biases and definitions regarding successful change in biases, such as the change in attention biases
towards threat to away from threat stimuli in attention bias modification treatment studies (see MacLeod & Clarke,
2015).

Challenges facing dissemination to the clinical science community

Several challenges and opportunities also arise for integration into the clinical science community. One example is
that the core of EP research does not become reductionistic to genetics and neuroscience but rather incorporates
the latest advances in genetics and neuroscience to complement cognitive, behavioral and self-report models and
paradigms into integrative formulations (see Mohlman, Deckersbach, & Weissman, 2015). Furthermore, clinical
scientists will remain skeptical of EP models and methods that do not extend to clinical populations. Hence, drawing
from an example based on research in our laboratories, EP researchers and clinical scientists can work together to
broaden the progression of experimental studies from non-clinical analogue samples (i.e., healthy children; e.g.,
Neumann, Waters, & Westbury, 2008), to clinical samples as traditionally defined (i.e., anxious children; e.g., Craske,
Waters et al., 2008; Waters & Kershaw, 2015), to treatment seeking samples (e.g., Waters & Pine, in press). This
 Psychopathology Review, Volume 4 (2017), Issue 2, 112-128 122

has resulted in principles of EP being incorporated into randomized controlled trials with treatment seeking samples,
such as the methods of exposure therapy incorporated into the treatment of anxiety in primary care (Craske et al.,
2009).

Challenges facing dissemination to the clinical practice community

Similarly, there are several challenges and opportunities for integration of EP research within the clinical practice
community. It will be essential that the translation of principles and methods derived from EP research, with its tight,
experimental controls and rigorous methodology, is not lost to weak implementation, and poor measurement in
clinical settings. In all formats in which EP research is disseminated into the clinical practice community, every effort
should be made to ensure that the relevance of EP research to clinical practice is made very clear. Otherwise, by
being theory-driven, laboratory-based research focused primarily on mechanistic processes with pre-clinical
samples, EP runs the risk of being unable to bridge the translational gap, and may be viewed as too far removed
from clinical practice at the patient level. Also, EP researchers need to devise ways to make experimentally-derived
techniques accessible, affordable and sustainable in applied settings. If not, EP research may also be seen as
economically unsustainable by major funding bodies and national health care systems.

Future Directions
As is clear from the review of the benefits and challenges facing EP and CP, both disciplines have much to offer, and
much to gain from, the other discipline. We have proposed an integrative conceptual framework to encourage greater
progression of EP-informed research into clinical science community and into the clinical practice community, with
the ultimate goals of advancing clinical psychological science and patient care. This makes it abundantly clear that
strong intra- and inter-disciplinary collaborative relationships are needed that cut across all sectors of the model,
including collaborations among EP researchers as well as with those from other clinical science disciplines, national
psychological science associations, training and professional development organizations, and clinical practice
settings. One way forward might be through the formation of an international EP research advisory committee to
identify and address the key challenges and opportunities within the discipline of EP and to systematically expand
its focus to key stakeholders within the clinical science and practice sectors in order to facilitate multi-disciplinary
dissemination and integration of EP research into science, training and practice. This calls for strong leadership and
direction from within the field of EP research.

Conclusion
In summary, EP research has made significant contributions to the advancement of psychological theory,
methodology and knowledge about a range of psychological problems and dysfunctions. We argue that the time is
ripe for greater integration of EP research with the discipline of CP, and we propose an integrative model that
describes the translation of EP research into clinical science and practice, with the goals of improving scientific
knowledge and patient care. We recommend that strong intra-disciplinary collaboration among EP researchers, as
well as broader inter-disciplinary collaboration with key stakeholders within other clinical science and practice sectors,
is needed to advance the contribution of EP research to the discipline of CP.

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