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Evidence Based Practices In Mental Health Debate And
Dialogue On The Fundamental Questions 1st Edition
John C. Norcross Digital Instant Download
Author(s): John C. Norcross, Larry E. Beutler, Ronald F. Levant
ISBN(s): 9781591472902
Edition: 1
File Details: PDF, 26.10 MB
Year: 2006
Language: english
Evidence-Based
Practices in
Mental Health
Debate and
Dialogue on the
Fundamental
Questions

Editors

John C. Norcross, Larry E. Beutler,

and Ronald F. Levant

American Psychological Association • Washington, DC

Copyright © 2006 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publication
may be reproduced or distributed in any form or by any means, including, but not limited to,
the process of scanning and digitization, or stored in a database or retrieval system, without
the prior written permission of the publisher.

Published by
American Psychological Association
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Library of Congress Cataloging-in-Publication Data

Evidence-based practices in mental health : debate and dialogue on the fundamental

questions / edited by John C. Norcross, Larry E. Beutler & Ronald F. Levant.
p. cm.
Includes bibliographical references and index.
ISBN 1-59147-290-3—ISBN 1-59147-310-1 (softcover)
1. Evidence-based psychiatry. I. Norcross, John C., 1957- II. Beutler, Larry E. III.
Levant, Ronald F.

RC455.2.E94E955 2005
616.89—dc22
2005004098

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

Printed in the United States of America

First Edition
 To the American Psychological Association:
Large, diverse, and inclusive enough for all of us
 CONTENTS

About the Editors yd

Contributors xiii
Prologue 3
John C. Norcross, Larry E. Beutler, and Ronald F. Levant
Chapter 1. What Qualifies as Evidence of Effective Practice? 13
Clinical Expertise 13
Geoffrey M. Reed
Scientific Research 23
John F. Kihlstrom
Patient Values and Preferences 31
Stanley B. Messer
Dialogue: Convergence and Contention 40

Chapter 2. What Qualifies as Research on Which to Judge

Effective Practice? 57
Case Studies 57
William B.Stiks
Single-Participant (S-P) Design Research 64
Ruth M. Hurst and Rosemery Nelson'Gray
Qualitative Research 74
Clara E. Hill
Change Process Research 81
Leslie S. Greenberg and Jeanne C. Watson
Effectiveness Research 89
Tom D. Borkovec and Louis G. Castonguay
Randomized Clinical Trials 96
Steven D. Holion
Dialogue: Convergence and Contention 105

Chapter 3. Does Manualization Improve Therapy Outcomes? 131

Psychotherapy Manuals Can Improve Outcomes 131
Michael E. Addis and Esteban V. Cardemil

vu
 Treatment Manuals Do Not Improve Outcomes 140
Barry L. Duncan and Scott D. Miller
Dialogue: Convergence and Contention 149

Chapter 4. Are Research Patients and Clinical Trials

Representative of Clinical Practice? 161
Patients and Treatments in Clinical Trials Are Not
Adequately Representative of Clinical Practice 161
Drew I. Westen
Research Patients and Clinical Trials Are Frequently
Representative of Clinical Practice 171
Shannon Wiltsey Stirman and Robert]. DeRubeis
Dialogue: Convergence and Contention 180

Chapter 5. What Should Be Validated? 191

The Treatment Method 191
Dianne L. Chambless and Paul Crits-Christoph
The Psychotherapist ZOO
Bruce E. Wampold
The Therapy Relationship 208
John C. Norcross and Michael]. Lambert
The Active Client 218
Arthur C. Bohart
Principles of Change 226
Larry E. Beutler and Brynne E. Johannsen
Dialogue: Convergence and Contention 234

Chapter 6. What Else Materially Influences What Is

Represented and Published as Evidence? 257
Theoretical Allegiance 257
Lester B. Luborsky and Marna S. Barrett
Impact of Funding Source on Published Research 267
David O. Antonuccio and Deacon Shoenberger
A Poor Fit Between Empirically Supported Treatments and
Psychotherapy Integration 275
George Strieker
Dialogue: Convergence and Contention 282

VIZI CONTENTS
Chapter 7. Do Therapies Designated as Empirically Supported Treatments
for Specific Disorders Produce Outcomes Superior to
Non-Empirically Supported Treatment Therapies? 299
Not a Scintilla of Evidence to Support Empirically Supported
Treatments as More Effective Than Other Treatments 299
Bruce E. Wampold
Empirically Supported Treatments Typically Produce Outcomes
Superior to Non-Empirically Supported Treatment Therapies 308
Thomas H. Ollendick and Neville J. King
Dialogue: Convergence and Contention 317

Chapter 8. How Well Do Both Evidence-Based Practices and

Treatment as Usual Satisfactorily Address the
Various Dimensions of Diversity? 329
Ethnic Minority Populations Have Been Neglected by
Evidence-Based Practices 329
Stanley Sue and Nolan Zane
Gender Is Neglected by Both Evidence-Based Practices and
Treatment as Usual 338
Ronald F. Levant and Louise B, Silverstein
The Neglect of Lesbian, Gay, Bisexual, and Transgendered Clients 346
Laura S. Brown
Evidence-Based Practices Have Ignored People With Disabilities 353
Rhoda Olkin and Greg Taliaferro
Dialogue: Convergence and Contention 359

Chapter 9. Are Efficacious Laboratory-Validated Treatments

Readily Transportable to Clinical Practice? 375
Efficacious Laboratory-Validated Treatments Are Generally
Transportable to Clinical Practice 375
Martin E. Franklin and Robert]. DeRubeis
Transporting Laboratory-Validated Treatments to the
Community Will Not Necessarily Produce Better Outcomes 383
Drew I. Westen
Dialogue: Convergence and Contention 393

Epilogue 403
John C. Norcross, Larry E. Beutler, and Ronald F. Levant
Author Index 407
Subject Index 427

CONTENTS IX
 ABOUT THE EDITORS

John C. Norcross, PhD, ABPP, is Professor of Psychology and Distinguished

University Fellow at the University of Scranton, a clinical psychologist in
part-time practice, and editor of the Journal of Clinical Psychology: In Session.
Author of more than 250 publications, Dr. Norcross has cowritten or edited
14 books, including Psychotherapy Relationships That Work, Authoritative Guide
to Self-Help Resources in Mental Health, Handbook of Psychotherapy Integration,
Psychologists' Desk Reference, and Systems of Psychotherapy: A Transtheoretical
Analysis. He is past president of the International Society of Clinical Psy-
chology and the American Psychological Association (APA) Division 29
(Psychotherapy). He currently serves on the Council of Representatives of
the APA and on the board of directors of the National Register of Health
Service Providers in Psychology. Dr. Norcross has received many professional
awards, such as the APA's Distinguished Contributions to Education and
Training Award, Pennsylvania Professor of the Year from the Carnegie Foun-
dation, and election to the National Academies of Practice.

Larry E. Beutler, PhD, ABPP, is Distinguished Professor of Clinical Psy-

chology at the Pacific Graduate School of Psychology, Professor of Homeland
Security at the U.S. Navy Postgraduate School in Monterey, California, and
a consulting professor of psychiatry and behavioral science at the Stanford
University School of Medicine. Dr. Beutler is the former editor of the Journal
of Clinical Psychology and the Journal of Consulting and Clinical Psychology. He
is a fellow of the APA and the American Psychological Society. He is past
president of the APA Division 12 (Society of Clinical Psychology), the APA
Division 29 (Psychotherapy), and the (International) Society for Psy-
chotherapy Research. He is the author of approximately 300 scientific papers
and chapters and is the author, editor, or coauthor of 14 books on psy-
chotherapy and psychopathology. Dr. Beutler is coeditor of a book on
empirically defined principles of therapeutic change that is cosponsored by the
APA Division 12 and the North American Society for Psychotherapy
Research.

Ronald F. Levant, EdD, ABPP, is Professor of Psychology at Nova South-

eastern University. Since earning his doctorate in clinical psychology and
public practice from Harvard, Dr. Levant has been a psychologist in inde-
pendent practice, a clinical supervisor in hospital settings, a clinical and aca-
demic administrator, and a faculty member. He has authored, coauthored, or
coedited over 250 publications, including 14 books and 140 journal articles
and book chapters. His books include Between Father and Child, Masculinity
Reconstructed, A New Psychology of Men, Men and Sex, and New Psychothera'
pies for Men. Dr. Levant served as editor of the Journal of Family Psychology
and is currently associate editor of Professional Psychology: Research and Prac-
tice. He served as president of the Massachusetts Psychological Association,
president of the APA Division 43 (Family Psychology), cofounder of the
Society for the Psychological Study of Men and Masculinity, two-term chair
of the APA Committee for the Advancement of Professional Practice, mem-
ber of the APA Council of Representatives, and recording secretary of APA.
Dr. Levant is the 2005 president of the APA. One of his presidential initia-
tives is evidence-based practice in psychology.

XII ABOUT THE EDITORS

 CONTRIBUTORS

Michael E. Addis, PhD, Department of Psychology, Clark University,

Worcester, MA
David O. Antonuccio, PhD, Department of Psychiatry and Behavioral
Sciences, University of Nevada School of Medicine, Reno
Marna S. Barrett, PhD, Department of Psychiatry, University of
Pennsylvania School of Medicine, Philadelphia
Larry E. Beutler, PhD, Pacific Graduate School of Psychology, Palo
Alto, CA
Arthur C. Bohart, PhD, Department of Psychology, California State
University, Dominguez Hills
Tom D. Borkovec, PhD, Department of Psychology, Pennsylvania State
University, University Park
Laura S. Brown, PhD, Washington School of Professional Psychology,
Argosy University, Seattle
Esteban V. Cardemil, PhD, Department of Psychology, Clark University,
Worcester, MA
Louis G. Castonguay, PhD, Department of Psychology, Pennsylvania
State University, University Park
Dianne L. Chambless, PhD, Department of Psychology, University of
Pennsylvania, Philadelphia
Paul Crits-Christoph, PhD, Department of Psychiatry, University of
Pennsylvania School of Medicine, Philadelphia
Robert J. DeRubeis, PhD, Department of Psychology, University of
Pennsylvania, Philadelphia
Barry L. Duncan, PsyD, Institute for the Study of Therapeutic Change,
Chicago, 1L
Martin E. Franklin, PhD, Department of Psychiatry, University of
Pennsylvania School of Medicine, Philadelphia

xm
Leslie S. Greenberg, PhD, Department of Psychology, York University,
Toronto, Ontario, Canada
Clara E. Hill, PhD, Department of Psychology, University of Maryland,
College Park
Steven D. Hollon, PhD, Department of Psychology, Vanderbilt University,
Nashville, TN
Ruth M. Hurst, MA, Department of Psychology, University of North
Carolina at Greensboro
Brynne E. Johannsen, BS, Pacific Graduate School of Psychology, Palo
Alto, CA
John F. Kihlstrom, PhD, Institute for the Study of Healthcare
Organizations and Transactions, University of California, Berkeley
Neville J. King, PhD, Faculty of Education, Monash University, Victoria,
Australia
Michael J. Lambert, PhD, Department of Psychology, Brigham Young
University, Provo, UT
Ronald E Levant, EdD, Center for Psychological Studies, Nova
Southeastern University, Fort Lauderdale, FL
Lester B. Luborsky, PhD, Department of Psychiatry, University of
Pennsylvania School of Medicine, Philadelphia
Stanley B. Messer, PhD, Graduate School of Applied and Professional
Psychology, Rutgers University, Piscataway, NJ
Scott D. Miller, PhD, Institute for the Study of Therapeutic Change,
Chicago, IL
Rosemery Nelson-Gray, PhD, Department of Psychology, University of
North Carolina at Greensboro
John C. Norcross, PhD, Department of Psychology, University of
Scranton, Scranton, PA
Rhoda Olkin, PhD, California School of Professional Psychology, Alliant
International University, San Francisco
Thomas H. Ollendick, PhD, Department of Psychology, Virginia
Polytechnic Institute and State University, Blacksburg, VA
Geoffrey M. Reed, PhD, Practice Directorate, American Psychological
Association, Washington DC
Deacon Shoenberger, MA, Department of Psychology, University of
Nevada, Reno
Louise B. Silverstein, PhD, Department of Psychology, Yeshiva
University, Bronx, New York
William B. Stiles, PhD, Department of Psychology, Miami University,
Oxford, OH
Shannon Wiltsey Stirman, MA, Department of Psychology, University of
Pennsylvania, Philadelphia
George Strieker, PhD, The Derner Institute, Adelphi University, Garden
City, New York

XW CONTRIBUTORS
Stanley Sue, PhD, Department of Psychology, University of California, Davis
Greg Taliaferro, PhD, Cincinnati Psychoanalytic Institute, Cincinnati, OH
Bruce E. Wampold, PhD, Department of Counseling Psychology, University
of Wisconsin—Madison
Jeanne C. Watson, PhD, Department of Adult Education and Counseling
Psychology, University of Toronto, Ontario, Canada
Drew I. Westen, PhD, Departments of Psychology and Psychiatry, Emory
University, Atlanta, GA
Nolan Zane, PhD, Department of Psychology, University of California,
Davis

CONTRIBUTORS XV
Evidence-Based
Practices in
Mental Health
 PROLOGUE
JOHN C. NORCROSS, LARRY E. BEUTLER, AND RONALD F. LEVANT

Few topics in mental health are as incendiary, consequential, and timely

as evidence-based practices. Yet, this multifaceted and complex topic has
been reduced to simplistic and polarized arguments; regrettably, more heat
than light has been shed on the topic. This book, designed primarily for men-
tal health practitioners, trainers, and graduate students, addresses nine fun-
damental questions in the debate on evidence-based practices (EBPs). Each
chapter centers on one particular question in the ongoing EBPs debate and
consists of several focused position papers on that question. The position
papers are followed by dialogues among the contributors on their respective
points of convergence and contention.
In this brief introduction, we begin by describing the purpose and struc-
ture of Evidence-Based Practices in Mental Health; Debate and Dialogue on the
Fundamental Questions. We then review the origins and controversies of EBPs
in mental health. With these as the background, we place the nine pivotal
questions in context.

PURPOSE AND STRUCTURE OF THE BOOK

Our abiding hope is that this book will explicate the central questions
in this fiercely contested subject, will provide balanced positions on these
polarizing questions, and will purge us of needless confusion and antagonism.
In doing so, our aim is to underscore both the robust commonalities and the
remaining contentions regarding EBPs in mental health.
The structure of the book follows directly from its purposes. Each chap-
ter consists of position papers on a specific question followed by brief
dialogues among the contributors. We recruited leading practitioners and
researchers to contribute position papers. The papers were designed to be
focused, persuasive pieces that advanced a particular perspective. The con-
tributors were asked to use any combination of clinical experience, research
findings, theoretical argument, and logical analysis to advance their posi-
tions. Contributors were free to take on a coauthor, and we requested them
to keep diversity in mind when doing so. We sought contributor diversity not
only in terms of gender, ethnicity, and sexual orientation but also in terms of
theoretical orientation and representation across the practice-research con-
tinuum. Although many of the contributors were understandably tempted to
comment upon multiple facets of the evidence-based debate, we asked them
to limit themselves to the specific question posed in that chapter.
Contributors to a particular chapter then received the final drafts of the
other contributors' position papers and were asked to comment briefly (1,000
words or less) on their respective points of agreement and remaining dis-
agreements. We desired candid, vigorous, but respectful exchanges that illu-
minated both areas of convergence and remaining areas of contention. We
specifically advised contributors that "the tone should be that of a respectful
discourse among colleagues. Please do not exaggerate or mischaracterize
other contributors' positions; we have plenty of substantive disagreement
without resorting to unsavory rhetorical devices. And, of course, please
refrain from any ad hominem attacks."

BRIEF HISTORY OF EMPIRICALLY SUPPORTED TREATMENTS

AND EVIDENCE-BASED PRACTICES

Evidence-based practices, as is often said about clinical psychology

(Boring, 1950), has a long past but a short history. The long past of EBPs
entails hundreds of years of effort to base clinical practice on the results of
solid, typically research, evidence. Starting with its separation from philoso-
phy and Wilhelm Wundt's early laboratory experiments, psychology has
always prided itself on its scientific roots and empirical rigor. Similarly, from
Emil Kraeplin's diagnostic scheme to Benjamin Rush's initial empirical
efforts, psychiatry has tried to distance itself from untested practices and to
locate itself as a science of mind. From their very inceptions, mental health
professions proclaim their allegiance to the methods and results of scientific
research.
In medicine, analysts point to three landmarks on the road to EBPs
(Leff, 2002). The first was the Flexner Report, which created a blueprint for
medical education on the basis of a scientific and uniform curriculum. The
second was medicine's first randomized clinical trial, which appeared in a
1948 issue of the British Medical Journal. The third landmark was the estab-
lishment of the Food and Drug Administration (FDA) and the related gov-

4 EVIDENCE-BASED PRACTICES IN MENTAL HEALTH

ernmental organizations mandated to test the safety and effectiveness of
health care interventions.
But the short past of EBPs in mental health traces back to the 1990s,
originally in Great Britain and then gathering steam in the United States and
around the globe. Foremost among these initiatives in psychology in the
United States was the American Psychological Association (APA) Society
of Clinical Psychology's (Division 12) Task Force efforts to identify empiri-
cally supported treatments (ESTs) for adults and to publicize these treatments
to fellow psychologists and training programs. Since 1993, a succession of
APA Division 12 Task Forces (now a standing committee) has constructed
and elaborated a list of empirically supported, manualized psychological
interventions for specific disorders on the basis of randomized, controlled
studies that pass for methodological rigor (Chambless & Hollon, 1998;
Chambless et al., 1996, 1998; Task Force on Promotion and Dissemination
of Psychological Procedures, 1995). Oxford University Press published the
influential A Guide to Treatments That Work (Nathan & Gorman, 1998), a
volume that emanated from the work of a related Division 12 Task Force.
Subsequently, ESTs were applied to children, adolescents, and older adults.
APA's Society of Clinical Psychology was not alone in developing and
promoting statements on EBPs. The APA Division 17 (Society of Counsel-
ing Psychology) issued their own principles of empirically supported inter-
ventions (Wampold, Lichtenberg, & Waehler, 2002), and the APA Division
32 (Humanistic Psychology; Task Force, 1997) published guidelines for the
provision of humanistic psychosocial services. The APA Division 29 (Psy-
chotherapy) responded with a task force that identified empirically supported
(psychotherapy) relationships or ESRs (Norcross, 2002).
Foremost among the evidence-based initiatives in psychiatry has been
the American Psychiatric Association's practice guidelines. The organization
has published a dozen practice guidelines on disorders ranging from schizo-
phrenia to anorexia to nicotine dependence. Although not explicitly identi-
fied as "evidence-based," they and similar guidelines are similar in scope and
intent: Use the best available knowledge to compile statements of "what
works" or "best practices."
Interestingly, the APA itself has not promulgated practice guidelines or
treatment guidelines for specific disorders. Instead, they have published "Cri-
teria for Evaluating Treatment Guidelines" (APA, 2002) as well as "Criteria
for Practice Guideline Development and Evaluation" (APA, 2002; and
before that, a Template for Developing Guidelines, Task Force, 1995). A key fea-
ture of guidelines for APA is that they are aspirational in nature, unlike stan-
dards that are mandatory. In fact, APA policy requires that any guidelines
note explicitly that they are not intended to be mandatory, exhaustive, or
definitive. "APA's official approach to guidelines strongly emphasizes profes-
sional judgment in individual patient encounters and is therefore at variance

PROLOGUE
with that of more ardent adherents to evidence-based practice" (Reed,
McLaughlin, & Newman, 2002, p. 1042).
APA policy distinguishes between practice guidelines and treatment
guidelines: The former consists of recommendations to professionals con-
cerning their conduct, whereas the latter provides specific recommendations
about treatments to be offered to patients. The evidence-based movement
addresses both types, but primarily treatment guidelines.
Dozens of organizations are already synthesizing evidence and dissemi-
nating their respective lists of EBPs in mental health. One of the oldest is the
Cochrane Collaboration (www.cochrane.org), founded in Great Britain and
named in honor of Archibald Cochrane, a noted British epidemiologist.
Another group modeled after the Cochrane Collaboration is the Campbell
Collaboration (www.campbellcollaboration.org), named in honor of the
American psychologist and methodologist. The American Psychiatric Asso-
ciation, National Association of Social Workers, and other professional orga-
nizations issue practice guidelines (see the National Guidelines
Clearinghouse at www.guideline.gov). Several federal agencies, the Sub-
stance Abuse and Mental Health Services Administration (SAMHSA) and
the Agency for Health Care Research and Quality among them, have spe-
cific centers or special initiatives devoted to the identification and transfer
of EBPs in mental health.
All these initiatives and policies are attempting to address the larger
societal context. The EBP movement is truly a juggernaut, racing to achieve
accountability in medicine, psychology, education, public policy, and even
architecture. The Zeitgeist is to require professionals to base their practice, to
whatever extent possible, on evidence. No profession can afford to sit on the
sidelines; the movement will not magically disappear by avoiding it.
In fact, EBPs are already being defined for mental health practitioners.
The APA Division 12's lists of ESTs have been referenced by a number of
local, state, and federal funding agencies who are beginning to reimburse
practitioners only for the use of these ESTs. Such lists are also being used by
some managed care and insurance companies to control costs by restricting
the practice of psychological health care.
All these efforts are part of a worldwide movement toward EBP in men-
tal health. In Great Britain, for one example, a Guidelines Development
Committee of the British Psychological Society authored a Department of
Health (2001) document entitled Treatment Choice in Psychological Therapies
and Counselling: Evidence-Based Practice Guidelines. In Germany, for another
example, the federal government commissioned an expert report on the
effectiveness of psychotherapy to guide the revisions of laws regulating psy-
chotherapy (Strauss & Kaechele, 1998).
Although the desire to base clinical practice on solid evidentiary
grounds is old and unanimous, the promulgation of specific practice guide-
lines and evidence-based treatments has been relatively recent and divisive.

6 EVIDENCE-BASED PRACTICES IN MENTAL HEALTH

Their introduction has provoked practice modifications, training refine-
ments, and organizational conflicts. For better and for worse, insurance car-
riers and government policymakers are increasingly turning to ESTs, EBPs,
and practice guidelines to determine which psychotherapies to approve and
fund. Indeed, along with the negative influence of managed care, probably
no issue is more central to clinicians than the evolution of EBP in mental
health (Barlow, 2000).

CULTURE WARS OF EBPS

Language is powerful, as any mental health practitioner can readily

attest. Freud famously remarked that words were once magic. Most social and
professional controversies entail powerful meanings of words. What is mar-
riage7. What is the definition of life7. What entails an imminent threat7. Words
can diminish or privilege.
So it is with EBPs. At first blush, there is universal agreement that we
should use evidence as a guide in determining what works. It's like publicly
prizing Mother and apple pie. Can anyone seriously advocate the reverse:
none vidence-based practice?
But it is neither as simple nor as consensual as that. Defining evidence,
deciding what qualifies as evidence, and applying what is privileged as evi-
dence are complicated matters with deep philosophical and huge practical
consequences. For example, 60% to 90% of ESTs identified to date accord-
ing to the Division 12 decision rules are cognitive-behavioral treatments
(CBTs). The ESTs typically involve skill building, have a specific focus,
involve relatively brief treatment, and rarely use traditional assessment mea-
sures (O'Donohue, Buchanan, & Fisher, 2000). The decision rules to require
treatment manuals, rely on controlled research, focus on specific disorders,
and validate specific treatment methods have all come under attack. In par-
ticular, EST lists do little for those psychotherapists whose patients and the-
oretical conceptualizations do not fall into discrete disorders (Messer, 2001).
Consider the client who seeks more joy in his or her life, but who does not
meet diagnostic criteria for any disorder, whose psychotherapy stretches
beyond 20 sessions, and whose treatment objectives are not easily specified
in measurable, symptom-based outcomes. Current evidence-based compila-
tions have little to contribute to his or her therapist and his or her treatment.
Not all psychotherapies or practitioners embrace an action-oriented,
symptom-focused model.
Mental health professionals have become polarized on EBPs and sepa-
rated into rival camps, with differing language systems and conflicting val-
ues. The controversy has spread into the professional literature and onto the
floor of the APA Council of Representatives. EBPs have become the latest
and most visible conflict in psychology's culture wars (Messer, 2004).

PROLOGUE 7
 Part of these culture wars involves theoretical orientation, practice set-
ting, and even professional associations. APA Division 12 and scientist-prac-
titioners in the cognitive—behavioral tradition are, as a group, favorably
disposed toward EBPs; APA Division 42 (Psychologists in Independent Prac-
tice) and full-time practitioners in the psychodynamic and humanistic tradi-
tions are, as a group, vigorously opposed. Tavris (2003), writing on this
widening scientist-practitioner gap, opines that, today,
calling it a "gap" is like saying there is an Israeli-Arab "gap" in the Mid-
dle East. It is a war, involving deeply held beliefs, political passions, views
of human nature and the nature of knowledge, and—as all wars ulti-
mately involve—money, territory, and livelihoods, (p. xiv)
And what of our (the editors') respective positions on EBP in mental
health? Are not the editors' orientations and values potentially in play?
Indeed they are.
The three of us are clinical psychologists, trained to value both practice
and science. We have all taught at universities, all directed psychology
departments or professional schools, all edited journals, all conducted private
practices, all produced research, and all participated in the governance of the
APA and its practice divisions. We are, at once, practitioners, researchers,
teachers, and administrators of psychology.
Our bias is toward informed pluralism. We oppose zealots on both sides;
we champion moderation in the middle. We value the integration of multi-
ple perspectives and the mutual enrichment of practice and science. We are
inveterate eclectics or integrationists, occupying the middle on many of these
questions. Our most cherished value is to give full voice to the field's differ-
ences through respectful discourse.
Having said that and having emphasized our commonalities, those who
know us and our professional contributions would probably align us slightly
differently on many of the evidence-based questions. One of us (Ronald E
Levant) is perceived as more sympathetic to practitioners, one of us (Larry E.
Beutler) is more inclined to scientists, and one of us (John C. Norcross) is a
hopeless eclectic straddling the middle line. These differences, though small,
have been exaggerated in political and professional circles. To the extent that
these differences are real and meaningful, we are reasonably certain that they
have helped us maintain a balance of perspectives in this volume.
Take the definition of evidence, for a prominent example. One of us
(RFL) endorses the inclusive definition of EBP (Institute of Medicine, 2001,
p. 147) as the integration of the best research evidence with clinical exper-
tise and patient values. Levant does not privilege one component over
another; he believes that a definition of practice based on evidence that
equally values all three components will advance our knowledge and provide
better accountability. Another one of us (JCN) embraces the same three
components of best available research, clinical expertise, and patient values.

EVIDENCE'BASED PRACTICES IN MENTAL HEALTH

At the same time, Norcross would privilege best research and elevate it above
the others in the hierarchy of evidence. The third one of us (LEB) is con-
cerned about the movement in some quarters to include, within the defini-
tion of evidence, clinician expertise on the basis of personal beliefs, clinical
experiences, and individual values. Beutler believes that, if unchecked
against objective validity criteria, these are potential sources of bias in judg-
ment and are the very sources of error that controlled research was designed
to overcome.
Our relative differences on this and other EBP questions led us to invite
contributions from champions of diverse perspectives for this book. More
important, our own differences help to transcend polarizing characterizations
on simplistic questions of evidence-based treatment to consider relative posi-
tions on the multiple, layered questions of EBP. Our hope is that the book
will illuminate multiple horizons and perhaps a fusion of horizons.

NINE FUNDAMENTAL QUESTIONS

One of the immediate and overarching questions concerning evidence-

based practice in mental health is what, exactly, qualifies as evidence. Must
EBP be based on research (of some form)? Should the evidence include prac-
titioner experience and expertise? And what about the consumer? Should the
evidence include what patients value and prefer in their treatment? Put
bluntly: What counts as evidence? Chapter 1 addresses this sticky wicket.
Definitions of EBP always embrace research as one of the sources of evi-
dence and frequently privilege research findings as the most important guide
to treatment selection. The "gold standard," particularly in the biomedical
fields, has been the randomized clinical (or controlled) trial (RCT). How-
ever, in mental health fields, a spirited debate concerns the privileged status
accorded to RCTs. Chapter 2 features five position papers on the question of
what qualifies as research to judge effective practice in mental health.
Whatever form it may take, research on the effectiveness of mental
health practices requires that patients receive similar, if not identically stan-
dardized, medication, treatment, or testing. In medication trials, this stan-
dardization involves administering the same medication at the same dose or
following a standard protocol to determine dosage. In mental health research,
this standardization has frequently involved the use of treatment manuals.
Practitioners are asked to adhere to a psychotherapy manual, and subsequent
fidelity or adherence checks are taken to ensure that the treatment is being
implemented as specified in the manual. In fact, manualization has been
deemed a prerequisite for inclusion in some compilations of ESTs or EBPs.
The position papers in chapter 3 tackle the advantages and disadvantages of
manualization in psychotherapy, particularly whether the use of manuals
improves treatment outcomes.

PROLOGUE
 EBPs seek to identify the most effective and efficient treatments in
research studies so that those same treatments can be widely implemented in
practice. However, such generalizations of research findings are not auto-
matic or inevitable. Many hitches occur in generalizing and in transporting
treatments from the lab to the clinic, and here we address two of these
hitches. In chapter 4, we consider the pressing question of whether research
patients and clinical trials are representative of clinical practice. Later, in
chapter 9, we consider the related concern of whether efficacious laboratory-
validated treatments readily transport to clinical practice.
Apart from the debate on the generalization and transportability of lab-
oratory treatments is the broader question of what should be validated. What
accounts for effective treatment? In biomedical research, it is traditionally
the specific treatment method—the medication, the surgery, the discrete
method applied to the patient—that is credited for effectiveness. In mental
health research, however, there are diverse conceptual perspectives and con-
flicting research results. Some argue that the treatment method is the natural
and inclusive target for research validation, whereas others argue that the
psychotherapist, the therapy relationship, the patient, or the principles of
change actually account for more of the success of psychotherapy and thus
should be targets for research validation and EBPs. These arguments are pre-
sented in chapter 5.
The research enterprise itself—securing funding, selecting measures,
collecting the data, interpreting the results, and then publishing the findings
—is a complicated human task. As mental health professionals, we know that
human behavior is materially influenced by a multiplicity of factors, some
beyond our immediate awareness, and research is no exception. What is rep-
resented and published as evidence can be influenced by the funding sources,
the researcher's theoretical allegiance, and conventional wisdom. These
potential biases are considered in chapter 6.
In chapter 7, we tackle the bottom-line issue of effectiveness. Do ther-
apies designated as ESTs for specific disorders produce outcomes superior to
non-EST therapies? By definition, ESTs have outperformed no treatment,
placebo, or treatment as usual (TAU). But do they outperform bona fide
treatments that have not met the criteria for designation as ESTs? Two posi-
tion papers provide contrasting answers.
In addition to their global effectiveness, we should also critically inquire
if EBPs are effective for the historically marginalized segments of our popu-
lation. Alas, insufficient research attention has been devoted in EBPs and
TAUs to race-ethnicity, gender, sexual orientation, and disability status.
Chapter 8 is the only chapter in which there was such unanimity that we
could not locate an alternative position; all agree that EBPs to date have not
satisfactorily addressed the various dimensions of diversity. The position
papers in that chapter review the extant evidence and recommend directions
that can make EBPs more applicable and effective in the future.

10 EVIDENCE-BASED PRACTICES IN MENTAL HEALTH

Another Random Scribd Document
with Unrelated Content
14 — 22, 82, 675; iv. no. Ibn Khallikan, No. 8, p. 15. Mst. 139. I. B.
ii. 132.
 IV] 'IRAK. 57 Takrit, lying thirty miles north of Samarra on
the west bank of the Tigris, was commonly counted as the last town
of 'Irak, and was famous for its strong castle which overlooked the
river. Ibn Hawkal in the 4th (10th) century states that the majority of
its population were Christians, and that they possessed a great
monastery here. Mukaddasi says the wool-workers of this town were
famous, and in its neighbourhood much sesame was grown ;
Mustawfi adds, also water melons, of which three crops a year were
produced in spite of the somewhat raw climate of Takrit. Ibn Jubayr
states that the city wall was 6000 paces in circuit, with towers in
good repair, when he passed through Takrit in 580 (1184), and Ibn
Batutah gives praise to both its markets and its numerous
mosques1. The great Nahrawan canal left the Tigris a short distance
below Dur, as already said, and in its upper course was known as Al-
Katul-al-Kisrawi, ' the Cut of the Chosroes,' for it owed its origin to
the Sassanian kings. It served to irrigate all the lands along the east
bank of the Tigris from above Samarra to about a hundred miles
south of Baghdad, and Ibn Serapion mentions a great number of
towns along its banks with bridges and weirs, but most of these
have now disappeared, though the line of the canal is still marked on
the map. Leaving Dur2, which, for distinction among the many
towns of this name, was called Dur-al-'Arabaya or of Al-Harith, the
canal passed to the back of the Mutawakkiliyah and other outlying
quarters north of Samarra, and here it was crossed by a stone
bridge. It next came to Itakhiyah, a village and fief called after Itakh
the Turk, sometime captain of the guard to the Caliph Mu'tasim ; this
had originally been a monastery called Dayr Abu-Sufrah, and here
stood the bridge of the Chosroes (Kantarah Kisrawiyah). The
monastery took its name from Abu Sufrah the Kharijite. Next the
Nahrawan came to Al-Muhammadiyah, a small town, where it was
crossed by a bridge of skiffs (Jisr Zawarik)3, and according to 1 1st.
77. I. H. 156. Muk. 123. I.J. 234. Mst. 138. I. B. ii. 133. 2 Dtir means
the 'Houses' or 'Habitations,' and is a common place-name, being
the plural form of Ddrah, ' a homestead.' 3 It is to be noted that in
the classical usage Jisr stands for ' a bridge of boats,' while Kantarah
is ' a masonry bridge of arches.' Shddhnrwdn, trans 
 58 'IRAK. [CHAP. Yakut this Muhammadiyah was but a later
name of Itakhiyah, the change having been effected by Mutawakkil
in honour of his son Muhammad-al-Muntasir, who afterwards
became Caliph by the murder of his father. At some distance below
these places the Nahrawan was joined successively by the three
lesser Katuls, namely the Yahudi, the Mamuni, and the canal of Abu-
1-Jund, which were all three taken from the left bank of the Tigris
near Matirah below Samarra, and which irrigated the fertile districts
south of that city. Above their inflow, the Nahrawan was dammed
back by the first of its many weirs (Ash-Shadhurwan), and where the
first canal came in stood the large village of Al-Mamuniyah. This, the
Yahudi (or Jews') canal, was crossed between Matirah and
Mamuniyah by a stone bridge called Kantarah Wasif, after Wasif, one
of the captains of the Turk bodyguard, in the reign of Mu'tasim. The
second canal, called Al-Mamuni, fell into the Nahrawan below the
village of AlKanatir, 'the Bridges.' The third canal was called Abu-1-
Jund — ' Father, or Supplier, of the Army ' — from the fact that the
crops raised on the lands watered by it were used as rations for the
troops. It was the largest canal of the three, and had been dug by
Harun-ar-Rashid, who built a palace there while superintending its
construction. On its banks stood the town of Taffir, and here it was
crossed by a bridge of boats. Yakut, who had himself visited Taffir,
describes it as occupying in the 7th (13th) century a waterless and
pastureless plain, where wild animals dwelt, lying between Ba'kiiba
and Dakuka. He passed through this going from Baghdad to Irbil ;
no habitations were to be met with, and Yakut says that his guide,
when the caravan travelled by night over this plain, ' was wont to
take his direction by the Pole-star, until, with the day, the plain had
been crossed.' lated by ' weir,' more properly designates a portion of
a canal, or river bed, that has been paved and embanked to confine
the stream. It should, however, be added that Jisr undoubtedly
sometimes also designated a stone bridge of arches, as in the
celebrated Jisr-al-Walid, the name given to the bridge over the river
Sams, between Adana and Mopsuestia, which was built by Justinian.
The word Kantarah also designates any arched structure, as a
viaduct or aqueduct, being borrowed from the Byzantines, who used
the word Kevrpov (the Latin centrum) to denote the central arch of a
bridge, and by extension applied it to mean the whole structure.
 IV] 'IRAK. 59 Four leagues below where the last of these
three canals joined the Nahrawan lay the town of Sula or Salwa,
otherwise called Bab Salwa or Basalwa. Below this again was the
town of Ba'kuba, some ten leagues north of Baghdad, and the
capital of the Upper Nahrawan district. At Ba'kuba the Great Katul
canal changed its name, and became the Tamarra, under which
name it passed on to Bajisra and thence to the city called Jisr
Nahrawan, beyond which the main waterway was more especially
known as the Nahrawan canal. Near Bajisra (the Aramaic form of
Bayt-al-Jisr, ' the bridge-house ') which stood in a well cultivated
district, surrounded by palm-trees, the Tamarra sent off a branch
from its right bank known as the Nahr-al-Khalis, which flowed out
into the Tigris at Baradan to the north of Baghdad, and from the
Khalis many of the canals of East Baghdad derived their water. Jisr
Nahrawan, the Bridge- town, where the Khurasan road from
Baghdad crossed, will be described presently ; and here a canal
called the Nahr Bin branched from the right bank of the Nahrawan,
flowing ultimately into the Tigris at Kalwadha. From this the water
channels of the lower quarters of East Baghdad derived their supply.
One mile below Jisr Nahrawan the Diyala. canal branched south from
the main stream, and after irrigating the outer gardens of East
Baghdad, reached the Tigris three miles below the capital. South of
Jisr Nahrawan the great canal took the name of the Nahrawan
exclusively, and after passing the Upper Weir (Shadhurwan) it came
to Jisr Buran, the bridge named after the wife of the Caliph Mamun.
Below this stood Yarzatiyah (or possibly Barzatiya), and then the
town of 'Abarta, which Yakut describes as of Persian origin, having
important markets. Beyond 'Abarta lay the Lower Weir and next
Iskaf (or Uskaf) of the Ban! Junayd, a city lying on both banks of the
canal, and the Ban! Junayd, Yakut reports, had been chiefs of this
district and famous for their hospitality. Yakut adds that by the 7th
(13th) century, when he wrote, the lands round here had entirely
gone out of cultivation, for the Nahrawan had gradually silted up
during the previous two centuries, the Saljuk Sultans having ever
 60 'irAk. [chap. been too much occupied with their wars to
attend to the needful dredging, and the mending of dykes: 'further,'
he adds, 'their armies had made a roadway of this same canal,
whereby both district and canal have now gone to ruin.' Beyond
Uskaf the Nahrawan flowed on for nearly 60 miles, between a
continuous line of villages and farmsteads, down to Madharaya
where its waters finally rejoined the Tigris. Madharaya, as already
said, stood to the south of Jabbul and above Al-Mubarak, which lay
opposite the town of Nahr Sabus. When Yakut wrote it was in ruin,
and its name is now no longer marked on the map, but it must have
stood just below the present Kut-al-'Amarah where, as already
explained, the Tigris now divides off from the Shatt-al-Hayy
channel1. This triple division of the Nahrawan canal (namely the
Katul, the Tamarra, and the Nahrawan proper), with the three
branch canals (the Khalis, the Nahr Bin, and the Diyala) which
flowed back to the Tigris after watering the East Baghdad region, is
the explanation which Ibn Serapion has given of a very complicated
skein of waterways. In later times the names were not always
applied as he gives them. A glance at the present map shows that
the Nahrawan, two hundred miles in length, must have taken up all
the streams from the Persian highlands which, had it not been dug,
would have flowed (at flood time) down to the left bank of the
Tigris. The Tamarra section was originally one of these streams, and
Yakut describes how its bed had been artificially paved for a length
of seven leagues to prevent the sands absorbing its waters, which
were divided up to irrigate the several districts of East Baghdad. The
Khalis and the Diyala were according to his account branches of the
Tamarra (in any case the Khalis of the Arab geographers cannot be
the river known by this name at the present day, for this now flows
at some distance to the north-west of Ba'kuba), and Khalis in the
time of Yakut was the name of the district, to the north of the
Khurasan road, which on one side came right up to the walls 1
Yarzatiyah is possibly the present Razatiyah or Zatariyah lying above
'Abarta. Ykb. 321. I. S. 19, 20. Baladhuri, 297. I. R. 90. I. K. 175.
Mas. Tanbih 53. Yak. i. 252, 454; iii. 539, 604 ; iv. 16, 381, 430.
 IV] 'IRAK. 6 1 of East Baghdad. In the 3rd (9th) century
Ibn Rustah and Ibn Khurdadbih give Nahrawan as the name of the
mountain stream, which came into the Great Katul at Salwa; in the
8th (14th) century Mustawfi writes that the Nahrawan was the name
of the Diyala river, which rose in the mountains of Kurdistan, and
which was formed by the junction of two streams, one the Shirwan
river which lower down was called the Taymarra, the other the
Hulwan river, which flowed down past Kasr Shirin and Khanikin ; and
these two streams united above Ba'kuba where they flowed into the
Nahrawan canal. In regard to Nahrawan town, otherwise called Jisr
Nahrawan (Nahrawan Bridge), this was the first stage out of
Baghdad along the great Khurasan road, and it was of old a place of
much importance, though now represented by the insignificant
hamlet of Sifwah. Ibn Rustah in the 3rd (9th) century describes
Nahrawan town as lying on both banks of the canal ; in the western
half were the chief markets, a Friday Mosque, and many
waterwheels for irrigation purposes ; while on the eastern side there
was a second Friday Mosque, and other markets, with many
hostelries round the mosque where the Mecca pilgrims and travellers
were wont to put up. Ibn Hawkal in the following century speaks of
the fertile lands lying round the town, and Mukaddasi adds that the
eastern part in his day was the most populous, its Friday Mosque
being then the only one in use. In the 8th (14th) century, when
Mustawfi wrote, Nahrawan town was in ruin, for the Khurasan road
no longer passed through it, but went north by Ba'kuba. The fertile
district about here was still called the Tarik-i-Khurasan (the District of
the Khurasan road) of which Ba'kuba, Mustawfi states, was the chief
town, and it was formed by a continuous line of gardens and palm-
groves from which magnificent crops of oranges and shaddocks were
harvested1. The town of Baraz-ar-Ruz (the Rice Field), now known
as Bilad-ar-Ruz, lay north-east of Nahrawan town, and is frequently
mentioned by Yakut. The Caliph Mu'tadid had built a palace here ; it
was counted as of the Tamarra district, and lay eastward 1 I. R. 90,
163. I. K. 175. 1st. 86. I. H. 167. Muk. m. Yak. i. 812; ii. 390, 638.
Mst. 139, 141, 216.
 62 'IRAK. [CHAP. off the Khurasan high road, being also
noticed by Mustawfi. Leaving Nahrawan town the next stage of the
Khurasan road was Daskarah-al-Malik, 'of the King,' which Ibn
Rustah describes as a considerable city, possessing a great walled
castle of Sassanian times, to which a single gateway on the west
side gave access. From its position this 'Daskarah of the King'
appears to be identical with the celebrated Dastagird, where
Khusraw Parwiz had his great palace, which history relates was
plundered and burnt to the ground by Heraclius in 628 a.d. This
palace, the ruins of which it would seem were in the 4th (10th)
century still known as Dastagird Kisrawiyah (of the Chosroes), was
seen by the traveller Ibn Muhalhal (quoted by Yakut) who says that
it then consisted of a wonderful edifice containing many halls and
domes, so finely built as to appear carved, each wall in a single
block of stone. In regard to the Arab town, Ibn Hawkal in the 4th
(10th) century describes Daskarah as possessing a strong castle,
doubtless of Moslem foundation, and Mukaddasi speaks of the place
as a small market town, with a Friday Mosque that had a finely
vaulted roof. Not far distant from Daskarah was the village of
Shahraban, mentioned by both Yakut and Mustawfi, the latter adding
that eighty villages belonged to this town, which had been founded
by Princess Gulban, a daughter of one of the Chosroes. The town of
Jalula was the next stage on the Khurasan road, surrounded by
many trees but unfortified. Not far from the town, standing in the
village of Haruniyah, was an ancient bridge of stone wrought with
leaden joints, which had been built by one of the Chosroes, and this
crossed the river by which, according to Yakut, boats went down to
Ba'kuba and Bajisra. In history Jalula was famous for the great
victory gained over the Persians by the Moslems here in the year 16
(637), which resulted in the final overthrow and flight of King
Yazdajird. At a later date Mustawfi names the place Rubat Jalula,
from the guard-house which had been built here by Malik Shah the
Saljuk ; and the position of Jalula corresponds with the modern
station of Kizil Rubat, 'the Red Guard-house.' East of Jalula was the
town of Khanikin, which is noticed by Mukaddasi as a city on the
road to Hulwan. Here Ibn Rustah says, there
 IV] 'IRAK. 63 was a great bridge of many arches over the
river, built of wellmortared kiln-bricks. Near Khanikin was a naphtha
spring that produced a large revenue, and Yakut describes the
bridge aforesaid as having 24 arches in his day, the 7th (13th)
century, across which passed the Khurasan road. When Mustawfi
wrote in the next century Khanikin had fallen to ruin, and was
merely a large village, but its district was still extremely productive.
Six leagues beyond Khanikin, and half-way to Hulwan the first town
of the Jibal province, lay Kasr Shirin, 'the Palace of Shirin,' the
mistress of King Khusraw Parvviz. There was a large walled village
here, and the ruins of the Sassanian palace, which Ibn Rustah
describes as consisting in the 3rd (9th) century of a mighty arched
hall, built of burnt brick, rising in the midst of chambers, the walls of
which were of solid masonry. Further there was a great platform
before the arched hall, paved with marble slabs. Yakut and Mustawfi
give long descriptions of Kasr Shirin, the ruins of which still exist ;
and it is to be noted that the legends of Farhad the lover of Queen
Shirin, and of Pahlabadh the musician, and of Shabdiz the famous
horse of King Parwiz, are found localised in many places of the
surrounding district1. Overhanging Kasr Shirin is the great mountain
wall forming the outpost of the Persian plateau, and Hulwan, the
next stage on the Khurasan road, though often counted as of 'Irak,
being in the mountain pass, will be described in a later chapter.
South of the line of the Khurasan road, and on the Khuzistan
frontier, two important towns remain to be noticed — Bandanijin and
Bayat. Bandanijin, a name no longer found on the map, was the
chief town of the districts of Badaraya and Bakusaya, and the village
of Bakusaya still exists near which the town of Bandanijin must have
been situated. The two districts lay beyond and north-east of the
Nahrawan canal, and comprised a great number of fertile villages.
Bandanijin the capital, according to Yakut, was called in Persian
Wandanigan, and Mustawfi says in his day the name was
pronounced Bandanigan, being of the Lihf district, the 'Foot-hills' of
the Kurdistan mountains, and its river came down from Ariwajan.
According to Ibn 1 I. R. 164. 1st. 87. I. H. 168. Muk. iai. Kaz. ii. 295.
Yak. i. 534; ii. 107, 393, 573, 575, 813 ; iv. 112. Mst. 137, 138, 139,
193.
 64 'IRAK. [CHAP. Khurdadbih Bandanijin was counted as of
the same district as Baraz-ar-Rilz. Bayat, the ruins of which still exist,
is mentioned by Mustawfi ; he adds that its river, which rose in the
Kurdistan mountains, became lost in the plains before reaching the
Tigris, and though its water was brackish, many fertile districts were
irrigated by it. Bayat appears to be practically the same place as the
town of At-Tib, mentioned by Ibn Hawkal, where excellent belts, like
the Armenian belts, were made. It was a city of some importance
under the Abbasids, and its ruins lie close to those of the later town
of Bayat. Yakut says that in his day the inhabitants of Tib were
Nabathseans, and still spoke their Aramaic dialect, tracing their
descent direct from Seth, son of Adam1. The cities of 'Irak which lay
on the Euphrates, and between the two rivers along the transverse
canals, must now be described. As already said, a line carried west
from the Tigris at Takrit to the Euphrates would cross that river a
little below 'Anah, where its course makes a great bend south, and
this is the natural frontier between Jazirah and 'Irak, as marked by
Mustawfi. To the south of this line begins the Sawad, or alluvial land,
of Babylonia ; to the north lie the more stony plains of Upper
Mesopotamia. The city of Al-Hadithah on the Euphrates, about 35
miles below 'Anah, is the northernmost town on this side. The name
signifies 'the New Town,' and to distinguish it from Al-Hadithah on
the Tigris, it was called Hadithah-an-Nurah, ' of the Chalk ' pit. Yakut
describes it as possessing a strong castle surrounded by the waters
of the Euphrates, and it was founded during the Caliphate of 'Omar,
not long after the Moslem conquest. Mustawfi describes it as in
every way the opposite of Takrit, both in situation and climate.
Between Hadithah and Hit, down stream, came the two towns of
Alusah and An-Nawusah, lying on the Euphrates seven leagues
distant one from the other, and Alusah, which Yakut refers to as a
small town, still exists. Both are frequently mentioned in the records
of the Moslem conquest \ 1 I. K. 6. 1st. 94. I. H. 176. Yak. i. 230,
459, 477, 745; iii. 566; iy« 353- Mst. 137, 138, 220. The Badaraya
district of Bandanijin must not be confused with Baduraya, the name
of the southern district of West Baghdad.
 IV] 'IRAK. 65 further, An-Nawusah was counted as a village
of Hit, which last was a walled town with a strong castle, celebrated
for its palmgroves and lying on the western side of the Euphrates.
Ibn Hawkal speaks of Hit as very populous, and Mustawfi in the 8th
(14th) century describes more than 30 villages, among the rest
Jibbah, as of its dependencies. Immense quantities of fruit, both of
the cold and the hot regions, were grown here ; nuts, dates,
oranges and egg-plants all ripening freely, but the town was
unpleasant to live in on account of the overpowering stench of the
neighbouring bitumen springs. At the time of the Moslem conquest
the famous Trench of King Sapor II (Khandak Sabur) still existed.
This had been dug by Sabur Dhu-1-Aktaf, as the Arabs called him, in
the fourth century a.d. It began at Hit and ran down to Ubullah
(near the later Basrah) where it reached the Gulf. Originally it carried
water, being intended as a line of defence for the rich lands of Lower
Mesopotamia against the desert tribes; and its dry bed may still, in
part, be traced. 'Ayn-at-Tamr, ' the Spring of the Date Palm,' due
south of Hit in the desert, is described by Mukaddasi as a small
fortress, and a stream running from here entered the Euphrates
below Hit. Dates and sugar-cane were exported from its district, the
latter more especially from a neighbouring town called Shafatha ;
but the exact site of these two places is unknown1. Twelve leagues
below Hit was the village of Ar-Rabb, where previous to the 4th
(10th) century the (earlier) Dujayl canal left the Euphrates ; and
taking its course due east, after watering the Maskin and Katrabbul
districts, reached the northern suburbs of West Baghdad. As already
mentioned, this western portion of the Dujayl soon became silted up
; and by the time when Istakhri wrote in 340 (951) the Dujayl
already took its waters from the Tigris opposite Kadisiyah, as
described in the paragraphs on the Maskin district. Al-Anbar, 'the
Granaries,' standing on the left bank of the Euphrates, was one of
the great cities of 'Irak in Abbasid times. It dated from before the
Moslem conquest, and by the Persians was called Firiiz Sabur (or
Fayruz Sabur, in 1 I. S. 10, 13. I. R. 107. Kud. 217. Baladhuri, 179.
1st. 77. I. H. 155. Muk. 117, 123, 135. Yak. i. 352; ii. 223; iii. 759; iv.
734, 997. Mst. 135, 141. LeS. 5
 66 'IRAK. [CHAP. Greek Perisabor) from its founder King
Shapur1; and under the Arabs Firilz Sabur became the name of the
surrounding district. It is said that the town was called ' the
Granaries ' because of old the Persian kings had stored the wheat,
barley, and straw for the rations of their troops in this city. The first
Abbasid Caliph, SafTah, had for a time made Anbar his residence,
and he died in the palace which he had built here. His brother
Mansur also for a time lived at Anbar, and from here went to
Baghdad, where the new Abbasid capital had begun to be built.
Mustawfi gives the tradition that the Jews whom Nebuchadnezzar
brought from Jerusalem to Babylonia were interned at Anbar. In the
8th (14th) century the town walls, he says, were 5000 paces in
circuit. The importance of Anbar lay in its position at the head of the
first great navigable canal which flowed from the Euphrates to the
Tigris, which it entered at the harbour (Al-Fardah) to the south of
the Round City of West Baghdad. This canal, the Nahr 'Isa, took its
name from an Abbasid prince Tsa who was either 'Isa ibn Musa,
nephew of Mansur, or 'Isa ibn 'Ali (the more usual ascription), the
uncle of that Caliph. In either case Prince Tsa gave the canal its
name, he having re-dug it, making thus a navigable channel from
the Euphrates into Baghdad. Where the canal left the Euphrates, a
little below Anbar, it was crossed by a magnificent bridge, called
Kantarab Dimimma, from the village of Dimimma which was on the
Euphrates bank close to the hamlet of Al-Fallujah. The Nahr Tsa,
passing by many villages and farms of the Firuz Sabur district, at
length came to the town of Al-Muhawwal, one league distant from
the suburbs of West Baghdad. Just before reaching this town the
Sarat canal branched from the left bank of the Nahr 'Isa, and this
canal formed the dividing line between the Katrabbul district to the
north and Baditraya to the south of West Baghdad. The Sarat canal,
following an almost parallel curve to the Nahr Tsa, poured its waters
into the Tigris immediately below the Basrah Gate of the Round City,
and from these two streams all the watercourses 1 Sabur is the Arab
form of the Persian Shapur or Shah-pur, which the Greeks wrote
Sapor.
 IV] IRAK. 67 of West Baghdad were derived, with the
exception of the few coming from the Dujayl canal. Al-Muhawwal
means ' the place of unloading,' and the town took its name from
the fact that the river barges going from the Euphrates towns to
Baghdad, had here to unload into small boats that could pass under
the numerous bridges which below Muhawwal spanned the Tsa canal
where this traversed the suburb of Karkh. Mubawwal was a fine
town, famous for its markets and its gardens, and as late as the 8th
(14th) century possessed some magnificent buildings, among which
Mustawfi counts a palace built by the Caliph Mu'tasim which stood
on the summit of a mound, and which, by the spell of a powerful
incantation, had been freed from the plague of mosquitoes. The
exact site of Muhawwal is not now known, but it must lie to the
north-east of the ancient Babylonian mound called the Hill of
'Akarkuf, which is frequently mentioned by the Arab geographers,
and which Mustawfi connects with the legends of the tyrant Nimrod
who threw Abraham into the fiery furnace1. Three leagues below the
village of Dimimma the second of the great transverse canals, the
Nahr Sarsar, flowed off towards the Tigris, which it entered four
leagues above Madain. This canal, in its lower reaches, traversed the
Baduraya district, which lay south of West Baghdad, and Ibn
Serapion describes how along its banks numerous waterwheels
{ddliya/i) and levers (shaduf) were set up for irrigating the fields.
Some way above where, near Zariran, the canal flowed into the
Tigris, and almost in sight of the White Palace of the Chosroes at
Madain, was the flourishing town of Sarsar, where a great bridge of
boats carrying the Kufah road crossed the canal. Sarsar town lay a
couple of leagues only from Karkh, the great southern suburb of
West Baghdad ; the Sarsar canal, Ibn Hawkal writes, was navigable
for boats, and Sarsar 1 I. S. 10, 14. I. K. 7, 72, 74. Kud. 217. 1st. 77.
I. H. 155, 166. Muk. 123, 134. Yak. i. 367 ; ii. 600; iii. 697 ; iv. 432.
Mst. 136, 138, 140, 141. The lower courses of the Nahr Tsa and of
the Sarat canal belong to the topography of Baghdad, and have
been fully described in a former work. The site of Anbar appears to
be that marked by the ruins at Sufayrah, or possibly those to the
north of this village of which Mr J. P. Peters has given a plan in
Nippur, i. 177. 5—2
 68 'IRAK. [CHAR town stood in a forest of date-palms.
Mukaddasi likens it to the towns of Palestine for the manner of its
building; and Sarsar continued to be a place of importance down to
the close of the 8th (14th) century when Timur took possession of
Baghdad and garrisoned the surrounding districts. The third
transverse canal was the Nahr-al-Malik, which began at the village of
Al-Fallujah1 five leagues below the head of the Nahr Sarsar, and
flowed into the Tigris three leagues below Madain. This, ' the King's
Canal,' dated from ancient times, and is mentioned by the Greeks as
the Nahar Malcha. Yakut reports that tradition gave it as having been
dug either by King Solomon or by Alexander the Great. On its banks
was the town called Nahr-al-Malik, with a bridge of boats on the
Kufah road, this lying seven miles south of Sarsar. According to Ibn
Hawkal Nahr-al-Malik town was larger by a half than the latter town,
being likewise famous for its corn lands and palm-groves ; Mustawfi
adding that over 300 villages were of its district. The fourth
transverse canal was the Nahr Kutha, its point of origin on the
Euphrates being three leagues below that of the Nahr-al-Malik, and
its outflow 10 leagues below Madain. The Kutha canal watered the
district of this name, which was also known as the Ardashir Babgan
district (after the first Sassanian king), though part of it was counted
as the Nahr Jawbar district on a branch canal. The city of Kutha
Rabba, with its bridge of boats, stood on the banks of the main
channel, and is said to be identical with the Biblical Cuthah,
mentioned in 2 Kings xvii. 24, an important town of the
neighbourhood of Babylon. According to Moslem tradition Kutha was
the place where Abraham was thrown into the fire by the tyrant
Nimrod, and the town took its name from Kutha, the grandfather of
Abraham, according to the Moslem tradition. In the 4th (10th)
century Ibn Hawkal describes the place as a double city, Kutha-at-
Tarik, 'of the Road,' and Kutha, Rabba, which last was a city larger
than Babil (Babylon), and near here, he says, were great mounds of
1 This is the Feluchia (Feluge or Felugia) of Caesar Frederick, and
other Elizabethan merchants, where coming down the Euphrates
they left their boats and went by land across to Baghdad : as
narrated in Hakluyt, Principal Navigations (Glasgow, 1904), v. 367,
455, 466; vi. 4.
 IV] 'IRAK. 69 ashes said to mark the place of Nimrod's fiery
furnace ; Mukaddasi adding that near the high road might be seen
an ancient tower, about which many legends were told. The
Itineraries state that Kutha town, the site of which appears to be
that marked on the map as Tall Ibrahim, ' the Hill of Abraham,' was
four miles south of Nahr Malik town. Some few miles to the north of
the Kutha canal stood the large village of Al-Farashah, the half-way
stage between Baghdad and Hillah, on the high road followed at the
close of the 6th (12th) century by the Mecca pilgrims going down to
Kufah. Ibn Jubayr, who was here in 580 (1184), describes it as a
populous well-watered village, where there was a great caravanserai
for travellers, defended by battlemented walls ; and Mustawfi also
gives Farashah in his itinerary, placing it seven leagues south of
Sarsar1. 1 I. S. 15. I. R. 182. 1st. 85, 86. I. H. 166, 168. Muk. 121.
I. J. 217. Yak. i. 768; iv. 317, 846. Mar. ii. 363. A. Y. i. 633. Mst. 141,
193. The course of the Nahr 'Isa is more or less that of the modern
Saklawiyah canal : the Sarsar appears to have followed the line of
the Abu Ghurayb canal ; the Nahr-al-Malik is the Radhwaniyah, and
the Nahr Kutha is the Habl Ibrahim, 'Abraham's rope,' of the modern
maps. These identifications, however, are only approximate, for
naturally in over a thousand years the face of the alluvial Sawad is
entirely changed from what it was in Abbasid times.
 CHAPTER V. 'IRAK {continued). The bifurcation of the
Euphrates. The Sura channel. Kasr Ibn Hubayrah. Nil and its canal.
The Nahr Nars. The Badat canal, and Pombedita. The Kufah channel.
Kufah city. Kadisiyah. Mashhad 'All, and Karbala. The twelve Astans
of 'Irak. Trade. The high roads of 'Irak. The river Euphrates in the
4th (10th) century bifurcated at a point some six leagues below
where the Kutha canal was led off. The western branch, to the right,
which was then considered the main stream of the Euphrates,
passed down by Kufah and thence to the Great Swamp ; while the
eastern branch, to the left, which now is the main stream of the
river, is by Ibn Serapion and the other Arab geographers called the
Nahr Sura, or As-Suran ; and this by many channels likewise poured
its waters finally into the swamp. Taking the Sura branch first (the
present Euphrates channel) we find that Ibn Serapion admits this
was greater even in his day than the Kufah branch and more broad.
Where the bifurcation took place, the Upper Sura canal watered the
three subdistricts of Sura, Barbisama, and Barusma, which formed
part of the middle Bih Kubadh district ; then bearing south the
channel passed a couple of miles to the westward of the city called
Kasr Ibn Hubayrah, and here it was crossed by the great bridge of
boats known as the Jisr Sura (or Suran) by which the Pilgrim road
went down from Kasr Ibn Hubayrah to Kufah. The town of Al-Kasr,
as it was called for short, the Castle or Palace of Ibn Hubayrah, took
the name from its founder, who had been governor of 'Irak under
Marwan II, the last Omayyad
 CHAP. V] 'IRAK. 71 Caliph. Ibn Hubayrah had not lived to
complete his work, but after the fall of the Omayyads, the first
Abbasid Caliph, Saffah, took up his residence here, finished the
palace, and called it Hashimiyah in honour of his own ancestor
Hashim. The town which rapidly sprung up round the palace of the
Caliph none the less continued to be called after the Omayyad
governor, and even though Mansur made Hashimiyah for a time his
residence, before the foundation of Baghdad, Kasr Ibn Hubayrah, or
Madinah (the City of) Ibn Hubayrah, was always the name of the
place in common use. In the 4th (10th) century Kasr Ibn Hubayrah
was the largest town between Baghdad and Kufah, and it stood on a
loop canal from the Sura, called the Nahr Abu Raha, ' the Canal of
the Mill.' The city was extremely populous, it had fine markets, many
Jews residing here, as Mukaddasi writes, and the Friday Mosque was
in the market place. By the early part of the 6th (12th) century,
however, it appears to have fallen to decay, being eclipsed by the
rising importance of Hillah ; and at the present day even the site of
it is unknown, though it is doubtless marked by one of the numerous
ruins which lie a few miles north of the great mounds of ancient
Babylon, or Babil as the Arabs name these. The city of Hillah, lying a
few miles below the Babil ruins, on the Euphrates, otherwise the
Sura, canal as it was called in the 4th (10th) century, was at this
date known as Al-Jami'an, 'the Two Mosques,' and the town at first
stood mostly on the eastern bank. It was a populous place, and its
lands were extremely fertile. Then Al-Hillah, 'the Settlement,' was
built on the opposite right bank, by Sayf-ad-Dawlah, chief of the
Bani Mazyad, in about the year 495 (1T02); and this quickly grew to
importance, for its bridge of boats became the new Euphrates
crossing for the Pilgrim road from Baghdad to Kufah, the high road
no longer passing down by Kasr Ibn Hubayrah (then a ruin) and the
Sura bridge. By the 6th (12th) century, also, the Sura arm comes to
be considered the main stream of the Euphrates, as at the present
day, and the name Nahr Sura gradually goes out of use. In 580
(1184) Ibn Jubayr crossed the Euphrates by 'a great bridge of boats,
bound by iron chains,' at Hillah, then already a large town stretching
along the western side of the Euphrates. Ibn Batutah,
 72 'IRAK. [CHAP. who followed in his footsteps in the early
part of the 8th (14th) century, gives a long account of this famous
bridge of boats at Hillah, the double iron chains of which were
secured at either end to immense wooden piles. He praises the town
markets, and his account is fully borne out by Mustawfi, his
contemporary, who speaks of Hillah as beginning to occupy the east
as well as the west bank of the Euphrates. It was surrounded by
date-groves and hence had a damp climate. Mustawfi adds that the
population of Hillah were all bigoted Shi'ahs, and they possessed a
shrine (Makam) here, where they believed that, in the fulness of
time, the promised Mahdi, who had disappeared at Samarra in 264
(878), would reappear and convert all mankind to their faith (see
above, p. 56) '. Returning once more to the account given by Ibn
Serapion in the 4th (10th) century of the Sura canal, this, as already
said, passed to the west of the great ruins of Babylon, or Babil.
These ruins Mukaddasi describes as then occupied by the site of a
village near a bridge of boats, and Mustawfi gives a long account of
the great magicians who had lived in Babil, and of the well at the
summit of the hill in which the fallen angels Harut and Marut were
imprisoned until the day of judgment. Above Babil, the last of the
many canals flowing from the Euphrates to the Tigris branched from
the Sura. This waterway, now known as the Shatt-an-Nil — 'the Nile
Stream' — Ibn Serapion calls the Great Sarat, the name is the same
as that of the more famous canal of West Baghdad (see p. 66) in the
upper reach lying to the west of the city of Nil. From its point of
origin the Great Sarat flowed eastward past many rich villages,
throwing off numerous water channels, and shortly before reaching
the city of Nil a loop canal, the Sarat Jamasp, branched left and
rejoined the main stream below the city. This loop canal had been
re-dug by Hajjaj, the famous governor of 'Irak under the Omayyad
Caliphs, but took its name, as was reported, from Jamasp, the chief
Mobed, or Fire-priest, who in ancient days had aided King Gushtasp
to establish the religion of Zoroaster in Persia. The 1 I. S. 10, 16.
Ykb. 309. 1st. 85, 86. I. H. 166, 168. Muk. mi. Yak. ii. 322 ; iii. 861 ;
iv. 123. I. J. 214. I. B. ii. 97. Mst. 138.
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