Closing the gap between practice and research

When researchers complain that practitioners pay little heed to research findings, practitioners counter that research isn’t always relevant to real-world practice. Studies conducted in controlled settings with defined samples of patients, they argue, miss the range of messy, real-life variables that practitioners face, whether they are patients’ health issues, cultural barriers, family problems or inadequate insurance coverage.

“There has always been a translation problem: How do you translate research findings into clinically meaningful information and then apply it?” asks Maryland practitioner Barry Wolfe, PhD, a former program officer at the National Institute of Mental Health who oversaw large portfolios of clinical research studies.

Two initiatives are seeking to answer that question by involving private practitioners more directly in the research loop. One is a survey launched by APA Div. 12 (Society of Clinical Psychology) asking practitioners to describe problems they’ve encountered implementing empirically supported treatments. The other is a Pennsylvania project where mostly non-university-affiliated practitioners are running studies looking at clinical phenomena they’ve noticed in their practices, using researchers’ assistance.

The efforts are important steps in addressing practitioners’ concerns and in making research more clinically relevant, says APA Executive Director for Professional Practice Katherine Nordal, PhD.

“Psychotherapy is not a linear process where ‘patient plus effective treatment always equals good outcomes,’” says Nordal. “Practitioner-researcher collaborations that take all variables into account can only serve to improve care — which is what we all want.”

They’re important for more pragmatic reasons, as well, adds APA Div. 29 (Psychotherapy) President Jeffrey Magnavita, PhD. With the increasing call for accountability, it behooves practitioners to have a say in what is studied and how.

“Clearly, we need to establish an evidence-based perspective for what we do, or we’re going to go by the wayside,” he says.

A new feedback strategy

Evidence, however, should be a two-way street. Practitioners should have a way to provide feedback to researchers on how well evidence-based treatments work, and to report problems they’ve encountered when applying them. To do that, Div. 12 leaders looked to the medical world, where physicians are able to file “incident reports” with the FDA about already-approved medical devices or medications that end up having problems that went undetected in clinical trials.

Similarly, clinical psychology leaders reasoned that it would be helpful to give practitioners a way to report difficulties in applying evidence-based treatments, says the division’s president, Marvin R. Goldfried, PhD.

“Clinicians say that some of these empirically supported therapies do work but that there’s more to applying them than treatment manuals suggest,” he says. “We’re trying to find out what that ‘more’ is.”

The effort will begin with a survey of practitioners who use cognitive behavioral therapy for panic disorder. It’s a good test case, says Goldfried, because the treatment has a particularly strong empirical base. If clinicians report problems using it, that will demonstrate the importance of addressing factors that aren’t accounted for in the prescribed treatment.

As one example, Goldfried and colleagues have noticed that their panic-disorder patients often have problems related to anger management — but that the phenomenon isn’t reported in the literature. Similarly, because the life issues associated with panic differ for individual patients, treatment must take into account their unique characteristics and concerns, says Wolfe, who has collaborated with Goldfried on articles related to translation problems.

“The issues associated with panic will differ depending on whether the person is leaving home for the first time at age 19, their marriage is breaking up or they have a potentially lethal condition,” says Wolfe. “A standard protocol of cognitive behavioral therapy can help reduce or eliminate the individual’s panic attacks, but to help patients come to terms with their differing life situations may require other forms of treatment.”

The survey — available online — gives clinicians ample opportunity to report on such factors. A Div. 12 committee will put the results into easy-to-read formats such as bar graphs and disseminate them to the websites and listservs of clinical research societies, APA’s practice divisions and at conferences.

The hope is that researchers tune in to practitioners’ more common concerns and address them with further research, Goldfried says.

In fact, the survey could be the start of a trend toward more accurately understanding and addressing practitioner concerns, says Virginia Tech clinical researcher Thomas Ollendick, PhD.

“I’ve seen lots of efforts to bridge the practice-research gap over the years, but to my knowledge, there hasn’t been a systematic survey like this that attempts to get meaningful input from clinicians,” says Ollendick.

Putting practitioners first

In another effort, called the Pennsylvania Psychological Association Practice Research Network, private practitioners aren’t just providing meaningful input, they are actively collaborating with researchers to define research questions, design research protocols and implement studies.

“Our philosophy is that since practitioners are the ones who know the issues they confront on a daily basis, they’re also the ones to decide which questions they want to pursue and get empirical data on,” says project co-founder Thomas D. Borkovec, PhD, a retired psychology professor at Pennsylvania State University.

The research network just completed a study that attempts to answer a question on many therapists’ minds: What takes place in therapy that can either help or hinder clients’ progress? To glean answers, both clients and therapists filled out cards after each session over an 18-month period. On one side, they described and rated helpful events, and on the other side, they described and rated hindering events.

Results in press at Psychotherapy: Research, Theory, Practice, and Training suggest that the most helpful interventions, as reported by both therapists and clients, were those that raised clients’ self-awareness. Neither therapists nor clients listed many hindering events, though both cited poor fit as the most unhelpful therapy circumstance.

In keeping with the general aim of the project, the study also demonstrated that there doesn’t need to be a distinction between research and practice, says the current chair of the network, Penn State researcher and psychology professor Louis Castonguay, PhD. “Many therapists were pleased with the fact that they were able to use data from client reports to immediately improve on their work,” he says.

In addition, a post-study survey gave researchers — who included the practitioners — insight into how to better involve other practitioners interested in doing this work, says Castonguay. While practitioners were glad to be involved in the research, parts of it weren’t easy, they said. It was difficult to remember to follow a precise research protocol after each session, for instance, and some complained that they or their clients weren’t compensated for their time. They also discussed ways they overcame these obstacles — for example, by discussing difficulties with other study practitioners or keeping their sights on the project goal when they started to feel frustrated.

Because the program has been so successful, Castonguay wants to spark other such networks across the United States and Canada to allow teams to pool data and share research designs. He’s already in contact with a number of groups interested in participating in such work.

Perhaps most important, the project shows that researchers and practitioners are on the same team — one that is seeking to understand how therapy works and how to make it better.

“It goes against the conventional wisdom that there’s this gap between research and practice,” he says. “There’s a gap, I think, because people don’t talk with one another.”