Integrating Research and Practice: Toward the End of

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Integrating Research and Practice Toward the End
of Empirical Imperialism and New Pathways for
Synergic Collaborations

• Louis Castonguay

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Different road trips

• Relevance of research
• Lack of external validity
• Inattention to clinicians concerns
• Engagement in research
• Trauma from graduate school
• Lack of collaborative opportunity

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A way to get to Rome together

• Rejecting the empirical Imperialism
• I know what is important to know
• Creating a collaborative infrastructure
• Active and mutual engagement in the design,
  implementation, and dissemination of knowledge

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Working List of Psychotherapy Training
Recommendations for Minimizing Potential Harmful
Effect

• Overarching principles
• Expose trainee to evolving list of PHT, and
  encourage him/her to approach the list carefully
  (e.g., with an eye on specific interventions that
  may be particularly harmful, as well as on others
  that may not be detrimental for all clients)
• Help trainee learn to monitor change, lack of
  improvement, and deterioration
• Help trainee learn to conduct a comprehensive
  psychological assessment

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Working List of Psychotherapy Training
Recommendations for Minimizing Potential Harmful
Effect

• Enhance therapeutic relationship
• Help trainee to establish and maintain a good
  therapeutic alliance
• Help trainee experience and communicate empathy
  for his/her client
• Use techniques skillfully and appropriately,
  including interventions prescribed in empirically
  supported treatments
• Help trainee to foster sufficient exposure to
  unpleasant situations when conducting behavioral
  therapy
• Help trainee learn to deliver interpretations
  after establishing a good working alliance in
  psychodynamic therapy
• Help trainee to avoid providing interpretations
  when conducting experiential therapy

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Working List of Psychotherapy Training
Recommendations for Minimizing Potential Harmful
Effect

• Prevent and repair toxic relational and technical
  processes
• Help trainee learn to measure the alliance and to
  explore own contribution to alliance problems
  (e.g., hostility toward his/her client)
• Help trainee become a participant-observer of the
  therapy process and to meta-communicate about the
  unfolding therapy process, especially during
  impasse
• Help trainee avoid relationship pitfalls when
  working with clients from a different cultural
  background
• Help trainee increase self-awareness and
  counter-transference management skills
• Help trainee avoid using confrontational
  self-disclosure
• Help trainee become aware of instances where
  inflexible adherence to techniques threatens the
  alliance. He/she should be trained to use
  potentially helpful interventions in a clinically
  flexible and sensible way

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Working List of Psychotherapy Training
Recommendations for Minimizing Potential Harmful
Effect

• Treatment choice, implementation, and expectation
  should adjusted to client characteristics and/or
  problems Help trainee learn to measure the
  alliance and to explore own contribution to
  alliance problems (e.g., hostility toward his/her
  client)
• Help trainee be aware that some clients (e.g.,
  diagnosed with a personality disorder, depressed
  clients with high level of perfectionism) are
  likely to require longer and/or modified forms of
  psychotherapy
• Help trainee be aware that other client
  characteristics (e.g., lack of depression and
  anxiety, extreme level of dependency) may require
  them to adopt reasonable expectations about
  outcome and anticipate alliance ruptures
• Help trainee be aware that clients with high
  levels of reactance are not likely to benefit
  from directive forms of therapy, and that clients
  with low levels of reactance are not likely to
  benefit from non-directive treatments
• Help trainee be aware that some clients (e.g.,
  with low level of cognitive development) may not
  benefit from treatments aimed at fostering
  insight

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Working List of Psychotherapy Training
Recommendations for Minimizing Potential Harmful
Effect

• Some therapists may be less effective (and/or
  produce more harmful effects) than others
• Help trainee with anxious attachment style become
  aware that he/she may be vulnerable to engage in
  less empathic exchanges
• Help trainee increase self-awareness of their
  hostility toward him/herself and potentially
  steer toward own personal psychotherapy
• Help trainee be aware that other vulnerabilities
  (e.g., excessive need to be liked or admired,
  inability to receive criticism, difficulty
  tolerating negative emotion) may reduce their
  ability to help client and/or damage their
  clients well-being
• Note Clinical/theoretical recommendation for
  which the authors of this paper are not aware of
  empirical support.

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PPA PRN

• Phase I (Borkovec, Echemendia, Ragusea, Ruiz,
  2001)
• Goals
• - Create a state-wide infrastructure
• - Obtain experience in the use of a core battery
  and in the conduct of collaborative research in
  the applied setting
• Phase II
• Goals
• - Examine what do clients find helpful (and
  unhelpful) during a session?
• - Investigate whether knowledge of clients
  perception of helpful (and hindering) events can
  improve the effectiveness of therapy.

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Questions

• What events are found by clients to be most
  helpful and hindering during sessions conducted
  within the context of regular private practice?
• What events are found by therapists to be most
  helpful and hindering during the same sessions?
• What are some of the content of discussions
  addressed within these helpful and hindering
  events?

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Method

• Design
• Within each of three age groups (child,
  adolescent, adult), clients were randomly
  assigned to experimental or control conditions
• Experimental condition HAT filled out by both
  client and therapist after every session
• Control condition HAT filled out by therapist
  only
• This presentation focus primarily on adolescents
  and adults clients (12 years old and older)

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Method

• Participants
• 13 experienced therapists in private practice
• 121 clients
• Clients per therapist, Mean of 9.31 (sd7.33)
  ranging from 2 to 24.
• Number of sessions Mean of 7.98 (sd8.17),
  ranging from 1 to 36

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Method

• Instruments
• Helpful Aspects Therapy Questionnaire (HAT,
  Llewelyn, 1985)
• 1. Did anything particularly helpful happen
  during this session? Circle Yes / No (If yes,
  please describe it briefly below and circle its
  helpfulness).
• 1-----------------2-------------------3-
  --------------4
• Slightly Moderately Greatly
  Extremely
• Helpful Helpful Helpful
  Helpful
• 2. Did anything happen during this session which
  might have been hindering?
• Circle Yes / No (If yes, please describe it
  briefly below and circle its hindering).
• 1-----------------2------------------3--
  -------------4
• Slightly Moderately Greatly
  Extremely
• Hindering Hindering Hindering Hindering

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Method

• B. Helpful aspects of experiential therapy
  content analysis system (Elliott, 1988)
• Impact 18 categories of helpful and hindering
  events
• Content 7 categories of focus of therapy
• 4-point confidence rating scale
• 3 -- Clearly or strongly present
• 2 -- Probably present
• 1 -- Probably absent
• 0 -- Clearly absent
• 3 coders (trained for 8 months) coded 1,480
  events, 1,052 reported by therapists and 428
  reported by clients

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TICAS Categories and Reliability

• Helpful Impacts
• Category alpha
• Self-Insight .878
• Other-Insight .712
• Self-Awareness .785
• Other Awareness .828
• Positive Self .923
• Positive Other .819
• Self-Metaperception .873
• Problem Clarification .752
• Problem Solution .870
• Alliance Strengthening .927
• Relief .820
• Other Specific Helpful .823

• Hindering Impacts
• Category alpha
• Unwanted Thoughts .920
• Therapist Omission .862
• Digression .715
• Poor Fit .838
• Other Hindering .881

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Content Categories and Reliability

• Category alpha
• Self-Only .830
• Family of Origin .979
• Marital Family .944
• Work .929
• Other Relationships .862
• Therapy .879
• Other Content .480

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Method

• Procedures
• All new clients completed the TOP before first
  session.
• HAT cards were filled out after every session.
• Therapists read the HAT filled out by the client
  before the next session.
• All new clients were asked to fill out the TOP
  after the last session of their treatment.

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Results

• IMPACT Client report
• Top three
• 1) Self-awareness
• 2) Problem clarification
• 3) Problem solution

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Results

• B) Helpful Events Therapist report
• Top three
• 1)Self-awareness
• 2) Alliance strengthening
• 3) problem clarification
• C) Hindering Events Therapist report
• 1) Therapist omission

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Results

• Content Client report
• Helpful events
• Therapy
• Self
• Family of Origin
• Hindering events
• Therapy

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Results

• Content Therapist report
• Helpful events
• Therapy
• Self
• Family of Origin
• Hindering events
• Therapy
• Marital Family

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Caveats

• Results reflect the perception of the clients and
  therapists about the impact of events that took
  place in sessions
• They also reflect the conceptual biases
  underlying the instrument that we used to code
  these helpful events.
• Results also fail to reflect the importance of
  the dimensions of psychotherapy that are not
  captured by this instrument.

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Therapistsexperience

• 1. What have you found the most interesting
  and/or beneficial about your participation in the
  HAT study?
• 2. What have you found the most difficult and/or
  frustrating about your participation in the HAT
  study?
• 3. What, if anything, was beneficial and/or
  detrimental about this study to your patients?
• 4. What have been the most frequent and/or
  important obstacles in conducting the study?
• 5. If you were confronted with important
  obstacles when conducting the study, what, if
  anything, has helped you dealing with these
  obstacles?
• 6. What would you change and/or add in the
  preparation and implementation of a similar study
  in the future?

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Benefits

• Participation fostered learning, empirical and
  clinical
• Clients may have gained therapeutically
• Therapists appreciate working with and learning
  from others (sense of community and mutual
  engagement toward shared goals)
• Participation provides opportunities for the
  establishment or strengthening of personal and
  professional relationship
• The development and implementation of a
  scientifically rigorous and clinically relevant
  study was experienced as a stimulating and
  gratifying process
• research participation was also intrinsically
  meaningful and rewarding for their clients
• Incentives (e.g., CE credits)

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Difficulties

• Pragmatic obstacles
• Research tasks may have, at times, interfered
  with clients needs

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Recommendations

• Research questions should be clinically relevant
  and scope of the study should be manageable
• Measures should be useful and simple to
  administer
• Substantial time should be devoted to developed
  research design and study protocol
• Research procedures should as simple and clear as
  possible
• Frequent meetings should be held
• An atmosphere of support and validation in the
  group should be created and maintained

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Recommendations

• Self-efficacy and motivation should be fostered
• Direct and easily accessible consultation should
  be made available
• Structured and continued supervision of the data
  collection should be planned and implemented
• Help from their administrative staff should be
  encouraged
• Strategies aimed at increasing clients and
  therapists motivation

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Phase III

• Keeping the good things
• Focus on the process of change (clients
  feedback) in order to confound research and
  clinical tasks
• Focus on outcome (experimental design) as a
  strategy to address the ultimate goal of science
• Active collaboration and full support in design
  and implementation

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Phase III

• Avoiding the bad things
• Making the protocol manageable
• Exporting strategies from controlled research
• Monitoring closely data collection
• Financial support (APA, BHL)

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Thanks To

• Pennsylvania Psychological Association and the
  Committee for the Advancement of Professional
• Practice of the American Psychological
  Association
• Behavioral Health Laboratories