Closing the Gap Between Research and Practice: The Two-Way Bridge Initiative
Psychology researchers have long lamented that practicing therapists do not make use of research findings in their clinical work. For their part, clinicians have argued that much of what researchers have studied has not adequately addressed the issues that they confront in their practices. This gap between research and practice continues to exist, even in the face of growing external pressures for empirical accountability among policymakers and insurance companies. There undoubtedly are numerous reasons for this long-standing gap. Clinicians and researchers live in different professional worlds. Researchers seek to advance the field and are involved with publications and research grants, whereas clinicians are concerned about what works best to help specific patients and are involved with referrals and insurance reimbursement; in addition, there exist few forums where the two can interact. Despite training models that seek to prepare psychologists in scholarship, science, and practice, the existence of these overlapping, yet separate, domains can result in a disconnect within the profession.
Another possible reason for the clinical-research disconnect is the fact that the two worlds have historically been connected by a “one-way bridge”: Researchers attempt to disseminate their findings to clinicians, but the voices of practicing clinicians typically go unheard.
Most research on the efficacy of psychotherapy has involved clinical trials carried out on interventions for treating various clinical disorders, resulting in what has been called empirically-supported treatments (ESTs). Although the findings of these clinical trials have provided important information for clinicians, they unfortunately do not offer all the information needed in using these treatments in clinical practice. Applying these findings to clinical practice often involves modification and, among other things, dealing with patients’ cultural values, beliefs, and preferences.
The use of randomized controlled trials (RCTs) has been modeled on research evaluating the efficacy of new drugs. Once a drug has been shown to be effective in two clinical trials, it is approved by the FDA for clinical use. There is, however, a mechanism in medicine whereby practicing physicians can report back to the FDA about their clinical experiences—particularly the difficulties they encounter when using these empirically supported medications in practice. Up until recently, no similar mechanism has been available for psychotherapy interventions demonstrated to have efficacy based on RCTs. The clinical feedback from those in the field, in our opinion, is critical to effectively shape clinical science.
In 2010, the first author was elected President of the Society of Clinical Psychology, Division 12 of APA, and began a presidential initiative to build a Two-Way Bridge between Research and Practice. The initiative established a mechanism whereby practicing clinicians could provide researchers with feedback about their clinical use of ESTs whose efficacy was supported by RCTs. We may usefully conceptualize such clinical observations as offering what is known in the sociology of science as “the context of discovery” (Reichenbach, 1938). Specifically, these clinical observations can help to point to those mediating, moderating, and contextual variables that were missing in clinical trials, but which nonetheless are important for the effective application of these interventions in practice. In 2011, the Two-Way Bridge initiative became a collaborative effort together with Division 29 (Society for the Advancement of Psychotherapy) when the fifth author was serving as president.
In supporting this Two-Way Bridge initiative, the Society of Clinical Psychology and the Society for the Advancement of Psychotherapy appointed a diverse subcommittee to spearhead the effort. In addition to the first author as Chair, the committee consisted of: Louis Castonguay, Jairo Fuertes, Jeffrey Magnavita, Michelle Newman, Linda Sobell, and Abraham Wolf. In our initial survey of practicing clinicians, which was internationally advertised and conducted online, therapists were asked to report on their experiences in using Cognitive-behavioral therapy (CBT) in the treatment of panic disorder (at the time, CBT was the only approved EST for this clinical problem). In addition to the questions asked of all participating clinicians, we also requested information about certain key classes of variables that they found to interfere with the clinical effectiveness of CBT in treating panic in actual practice, including:
- variables associated with patient symptoms
- patients’ other problems or characteristics
- patient expectations about treatment
- patient beliefs about symptoms
- patient motivation
- social system (home, work, other)
- problems/limitations with the intervention procedure
- therapy relationship issues
The reason we wanted to know about factors that interfered with the successful treatment in clinical practice was to identify those variables that would provide important issues for therapy researchers to investigate. In addition, identifying factors that could interfere with successful treatment could also provide valuable information to practitioners that could enhance their clinical effectiveness.
Since the initial survey of therapists on their experiences in dealing with panic disorder patients, the Two-Way Bridge initiative has looked at clinical experiences associated with the use of empirically supported treatments in dealing with social anxiety and general anxiety disorder. The findings of these three surveys, together with the supportive comments by two internationally known therapy researchers—Dianne Chambless and Tom Ollendick—have appeared in the journal Behavior Therapy (Chambless, 2014; Goldfried et al., 2014; Jacobson, Newman, & Goldfried, 2016; McAleavey, Castonguay, & Goldfried, 2014; Ollendick, 2014; Szkodny, Newman, & Goldfried, 2014a; Wolf & Goldfried, 2014). The published results are also posted on the Two-Way Bridge website (www.stonybrook.edu/twowaybridge).
The following survey focusing on PTSD has been conducted, analyzed, written up, and submitted for publication:
- Lauren E. Szkodny, Michelle G. Newman, and Marvin R. Goldfried (2014b): The Use of Empirically Supported Psychological Treatments for Posttraumatic Stress Disorder in Clinical Practice.
When this survey is published, its availability will be announced on various listservs and the Two-Way Bridge website.
The overall objective of the Two-Way Bridge initiative is to call attention to the importance of having a mechanism whereby the dissemination of clinical observations can be sent to therapy researchers. In doing so, what gets created is a productive synergy, allowing both clinicians and researchers to have a voice in forming a consensus, and in jointly developing practice guidelines. The potential is for the advancement of psychological practice, with research in psychotherapy being informed and advanced by clinical practice, thereby leading to future research that is timely and that has greater clinical relevance.
Editors’ Note: This article is being simultaneously published in The Clinical Psychologist, the official publication of Division 12.