The practice of psychotherapy is not an easy task. Many psychotherapists are balancing multiple responsibilities and roles at any given moment. As clinicians, they have to conduct assessments, develop case conceptualizations and treatment plans, relate to their patients therapeutically, and deliver interventions effectively. As mental health providers, they have to find time to manage responsibilities such as paperwork and documentation, communication and coordination of care, and insurance issues. When dealing with these competing demands, therapists generally resort to knowledge and expertise derived from their own training, clinical experience, colleagues, and supervisors—and, much less so, to research. There is a well-recognized divide between research and clinical practice, and many psychotherapists do not rely substantially on empirical results in their clinical practice (Castonguay, Youn, Xiao, Muran, & Barber, 2015). For many clinicians, these findings are viewed as not applicable to the everyday clinical reality (Castonguay, Locke, & Hayes, 2011).
One way to address the gap between science and practice is through practice-oriented research (POR), a bottom-up approach that encourages a sense of joint ownership, mutual collaboration, and respect between researchers and clinicians when conducting psychotherapy research, so that it is clinically informative and scientifically rigorous (Castonguay, Barkham, Lutz, & McAleavey, 2013). In POR, practitioners, in collaboration with researchers, can be actively involved in all aspects of research, including the design and implementation of research protocols, collection of data, analysis, and dissemination of results. By emerging from, and taking place in, the setting in which therapists practice their clinical work, POR is a way to “confound” research and practice (Castonguay, 2011) by involving specific tasks that simultaneously meet both research and clinical purposes. At a broader level, because it is based on complementary expertise, POR allows for innovative methods of conducting psychotherapy research that embed and enhance the vision of both researchers and clinicians.
A variety of POR studies have already been conducted in different naturalistic settings across the world and have addressed several topics, such as the effectiveness of psychotherapy, client and therapist characteristics, utilization of services, process studies, including the therapeutic alliance and principles of change, as well as supervision and training initiatives (Castonguay et al., 2015). The patient-focused approach has been a particular focus of naturalistic research. It involves the careful assessment and tracking of patients’ progress over the course of treatment, using standardized outcome measures, and providing clinically relevant feedback to therapists that can be useful to their practice (Boswell, Kraus, Miller, & Lambert, 2015). This type of research aims to provide clinicians with tools that can be used to augment clinical decision making with results that are directly applicable to day-to-day practice.
How Can Outcome Monitoring Inform Clinical Practice?
Drapeau (2012) has identified 10 different measures/systems developed to track mental health change in routine care, each with its own strengths and limitations. Regardless of the system used, the most common use of outcome monitoring has been to track symptomatology change. By administering an outcome measure pre- and post-treatment, clinicians can have access to data from the client to supplement their clinical judgment as to when to conclude treatment. Outcome monitoring can also provide more frequent information regarding the patient’s progress when administered at shorter intervals, such as after each session. Not only can this information be helpful for therapists in terms of treatment planning and implementation, it can also serve as a powerful tool for patients to have information regarding their own improvement—which can further improve the therapeutic alliance, as well as their adherence to and belief in treatment (Youn, Kraus, & Castonguay, 2012).
Regularly monitoring outcomes can also aid therapists in detecting when patients are “off-track” in their treatment. For example, if clinicians are alerted to the fact that a patient’s progress is slower than expected when compared to other patients who shared similar demographics and initial severity status, they can use this information to inform treatment, discuss it with the patient, and/or seek supervision. Additionally, some feedback systems have also shown to accurately predict potential treatment failure, risk of hospitalization, or other negative outcomes, such as drop-out (Boswell, et al., 2015; Xiao et al., 2013). It is difficult for psychotherapists to predict who will deteriorate or be at risk for experiencing negative outcomes during treatment (Lambert, 2010). Therefore, clinical tools that can aid judgment and decision making surrounding this type of care for patients can help to intervene effectively, while reducing the probability of premature termination or harm during treatment.
In addition to tracking symptomatology change, the inclusion of standardized outcome measures in routine care can serve a diverse range of clinical functions. For example, for various reasons, such as embarrassment, ambivalence about areas of distress, or unawareness, patients may be reluctant to verbally discuss or bring up difficulties with psychotherapists during session. In these situations, outcome measures can provide alternative communication outlets through which patients express distress to their providers (Youn, Kraus, & Castonguay, 2012; Youn et al., 2015). Additionally, ongoing assessments can provide clients feedback about their progress, which can also be discussed with providers in relation to treatment goals and various clinical interventions, such as development of new perspective of self. For example, seeing improvements in outcome scores, or areas of strength if using a multidimensional outcome measure, can help clients increase their sense of agency in their development, as well as highlight positive attributes (Youn et al., 2015).
Challenges Conducting Practice Oriented Research
As is the case with the implementation of any kind of research, a number of obstacles and challenges have been identified when trying to build clinician-researcher partnerships, as well as conducting POR (Castonguay et al., 2013). One of the biggest challenges is encountered when POR is perceived as irrelevant, or even hindering the clinical work. For example, from the practitioners’ perspective, if outcome monitoring is viewed as impeding the therapeutic relationship, increasing client resistance, or resulting in negative evaluation of services (and potentially decreasing referrals or income), then the likelihood that the research is actually conducted in clinical practice decreases substantially (Boswell et al., 2015; Fernández-Álvarez, Gómez, & García, 2015; Holmqvist, Philips, & Barkham, 2015; Strauss et al., 2015). Additionally, as is the case with any partnership, problems of collaboration and communication can impact the sense of shared ownership that is the backbone of all POR (Castonguay et al., 2015). Last but not least, there are pragmatic obstacles, such as availability of time, staff, and resources to implement the research procedures, especially if there are incompatibilities between research and clinical tasks.
Benefits of Conducting POR
Despite some of the challenges in conducting research in private practice, clinicians have reported benefits in conducting POR. For example, some therapists have found it professionally validating to investigate phenomena that occur in their day-to-day routine (Koerner & Castonguay, 2015). Clients have reported experiencing a feeling of pride in their contribution to projects that increase our understanding of psychotherapy (Castonguay, Nelson et al., 2010). The implementation of different research protocols can also lead to immediately useful clinical information. For example, clients’ feedback about helpful and hindering events in session has allowed clinicians to be more attuned to their clinical needs while also collecting research data (Castonguay, Boswell et al., 2010). Training studies provide therapists with tools to implement evidence based treatment procedures (Koerner & Castonguay, 2015). Additionally, if desired, clinicians can use their own outcome data for quality control, as well as for making referral decisions, and even to advocate for increased reimbursement for their services (Adelman, Castonguay, Kraus, & Zack, 2015). Across varied naturalistic settings, POR can not only be clinically informative, but can also seamlessly integrate and potentially bridge the gap between research and practice.