Internet Editor’s Note: Dr. Tasca and his colleagues recently published an article in Psychotherapy titled “What clinicians want: Findings from a psychotherapy practice research network survey” in Psychotherapy.
You can access a free copy of their journal article here.
The Practice-Research Divide in Psychotherapy
The tension between science and practice in psychotherapy has been described as a war or a “bad marriage” (Greene, 2014). Some writers on the research side of the divide characterize clinicians as lacking in knowledge and skill in empirically supported interventions (Karlin & Cross, 2014), while others suggest that clinicians are romantics when it comes to psychotherapy practice, and that they may be subject to cognitive biases when making clinical decisions (Lilienfeld et al., 2013). Writers on the clinical side of the divide argue that randomized controlled trials represent a limited form of evidence (Westen et al., 2004), and that there may be a feeling of resentment among practitioners that researchers disseminate their findings upon clinicians (Greene, 2014). The result is that patients may not be receiving the best of evidence-based care.
Psychotherapy is not alone with this dilemma. There are long standing problems with nurses’ low adherence to hand hygiene practices to reduce the spread of infectious agents in hospitals and nursing homes (Schweizer et al., 2013), the over-prescription of antibiotics by family physicians resulting in population-based problems with resistance to certain microbes (Costelloe et al., 2010), and unnecessary use of invasive diagnostic tests among medical specialists to reduce the threat of litigation (Studdert et al., 2005).
Dissemination vs. Knowledge Translation and Exchange (KTE)
In this context, I find it useful to note the distinction between dissemination and knowledge translation and exchange (KTE; Graham et al., 2006). Dissemination refers to researchers relaying their findings by traditional means like manuscript publications, and creating lists of evidence based treatments and practices. The expectation is that clinicians will read the research and change their practices accordingly. The current state of the psychotherapy practice-research divide indicates that dissemination alone has not been effective to move research into the therapy room.
On the other hand, KTE, which has its roots in implementation science (Madon et al., 2007), includes efforts at dissemination, but also more actively involves clinicians and researchers in a mutually beneficial partnership to advance research and to affect practice. When engaging in KTE, both researchers and clinicians are transformed by their partnership (see for example, Castonguay et al., 2010). One of the key advantages of KTE is that it focuses on identifying barriers to translating research leading to the development of specific interventions to overcome those barriers and improve research uptake.
One such intervention for psychotherapy might be the development of practice research networks.
Practice Research Networks
In practice research networks, clinicians and researchers come together to define research agendas and to engage in practice-based research (Castonguay et al., 2013). The goal for researchers is to produce studies with valid findings that are informed by clinicians so the findings will have a greater impact on clinical practice. The goal for clinicians is to have an effect on the types of studies that are developed, to gain a greater appreciation for the process of producing science, and to provide the best possible care to clients informed by the most up to date research.
Engaging in a practice research network may result in an elevated level of readiness or intention among clinicians to allow their practice to be informed by research (Tasca et al., 2014).
The Psychotherapy Practice Research Network (PPRNet)
With KTE as our orientation, a group of clinicians, researchers, and educators in Canada developed the Psychotherapy Practice Research Network (PPRNet). We took a ground-up approach to defining a research agenda. The process, also called deliberative priority setting (Campbell, 2010), involved systematically asking clinician what they wanted from psychotherapy research. We held a conference in Ottawa, Canada in November 2012 in which over 100 clinicians, researchers, and educators came together to discuss practice and research in psychotherapy.
The morning session involved several talks about psychotherapy research, including a presentation by Dr. Louis Castonguay on practice research networks.
Later in the morning, clinicians were placed in 10 focus groups of 8-10 participants each that were moderated by two members of the PPRNet Working Group. Focus group discussions centered on what participants wanted from PPRNet and what barriers might impede their participation in practice-based research.
Need for Readable and Easy to Digest Research
One of the key issues that emerged from clinicians was a need for easily readable research digests with clear practice implications. Clinicians noted that original research was difficult to access without a university appointment, the volume of the research was overwhelming, the methodology was difficult to evaluate, and the findings often were not directly discussed in relation to clinical practice.
As a result of this, the PPRNet developed its website hosted by the University of Ottawa (www.pprnet.ca) featuring the PPRNet Blog, which is a monthly digest of three reviews, meta analyses, or large scale studies. A key aspect of the blog is to draw direct usable practice implications of the research. To reduce barriers, membership in PPRNet is free, and members receive a monthly E-Newsletter with that month’s blog and other news. Currently, over 700 psychotherapists are members of PPRNet.
The afternoon conference focus groups zeroed-in on research themes or agendas that are particularly relevant to clinicians. The group discussions were recorded and we did a qualitative coding of the content. Some of this is described in our article: “What Clinicians Want: Findings from a Psychotherapy Practice Research Network Survey” which appears in the March, 2015 issue of Psychotherapy (Tasca et al., 2015).
We took the content of these focus groups and generated 41 items for a large-scale survey of psychotherapists. The survey continued the deliberative priority setting process as it was the next step in polling the psychotherapy practitioner community about their needs and preferences for research.
What struck me about the 41 survey items was that they represented important themes of psychotherapy research found in the content of most major journals. The survey included over 1000 psychotherapist respondents who rated the importance of the items to their practice. In this way we were able to rank order the most important research themes for psychotherapists. We statistically grouped the items into 9 research themes based on the responses.
Most Important Research Themes for Psychotherapists
The most important items for psychotherapists were associated with the following themes:
- mechanisms of change/therapeutic relationships;
- therapist factors;
- professional development; and
- client factors.
Theoretical orientation, age, gender and other respondent characteristic were not associated these rankings.
After the survey, we continued to process of canvassing clinicians by asking two smaller focus groups about why they thought these were the highest ranked themes. The focus group members felt that the high ranking research areas were those: perceived to be most likely under clinicians’ control, that had direct implications for their work with clients during a therapy session, and that could help them become better therapists.
Least Important Research Themes for Psychotherapists
The least important research items for psychotherapists were associated with the following themes:
- progress monitoring;
- matching client to therapy; and
- therapy manuals.
Post-survey focus groups suggested that these areas might be perceived: as agendas external to and imposed upon the therapist, as distant from or interfering with the therapist-patient relationship, and with some suspicion by therapists. We were disheartened by the low ranking of the progress monitoring items, since research in this area is promising to improve patient outcomes (Lambert & Shimokawa, 2011). The post-survey focus groups also suggested that perhaps clinicians were not aware of the benefits of progress monitoring (see also Ionita & Fitzpatrick, 2014). Again, there was no relationship between these rankings and respondent factors like age and theoretical orientation.
Take Home Message for Researchers
Conducting psychotherapy research that has little or no impact on clinical practice is like re-arranging chairs on the deck of the Titanic. Researchers have to find a way of influencing clinical practice that goes beyond traditional means of knowledge dissemination. Principles of KTE and practice research networks provide models for changing the conduct of research that involve clinicians as partners from the outset to develop interventions, design studies, and disseminate the findings.
Some areas of research, like progress monitoring and therapy manuals will require substantial dialogue with clinicians in order to make this research meaningful and less daunting to clinicians. Simply disseminating good research findings from these areas will not be enough to have an impact on clinical practice. Findings from our focus groups also suggested that researchers must engage clinicians when writing discussion sections of manuscripts in order make the findings practically relevant.
Finally, lamenting that clinicians do not always practice according to research findings and speculating about clinical decision making biases will not indicate effective interventions to change practice and may further alienate clinicians. Research is needed on the barriers to implementing psychotherapy research so that we can come to a better understanding of how best to translate the research into practice.
Take Home Message for Clinicians
Research findings can be complex and voluminous, and debates like those between evidence based practice versus empirically supported treatments (Laska et al., 2015) appear academic, at least on the surface (however, they are not trivial when you dig past the esoteric labels).
Access to Resources
Nevertheless, psychotherapists have a responsibility to provide care that is backed by the best evidence. This means that despite having a busy practice, one must keep abreast of the latest research. There are a number of resources available to clinicians including the Society for the Advancement of Psychotherapy web site (https://societyforpsychotherapy.org/) and the PPRNet blog (www.pprnet.ca) that provide short, readable, and practice-oriented articles based on the most current research.
Focus on Systematic Reviews and Meta Analyses
I have also advised clinicians to focus on systematic reviews and meta analyses, rather than individual studies, when they turn to research to make practice decisions (Tasca, 2014). Systematic reviews and meta analyses are much more reliable sources of evidence than findings form an individual study.
Practice Research Networks
Finally, psychotherapy practice research networks exist and are developing around the world (Castonguay & Muran, 2015). Such networks provide opportunities for clinicians to have an input into what gets researched and how the findings get translated. Participating in such endeavours will have a positive effect on clinicians’ attitudes about research, their sense of research efficacy, and their intention to use research when making clinical decisions (Tasca et al., 2014). Practice research networks might allow even the busy clinician to have a say about psychotherapy research.
Cite This Article
Tasca, G. (2015, March). What clinicians want from psychotherapy research. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/what-clinicians-want-from-psychotherapy-research
Beutler, L. E., Williams, R. E., Wakefield, P. J., & Entwistle, S. R. (1995). Bridging scientist and practitioner perspectives in clinical psychology. American Psychologist, 50, 984-994.
Campbell, S. (2010). Deliberative priority setting: A CIHR KT module. Retrieved from: http://www.cihr-irsc.gc.ca/e/documents/deliberative_priority_setting_module_e.pdf, February 9, 2015.
Castonguay, L.G., Barkham, M., Lutz, W., & McAleavy, A. (2013). Practice oriented research: Approaches and applications. In. M.J. Lambert (Ed.), Bergin & Garfield’s handbook of psychotherapy and behavior change. 6th Edition. Hoboken, N.J.: Wiley. pp. 85-133.
Castonguay, L.G. & Muran, J.C. (2015). Fostering collaborations between researchers and clinicians through building practice-oriented research: An introduction. Psychotherapy Research, 25, 1-5.
Castonguay , L. G. Nelson , D. Boutselis , M. Chiswick , N. Damer , D. Hemmelstein , N. (2010). Clinicians and/or researchers? A qualitative analysis of therapists’ experiences in a practice research network. Psychotherapy, 47, 345-354.
Costelloe, C., Metcalfe, C., Lovering, A., Mant, D., & Hay, A. D. (2010). Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. Bmj, 340.
Graham, I.D., Logan, J., Harrison, M.B., Straus, S.E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26, 13-24.
Greene, L. R. (2014). Dissemination or dialogue? American Psychologist, 69(7), 708-709.
Ionita, G., & Fitzpatrick, M. (2014). Bringing science to clinical practice: A Canadian survey of psychological practice and usage of progress monitoring measures. Canadian Psychology/Psychologie canadienne, 55(3), 187-196.
Karlin , B. E. Cross , G. (2014). From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs health care system. American Psychologist, 69, 19-33. Lambert, M.J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72-79.
Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51(4), 467-481.
Lilienfeld , S.O. Ritschel , L.A. Lynn , S.J. Brown , A.P. Cautin , R.L. Latzman , R.D. (2013). The research-practice gap: Bridging the schism between eating disorder researchers and practitioners. International Journal of Eating Disorders, 46(5), 386-394.
Madon, T., Hofman, K.J., Kupfer, L., & Glass, R.I. (2007). Public health. Implementation science. Science, 318, 1728-1729.
Schweizer, M. L., Reisinger, H. S., Ohl, M., Formanek, M. B., Blevins, A., Ward, M. A., & Perencevich, E. N. (2013). Searching for an optimal hand hygiene bundle: a meta-analysis. Clinical infectious diseases, doi: 10.1093/cid/cit670.
Studdert, D. M., Mello, M. M., Sage, W. M., DesRoches, C. M., Peugh, J., Zapert, K., & Brennan, T. A. (2005). Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Journal of the American Medical Association, 293(21), 2609-2617.
Tasca, G.A. (2014). Don’t pay attention to that one study behind the curtain: Why clinicians should mainly read meta analyses. Retrieved from: http://www.med.uottawa.ca/pprnet/eng/pprnet_blog_nov2013.html, February 9, 2015.
Tasca, G.A., Grenon, R., Fortin-Langelier, B., & Chyurlia, L. (2014). Addressing challenges and barriers to translating psychotherapy research into clinical practice: The development of a Psychotherapy Practice Research Network in Canada. Canadian Psychology, 55, 197-203.
Tasca, G.A., Sylvestre, J., Balfour, L., Chyurlia, L., Evans, J., …Wilson, B. (2015). What clinicians want: Findings from a psychotherapy practice research network survey. Psychotherapy. doi: http://dx.doi.org/10.1037/a0038252
Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130(4), 631-663.