Integrating Research and Integrating Research and Practice: Toward the End Practice: Toward the End

of “Empirical of “Empirical Imperialism” and New Imperialism” and New Pathways for Synergic Pathways for Synergic

CollaborationsCollaborations

Louis CastonguayLouis Castonguay

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Different road tripsDifferent road trips

• Relevance of researchRelevance of research– Lack of external validityLack of external validity– Inattention to clinicians’ concernsInattention to clinicians’ concerns

• Engagement in researchEngagement in research– Trauma from graduate schoolTrauma from graduate school– Lack of collaborative opportunityLack of collaborative opportunity

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A way to get to Rome A way to get to Rome togethertogether

• Rejecting the “empirical Rejecting the “empirical Imperialism” Imperialism” – ““I” know what is important to knowI” know what is important to know

• Creating a collaborative Creating a collaborative infrastructure infrastructure – Active and mutual engagement in the Active and mutual engagement in the

design, implementation, and design, implementation, and dissemination of knowledgedissemination of knowledge

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Working List of Psychotherapy Training Working List of Psychotherapy Training Recommendations for Minimizing Potential Harmful Recommendations for Minimizing Potential Harmful

Effect Effect

• Overarching principlesOverarching principles– Expose trainee to evolving list of PHT, and Expose trainee to evolving list of PHT, and

encourage him/her to approach the list encourage him/her to approach the list carefully (e.g., with an eye on specific carefully (e.g., with an eye on specific interventions that may be particularly harmful, interventions that may be particularly harmful, as well as on others that may not be as well as on others that may not be detrimental for all clients)detrimental for all clients)

– Help trainee learn to monitor change, lack of Help trainee learn to monitor change, lack of improvement, and deterioration improvement, and deterioration

– Help trainee learn to conduct a comprehensive Help trainee learn to conduct a comprehensive psychological assessment*psychological assessment*

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Working List of Psychotherapy Training Working List of Psychotherapy Training Recommendations for Minimizing Potential Harmful Recommendations for Minimizing Potential Harmful

Effect Effect

• Enhance therapeutic relationshipEnhance therapeutic relationship– Help trainee to establish and maintain a good therapeutic Help trainee to establish and maintain a good therapeutic

alliancealliance– Help trainee experience and communicate empathy for Help trainee experience and communicate empathy for

his/her clienthis/her client

• Use techniques skillfully and appropriately, including Use techniques skillfully and appropriately, including interventions prescribed in empirically supported treatments interventions prescribed in empirically supported treatments – Help trainee to foster sufficient exposure to unpleasant Help trainee to foster sufficient exposure to unpleasant

situations when conducting behavioral therapysituations when conducting behavioral therapy– Help trainee learn to deliver interpretations after establishing Help trainee learn to deliver interpretations after establishing

a good working alliance in psychodynamic therapy*a good working alliance in psychodynamic therapy*– Help trainee to avoid providing interpretations when Help trainee to avoid providing interpretations when

conducting experiential therapy*conducting experiential therapy*

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Working List of Psychotherapy Training Working List of Psychotherapy Training Recommendations for Minimizing Potential Harmful Recommendations for Minimizing Potential Harmful

Effect Effect

• Prevent and repair toxic relational and technical processes Prevent and repair toxic relational and technical processes – Help trainee learn to measure the alliance and to explore own Help trainee learn to measure the alliance and to explore own

contribution to alliance problems (e.g., hostility toward his/her contribution to alliance problems (e.g., hostility toward his/her client)client)

– Help trainee become a participant-observer of the therapy Help trainee become a participant-observer of the therapy process and to meta-communicate about the unfolding therapy process and to meta-communicate about the unfolding therapy process, especially during impasse process, especially during impasse

– Help trainee avoid relationship pitfalls when working with Help trainee avoid relationship pitfalls when working with clients from a different cultural background*clients from a different cultural background*

– Help trainee increase self-awareness and counter-transference Help trainee increase self-awareness and counter-transference management skillsmanagement skills

– Help trainee avoid using confrontational self-disclosureHelp trainee avoid using confrontational self-disclosure– Help trainee become aware of instances where inflexible Help trainee become aware of instances where inflexible

adherence to techniques threatens the alliance. He/she should adherence to techniques threatens the alliance. He/she should be trained to use potentially helpful interventions in a clinically be trained to use potentially helpful interventions in a clinically flexible and sensible way flexible and sensible way

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Working List of Psychotherapy Training Working List of Psychotherapy Training Recommendations for Minimizing Potential Harmful Recommendations for Minimizing Potential Harmful

Effect Effect

• Treatment choice, implementation, and expectation should adjusted to client Treatment choice, implementation, and expectation should adjusted to client characteristics and/or problems Help trainee learn to measure the alliance characteristics and/or problems Help trainee learn to measure the alliance and to explore own contribution to alliance problems (e.g., hostility toward and to explore own contribution to alliance problems (e.g., hostility toward his/her client)his/her client)

– Help trainee be aware that some clients (e.g., diagnosed with a Help trainee be aware that some clients (e.g., diagnosed with a personality disorder, depressed clients with high level of perfectionism) personality disorder, depressed clients with high level of perfectionism) are likely to require longer and/or modified forms of psychotherapyare likely to require longer and/or modified forms of psychotherapy

– Help trainee be aware that other client characteristics (e.g., lack of Help trainee be aware that other client characteristics (e.g., lack of depression and anxiety, extreme level of dependency) may require them depression and anxiety, extreme level of dependency) may require them to adopt reasonable expectations about outcome and anticipate alliance to adopt reasonable expectations about outcome and anticipate alliance ruptures*ruptures*

– Help trainee be aware that clients with high levels of reactance are not 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 likely to benefit from directive forms of therapy, and that clients with low levels of reactance are not likely to benefit from non-directive treatmentslevels 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 Help trainee be aware that some clients (e.g., with low level of cognitive development) may not benefit from treatments aimed at fostering development) may not benefit from treatments aimed at fostering insight*insight*

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Working List of Psychotherapy Training Working List of Psychotherapy Training Recommendations for Minimizing Potential Harmful Recommendations for Minimizing Potential Harmful

Effect Effect

• Some therapists may be less effective (and/or produce more Some therapists may be less effective (and/or produce more harmful effects) than others harmful effects) than others – Help trainee with anxious attachment style become aware that Help trainee with anxious attachment style become aware that

he/she may be vulnerable to engage in less empathic exchangeshe/she may be vulnerable to engage in less empathic exchanges– Help trainee increase self-awareness of their hostility toward Help trainee increase self-awareness of their hostility toward

him/herself and potentially steer toward own personal him/herself and potentially steer toward own personal psychotherapypsychotherapy

– Help trainee be aware that other vulnerabilities (e.g., excessive Help trainee be aware that other vulnerabilities (e.g., excessive need to be liked or admired, inability to receive criticism, need to be liked or admired, inability to receive criticism, difficulty tolerating negative emotion) may reduce their ability difficulty tolerating negative emotion) may reduce their ability to help client and/or damage their clients’ well-being*to help client and/or damage their clients’ well-being*

Note: *Note: * Clinical/theoretical recommendation for which the authors Clinical/theoretical recommendation for which the authors of this paper are not aware of empirical support. of this paper are not aware of empirical support.

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PPA PRN PPA PRN

Phase I (Borkovec, Echemendia, Ragusea, & Ruiz, Phase I (Borkovec, Echemendia, Ragusea, & Ruiz, 2001)2001)

• Goals: Goals: • - Create a state-wide infrastructure - Create a state-wide infrastructure • - Obtain experience in the use of a core battery and - Obtain experience in the use of a core battery and

in the conduct of collaborative research in the in the conduct of collaborative research in the applied setting applied setting

Phase IIPhase II• Goals:Goals:• - Examine what do clients find helpful (and - Examine what do clients find helpful (and

unhelpful) during a session?unhelpful) during a session?• - Investigate whether knowledge of client’s - Investigate whether knowledge of client’s

perception of helpful (and hindering) events can perception of helpful (and hindering) events can improve the effectiveness of therapy. improve the effectiveness of therapy. 9

QuestionsQuestions

• What events are found by clients to be most What events are found by clients to be most helpful and hindering during sessions conducted helpful and hindering during sessions conducted within the context of regular private practice?within the context of regular private practice?

• What events are found by therapists to be most What events are found by therapists to be most helpful and hindering during the same sessions?helpful and hindering during the same sessions?

• What are some of the content of discussions What are some of the content of discussions addressed within these helpful and hindering addressed within these helpful and hindering events?events?

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MethodMethod

DesignDesign• Within each of three age groups (child, Within each of three age groups (child,

adolescent, adult), clients were randomly adolescent, adult), clients were randomly assigned to experimental or control conditions assigned to experimental or control conditions

• Experimental condition: HAT filled out by both Experimental condition: HAT filled out by both client and therapist after every sessionclient and therapist after every session

• Control condition: HAT filled out by therapist Control condition: HAT filled out by therapist only only

• This presentation focus primarily on This presentation focus primarily on adolescents and adults clients (12 years old adolescents and adults clients (12 years old and older)and older)

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MethodMethod

ParticipantsParticipants• 13 experienced therapists in private 13 experienced therapists in private

practicepractice• 121 clients 121 clients • Clients per therapist, Mean of 9.31 Clients per therapist, Mean of 9.31

(sd=7.33) ranging from 2 to 24.(sd=7.33) ranging from 2 to 24.• Number of sessions: Mean of 7.98 Number of sessions: Mean of 7.98

(sd=8.17), ranging from 1 to 36(sd=8.17), ranging from 1 to 36

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MethodMethodInstrumentsInstruments

A.A. Helpful Aspects Therapy Questionnaire (HAT, Llewelyn, Helpful Aspects Therapy Questionnaire (HAT, Llewelyn, 1985) 1985)

• 1. Did anything particularly helpful happen during this 1. Did anything particularly helpful happen during this session? Circle: Yes / No (If yes, please describe it briefly session? Circle: Yes / No (If yes, please describe it briefly below and circle its helpfulness).below and circle its helpfulness).

• 1-----------------2-------------------3---------------41-----------------2-------------------3---------------4• Slightly Slightly Moderately Moderately Greatly Greatly Extremely Extremely• HelpfulHelpful Helpful Helpful Helpful Helpful Helpful Helpful

• 2. Did anything happen during this session which might have 2. Did anything happen during this session which might have been hindering? been hindering? Circle: Yes / No (If yes, please describe it briefly below and Circle: Yes / No (If yes, please describe it briefly below and circle its hindering).circle its hindering).

• 1-----------------2------------------3---------------41-----------------2------------------3---------------4• Slightly Slightly Moderately Moderately Greatly Greatly Extremely Extremely• HinderingHindering Hindering Hindering Hindering Hindering Hindering Hindering 13

MethodMethodB. Helpful aspects of experiential therapy content B. Helpful aspects of experiential therapy content

analysis system (Elliott, 1988)analysis system (Elliott, 1988)• Impact: 18 categories of helpful and hindering Impact: 18 categories of helpful and hindering

eventsevents• Content: 7 categories of focus of therapy Content: 7 categories of focus of therapy • 4-point confidence rating scale 4-point confidence rating scale

3 -- Clearly or strongly present3 -- Clearly or strongly present

2 -- Probably present 2 -- Probably present

1 -- Probably absent 1 -- Probably absent

0 -- Clearly absent0 -- Clearly absent• 3 coders (trained for 8 months) coded 1,480 events, 3 coders (trained for 8 months) coded 1,480 events,

1,052 reported by therapists and 428 reported by 1,052 reported by therapists and 428 reported by clientsclients 14

TICAS Categories and ReliabilityTICAS Categories and Reliability

Helpful ImpactsHelpful Impacts

CategoryCategory alphaalphaSelf-InsightSelf-Insight .878.878Other-InsightOther-Insight .712.712Self-AwarenessSelf-Awareness .785.785Other AwarenessOther Awareness

.828.828Positive SelfPositive Self .923.923Positive OtherPositive Other .819.819Self-MetaperceptionSelf-Metaperception .873.873Problem ClarificationProblem Clarification .752.752Problem SolutionProblem Solution .870.870Alliance StrengtheningAlliance Strengthening .927.927ReliefRelief .820.820Other Specific HelpfulOther Specific Helpful .823.823

Hindering ImpactsHindering Impacts

CategoryCategory alphaalpha

Unwanted ThoughtsUnwanted Thoughts .920.920Therapist OmissionTherapist Omission .862.862DigressionDigression .715.715Poor FitPoor Fit .838.838Other HinderingOther Hindering .881.881

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Content Categories and ReliabilityContent Categories and Reliability

CategoryCategory alpha alpha

Self-OnlySelf-Only .830.830

Family of OriginFamily of Origin .979.979

Marital FamilyMarital Family .944.944

WorkWork .929.929

Other RelationshipsOther Relationships .862.862

TherapyTherapy .879.879

Other ContentOther Content .480.480

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MethodMethod

ProceduresProcedures• All new clients completed the TOP before All new clients completed the TOP before

first session.first session.• HAT cards were filled out after every HAT cards were filled out after every

session. session. • Therapists read the HAT filled out by the Therapists read the HAT filled out by the

client before the next session. client before the next session. • All new clients were asked to fill out the All new clients were asked to fill out the

TOP after the last session of their TOP after the last session of their treatment. treatment.

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ResultsResultsA)A) IMPACT – Client reportIMPACT – Client report

• Top threeTop three1) Self-awareness *1) Self-awareness *

2) Problem clarification2) Problem clarification

3) Problem solution3) Problem solution

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ResultsResultsB) Helpful Events– Therapist reportB) Helpful Events– Therapist report

• Top threeTop three1)Self-awareness *1)Self-awareness *2) Alliance strengthening *2) Alliance strengthening *3) problem clarification3) problem clarification

C) Hindering Events– Therapist reportC) Hindering Events– Therapist report

1) Therapist omission *1) Therapist omission *

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ResultsResults

Content – Client reportContent – Client report• Helpful eventsHelpful events

– TherapyTherapy– SelfSelf– Family of OriginFamily of Origin

• Hindering eventsHindering events– TherapyTherapy

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ResultsResults

Content –Therapist reportContent –Therapist report• Helpful eventsHelpful events

– TherapyTherapy– SelfSelf– Family of OriginFamily of Origin

• Hindering eventsHindering events– TherapyTherapy– Marital FamilyMarital Family

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Caveats Caveats

• Results reflect the perception of the Results reflect the perception of the clients and therapists about the impact of clients and therapists about the impact of events that took place in sessionsevents that took place in sessions

• They also reflect the conceptual biases They also reflect the conceptual biases underlying the instrument that we used to underlying the instrument that we used to code these helpful events.code these helpful events.

• Results also fail to reflect the importance Results also fail to reflect the importance of the dimensions of psychotherapy that of the dimensions of psychotherapy that are not captured by this instrument.are not captured by this instrument.

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Therapists’experienceTherapists’experience• 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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BenefitsBenefits• 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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DifficultiesDifficulties

• Pragmatic obstacles

• Research tasks may have, at times, interfered with client’s needs

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RecommendationsRecommendations

• 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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RecommendationsRecommendations

• 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 IIIPhase III

• Keeping the good thingsKeeping the good things– Focus on the process of change (client’s Focus on the process of change (client’s

feedback) in order to “confound” feedback) in order to “confound” research and clinical tasksresearch and clinical tasks

– Focus on outcome (experimental Focus on outcome (experimental design) as a strategy to address the design) as a strategy to address the ultimate goal of scienceultimate goal of science

– Active collaboration and full support in Active collaboration and full support in design and implementationdesign and implementation

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Phase IIIPhase III

• Avoiding the bad thingsAvoiding the bad things– Making the protocol manageable Making the protocol manageable – Exporting strategies from controlled Exporting strategies from controlled

researchresearch• Monitoring closely data collectionMonitoring closely data collection• Financial support (APA, BHL)Financial support (APA, BHL)

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Thanks To…Thanks To…

• Pennsylvania Psychological Association and the Committee for the Advancement of Professional

• Practice of the American Psychological Association

• Behavioral Health Laboratories

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