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Although the gap between psychotherapy practice and re- efficacy of specific interventions (e.g., Task Force on Pro-
search has been present for some time, recent pressures motion and Dissemination of Psychological Procedures,
for accountability from outside the system--managed 1995). It is in this context that we believe it essential for
health care and biological psychiatry--necessitate that clinician and researcher to join forces to come up with a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
we take steps to close this gap. One such step has been better way of demonstrating how our various psycho-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
for psychotherapy researchers to specify a list of empiri- therapy interventions are not only empirically grounded
cally validated therapies. However, as researchers who also but also clinically meaningful.
have a strong allegiance to clinical practice, we are con- We wrote this article as psychotherapy researchers
cerned that the conceptual and methodological constraints who also have a strong affinity for clinical practice. As
associated with outcome research may become clinical researchers, we feel more than a little bit of guilt for having
constraints for the practicing therapist. We firmly believe become involved in a research paradigm that has been
that, more than ever before, the time is ripe for us to de- too far removed from the real world of therapy practice.
velop a new outcome research paradigm that involves an This is certainly not a new phenomenon, and it has even
active collaboration between researcher and practicing been suggested in the past that "there apigears to be an
clinician. inverse relationship between the frequency with which a
treatment form is actually used by practitioners and the
frequency with which that treatment has been studied"
(Parloff, 1979, p. 304). At present, however, we are par-
S
ociologists have long documented how economic
ticularly concerned that the methodological and concep-
~and political forces can have an unexpected and
tual constraints associated with outcome research may
very powerful impact on various scientific disci-
very well turn into clinical constraints for the practicing
plines (Cole & Cole, 1973; Merton, 1938/1970). In the
therapist (cf. Frances, 1994). Yet, we continue to remain
early 1940s, World War II created numerous challenges
strong advocates of psychotherapy research. In many re-
that resulted in a huge collaborative effort in the field of
spects, our dilemma may be thought of as reflecting a
physics and other disciplines. Similarly, the Soviet Union's
conflict between a wish and a fear: Our wish is that therapy
Sputnik in the late 1950s gave rise to a host of scientific
interventions be based on psychotherapy research; our
and technological advances that might not otherwise have
fear, however, is that they might.
occurred. Although there is no doubt that the field of
psychotherapy has made important progress in the past The Worlds of the Scientist and
decade or two, it is likely that the most dramatic changes Practitioner
we are about to witness are likely to come from outside
forces. These external factors consist of pressures to justify Although therapists and researchers often begin with
empirically how we practice clinically, coming in the form similar professional training, they eventually end up living
of challenges from biological psychiatry and managed and working in very different worlds. We are keenly aware
health care. of this distinction; between the two of us, we have spent
The impetus for writing this article was our concern
that, in response to such pressures, psychotherapy out- Marvin R. Goldfried, Department of Psychology,State University of
come researchers may have overreacted and moved the New Yorkat Stony Brook; Barry E. Wolfe,American Schoolsof Profes-
field in the wrong direction, in other words, away from sional Psychology,Virginia Campus.
We would like to acknowledgewith appreciation the helpful com-
the day-to-day context of clinical practice. Although psy- ments and feedback on an earlier version of this article by Thomas D.
chotherapy research has appropriately increased in Borkovec, Louis G. Castonguay, Dianne L. Chambless, Robert M.
methodological rigor, it has become overly dependent on Liebert, Morris B. Parlofl, George Stricker, and Phoebus N. Tongas.
the "clinical trials" method to determine how to best Work on this article was supported in part by National Institute
treat "disorders." In addition to condoning the medical- of Mental Health Grant 40196.
Correspondence concerning this article should be addressed to
ization of psychotherapy, psychotherapy researchers may Marvin R. Goldfried, Department of Psychology,State University of
unwittingly be playing into the hands of third-party payers New York at Stony Brook, Stony Brook, NY 11794-2500. Electronic
in placing unwarranted emphasis on the putative fixed mail may be sent via Internet to mgoldfried@ccmail.sunysb.edu.
obtaining research grants, and achieving professional Psychiatric Association, 1987). At present, panic is seen
This document is copyrighted by the American Psychological Association or one of its allied publishers.
important clinical implications are those indicating that there was little specification or differentiation among the
in a psychodynamically oriented intervention, the ther- forms of therapy that were addressed and that the clinical
apist's interpretations that are based specifically on case problems and the nature of outcome were usually con-
formulations have more of an immediate emotional im- sidered in a very general way (Kiesler, 1966).
pact than do transference interpretations that are based During the 1960s and 1970s, we moved into the
on general theoretical considerations (Silberschatz, Fretter, next generation of research, in which there was a change
& Curtis 1986). In process analyses of cognitive therapy in the question that was being addressed by psychotherapy
for depression, an intriguing and somewhat unexpected outcome researchers. Largely because of the efforts of be-
finding has been that clients' level of emotional experience havior therapists, the question became not whether "psy-
and a focus on their relationship with their parents are chotherapy works" but which specific procedures are
positively associated with treatment outcome (Caston- more effective in dealing with a specific clinical problem
guay, Goldfried, Wiser, Raue, & Hayes, 1996; Hayes, (Franks, 1969). Consequently, various target problems
Castonguay, & Goldfried, 1996). were dealt with (e.g., phobias and unassertiveness), and
It is of particular interest that many of the coding specific therapy interventions that were based on written
systems used by psychotherapy process researchers can guidelines, in which there was random assignment of pa-
be used as training guidelines for practicing therapists. tients to different treatment conditions, became the state
Thus, Benjamin's (1993) Structural Analysis of Social of the art. Although a methodological advance over the
Behavior (SASB) can allow the clinician to monitor on earlier approach to answering the outcome question, this
an ongoing basis the nature of the therapeutic interaction second generation was limited because college student
along the dimensions of control and affiliation. Safran volunteers rather than actual patients were used in much
and his colleagues (Safran, Crocker, McMain, & Murray, of the research, and graduate students often served as the
1990) have provided guidelines for recognizing aspects of therapists. Still, it set the stage for the next generation of
the therapeutic interaction in which there may be a strain research.
in the alliance and what might be done to alleviate this Beginning in the 1980s, psychotherapy research
situation. The work of Greenberg, Rice, and Elliott (1993) moved onto a third generation of methodology. Continu-
on therapeutic markers can alert therapists to those points ing in the tradition of Generation II, which involved time-
in the therapy session that can call for them to proceed limited interventions that compared different treatments
therapeutically in different ways. Methods for classifying for particular clinical problems, Generation III research
a therapist's style of responding can provide clinicians has been called clinical trials--the terminology associated
with guidelines for how to word a verbal interaction (Hill, with drug studies. Further reflecting the shift toward the
1986; Stiles, 1992). Finally, process research on the ther- medical model, the methodology constituting this most
apeutic focus can have important clinical implications recent approach to psychotherapy outcome research in-
for identifying the dynamics/determinants of clinical volves the use of D S M diagnoses, particularly on Axis I.
problems, thereby assisting in both the initial and ongoing In addition, highly detailed therapy manuals are used,
case formulation (Goldfried, 1995). whereby therapists are monitored for their adherence to
the particular procedures being studied.
Psychotherapy Outcome Research Many of these methodological "upgrades" were fos-
In 1950, Snyder provided the first review of psychotherapy tered and ratified by the NIMH Treatment of Depression
research to appear in the Annual Review of Psychology, Collaborative Research Program, in which the original
in which he was able to cover the work done in the entire purpose was to test the feasibility of conducting a multisite
field within a single chapter. Four decades later, Goldfried, clinical trial in psychotherapy (Elkin, Parloff, Hadley, &
Greenberg, and Marmar (1990), representing cognitive- Autry, 1985). Although this question was intrinsically of
It should be noted that these large studies focus primarily likely that N I M H funding would be available to psycho-
on the use of a particular theoretical approach in reduc- therapy outcome researchers who wanted to study this
tion of the symptomatology associated with specific D S M clinically relevant characteristic.
diagnosed disorders. Our sense is that the field has become caught up in
One of the casualties of this movement to large-scale a research paradigm that does not faithfully reflect clinical
clinical trials--at least with respect to N I M H research reality. The very nature of our current research meth-
grant funding--was psychotherapy process research. odology, constrained by a need for D S M diagnoses, limits
Process research was increasingly subordinated to the task the kinds of questions that are studied. For example, the
of establishing the efficacy of standardized psychothera- typical finding that patients with personality disorders
pies. Its deemphasis was rationalized by the contention have poorer prognoses in the treatment of various clinical
that it was not necessary or useful to conduct research symptoms has raised the question about the ways that
on the process of a specific psychotherapy until it had Axis II disorders are related to Axis I disorders. We would
been established that psychotherapy was effective. As a think that a more relevant question to ask would be about
result, N I M H funding for psychotherapy process research how certain personality characteristics contribute to the
began to p l u m m e t in the late 1980s. The grant portfolio development of anxiety and depression, such as the extent
in psychotherapy process research was reduced by over to which patients become depressed because of patterns
60%, going from 16 grants in 1986 to 6 grants in 1990 of interpersonal behavior that bring about negative re-
(Wolfe, 1993). actions from others; unfortunate life circumstances; the
The medical model of outcome research, with its failure to grieve a loss; a passive interpersonal style in
emphasis on disorders and their symptoms in current responding to problematic life issues; a tendency to cog-
clinical trials, also has the particular limitation of ne- nitively distort; or a prevailing view of oneself as a failure.
glecting the key determinants/dynamics that clinicians In the typical clinical trials paradigm, one "pure-
know well to be essential to the change process. This lim- form" theoretical approach is compared with another in
itation is illustrated in a recent N I M H conference devoted the treatment of a D S M category. Unlike clinical practice,
to developing a standardized outcome battery for panic in which we as therapists often find it more effective to
disorder research (Shear & Maser, in press). After speci- use interventions associated with different therapeutic
fying m a n y of the indications of symptomatology that orientations (Norcross & Goldfried, 1992), our current
should be included in any clinical trial focusing on panic research methodology allows little room for taking into
disorder, the conference participants concluded that it account the relevant patient determinants/dynamics that
was "not essential" to include any evaluation of person- may influence what we should do clinically. Instead, dif-
ality variables in measuring outcome. This somewhat ferent therapy interventions are administered, which typ-
surprising conclusion was based on the lack of clarity in ically focus on the preferred variables associated with a
"comorbidity" between Axes I and II as well as the dif- given theoretical orientation (e.g., cognition, behavior, af-
ficulty in measuring "personality disorders." fect, and interpersonal systems). These different therapy
Like our clients, we as psychotherapy researchers approaches are compared, often resulting in findings that
become socialized to think and behave in ways that can fail to result in a differential effectiveness between
be limiting. In our own involvement in a 1994 American orientations.
Psychological Association (APA) sponsored conference Moreover, our outcome research is characterized by
at Vanderbilt University on the development of a core a basic dilemma with respect to the type of patients that
assessment battery for outcome research, we encountered eventually participate in treatment efficacy studies. This
a similar phenomenon. Representing a cognitive-behav- quandary might be called the interpretability/generaliz-
ioral orientation, we found ourselves trying to convince ability dilemma. In order to improve the interpretability
manual-driven intervention that has been used in our Standardized therapies that have been tested and found
clinical trials. We are very concerned that the available efficacious need to be applied in more everyday settings,
outcome research findings will be taken too literally (a) such as primary care settings, outpatient clinics, and
by therapists, who learn only the pure-form interventions community mental health centers. At this writing, the
used in clinical trials; (b) by clients, who expect that their N I M H has been attempting to support increasing re-
progress will parallel those carefully selected participants search out of its Services Research Branch to test the
in the research and be s y m p t o m free by a certain number clinical effectiveness of efficacious, standardized psycho-
of sessions; and (c) by managed health care policymakers, social treatments. Such research can give us clearer in-
who will limit clinical practice so that it conforms to the dications of the effects of treatments once they are applied
methodological constraints associated with psychotherapy in more real-world settings than those in which their ef-
outcome research. ficacy in controlled settings is tested.
There is yet another dilemma involved in this use
If we are to continue conducting clinical trials of
of clinical trial efficacy data, and that is the impossibly
standardized treatments, we must also focus on more than
large volume of research that will be required to establish
just the symptoms of a particular Axis I disorder. The
an EVT for a particular disorder. In 1980, Parloff and
high relapse rates and mediocre recovery rates that are
Wolfe (as cited in Herink, 1980) had calculated that the
associated with tested therapies in which efficacy has been
250 identified brand-names of therapy could be reduced
established for specific disorders indicate that symptom-
to 17 generic forms, and the number of groupings of pa-
tients from the 150 disorders listed in the D S M - I I I c o u l d focused treatments are necessary but not sufficient (Wolfe,
be collapsed to about 50. Parloff (1982) later reported, 1994). Clinical trials should now routinely study life
"Even this gross oversimplification would require 6,800 events, personality characteristics, as well as other theo-
clinical trial studies" (p. 724). retically derived variables that are presumed to be in-
In the current research scene, "Parloff's parody" volved in the generation or maintenance of symptoms of
still applies. Currently, the D S M - I V (American Psychi- the disorders under study. A related issue is the need to
atric Association, 1994) includes over 300 separate dis- study patients who are "comorbid" for more than one
orders. Even if we were to collapse them into 100 different D S M disorder, particularly those who would meet criteria
patient groups and reduce the therapeutic approaches to for an Axis II as well as an Axis I disorder.
10, we are talking about 1,000 clinical trials just to have In commenting on our current outcome research
1 study of each treatment for each separate patient group. paradigm, other psychotherapy researchers (e.g., Borko-
And if we adopt the APA Division of Clinical Psychology's vec, 1994; Davison, 1994; Davison & Lazarus, 1994) have
task force's recommendation of requiring at least 2 studies noted that the typical practice of comparing one type of
to verify the efficacy of a potential EVT, then we are up therapy with another is severely limited in that it provides
to 2,000 studies. Our question is, who will fund this no conceptual understanding about the clinical problem
quantity of research? As m a n y of us have so painfully or how the treatment might work. Answers to these ques-
learned in recent years, it will not be the N I M H . Unless tions can be built into the research design, argued Bor-
the field of psychotherapy research acquires a patron with kovec, if we were to include conditions that were com-
extremely "deep pockets," the task of establishing EVTs posed of different aspects of a treatment package, either
for the full range of D S M disorders is clearly not feasible. individually or in varying combinations. This is the re-
search strategy used in the second generation of outcome
W h e r e Do W e Go From Here? research on behavior therapy techniques, as when treat-
There is no question that the field of psychotherapy is ment conditions involving relaxation and imaginal ex-
approaching a crisis. Whether this crisis can also be turned posure to fearful situations were compared with system-
ticular case at hand. The implication of such research is of a cognitive-behavioral intervention that focuses on
that what needs to be specified and replicated is not brand- the particular variables that appear to be associated
name therapies but identifiable processes of patient with the patient's depression, such as irrational beliefs,
change and the therapist behaviors that bring these about. deficiencies in interpersonal behavior, or infrequent
Such research would be focused on at least two different gratifying activities. Similar encouraging but similarly
types of change processes: (a) intrapersonal and inter- preliminary findings were obtained by Jacobson and
personal indications of patient change and (b) therapist colleagues (Jacobson et al., 1989), who found a trend
actions that reliably bring about such patient change. For for cognitive-behavioral marital therapy to be m o r e
example, what therapist behaviors and patient indicators effective when it was individually designed to the needs
of change are present when intrusive traumatic memories of the particular couple than when it was based on a
have been emotionally processed (allowing the patient to predetermined intervention.
rebuild his or her sense of trust in people)? Another a p p r o a c h to individualizing our inter-
The need to develop a research paradigm that also ventions is to bring back research on the intensive study
individualizes the intervention on the basis of an initial of the single case. In c o m m e n t i n g on the need for a
assessment and case formulation is essential for closing m o r e idiographic research methodology for studying
the clinical-research gap, a point that has been discussed applied problems, Skinner was once said to have ob-
by Fishman (1981) and Persons (199 I), both practicing served that no one goes to the circus to see the average
clinicians. Referring to the second generation of outcome dog j u m p through the average hoop. Single-subject
research, Fishman (1981) commented on the gap between methodology in the study of psychotherapy outcome
research and practice by noting that "in their quest for has been c h a m p i o n e d in the past (e.g., Barlow, 1981;
'topographical equivalence,' researchers tend to lump to- Kazdin, 1981) but has fallen by the wayside with the
gether all subjects with the same manifest problem, re- ascendence of clinical trials. In a m o r e recent consid-
gardless of the etiological, mediational, contextual, and eration of single-case research in psychotherapy, Jones
maintenance facts that underlie and act to perpetuate the (1993) noted, " T h e p r i m a r y m e a n s of clinical inquiry,
maladaptive pattern" (p. 244). This issue was expanded teaching, and learning in psychotherapy has been and
on a decade later by Persons (1991) with the third gen- still remains the case-study method, grounded in the
eration of outcome research. Without an individualized tradition of naturalistic observation" (p. 371). The
assessment and case formulation as a key element in our promise of single-case research is that it may elucidate
outcome research, argued Persons, there is no way that with precision the link between what transpires in ther-
these research findings can intelligently inform practicing apy and patient change.
therapists; clinicians do not randomly assign patients to One of the main objections to single-case research
therapeutic interventions. Although we very much agree has been the difficulties that it presents for generalizing
with Person's thesis, we would go beyond her suggestion its findings to other patients. What has been either over-
that case formulation-intervention matching be done looked or just rejected is the idea that such studies rep-
within a particular theoretical orientation. Given the fact resent a different method of aggregating information
that practicing therapists do not typically adhere to a given across cases. Single-case data, as Hilliard (1993) proposed,
orientation (Norcross & Goldfried, 1992), the most clin- are basically intrasubject designs that explore the tem-
ically valid research paradigm is one that would not nec- poral unfolding of variables in individual participants.
essarily involve pure-form therapies (Wolfe & Goldfried, Generalization of findings is achieved by replication on
1988). a case-by-case basis. Too often in the past, single-case
To make our research findings more relevant to the research has not been conducted with clearly formulated
clinical setting, our paradigm needs to take into account questions in mind. However, Hilliard m a i n t a i n e d - - a n d
relying on overlearned, favored, but invalid approaches is not situation that cannot be easily specified in therapy man-
justified. (p. 546) uals. Still, it is possible that the interventions that are
studied in our outcome research, and even the nature of
For practicing therapists to keep abreast of clinically the designs themselves, can be better clinically informed
relevant research findings, they must be presented in a than they are at present. In her presidential address before
form they can readily use. As we suggested earlier, re- the 1994 Association for the Advancement of Behavior
search reports and reviews of research findings are written Therapy, Sobell (in press) addressed this issue of the gap
mainly for other researchers, not clinicians. In doing so, between research and practice. Her premise was one that
these reports have understandably emphasized research we touched on earlier in this article, namely that it is
design and the methodological constraints associated with important for the producers of research findings to meet
various studies, pointed to important research issues, and the needs of the clinical consumers. The impetus for her
focused on possible future research directions. Although concern came from the Ministry of Health in Ontario,
this information is essential to researchers, it says rela- Canada, which was interested in having various agencies
tively little to the practicing clinician. show better accountability for meeting community needs,
As a way of addressing this shortcoming, a new jour- including outpatient treatment.
nal for the practicing clinician has a p p e a r e d - - I n Session: Influenced by the relevance of a needs assessment
Psychotherapy in Practice. Each issue deals with a the- as carried out in the corporate world as well as its practice
matic t o p i c - - f o r example, the therapeutic alliance, panic of having customers participate in the development of the
disorder, and resistance--and contains a review of the product, Sobell (in press) approached the clinicians in
relevant research in a format that is useful to the prac- her community who dealt with addictive behaviors, the
ticing therapist. Thus, instead of presenting study-by- area of research in which she had been involved. Toward
study accounts of research, which emphasize their meth- the goal of making her research findings more applicable
odological strengths and limitations, reviews of both basic to the practicing clinician, she involved them in the actual
and applied research offer jargon-free summaries of what design of the intervention protocol, which ended up as
we currently know about the clinical problem and its having individualized flexibility, depending on the pro-
treatment.
gress made by clients during treatment. In meeting the
For example, the purpose of the third issue of In realistic clinical needs in the community, Sobell hoped
Session was to highlight, against a backdrop of current
that the findings would ultimately be of use to practicing
research findings, the conceptualizations and intervention therapists.
strategies used by the practicing clinician in treating in-
Although the success of this innovative approach to
dividuals suffering from panic disorder with agoraphobia
outcome research is still being evaluated, preliminary as-
(Wolfe, 1995). A second purpose was to explicate what
sessments have found that therapists and clients alike re-
clinicians deem necessary for the treatment of this dis-
sponded quite favorably to the project. Despite the ad-
order in addition to the symptom-focused treatments that
ditional efforts needed to develop a working alliance be-
have been empirically tested. Thus, the issue included
tween researchers and clinician, Sobell (in press) was very
two research reviews, one of the basic research literature
much convinced it was more than worthwhile. As she
and the other of the treatment research literature. In ad-
indicated,
dition, four different approaches to treatment were pre-
sented by clinicians who all began with the mainstream, My only regret is that I did not get here sooner. By adopting a
empirically tested, cognitive-behavioral treatment for the new approach to the dissemination of my research, similar to
management of panic symptoms and agoraphobic avoid- that used in the business community, I have reached more agen-
ance. Once s y m p t o m reduction had been accomplished, cies, more practitioners, and ultimately, more clients than in
it is practiced in actual clinical settings. We would also maintain that psychotherapy outcome
research is ready to move onto a fourth generation, one
Conclusion that allows us to generalize our findings more faithfully
to what is needed clinically. Until that happens, however,
Ever since the Boulder Conference on clinical training we need to deal with the question of whether our existing
urged the implementation of the scientist-practitioner psychotherapy outcome findings should be used to de-
model (Raimy, 1950), the field has struggled to foster the termine clinical practice. Our answer to this question is
synergy between therapy research and practice. Given the a qualified "yes, but." Yes, sometimes the emperor does
external pressures facing the field to provide an empirical indeed have new clothes, and it is important for us to
accounting for what we do clinically, the long-standing acknowledge it. Other times, however, he is naked, and
gap between practice and research is in need of serious that should also be acknowledged. Researchers, working
reexamination. with practicing clinicians, need to collaborate in making
Despite the fact that outcome research has advanced this distinction.
in its methodological rigor over the past few decades, the
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