Research for the Psychotherapist

From Science to Practice

Jay L. Lebow, Paul H. Jenkins

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351689267
• Edition: 2
• Topic: Psychologie
• Subtopic: Psychothérapie

While empirical, scientific research has much to offer to the practice-oriented therapist in training, it is often difficult to effectively engage the trainee, beginning practitioner, or graduate student in the subject of research. This fully revised and expanded edition of Research for the Psychotherapist is an engaging, accessible guide that bridges the gap between gathering, analyzing, presenting, and discussing research and incorporating that research into practice. The authors present concise chapters that distill research findings and clearly apply them to practical issues, while also helping readers progress as consumers of relevant research.

Part I

Foundations of Psychotherapy and Psychotherapy Research

1 Introduction

Conducting psychotherapy is a complex and in many ways a difficult task, which is based on a number of interlacing beliefs and requires a number of different skills. For clinicians who are new to the challenge, as well as those who have been doing it for a while, many basic questions arise. How do I figure out what is wrong (or right) with my client? What should I be trying to do, as a therapist, to help? How should it be different, or the same, from client to client? What do I need to know, and what should I be able to do, to be a good therapist? How do I know if it is working? Making these questions even more difficult to answer is the fact that our field has spawned a number of very different kinds of psychotherapy, which provide different answers to these questions. For instance, a humanistic therapist may say that we know if the therapy is working if our clients feel more authentic and integrated, whether or not anything has changed in their behavior. The behavioral therapist would naturally have a quite different answer. He or she would say the therapy is working if their clients are behaving in ways that are more adaptive and successful in a clear, measurable way. The two therapists in question could easily fall into an argument when discussing the same client, describing the client and their progress (or lack thereof) in very different ways, reflecting profound differences in how they view human nature, psychopathology, and appropriate psychotherapy goals and techniques.

Practitioners working in the medical field don’t have this problem. While they may disagree on the treatment, all practitioners would at least agree on the goal of getting rid of the cancer, of reducing it in a measurable way. In the world of psychotherapy, the core question of how to do our job is complicated by the question of what job we are trying to do, which is, in turn, complicated by the question of what goal one is trying to reach, which is further complicated by the question of how one is even conceptualizing something we call mental health or mental illness in the first place.

Hopefully, this ‘drilling down’ on the question of ‘how to do our job’ is meaningful. Many do not want to be bothered to do this. We just want a ‘how-to’ book, a cookbook, if you will, to tell us what to do. This is the struggle of many students and interns, who, understandably, react to the stress of developing new skills and want concrete direction, not philosophical ambiguities. Yet there is great value for most in exploring the complexities of practice and even in challenging our own and our field’s assumptions. If we do this, we are forced to ask questions such as “What is mental illness and how do I differentiate it from mental health?” or “Am I trying to get my clients to think, feel, and act the way I personally think they should rather than some objective standard?”

This book offers an introduction to how the field of psychotherapy approaches these areas of knowledge and what sorts of answers are being developed. In doing so, we will look at some basic areas in the field of psychotherapy, including assessment, different models of psychotherapy, and measuring outcomes. We will look at these areas in the context of trying to figure out what is true about them. It is in this search for truth that we explore the idea and actual results of something called ‘research.’

There is a reason we put that word, ‘research,’ in quotes. A dictionary (Google Search) might define research as “the systematic investigation into and study of materials and sources in order to establish facts and reach new conclusions.” In doing so, it begs a number of questions, including what is meant by the words ‘systematic,’ ‘investigation,’ ‘facts,’ and ‘conclusions.’ In reality, people use the word ‘research’ in many different ways. Some people will say they ‘researched’ something by putting a question in their computer’s Google bar and reading the first few ‘hits’ that came up. Some people will say they researched something by asking readers of a magazine (or viewers of a webpage) to respond to a survey. Others will say they researched something by spending years or even decades gathering data within a carefully designed study, with many internal controls built in to increase the overall reliability and validity of the results. Because of this range of application and thus understanding of the word ‘research,’ it is important to explore what it means and how we intend to use it in this book.

The first word to explore is ‘systematic.’ By this, what is meant is using a fixed plan or system to find something out. This implies that conscious thought and effort go into the process. A clear, logical, consistent, and orderly plan of action is developed. Possible problems or weaknesses in the plan are considered, and the plan is adjusted to deal with them. The word ‘investigation’ implies that something is being examined. There is a specific question to answer or a specific phenomenon to be understood in a particular way. Combined with the word ‘systematic,’ this means that a great deal of thought must be put into how one frames a particular question, often developing a hypothesis to test. The hypothesis refers to a proposed explanation or answer to a question, which will be the target of the investigation. That leads to the gathering of ‘facts.’ This sounds easy but is typically the most difficult part of the process. Just how will I gather the relevant facts (data) to answer my question (hypothesis) in order to reach a valid and reliable conclusion, which is, of course, the final result of the research?

For those familiar with the world of research, that explanation was very familiar (and necessarily rudimentary), but for those new to it, it is important to establish a basic understanding of what we are exploring in this book. It is also important to point out that the practice of research is based on the conceptual foundation of empiricism. Scientific research is empiricism in action. Much more will be said about this later in this book, but to get started, let us establish that empiricism is a theory that all knowledge derives from sense-experience. What this means is that rather than starting with preconceptions about ourselves, others, and the world around us, empiricism says we should gather raw information and let it guide us to what is true. This is particularly important in the world of psychotherapy and counseling. When it comes to physics and chemistry, we don’t carry around many preconceptions, and the ones we may have probably don’t have much emotional weight for us. I just don’t know or care very much about the third law of thermodynamics (the entropy of a system at absolute zero is a well-defined constant, by the way, in case you were curious, which you probably were not). On the other hand, we all carry around many preconceptions about human psychology, and many of them with a great deal of emotional weight. For instance, do you believe that people are basically good unless they get screwed up, or do you believe that people are basically immature and selfish (bad) unless they receive proper upbringing and cultural/religious support? Whichever ‘truth’ you ascribe to, you probably hold to it strongly and are typically unaware that you think, feel, and act on it every day, including in your professional life. As a therapist, should you (a) help relieve people of the effects of different forms of abuse/neglect in order to free the naturally good/happy person within or (b) help people develop better habits of thinking/feeling/behaving to improve on their inherent weaknesses? These core choices are typically based on preexisting beliefs (schema) that we learned early in life and rarely think about consciously. It is the deeply ingrained, mostly unconscious, and emotionally reinforced nature of beliefs about human functioning that make it difficult but extremely necessary to base our ‘truths’ in this field on a foundation of empiricism.

Empiricism invites us to doubt everything and let the facts guide us where they will. In its purest form, this is called inductive reasoning. We start with a series of observations or gathering of data, discern a pattern, make a generalization, and then propose an explanation or theory. The problem, of course, is that we do not typically gather facts randomly and wait for a pattern to emerge. We are not really tabula rasa. Instead, we typically start with a hypothesis. We have a starting idea or guess about what is going on. Then we figure out the best way to gather data that will prove or depose the hypothesis. That is called deductive reasoning and is the standard way that we use empiricism in the practice of science. Whether we approach truth through induction or deduction, it is the gathering of data and letting those data guide us that separates scientific research based on empiricism from other ways of establishing truth.

In the first part of this book section, we explore the foundations of the empirical research in the field of psychotherapy. Chapter 2 discusses how empirical research is related to the theory and practice of psychotherapy and how to be a good consumer of such research. We utilize research in a number of different ways in this field, including the development of theoretical models of the psyche and the psychotherapeutic approaches that are related to them. Just as important as knowing what is being researched is understanding how the research is being conducted and what level of quality is being attained in any given study, journal article, or book. Chapter 3 explores how to evaluate the quality of a given piece of research. Through a commonsense approach, we look at the basic qualities of good research, including the consideration of who is conducting it, where it was published, how it was designed, what kind of data emerged, how that data was analyzed, how it was interpreted, how the results and conclusions of a study derive from the data, if they can be trusted, and what they mean to our clients and the field in general.

In Chapter 4, we dig deeper into this issue of what is true. The conceptual foundation of any field of study is the most important part. It lays out the core standards and beliefs for everything that follows. Without a thorough grounding in how we establish truth in psychology, it is likely that everything that follows will be based on assumptions, preconceptions, mythology, culturally based beliefs, and so forth. That may be fine until we run into someone who doesn’t happen to share those beliefs. One of Paul’s favorite stories, which he shares with students, is from his first year as a psychotherapy intern. He was sitting in group supervision, listening to another student counselor talk about a client. The counselor was worried about her 16-year-old client’s problem with promiscuity. After a few minutes of discussion about this problem, someone in the group finally asked, “Well, how many guys has she been with?” The answer was, “two.” The rest of the group shared surprised glances. Really, two? It was clear that the client’s counselor had pretty strong ideas about sexual morality that the rest of the group did not share, and those ideas were strongly impacting her view of her client’s mental health. After Paul’s initial shock, however, he was forced to ask himself, “Well, what number would make me concerned about a client’s promiscuity—five, ten, twenty?” He began to realize, (1) any number reflects a social/cultural judgment, not an objective one, (2) everybody has one, and (3) we typically don’t question it or even think about it—we just assume we are right and anyone with a different answer is wrong. The challenge, of course, is differentiating (if possible at all) subjective, personally based opinion from objective truth. Before we can begin utilizing actual research and drawing conclusions based on our findings, we have to try and figure out the source of real, objective truth or at least be able to recognize when it is possible and when it is not.

The second section of the book explores the issue of evidence-based practice. This kind of research is, naturally, more controlled and experimental than the theory-building kind. In fact, it is probably the kind of research most closely associated with the field of psychotherapy. Because it fits better in the classic idea of a research study, with control groups, outcome forms, practice manuals, and statistical analysis of data, it lends itself to the extremes of both powerful adherence to and trust in its findings, as well as controversy and rebellion against trusting its validity and appropriateness for everyday practice. The ongoing debate discussed in Section II is important for every professional to be familiar with and to understand. It is also important to be aware of at least some of the findings from this research, both in its general outline as well as in some particulars. One does not have to attain an encyclopedic knowledge of the subject to be considered a professional, but we all have an ethical duty to have both a solid working knowledge of such important issues in our professional field and also keep up as the state of knowledge changes. As the ‘state of the art’ develops, we are learning surprising new things about what works and what does not. Most of us are aware there is strong research support for teaching our clients how to meditate, relax, and change the way they think. You may know that there is a great deal of research supporting what we call Common Factors and a generally humanistic approach to therapy. But what do we know, more specifically, about what works best when working with couples? Do programs work that are designed to help families reduce the pathology of individual members? Do new, ‘alternative’ therapies like neurofeedback help clients with PTSD and other trauma-related problems? What seems to work best for clients with drug and alcohol problems? Obviously, a relatively short text like this cannot answer all questions about effective psychotherapy, but it can answer a few, and it can help to firmly establish the reader as a well-prepared consumer of such research.

Obviously, all therapists want to be effective in their work. They want to assist their clients in improving their lives. This can mean many different things for different people in different circumstances. For one, it could mean reducing or stopping a destructive pattern of substance use. For another, it could mean finding a deeper, more meaningful, and rewarding path in life. For a family, it could mean reducing a pattern of angry fighting and alienation and increasing their sense of mutual support and love. Whatever our goals as therapists, we all want to feel that we are doing something useful and effective, and most of us would like to know more about how to do it better. And while this sounds simple and obvious, the challenge is that figuring out how to ‘do it better’ is not easy or simple at all. There are difficulties in how we conceptualize, design, and conduct our research, how we translate the results of research into the ‘real life’ of everyday therapy, and the politics of free choice in how a therapist chooses to conduct his or her practice. There is great hope that research is helping us do our work better but also profound fears that it is biased toward particular types of therapy that are easier to study, that it is narrowing the choices of professionals without adequate cause, that it is limiting the bounds of future research and practice—stifling creativity—and that it may be distorting the very foundation of what it means to be therapeutic, forcing us toward a model of psychotherapy that represents only part of what our field has been and can be.

The third section of the book is dedicated to a specific area of research in our field, assessing the effectiveness of couple and family psychotherapy. Here, we use couple and family therapy as an area of in depth analysis about what we know and need to know from research about couples, families, and couple and family therapy.

Section IV looks at the increasingly important area of self-assessment. For many decades, the practice of psychotherapy was shrouded in mystery. Paul loves to tell his students the story of a friend who was a psychologist in the American military in the 1960s. He worked in a military hospital, and the medical officers who were in charge of his section were typically so estranged from the world of psychology in general and psychotherapy in particular that they never asked him what he was doing. They just referred patients to him and hoped for the best! His friend said that he liked the independence but also felt a bit lonely within the wider professional community in which he operated. The world has changed since then. Psychotherapists no longer have a Svengali-like professional reputation. We work in far more integrated ways with other professionals (medical doctors, social workers, teachers, lawyers, etc.). We are a more accepted part of the overall cultural community, and although mental health stigma still exists, it is generally far less than it used to be. A far higher percentage of people receive treatment for psychological problems than earlier. As a result of all this, there is a higher demand that we be open and transparent about what we do and that we establish and report the efficacy of our work, like anyone else. In other words, we are expected to earn our paycheck through our proven performance.

This seems fundamentally fair, but it begs the ques...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• About the Authors
• Part I Foundations of Psychotherapy and Psychotherapy Research
• Part II Research Focused on Psychotherapy
• Part III Research Focused on or Relevant to Couple and Family Therapy
• Part IV Doing Research on Your Practice
• Part V Research in Psychology That Informs the Practice of Psychotherapy
• Index