Practice-Based Research

A Guide for Clinicians

R. Trent Codd, III

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315524597
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Practice-Based Research shows mental-health practitioners how to establish viable and productive research programs in routine clinical settings. Chapters written by experts in practice-based research use real-world examples to help clinicians work through some of the most common barriers to research output in these settings, including lack of access to institutional review boards, lack of organizational support, and limited access to financial resources. Specialized chapters also provide information on research methods and step-by-step suggestions tailored to a variety of practice settings. This is an essential volume for clinicians interested in establishing successful, long-lasting practice-based research programs.

PART I
Introduction to Practice-Based Research

CHAPTER 1
Introduction to Practice-Based Research

R. Trent Codd, III

Introduction

Robert Boyle, James Joule, and Albert Einstein were remarkable scientists. Boyle’s work had a substantial impact on several areas of science and he is often regarded as the first modern chemist. He is probably most famous for what is now known as “Boyle’s law,” which expresses the inverse relationship between the pressure and volume of a gas at a constant temperature (West, 1999). Joule, a physicist and mathematician, for whom the unit of energy we describe as a “joule” is named, made a series of important scientific discoveries including those that laid the foundation for the first law of thermodynamics. Einstein, a theoretical physicist, developed the theory of relativity. The respective productivity of these scientists is a readily apparent commonality among them. However, they have something else in common that is less well-known: all three produced much of their scientific findings while in non-academic jobs. Boyle worked in a lab that he established in his sister’s home, where he also resided, and where he produced roughly one book each year (Principe, n.d.). Joule conducted experimental work while working as a businessman running a brewery. Einstein produced his paradigm-shifting work in physics while he was employed in the Swiss Patent Office.

The important work that Boyle, Joule and Einstein accomplished outside of an academic setting is germane to research activity in mental health practice settings. Many barriers to practice-based research are discussed in this book, but one barrier, because it is psychological and therefore more camouflaged than the others, is important to bring into the open early on. This barrier involves the false idea that clinical research primarily or exclusively occurs, or should only occur, within the confines of academic settings. It is a formidable obstacle. This notion, however, does not comport with the history of science as Boyle, Joule, and Einstein (among others) demonstrate, and to endorse this idea is to place an unnecessary boundary around clinical mental health research. The constraining effects of this barrier are observable in several ways. First, after graduation clinical settings may be chosen for employment when the individual lacks interest in research activity. This choice is frequently derived from the belief that research activity does not occur in such settings, thus aligning their interests (or lack thereof) with their work setting. In contrast, a graduate with a keen interest in research would likely pursue an academic career based on the same belief about the locus of research activity. Thus, clinical settings select persons, on average, with minimal research interests. Also, because it is not seen as important, graduate training tends not to provide instruction in research methods most relevant to the practice setting, thus failing to develop an appropriate repertoire for conducting research in these settings among their graduates. Programs also fail to deliver instruction in navigating the unique barriers to research activity present in those settings, which further reduces the probability that those with adequate repertoires will be successful in establishing a program of research. Finally, inadequately prepared clinicians contribute to negative downstream effects at the organizational level. Clinical organizations typically do not have contingencies in place that support research activity and this is likely a result of would-be-clinician researchers who are ineffective at advocating for such organizational support and who, as they climb the organizational ladder, either do not appreciate the importance of research among their subordinates or do not know how to arrange effective supporting contingencies.

Advantages of Practice-Based Research

Practice-based research, in simple terms, refers to research conducted within natural practice settings (Nutting & Strange, 1998). Despite many calls for increased research activity of this kind among mental health professionals (e.g., DeFife et al., 2015), research productivity among the professions has remained staggeringly low, with the modal publication rate among clinical psychologists, for example, being a depressing zero (Davis et al., 2013; Eke, Holttum, & Hayward, 2012; Lundervold & Belwodd, 2000).

This is unfortunate because practice-based research offers several advantages to the field. First, it provides a mechanism for increasing the representation of diverse populations and less frequently occurring clinical presentations in empirical work. Designs that do not require large sample sizes are available (e.g., Single Case Experimental Designs), thus allowing clinicians, who make contact with these patients as part of routine practice, to ask and answer important empirical questions. Second, because efficacy and effectiveness can be evaluated simultaneously, rather than through the typical so-called efficacy-effectiveness pipeline, it frequently results in more rapid translation of research to clinical practice. Third, since it occurs in the practice setting it is more representative of the complexities found in clinical practice. This advantage escapes the often-encountered difficulties with translating research findings discovered in tightly controlled settings to the natural practice environment. A fourth advantage relates to long-standing difficulties with the dissemination of empirically supported treatments (ESTs). Substantial evidence suggests many patients with indications for an EST, many of which have been available for a long time, are not receiving them (e.g., see Lilienfeld et al., 2013; Shafran et al., 2009). The reasons for dissemination difficulties are multifactorial, but likely to be attenuated through an increased frequency of empirical investigation in “real world” contexts where the complexities of those environments must be considered from the beginning. Such investigations may reduce practitioner resistance to the adoption of treatment practices based on these empirical findings because they may be less likely to be seen as irrelevant to their patient and practice population.

Plan of the Book: Addressing one Key Barrier at a Time

The impoverished research rate among mental health practitioners is not surprising given the plethora of barriers to practice-based research activity. One barrier has already been mentioned: the notion that research activity is or should be confined to the academic setting. To dispel this notion, several chapters in this book highlight the ongoing vibrant research programs of their authors, collectively representing several different practice settings. A related psychological barrier is the inability to see what’s possible in the practice setting. Toward this end, Soo Jeong Youn, Louis G. Castonguay, and Henry Xiao present a chapter on practice research networks in their aptly titled chapter Practice research networks: Where science and practice meet, and Amy Wenzel in Practice Based Scholarship emphasizes several not-so-apparent ways a private practitioner can be involved with empirical research and contribute to the field.

Another barrier relates to a clinician/would-be researcher’s research repertoire, which is absent or inadequate to the practice setting. Indeed, several researchers have identified poor research methods training as a barrier to practice-based research activity (e.g., Baker, McFall, & Shoham, 2009; Davis et al., 2013; Lundervold & Belwodd, 2000). In addition, research methods emphasized in the graduate training of most mental health professionals center around group designs, especially randomized controlled trials, which are more challenging to execute in practice settings relative to other research methods (Codd, 2017). These barriers are directly addressed in the chapters Research Methods in Practice Settings by Scott Waltman, Single-case experimental designs by Trent Codd, and Practice-Based Research: A Pragmatic Approach by Guy Bruce. Additional considerations for research methods are addressed in various chapters regarding practice-setting.

Lack of access to an Institutional Review Board (IRB) is another barrier to practice-based research activity. IRB review and monitoring of research projects are important ethical components of research. IRB involvement is also required by many journals and conferences for publication and presentation respectively. Travis Osborne addresses this difficulty, along with possible solutions, in two chapters. In the first, Research in private practice settings, he discusses several barriers encountered in these settings including the problem of IRB access, and in the second, A step-by-step guide for creating an independent Institutional Review Board (IRB) for private practitioners, he offers a chapter whose only focus is a detailed description of a solution to this hurdle.

Unsurprisingly, financial considerations represent another set of obstacles. While this is addressed in many of the setting-specific chapters, Jenna LeJeune and Jason Luoma provide us with a fresh and innovative solution in Using Social Enterprise Concepts to Create a Sustainable Culture to Fund Research in a Fee-For-Service Setting.

There are many different practice settings, each with their own unique considerations and barriers. Three chapters located in the second and third parts of this book, each focus on a different practice setting. Jacqueline Persons complements Travis Osborne’s chapter with her focus on private practice considerations in Simultaneous Practice and Research: A Model for Conducting Research in Private Practice. This is followed by Jodi Polaha and Ivy Click’s Implementation Science at the End-Point: A New Approach for Researchers in Primary Care as well as in Research in Partial Hospital Settings by Marie Foregeard, Courtney Beard, Norik Kirakosian, and Throstur Bjorgvinsson. These chapters also address organizational factors, another common impediment to the initiation and maintenance of a practice-based research program.

Finally, Shannon Wiltsey Stirman in Future Directions for Practice-Based Research, pulls everything together and offers an elaborated discussion of two important areas: 1) academic partnerships for implementation research and 2) the use of technology in the facilitation of practice-based research endeavors.

Because space is limited and the barriers are numerous, the research methods and barriers to practice based research (PBR) addressed in this book are not comprehensive (e.g., clinician attitudes toward research are not addressed in the present volume). However, careful consideration resulted in the identification of the most fundamental factors impeding PBR and the authors in this volume address these items thoroughly. The sincere hope is that the strategies and solutions described in this volume result in the initiation or expansion of vibrant practice-based research programs.

References

Baker, T. B., McFall, R. M., & Shoham, V. (2009). Current status and future prospects of clinical psychology: Toward a scientifically principled approach to mental and behavioral health care. Psychological Science in the Public Interest, 9, 67–103.

Codd, III, R. T. (2017). Protecting the Scientific Lexical Canon. The Behavior Therapist, 40(5), 185–191.

Davis, S., Gervin, D., White, G., Williams, A., Taylor, A., & McGriff, E. (2013). Bridging the gap between research, evaluation, and evidence-based practice. Journal of Social Work Education, 49(1), 16–29.

DeFife, J., Drill, R., Beinashowitz, J., Ballantyne, L., Plant, D., Smith-Hansen, L., Teran, V., Werner-Larsen, L., Westerling, III, T., Yang, Y., Davila, M., & Nakash, O. (2015). Practice-based psychotherapy research in a public health setting: Obstacles and Opportunities. Journal of Psychotherapy Integration, 25(4), 299–312.

Eke, G., Holttum, S., & Hayward, M. (2012). Testing a model of research intention among U.K. clinical psychologists: A logistic regression analysis. Journal of Clinical Psychology, 68(3), 263–278.

Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Cautin, R. L., & Latzman, R. D. (2013). Why many clinical psychologists are resistant to evidence-based practice: Root causes and constructive remedies. Clinical Psychology Review, 33, 883–900.

Lundervold, D. A. & Belwood, M. F. (2000). The best kept secret in counseling: Single-case (N = 1) experimental designs. Journal of Counseling & Development, 78, 92–102.

Nutting, P. A., & Strange, K. C. (1998). Practice-based research. In R. B. Taylor (Ed.) Family Medicine: Principles and practice (5th ed.). New York: Springer.

Principe, L. M. (n.d.). Robert Boyle. In Encyclopaedia Britannica Online. Retrieved from www.britannica.com/biography/Robert-Boyle

Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., Freeston, M., Garety, P. A., Hollon, S. D., Ost, L. G., Salkovskis, P. M., Williams, J. M. G., & Wilson, G. T. (2009). Minding the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47, 902–909.

West, J. B. (1999). The original presentation of Boyle’s law. Journal of applied physiology, 87(4), 1543–1545.

CHAPTER 2
Practice Research Networks: Where Science and Practice Meet

Soo Jeong Youn, Louis G. Castonguay, Henry Xi

Being a private practitioner is a demanding task, requiring providers to juggle various responsibilities and roles just to accomplish the day-to-day responsibilities of providing clinical care to their patients. In addition, they are faced with the challenge of increasingly having to demonstrate adherence to evidence-based practice and accountability from insurance companies. However, the divide between research and clinical practice is well documented, and many psychotherapists do not resort to empirical findings to aid their clinical practice (Castonguay, Youn, Xiao, Muran, & Barber, 2015), as many clinicians view it difficult to apply the results to their individual clients (Boswell, Kraus, Miller, & Lambert, 2015; Castonguay, Locke, & Hayes, 2011).

Various reasons have been proposed to understand this difficulty in implementing research findings into routine clinical work. For example, the generalizability of findings from traditional randomized controlled trials (RCTs) has been perceived as being limited in clinical relevance (Castonguay, Barkham, Lutz & McAleavey, 2013). Additionally, others have argued that research does not focus on concerns that are applicable to routine clinical care and clients seen in these settings (e.g., Beutler, Williams, Wakefield, & Entwistle, 1995). Different evidence based practice efforts have tried to address this science-practice gap through validation and dissemination of specific treatments or emphasizing common mechanisms of change across modalities. For example, effectiveness studies have been conducted in order to assess whether treatments shown to be effective in RCTs can be implemented and adopted in routine clinical care (e.g., Tai et al., 2010). Others have focused on empirically based principles of change (Castonguay & Beutler, 2005) and common mechanisms across orientations, such as the therapeutic alliance (Norcross, 2011).

An alternative proposed to this top-down approach, or “empirical imperialism” (Castonguay, 2011), is practice-oriented research (POR). In POR, clinicians are active participants in all aspects of research, including the design, implementation and dissemination of research protocols and findings, which allows them not only to contribute to the advancement of scientific knowledge but to also be involved in setting up the agenda of future research (Zarin, Pincus, West, & McIntyre, 1997). This bottom-up approach encourages and fosters a sense of joint ownership, mutual collaborations, and respect between researchers and clinician...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Author Biographies
• Foreword
• Acknowledgments
• Part I: Introduction to Practice-Based Research
• Part II: Research Methods in Practice-Based Research
• Part III: Practice-Based Research in Private Practice
• Part IV: Practice-Based Research in Other Clinical Setting
• Part V: Conclusion and Future Directions
• Appendix: Research Consultant Directory
• Index