Using Research in Counselling and Psychotherapy

John McLeod

• Publisher: SAGE Publications Ltd
• Year: 2016
• ISBN:
  9781473987623
• Edition: 1
• Topic: Psicología
• Subtopic: Psicoterapia

In this book bestselling author John McLeod examines the multiple ways in which research can be used to inform and enhance counselling practice. The author discusses how research impacts on policy and practice, covering research knowledge, values, research awareness and skills. Further chapters cover:

• Using research to understand the therapy process and outcomes
• Using research to make sense of other lives
• Using client feedback to enhance practice
• Using research to build professional networks and effective organisations.

The book can be used throughout training on counselling, psychotherapy and counselling psychology courses, to support the development of professional competencies and personal development. It will also be valuable reading for bothpractitioners and researchers.

1 Practitioner Attitudes to Research

• Introduction 1
• Mapping practitioner attitudes to research 2
• Questionnaire measures 3
• Interview-based studies 7
• Performance-based measures 9
• Conclusions 9

Introduction

The background to everything that follows in this book is the concept of Evidence Based Practice (EBP), an idea and policy strategy that emerged within medicine and health care in the 1960s. Historically, medical treatments had been based on a mixture of careful observation and theorising that was handed down from one generation of doctors to the next, with minimal empirical evaluation of effectiveness. In fact, as Wootton (2006) has demonstrated, until the middle of the twentieth century, it could be argued that medicine, overall, did more harm than good. By that time, rigorous scientific experimentation, the collection of health statistics, and the availability of potent interventions such as penicillin, meant that health care could begin to draw on a body of reliable scientific evidence. In the closing decades of the century, spiralling health costs associated with the development of new treatments, heightened public expectations, and an ageing population meant that it was essential for government and private health providers to find some way of making rational choices about which treatments were most cost-effective for which condition. Evidence Based Practice offered a positive solution to this set of dilemmas – whenever possible, treatment would be informed by research evidence.

It is hard to argue with the basic concept of EBP. However, implementing an evidence-based approach in front-line health care is another matter. A classic, widely cited, definition of EBP is:

the conscientious, explicit and judicious use of current best evidence in decision-making about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external evidence from systematic research…. [C]linical expertise [involves] the thoughtful identification and compassionate use of individual patients’ predicaments, rights and preferences. (Sackett et al., 1996: 71)

This definition raises many questions, all of which are familiar to any practitioner. How do we know what ‘current best evidence’ consists of? ‘Clinical expertise’ comprises a complex and subtle blend of personal and professional experience – how can this be ‘integrated’ with research evidence? How do we understand the difference between ‘judicious’ and non-judicious use of evidence? What happens if the patient’s preferences contradict the treatment recommended by the research evidence?

Gradually, the influence of Evidence Based Practice spread from health care to social care, to education, and to criminal justice. By the 1980s, there was sufficient research evidence available in the field of psychotherapy for EBP to be implemented in a meaningful way within that discipline. What this book is about is the struggle that has taken place since that time, within the field of counselling and psychotherapy, around the question of how best to make ‘judicious’ use of research findings in order to provide better therapy for clients.

Compared to medicine, counselling and psychotherapy has always been a tough area for proponents of Evidence Based Practice. In medicine, there are many key variables that can be objectively measured – temperature, heart rate, blood pressure, and mortality. By contrast, in psychotherapy there is a lack of such measures. Psychotherapy depends to a large extent on the quality of the therapeutic relationship. It is a complex intervention that usually unfolds over a considerable period of time. It is not possible to give the patient a pill and see what happens over the next hour. It is not possible to devise meaningful placebo treatments that can be delivered in double blind trials. As a result of these and other factors, there has been a great deal of resistance to EBP within the psychotherapy profession.

Mapping practitioner attitudes to research

To appreciate the underlying issues that have shaped the current relationship between research and practice in counselling and psychotherapy, it is necessary to understand how therapists view research, how they feel about it, and how they engage with it. The following sections of this chapter offer a map of that territory. We will look at the methodologies that have been used to collect data on therapist attitudes, and at the conclusions that have emerged from studies that have applied these methods with different samples of therapists.

Three contrasting research approaches have been used within this area of inquiry: questionnaires, interviews, and performance measures (e.g., counting numbers of publications produced by practitioners). It is an area in which a substantial amount of research has been carried out. In addition, there exist relevant findings from studies of cognate professional groups, such as nurses or social workers. Unfortunately, as far as I know, no one has conducted a systematic review of research studies of counsellor and psychotherapist attitudes to research. This is a pity, because such a project would be valuable in both consolidating knowledge within this topic area and providing an agenda for future research. For reasons of space the discussion that follows, within this section of the present book, cannot claim to represent a comprehensive systematic review of all relevant studies. The intention, instead, has been to indicate key themes, highlight some of the main conclusions that can be drawn, and point readers in the direction of further sources.

Questionnaire measures

In relation to the use of questionnaires, these research tools have been applied to one set of questions that are fairly tightly focused, and another set of questions that are of broader significance. Tightly focused questionnaires have considered the issue of research competence, defined in terms of ‘self-efficacy’ – how competent the individual believes that he or she is in their ability to undertake various research tasks. Questionnaires of this type ask respondents to rate their level of confidence (e.g., on a 0–100 scale) in relation to statements that reflect key research tasks. Examples of typical items are: ‘Follow ethical principles of research’, ‘Generate researchable questions’, and ‘Knowing which statistics to use’. At the present time, there are three questionnaires that have been developed to assess researcher self-efficacy. These measures are described and evaluated in a useful paper by Forester, Kahn, and Hesson-McInnis (2004). Examples of studies that have employed such measures, for instance, to explore the outcomes of research training, can be found in Gelso et al. (2013). It is important to acknowledge that researcher self-efficacy represents just one aspect of practitioner attitudes to research. However, it is a vital aspect of such attitudes, because if a counsellor or psychotherapist defines himself or herself as incompetent or not research-literate, they are not likely to want to use research to inform their practice. Unfortunately, at the present time such scales have only been used in studies that have investigated the outcomes of primary research training. It would be interesting to know about the general research self-efficacy/confidence of practitioners at later stages in their careers.

Linked to the topic of researcher self-efficacy is the actual research knowledge that therapists have available to them, to use to inform their practice. This issue has been explored by Boisvert and Faust (2006) and Stumpf, Higa-McMillan, and Chorpita (2009) through questionnaires that tested the knowledge base of clinicians, and in an open-ended, online survey questionnaire by Ogilvie, Abreu, and Safran (2005). There is not sufficient research around this area to arrive at any firm conclusions. What seems to be apparent in the findings of these studies, though, is that therapist knowledge of research is patchy – they exhibit in-depth knowledge and curiosity in respect of areas of research that are of particular relevance to them, while having a very limited understanding of other research domains. In the Boisvert and Faust (2006) study, some therapists appeared to have a highly developed awareness of research findings, while others had a limited knowledge base. However, these differences did not seem to be related to years since training, occupational setting, or any of the other demographic factors that were assessed in the study. It is perhaps worth noting that the findings reported by Boisvert and Faust (2006) need to be interpreted in the context of an earlier study that they carried out, in which the same knowledge test was administered to leading researchers, who only agreed on the correct answer 50% of the time (Boisvert & Faust, 2003). The relevance and impact of the actual level of research knowledge available to therapists was also explored in a study by Safran, Abreu, Ogilvie, and DeMaria (2011), who carried out a survey of attitudes to research, and the relevance of research for practice, of therapists who were members of the Society for Psychotherapy Research (SPR). This was a sample of therapists who undoubtedly possessed a high level of interest and knowledge around research findings. Nevertheless, these individuals did not differ from non-researcher colleagues in reporting that research findings had a very limited impact as a source of influence on their practice.

Other questionnaire measures have been developed to look at therapist attitudes to research more widely. Several of these questionnaires have consisted of attitude questions developed for one-off use in a particular study (e.g., Dutch & Ratanasiripong, 2016; Gyani, Shafran, Myles, & Rose, 2014; Morrow-Bradley & Elliott, 1986; Ogrodniczuk, Piper, Joyce, Lau, & Sochting, 2010; Safran, Abreu, Ogilvie, & DeMaria, 2011). Some of the more recent therapist survey questionnaires have borrowed items from the Morrow-Bradley and Elliott (1986) questionnaire. Such scales produce valuable data, but their use in only a single study makes it hard both to know whether they are in fact measuring what they claim to measure (validity) and to accumulate knowledge by comparing findings from different studies. As a result, there has been a tendency in more recent studies to use standardised attitude-to-research scales that are supported by evidence of reliability and validity. These measures make a particularly important contribution to our understanding of the relationship between research and practice, because the process of developing such scales involves making a systematic effort to map all possible aspects of the phenomenon.

One key finding that has emerged, in all of the therapist attitude-to-research studies listed in the previous paragraph, is that experienced therapists report that research evidence, and information and insight gleaned from research papers, have a relatively low level of influence on their practice, compared to other sources of learning such as experience with clients, supervision, speaking to colleagues, or reading books. Another important theme is that practitioners express dissatisfaction with the kind of research that has been carried out, in terms of clinical relevance and clarity of reporting of results.

Moving on now to consider the use of standardised measures of attitudes to research, a great deal can be learned by noting the achievements and challenges associated with the Barriers to Research Utilization scale, which has been widely used in the field of nursing (Kajermo et al., 2010). The BARRIERS scale consists of 29 items on different aspects of research utilisation. Statements are rated on a four-point scale (1 = to no extent, 2 = to a little extent, 3 = to a moderate extent, 4 = to a great extent); respondents can also choose a ‘no opinion’ alternative. It measures four dimensions of research attitude:

• research values, skills, and awareness (typical items: ‘Unaware of the research’, ‘Does not feel capable of evaluating the quality of the research’);
• barriers and limitations associated with the work setting (typical items: ‘There is insufficient time on the job to implement new ideas’, ‘Do not have time to read research’, ‘Not enough authority to change patient care procedures’);
• qualities of the research (typical items: ‘Uncertain whether to believe the results of the research’, ‘The conclusions drawn from the research are not justified’);
• presentation and accessibility of the research (typical items: ‘The statistical analyses are not understandable’, ‘Research reports/articles are not readily available’, ‘Implications for practice are not made clear’).

The relevance of the BARRIERS scale, for counsellors and psychotherapists, is that the attitude dimensions that it describes are basically the same as those emerging from studies of therapists. It is therefore clear that the difficulties experienced by counsellors and psychotherapists in terms of using research knowledge are not unique to that profession, but in fact reflect more general characteristics of professional practice in contemporary society (similar studies and scales can be found in research on other professions, such as medicine, social work, and teaching). What the BARRIERS scale tells us is that some of the problem lies in the confidence and competence of the practitioners; other difficulties arise from the characteristics of the workplace; and yet further issues are linked to the ways in which research itself is carried out and reported. In other words, the research–practice challenge is multi-faceted, with the implications that different solutions are required in respect of different factors. The final point that can be made about the BARRIERS scale is that, like other scales in this area, it is predominantly negatively framed, consisting of questions about problems and difficulties rather than opportunities and possibilities. Obviously, it is vital to be able to identify barriers and difficulties. But, at the same time, there may be a tendency for such scales to reify problems, rather than open up solutions. This is exactly the conclusion reached by Kajermo et al. (2010) in their review of the use of the BARRIERS scale over a 20-year period: ‘it has not been used to … inform the development of strategies and interventions to promote research use’ (p. 20).

Within the field of counselling and psychotherapy, there are several standardised measures that have been devised to assess practitioner attitudes to research. Some of these scales evaluate therapists’ positions in relation to specific activities or aspects of research-informed practice, such outcome monitoring and use of Evidence Based Practice protocols and treatment manuals. The Outcome Measurement Questionnaire (OMQ) and the Clinician Readiness for Measuring Outcomes Scale (CReMOS) have been used to assess therapist attitudes to using routine feedback and outcome monitoring as part of their practice (Smits, Claes, Stinckens, & Smits, 2015). The Clinician Readiness for Measuring Outcomes Scale (CReMOS; Bowman, Lannin, Cook, & McCluskey, 2009) is a 30-item scale that draws on the widely known transtheoretical Stages of Change model to examine the point that the person has reached in relation to incorporating an outcome measure into their practice (Levesque, Prochaska, Prochaska, Dewart, Hamby, & Weeks, 2001; Parker & Parikh, 2001; Prochaska & DiClemente, 1983; Prochaska, Prochaska, & Levesque, 2001). Items in this scale include:

• ‘I know my interventions work; I don’t need to measure them’ (pre-contemplation: no perceived need to change).
• ‘Measuring outcomes would be good if it didn’t mean spending time doing extra paperwork’ (contemplation: aware of problem but no commitment to take action).
• ‘I have had someone teach me how to search electronic databases to locate relevant outcome measures for my clients’ (preparation: preparing for action/initial behaviour change).
• ‘I have trialled some outcome measures with my clients’ (action stage).
• ‘I have been measuring outcomes with my clients for at least 6 months’ (maintenance).

The Evidence-Based Practice Attitude Scale (EBPAS; Aarons, 2004; Aarons, Cafri, Lugo, & Sawitzsky, 2012; Ashcraft et al., 2011) provides information on eight dimensions of therapist attitudes to...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Acknowledgements
• Contents
• About the Author
• Preface
• Acknowledgements
• 1 Practitioner Attitudes to Research
• 2 Building Connections between Research and Practice The Story So Far
• 3 Multiple Points of Contact between Research and Practice An Alternative Model
• 4 Using Different Types of Knowledge in Therapeutic Practice
• 5 The Politics of Research Reading between the Lines
• 6 Using Research to Do Better Therapy
• 7 Using Research to Understand the Client’s Perspective on Therapy
• 8 Using Research to Inform Personal and Professional Development
• References
• Index