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Psychotherapy between
practice and research
Practice
Omar C. G. Gelo
omar.gelo@unisalento.it
1 2
Practice
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Beyond the limits Beyond the limits
Research Research
Practice Practice
Problem Problem
• Most of psychotherapy theories: supported and • Most of psychotherapy theories: supported and
validated by means of professional practice (practice- validated by means of professional practice (practice-
based knowledge). based knowledge).
- Pros:
• very close to practice • On the contrary, still few attempts to validate and
- Cons: support psychotherapy theories by means of empirical
• biased by personal judgment (e.g.: overestimation research (research-based knowledge)
of success and underestimation of failure) - Pros:
• offers a systematic 3rd person perspective
- Cons:
• can be far away from practice
7 8
Problem Problem (cont.)
• Most of psychotherapy theories: supported and • Reasons for the Science-Practice Gap:
validated by means of professional practice (practice-
- Methodological complexity of research:
based knowledge).
• research design, data collection, data analysis
- Misconceptions about research (from the side of
• On the contrary, still few attempts to validate and practitioners):
support psychotherapy theories by means of empirical • research has little clinical relevance (RCTs; quantitative
research (research-based knowledge) research in general; etc.)
- Misconceptions about practice (from the side of
• This situation is known as Science-Practice Gap, which researchers):
hinders the development and dissemination of • practice can be investigated by means of a few “elective”,
psychotherapy as a discipline reductionistic research approaches (RCTs; quantitative
research in general; etc.)
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11 12
1) Theory and
Summary
Psychotherapy
1) Theory and Psychotherapy • Theory:
- organized set of knowledge allowing us to make sense of our
2) Practice and Research experience
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3) A short review
Theoretical models
“Description and explanation”
4) Empirical strategies
5) Conclusions
Empirical research
6) Questions and discussion “Validation and development”
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2) Practice & Research 2) Practice & Research
Practice Practice Evidence-
“What actually happens“ “What actually happens“ Based Practice
kbklkjhljhlkjhlkjhlkjhlkjhkljhlkjhlkjhlkjhlkjhkhlkjh kbklkjhljhlkjhlkjhlkjhlkjhkljhlkjhlkjhlkjhlkjhkhlkjh
fddddf fddddf
Theoretical models
Practice-Research Gap Theoretical models
Practice-Research Gap
“Description and explanation” “Description and explanation”
fff fff
Practice-based
Empirical research Evidence Empirical research
“Validation and development” “Validation and development”
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Meta-analysis Meta-analysis
(quant.) (quant.)
Naturalistic studies (qual. & quant.) Naturalistic studies (qual. & quant.)
Clinical case studies, theoretical studies Clinical case studies, theoretical studies
19 20
Quantitative Qualitative Hierarchy of evidence
(Natural science) (Human science)
Objectivity (Inter-)Subjectivity Meta-analysis
me
Explanation Understanding (quant.)
tco
Contextualization
Ou
Generalization RCTs and N=1
Field studies experiments (quant.)
Experimentation
tco ss-
Control Sharing
me
Quasi-experiments (quant.)
Ou oce
Hypothesis testing Hypothesis developing
Pr
Replicability Uniqueness Naturalistic studies (qual. & quant.)
QUANT naturalistic studies: se sono
Words
s
Numbers
single-case,alcuni li chiamano
iou
Evidence-Based case studies (see
Hilsenroth in call for special issue:http://
www.apa.org/pubs/journals/pst/
Interpretation
r
Statistics Clinical case studies, theoretical studies
Va
CLINICAL CASE STUDIES: alcuni li
21 chiamano narrative case studies anche
22
se formale non sono EMPIRICI (see
me
• Pros: high internal validity
(quant.) Based Practice (quant.) Based Practice
(ESTs) (ESTs)
tc o
tc o
• Cons: low ecological validity
Ou
Ou
RCTs and N=1 RCTs and N=1
experiments (quant.) • Relevant for Health policy
experiments makers
(quant.)
(biased by a (post)positivistic culture)
es e
tc o s s -
Pr tcom
me
s
Quasi-experiments (quant.) Quasi-experiments (quant.)
Ou oce
oc
Ou
Pr
Naturalistic studies (qual. & quant.) Naturalistic studies (quant. & qual)
s
s
iou
iou
r
Clinical case studies, theoretical studies Clinical case studies, theoretical studies
Va
Va
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Hierarchy of evidence Hierarchy of evidence
Meta-analysis Meta-analysis
(quant.) • Cons: lower internal validity
(quant.)
• Pros: higher ecological validity
RCTs and N=1 RCTs and N=1
experiments (quant.) experiments (quant.)
• Relevant for Practitioners
Quasi-experiments (quant.) Quasi-experiments (quant.)
Practice-based Naturalistic studies (qual. & quant.) Practice-based Naturalistic studies (quant. & qual)
Evidence Evidence
Clinical case studies, theoretical studies Clinical case studies, theoretical studies
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Prac%ce'based+ Evidence'based+
Theoretical models Evidence+ Prac%ce+
“Description and explanation”
Practice-based
Evidence Empirical research
“Validation and development”
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Ideal scenario Ideal
Pluralism
scenario
Prac%ce'based+ Evidence'based+
Evidence+ Prac%ce+
29 30
31 32
20,00%
18,00%
16,00%
14,00% 13,04%
12,00% 11,54%
10,00%
21,58% 8,00%
6,21%
6,00% 5,24% 5,10%
4,51% 4,42%
4,08%
4,00% 3,04%
2,89% 2,72% 2,57%
1,99% 2,15% 2,13%
1,74% 1,77%
2,00%
0,72% 0,51% 0,63% 0,51% 0,65% 0,61% 0,81%
0,29% 0,42% 0,42% 0,38%
0,10%
78,42% 0,00%
25,00% 23,95%
5,43%
20,00%
16,62%
14,68%
15,00%
10,00%
7,81%
5,74% 6,04% 5,75%
4,88%
5,00%
2,90% 2,49%
1,78% 1,90% 0,74%
0,98… 0,76% 0,52% 0,30% 0,35%
0,01% 0,03% 0,64% 0,04% 0,04% 0,01% 0,33% 0,23% 0,23%
0,10% 0,13%
0,00%
94,57%
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Hierarchy of evidence 2) Clinical (narrative)
case studies
Meta-analysis
(quant.) • Specific kind of single-case study (N=1)
RCTs and N=1
experiments (quant.) • Narrative account of intrasubject variability
Aims:
• Use intersubjective understanding in order to
1. In-depth exploration of personal meaning and experiences of clients, therapists, etc.
develop theories about psychotherapy (change)
2. In-depth exploration of the communicative (inter)actions shaping the dialogue between
clients, therapist, etc.
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Aims:
• Use statistics in order to objectively test
• Specific hypothesis-testing generated from theory about psychotherapy
theories about psychotherapy (change) in non- (change)
experimental settings
Tools:
a) Formulate a theory-driven hypothesis
• Reflect a positivist-postpositivist paradigm:
b) Gather a medium to large sample (although also N=1 studies are possible)
- emphasize statistical control and replicability c) Collect data by means of closed-ended questions or observation (e.g.,
standardized questionnaires, rating-scales) (see measurement systems)
- tend to focus on the extensive nature of d) Analyze data by means of statistics (e.g., ANOVA, t-test, chi-squared)
general laws (although also individuality can e) Draw conclusions based on the refusal of the null hypotheses
be studie; see N=1 studies)
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2,00 2,00
1,00 1,00
0,00 0,00
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Sessions Sessions
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Example: Relational “resonance” Use for feedback and benchmarking
Case “Clara”
in an outpatient clinic
high
4,00
Relational “resonance” 4,00
Alliance convergence score
2,00 2,00
1,00 1,00
0,00 0,00
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Relational “resonance” 53 54
Weight (Kg.)
a) Formulate a theory-driven hypothesis about efficacy
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b) Gather a medium to large sample
Summary Conclusions
1) Theory and Psychotherapy 1. Extend the concept of “Evidence”:
• Evidence = not only through RCTs (EBP)
2) Practice and Research • Evidence = through more ecological and practice-close approaches
(PBE)
6) Questions and discussion - If you endorse PBE, explore EBP (more RCTs, quasi-experiments)
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Conclusions Conclusions
2. Be a dialogical pluralist (cont.): 2. Be a dialogical pluralist (cont.):
• For psychotherapy researchers: • For psychotherapy journals editors:
- Do not ignore clinical complexity - review editorial policy
• For psychotherapy practitioners: 3. Create Networks:
- Do not underestimate methodological rigour • Set up/Get involved in Practice Research Networks (PRNs; i.e.,
• Attend research workshops/summer schools multicentric practitioners-researchers collaborations)
• Read about research - For example: SPR-PRN on “Therapist Training and
- Use research to inform your clinical practice (feedback systems) Development” (see our work here at the SFU)
• For psychotherapy trainers:
- Refine training curricula with research issues
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Conclusions Acknowledgments
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Questions and discussion
• To be cited as: