The researcher defines the purpose the research

The gap between research and clinical practice is one of the key challenges facing family therapy. Clinicians often fail to incorporate research findings into their practice because they do not know how to search, evaluate, or apply research to their clinical work. The purpose of this article is to help clinicians become better consumers of research. This article explores the potential value of research to clinicians, as well as negative beliefs that clinicians may have about research. The article also describes how clinicians can use research to inform their clinical work, as well as potential challenges that can be encountered.

One issue facing the family therapy field is the gap between clinical research and clinical practice. Sprenkle (2003) has stated that “a major gap exists between research and practice in MFT, and the consequences of this gap are deleterious to the field” (p. 87). With the emergence of the Empirically Supported Treatment movement, which has placed an emphasis on using treatment models that have been empirically validated by outcome studies, science has increasingly become integrated with the actual delivery of therapy (Alexander, Sexton, & Robbins, 2002). There is now a substantial marriage and family therapy (MFT) outcome literature, with a number of MFT treatment approaches receiving empirical validation (Sexton, Alexander, & Mease, 2005; Sprenkle, 2002).

The challenge facing clinicians who attempt to use research to inform their work is similar to the challenge facing a prospector looking for gold. A prospector must first search for a stream that is likely to have gold. Then the prospector must patiently sort through material to find the valuable nuggets. On occasion, the prospector must distinguish fool’s gold from the genuine article. This article will help to guide clinicians on where they might go prospecting, and the most effective strategies for sifting through the research to find something of value. It will also help the clinician to evaluate the quality of research so as not to be deceived by “fool’s gold.”

THE VALUE OF RESEARCH FOR MFTS

Research can be valuable to clinicians in four general ways. First, research can confirm something that we already know or practice. Thus, research can reinforce or give clinicians greater confidence in their work. Second, research can add to what we know. Clinicians who use research often have this benefit in mind. Doing a search of the research may help clinicians to better understand a phenomenon with which they have limited experience. Or, they may use the research to identify the most effective treatment for a problem or issue.

A third way in which research can inform clinical work is to disconfirm what we think we know. Research may contradict conventional wisdom or challenge an individual to adopt a different way of thinking or practice. A clinician who is treating an individual presenting with both marital difficulties and a substance abuse problem may insist that the client seek help with the substance abuse problem first before working on the marriage. Yet, research suggests that behavioral couples therapy can be used in the treatment of substance abuse (Rowe & Liddle, 2003; O’Farrell & Fals-Stewart, 2003). For research to inform a clinician’s work in this manner, he or she must be open to examining his or her clinical work critically and changing it.

means of helping family members who are related an individual with a substance abuse problem (O’Farrell & Fals-Stewart, 2003). Research could also guide treatment by suggesting important principles to follow in treatment. McFarlane, Dixon, Lukens, and Luckstead (2003), for example, summarized treatment principles for working with families with a member struggling with schizophrenia. These principles are based on a consensus of several clinical researchers who have developed family-based treatments for schizophrenia.

Parallels also exist between quantitative research and clinical work. The clinician often develops hypotheses about the causes of the presenting problem and then collects data to confirm or disconfirm the hypotheses. Given that the success or failure of an intervention can yield important assessment information, an intervention could be conceptualized as an experiment to confirm or disconfirm a hypothesis. Thus, researchers and clinicians often share many of the same critical thinking skills.

Schön (1995) has also challenged the dichotomy that research creates knowledge and practice applies knowledge. Schön asserts that we should think of practice as a setting capable of both applying and generating knowledge. Clinicians, like researchers, have the ability to create knowledge through careful observation and reflection on their work. In a similar manner, Sprenkle (2003) has argued that, “clinical judgment and the scientific method are two overlapping ways of knowing, both to be valued and both to be questioned” (p. 87).

DIFFERENT APPROACHES TO CONSUMING RESEARCH

There are multiple ways in which clinicians can consume research, each with their own advantages and disadvantages. In response to the increased call to make research more accessible to clinicians, some publications (e.g., Psychotherapy Networker, Family Therapy Magazine) now include brief summaries of research studies. These summaries are similar to abstracts in that they provide a brief overview of a study. They are also are written in a clinician-friendly manner. Thus, this approach provides clinicians with a quick and easy way to read about research. The limitation of this approach, however, is that the summaries may not always address a topic or issue that is of most immediate concern to the reader. In addition, these brief summaries may not address the strengths and limitations of a study. Thus, the reader is dependent on the author’s judgment in evaluating the quality of the research. The reader may also want additional information or details if the study is particularly relevant to the clinician’s practice. One way to address this latter concern is to obtain the original article on studies that are particularly salient to the reader.

also clearly specify the criteria for including or excluding studies, reducing a potential source of bias. In addition, meta-analyses can study which factors have an impact on the effect size of a treatment, such as the methodological rigor of the studies. Thus, meta-analyses can be an especially helpful way to review outcome research in a particular area. In addition to meta-analysis, new methodologies for summarizing and synthesizing multiple qualitative studies are beginning to emerge (Sandelowski & Barroso, 2003). One potential limitation of literature reviews or meta-analyses is that they are generally available only for more established areas of research. Thus, the clinician may have no alternative but to review individual studies for emerging areas of research.

For some disorders or issues, the clinician may also find it helpful to search through medical databases. Medline offers the most extensive database of biomedical articles. Medline can be accessed for free through PubMed (http://www.ncbi.nlm.nih.gov/pubmed). PubMed also links to other sites that provide free access to full-text articles in medical and life science journals. Highwire (http://highwire. stanford.edu) is another free database of medical and life science journals. Like PubMed, Highwire also contains free on-line access to many full-text articles. Doctor’s Guide (http://www.docguide.com) is another resource for searching and locating medically related articles on mental health issues. Literature reviews or summaries of individual articles can also be obtained by searching other sources such as the Cochrane Database of Systematic Reviews (http://www.cochrane.org), Clinical Evidence (http://www. clinicalevidence.com), Evidence Based Medicine (http://ebm.bmjjournals.com), or Evidence Based Medicine Reviews (http://www.ovid.com).

Many databases offer the option of doing a simple or advanced search. The advanced search is most effective when combining key words to do a search or when limiting the type or range of articles is necessary. The American Psychological Association (APA) website outlines the basic steps needed to do a search (see http://www.apa.org/psycinfo/training/searchsteps.html). The website also offers advanced tips for doing a search using PsycINFO (see http://www.apa.org/psycinfo/training/tips.html).

Step Four—Evaluating Research Quality
The level of confidence that one can place in research depends greatly on whether or not the study has significant methodological flaws. Therefore, the clinician will ideally evaluate a study to determine its quality. This section will discuss a direct approach to evaluating an article based on a set of questions or criteria. In the next section on short cuts, an easier but less direct approach to evaluating research will be presented.

Using the direct approach, the clinician reads the entire article to evaluate the study on several methodological criteria. This approach requires the reader to have a fundamental understanding of research methods. However, one can evaluate the strength of a study using a surprisingly small number of concepts. Therefore, one should not automatically assume that he or she is incapable of being able to critically evaluate a study in this manner. The Appendix lists questions the reader can ask while evaluating a research study. The concepts in the Appendix should be familiar to those who have completed an introductory course in research methods (currently a requirement for therapists attending a program accredited by the Commission on Accreditation of Marriage and Family Therapy Education).

In some cases, the reader may have difficulty finding more than one or two studies on the topic of interest. In these cases, the clinician should be careful not to put too much weight on any one study. Conclusions based on one study can still guide treatment or assessment, but should be viewed more tentatively.

Step Six—Clinical Application
In the final step, the clinician must decide what information will be useful clinically and how to apply this knowledge to a particular case. One should consider several issues when applying the information. First, the individual needs to consider the extent to which the research is relevant to the issue at hand. If the research does not address the specific disorder or problem the clinician is facing, then he or she needs to be more tentative in applying the research. In some instances, however, the research does not necessarily need to address the exact disorder or problem to be relevant or useful. Much of what has been learned through research about treating schizophrenia using family psychoeducation models is being successfully applied to other forms of mental illness (McFarlane et al., 2003).

The following short cuts are offered as a way of making using research either easier and/or less time consuming. The potential advantages and tradeoffs for each short cut are discussed.

Short Cut One—Use Electronic Articles
One potential short cut is to rely solely on electronic journal articles. As stated earlier, many electronic journal articles can be easily and freely accessed through the Internet through sites such as Google Scholar, Highwire, or Doctor’s Guide. This saves the reader considerable time in going to a library to locate and copy articles. Even if the individual needs to go to a library to access a more extensive database or collection of articles, using electronic articles will still save time and effort in terms of locating and copying the actual article. The potential tradeoff is that the reader may not have access to some articles if they limit themselves to only electronic journal articles. Thus, there is the potential that key articles may be missed if one relies solely on electronic journal articles. The Journal of Marital and Family Therapy, for example, does not offer electronic versions of the articles through PsycINFO. Thus, the clinician may want to supplement his or her search with journals like Journal of Marital and Family Therapy that are key to field, but are not traditionally offered in an electronic version. In the specific case of the Journal of Marital and Family Therapy, members of the AAMFT do have electronic access to the journal through membership in the organization.

Short Cut Four—Use Indirect Measures of Research Quality
Step Four of the model provided a set of questions that the clinician could use to evaluate research studies. As an alternative, the reader can use an indirect approach to evaluating the quality of a study. The advantage of the indirect approach is that it requires less effort or time in evaluating a study. It also requires less knowledge of research concepts. The tradeoff, however, is that it may be less reliable in identifying major weaknesses in a study. Studies published in peer-reviewed journals are less likely to have critical flaws because one or more reviewers have had the opportunity to examine the article for such flaws. This approach is not infallible given that the quality of the reviews or number of reviewers can vary from journal to journal. Articles from more prestigious journals are likely to be of higher quality. These journals generally have a higher number of submissions, permitting them to be more selective in what they publish. These journals are also more likely to use reviewers who are recognized experts in the field. Some journals or databases, such as the Evidence Based Mental Health, only include studies that meet specific methodological standards. Thus, the reader has some assurance that studies reviewed on these sites have sufficient rigor. Finally, researchers usually advertise the limitations of their study. Thus, the reader can often get a sense of the key limitations of a study by reading the discussion. The potential downside is that less sophisticated researchers may not be aware of or have addressed all the key limitations.

CASE ILLUSTRATION

The article on integrating family and individual therapy (Miklowitz et al., 2003) made Dr. P consider the possible role of individual therapy as an adjunct to couples therapy. Making a referral for individual therapy could offer advantages to the client, such as examining the role of social rhythms in bipolar. The study supports the idea that bipolar individuals can better manage their

illness by maintaining consistent daily routines and sleep–wake cycles. Dr. P wondered what impact having young children had on Mary’s social rhythms (e.g., being awakened in the middle of the night by children). Mary also wanted to fly across the country to see her parents. Dr. P wondered what impact traveling across three time zones to see her parents would have on Mary’s sleep and bipolar illness, particularly given that her symptoms were not yet stable. An individual therapist could help Mary explore these issues. Yet, Dr. P wondered if the couple could afford a second therapist. Would insurance cover both individual and couples therapy? If not, this might be an important area to explore with Mary in couples therapy.

POTENTIAL CHALLENGES OF USING RESEARCH

The clinician who attempts to use research to inform his or her work can face a number of challenges. The cost and availability of databases can be one potential challenge. Some of the databases (e.g., PsychINFO, Clinical Evidence, Evidence Based Medicine Reviews) require paid subscriptions to access. Fortunately, PsychoINFO (or a variation of it) is widely available through most universities and community colleges. Thus, a clinician who is willing to visit the local community college or university library would have free access to this extensive database of psychological research. For many clinicians, this will be sufficient for their needs.

Another challenge the clinician may face is finding little or no research on the topic of interest. The authors have hypothesized that there is a funnel phenomenon when looking for empirically supported treatments. Because of the nature of the medical field, the clinician will likely find an abundance of articles on a topic of a medical nature. A significantly smaller pool of research will be available to those searching the mental health literature in general. Unfortunately, an even smaller pool of research will be available to the clinician seeking research specifically within the MFT field. As result of this funneling phenomenon, the clinician will probably have an easier time identifying research on issues related to psychopathology or problems with a biological component. With time, the body of evidence within family therapy should continue to grow, making it easier for clinicians to find research on issues that they typically treat.

Ironically, the clinician can also face the opposite problem, that of too much information. The challenge in this instance is to select and synthesize the information into a manageable form. As suggested earlier, reading literature reviews or meta-analyses can be an expedient way for the reader to learn the research in a particular area if it is developed enough.

managing the time commitment.

Searching and locating articles can require an investment in time. Although some of the articles can be conveniently located and viewed on the Internet from the home or office, in other cases the individual may need to visit a local university or community college to access a database (e.g., PsychINFO) or journal articles. Ideally, one would be able to set aside a block of time (2–3 hours) periodically to visit the library to search and locate some key articles. The individual could copy or printout articles for later reading at one’s convenience. Even doing this only two or three times a year could provide information that can be useful to one’s practice.

REFERENCES

Alexander, J. F., Sexton, T. L., & Robbins, M. S. (2002). The developmental status of family therapy in family psychology intervention sciences. In H. A. Liddle, D. A. Santisteban, R. F. Levant, & J. H. Bray (Eds.), Family psychology: Science-based interventions (pp. 17–40). Washington, DC: American Psychological Association.

Brett, P. J., Graham, K., & Smythe, C. (1995). An analysis of specialty journals on alcohol, drugs and addictive behaviors for sex bias in research methods and reporting. Journal of Studies on Alcohol, 56, 24–34.

Crane, D. R., Wampler, K. S., Sprenkle, D. H., Sandberg, J. G., & Hovestadt, A. J. (2002). The scientist practitioner model in marriage and family therapy doctoral programs: Current status. Journal of Marital and Family Therapy, 28, 75–83. Davidson, K. W., Goldstein, M., Kaplan, R. M., Kaufmann, P. G., Knatterud, G. L., Orleans, C. T., et al. (2003). Evidence- based behavioral medicine: What is it and how do we achieve it? Annals of Behavioral Medicine, 26, 161–171.

Lebow, J. (1988). Research into practice/practice into research. Journal of Family Psychology, 1, 337–351.

McFarlane, W. R., Dixon, L., Lukens, E., & Luckstead, A. (2003). Family psychoeducation and schizophrenia: A review of the literature. Journal of Marital and Family Therapy, 29, 223–245.

Rea, M. M., Tompson, M. C., Miklowitz, D. J., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 3, 482–492.

Robinson, E. H. (1994). Critical issues in counselor education: Mentors, models, and money. Counselor Education and Supervision, 33, 339–343.

Sexton, T. L., Alexander, J. F., & Mease, A. L. (2005). Levels of evidence for the models and mechanism of therapeutic change in family and couple therapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 590–646). New York: Wiley.

Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15–28.

Research methods in family therapy (pp. 286–303). New York: Guilford Press.

APPENDIX—QUESTIONS TO ASK WHEN REVIEWING A STUDY

4. Does the literature review critique the existing literature or simply summarize it?

METHODOLOGY

5. Are there other measurement concerns (e.g., reactivity, sensitivity)?

Sampling Issues and External Validity
1. What steps were taken to make sure the sample was representative of the population of interest?

5. Are the possible threats to generalizability (external validity) addressed in the research?

Issues of Internal Validity
1. For experimental studies, does the study include both a treatment and a comparison group (control or alternative treatment)? Are subjects randomly assigned to the groups?

5. Are threats to internal validity from cohort effects addressed in cross-sectional research?

Methodological Issues for Qualitative Research
1. Does the researcher identify the theoretical framework and other potential biases that may influence interpretation of the data?

6. Does the researcher report how they established reliability and validity (e.g., triangulation of data, saturation, having participants examine the findings)?

7. Do the illustrative quotes or descriptions support the conclusions?

3. Were appropriate statistical tests used to analyze the findings?

RESULTS AND DISCUSSION

5. Are recommendations for future research included?

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