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Integrating Science and Practice: Reclaiming the Science in Practice Jean A. Carter Independent Practice, Washington, D.C. This article is intended to be somewhat provocative, stimulating discus- sion in our efforts to better integrate science and practice. Three major areas of divisiveness between science and practice are posited— understanding of practitioners’ approach to practice, definition of scholar- ship, and the role of theory and diagnosis in practice. Some general principles are offered that may further our thinking about integration of the applications of science in the practice of psychology and the partici- pation of practitioners in science: (a) all practitioners do evidence-based practice; (b) scholarship has many forms, each of which provides an impor- tant piece of the puzzle of advancing knowledge; and (c) “eclectic” is a theoretically and practically meaningful term. © 2002 Wiley Periodicals, Inc. J Clin Psychol 58: 1285–1290, 2002. Keywords: scientist-practitioner model; practice; eclectic It is always a privilege to have the opportunity to provide comment on my colleagues’ writing, particularly in an area as important as the scientist-practitioner model in psy- chology. This model is indeed the hallmark of our discipline, providing us with the strong undergirding of research and scholarship for the applications of practice. We must con- tinue to strive for the best ways to understand and implement such a model. These five articles provide valuable perspectives from our primarily academic voices. I hope that my primarily practice voice will provide a useful perspective as well. I admire the seriousness with which my colleagues have approached the topic. At the same time, this comment was difficult to write. The articles raised many strong reactions that I wanted to use as guidance to help our dialogue, but that were hard to put into words without undue ire—or perhaps some of the ire was due! So my intent is indeed to be somewhat provocative, stimulating discussion in our efforts to better integrate science and practice. Correspondence concerning this article should be addressed to: Jean A. Carter, 3 Washington Circle, Suite 205, Washington, DC 20037; e-mail: [email protected]. JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 58(10), 1285–1290 (2002) © 2002 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10112

Integrating science and practice: Reclaiming the science in practice

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Integrating Science and Practice:Reclaiming the Science in Practice

Jean A. Carter

Independent Practice, Washington, D.C.

This article is intended to be somewhat provocative, stimulating discus-sion in our efforts to better integrate science and practice. Three majorareas of divisiveness between science and practice are posited—understanding of practitioners’ approach to practice, definition of scholar-ship, and the role of theory and diagnosis in practice. Some generalprinciples are offered that may further our thinking about integration ofthe applications of science in the practice of psychology and the partici-pation of practitioners in science: (a) all practitioners do evidence-basedpractice; (b) scholarship has many forms, each of which provides an impor-tant piece of the puzzle of advancing knowledge; and (c) “eclectic” is atheoretically and practically meaningful term. © 2002 Wiley Periodicals,Inc. J Clin Psychol 58: 1285–1290, 2002.

Keywords: scientist-practitioner model; practice; eclectic

It is always a privilege to have the opportunity to provide comment on my colleagues’writing, particularly in an area as important as the scientist-practitioner model in psy-chology. This model is indeed the hallmark of our discipline, providing us with the strongundergirding of research and scholarship for the applications of practice. We must con-tinue to strive for the best ways to understand and implement such a model. These fivearticles provide valuable perspectives from our primarily academic voices. I hope thatmy primarily practice voice will provide a useful perspective as well.

I admire the seriousness with which my colleagues have approached the topic. At thesame time, this comment was difficult to write. The articles raised many strong reactionsthat I wanted to use as guidance to help our dialogue, but that were hard to put into wordswithout undue ire—or perhaps some of the ire was due! So my intent is indeed to besomewhat provocative, stimulating discussion in our efforts to better integrate scienceand practice.

Correspondence concerning this article should be addressed to: Jean A. Carter, 3 Washington Circle, Suite 205,Washington, DC 20037; e-mail: [email protected].

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 58(10), 1285–1290 (2002) © 2002 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10112

Georgios Lampropoulos and Paul Spengler have gathered a selection of articles fromrespected researchers and scholars in psychotherapy process and outcome who are deeplyinvested in an integrated model of the scientist-practitioner, in which science informspractice and practice guides science. In this model, scientists would design and imple-ment research programs that would be directly applicable to, and would be applied in,practice. Practitioners would utilize research findings in their daily practice and wouldparticipate in research programs, including the publication of research findings. Soundsvery good so far. But this is the same model that has sounded good each time it isproposed, described, redeveloped. So where are the problems? Why have we not beenbetter able to integrate science and practice, despite the prolonged and significant effortsof many bright people? What more can we do about it?

Let me start with appreciation for the articles included in this special issue. As apsychologist whose work is primarily in the application of psychological principles inpsychotherapy, I appreciate researchers who take seriously the practice of psychology,and its relationship to the science of psychology. These authors are attempting to provideresources for practitioners to enhance their practice and to encourage scientists and prac-titioners to share in the research endeavor. They are considering tools, approaches, andphilosophies that they hope will enhance both evidence-based practice and clinicallymeaningful research (Lampropoulos & Spengler, 2002). But why have I experienced ireas I read the articles?

My discomfort revolves around attitude, definition, and approach that I think inad-vertently add divisiveness to an admittedly divided set of perspectives. There are threemajor areas in which that divisiveness occurs—understanding of practitioners’ approachto practice, definition of scholarship, and the role of theory and diagnosis in practice. Bigareas, big misunderstandings, but made up of small pieces that I believe can be changed.Now, to my ire again. It is based on three ideas that I will elaborate on below.

I keep waiting to meet the practitioners described by our science-academic col-leagues (this description is not limited to the authors in this issue, nor is it of course theapproach taken by all academic scientists, although it is the “music” that plays repeatedlyabout practitioners). Those practitioners are thoughtless, reckless, cavalier, and do notlearn from experience. Since they follow charismatic-leader-driven treatment approacheswithout thought, they really need to be provided with manuals to tell them exactly whatto do when. They pick treatment approaches according to categorical diagnoses based onsymptoms without regard for context, level of distress, functionality, or other patient,therapist, or treatment factors. They apply those approaches in a uniform way no matterwhat seems to happen with the patient. They consider it random when patients improve,and equally random when patients do not. They do not read; they do not think; and, aboveall, they have lost all capacity and interest in learning. They have forgotten the interest ininvestigation and causal connection that was part of what drew them to be psychologists.

These are not the practitioners I know. Granted, there are bad practitioners out there,just as there are bad researchers. We all unfortunately know them. But in our own area,we also know they are not the norm.

The practitioners I know are thoughtful. They continually ask questions of them-selves about their practices—which patients are getting better, what is it about what theyare doing with those patients and/or what is it about those patients who get better, whatis happening (or not) when a patient is not improving, how do we know if someone isgetting better, what criteria do we use to assess improvement and make planful termina-tions, and so on. Although I have found these same questions to be important for practi-tioners of different training backgrounds, psychologists are typically readily distinguishablein interdisciplinary or multidisciplinary practice groups; they are the ones asking, “How

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do you know that what you did made that change? Why do you think that? What evidenceare you using?” Even in practice, psychologists are continually generating hypotheses,collecting data, revising hypotheses based on the data, evaluating outcome, making inter-pretations, and beginning the process all over again. This sounds like scientific thinkingvery well applied in the context and setting in which it occurs. So why has that beenmissed, so that practitioners are almost uniformly dismissed (including by themselves) asbeing unscientific dodos who may win a prize, but presumably have no clue why!

Below I will posit some general principles that may further our thinking about inte-gration of the applications of science in the practice of psychology and the participationof practitioners in science.

All Practitioners Do Evidence-Based Practice

As noted above, practitioners are engaged in asking questions of “what works in psycho-therapy and how it works” (Castonguay, 2002). As Castonguay notes with surprise, thereis a high level of convergence with respect to this primary interest of both psychotherapyresearchers and psychotherapy practitioners. This convergence is not surprising to thoseof us in practice, and the surprise he notes is disheartening. We are continually askingthose questions, and trying seriously to find the answers. We are continually gatheringevidence through our practices and making ongoing corrections as we do so. Althoughthe evidence is most often not gathered in the practice setting in scientifically rigorousways, neither is clinical experience just personal opinion (as implied by Beutler, Moleiro,& Talebi, 2002). Rather, the methods, data sources and goals of data collection in practiceare different from those in science, not because one is better than another, but because theprocess and the needed outcome are different, and the understanding that comes fromconverging sources, processes, and outcomes has good likelihood of being of far greatervalue ultimately in both our understanding and applications of psychological principlesin psychotherapy.

It is no surprise that many practitioners believe that manualized treatments designedfor discretely diagnosed patients and based on empirical validation of a rigorous scien-tific sort can be helpful. It is also no surprise that most practitioners do not use suchtreatment manuals—they are too clean for the messiness of human lives. If they in factinclude mid-course correction (as only one alteration of the manualization), then theysuddenly become like other treatments—often more intuitive than discursive, fluid withthe complexities of human relationships.

It is in that messiness that practitioners and their patients dwell—no RTCs, fewdiscrete diagnoses, stable treatment plans that do not become suddenly altered by lifeevents. Yes, practitioners can use all the help we can get at understanding the complexi-ties of the psychotherapy relationship and the change process; Asay, Lambert, Gregersen,and Goates (2002) describe one process for assisting practitioners through feedback.Research findings, translated for our use (see below), can also help with that. But pleasedo not dismiss the process by which treatments are planned, carried out, and assessed inthe real world of practice. And please do not dismiss the practitioners’ process. We think;we think hard; and we do learn.

Scholarship Has Many Forms

Scholarship has many forms, each of which provides an important piece of the puzzle ofadvancing knowledge. By scholarship I am referring both to the activities of the individ-ual who is engaging in scholarly behavior and to the output of scholarly work.

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We typically think of participating in classic research designs, data gathering, andanalysis and interpretation of the data as the way of being a scientist. Do all psychologistsneed to have that form of research as their primary goal in the scholarly process? It isindeed intellectual imperialism to assume that as the pinnacle of involvement in scholarlywork (Castonguay, 2002).

We might note that two other levels of being a scientist are noted in the literature(Gelso & Fretz, 1992). Those other levels include adhering to scientific thinking as fun-damental to scientifically based practice and consumption of research (the ability to reviewand utilize research findings). It is on these latter ways of being a scientist that I wouldlike to comment on here.

Adherence to scientific thinking is an essential part of all practice being evidence-based. I believe two principles to be quite important in this regard.

First, we should recognize and appreciate the extent to which practitioners in facthave learned from their teachers and mentors in graduate school and continue to appre-ciate the scientific approach that they were taught. Practitioners are typically using sci-entific thought when doing practice, although admittedly not in the kind of rigorous waythat one does when doing science (e.g., variables are neither controlled nor often clearlydelineated, measures are often global assessments of satisfaction that may be neithervalid nor reliable, etc.). This is not something to be bemoaned, but rather something to becelebrated, respected, and valued, and the contributions to knowledge that come fromdirect observation in the clinical experience should be sought out, instead of merelytolerated with regret and mildly disguised disdain.

Second, we should recognize that the process of scientific disproof of null hypoth-eses and doubt are extremely important, but that the process of operating from smaller“hunches” in practice and gradually building a picture is also extremely important. Itdoes not rest on the same kind of doubt and disproof and does not lead to the relativecertainty of knowledge that can be readily replicated. It does, however, lead to a greatstore of organized information about clinical practice, about clients, about issues, andtreatment processes, about therapists, and about outcomes. And this again should berespected and valued, and our understanding of this as a valid way of knowing should beappreciated. Useful tools for practitioners might well be ways for organizing the infor-mation that they do already have and could have for easier access if better organized. It isextremely important that these tools, like Beutler et al.’s STS (Beutler et al., 2002), bepresented as ways to organize and add to what we know, rather than as if those of us inpractice have never had these ideas. We have had these ideas, and little of what Beutleret al. (for example) had to say was significantly additive to what we already know fromdealing with practice, although what we already know was organized in a way that maybe useful.

In summary, the key point is respect and value for the processes and knowledgegained through clinical practice and by practitioners. The following recommendationcomes directly from this point: in graduate training, it would be useful for students (par-ticularly those who will enter practice, but also those who will study practice) to under-stand and appreciate the processes by which they can (and do) utilize scientific thinkingand consume research in the practice of psychology. Faculty can model such respect andactively teach the value of those ways of being a scholar.

Research findings usually require translation from the general case to make themuseful for the specific case in front of the practitioner. Two types of scholarly productionswould be useful to aid in that translation. One would be synthesis and translation ofscientific data into practice relevant materials, much as Beutler et al. attempt to do in thisissue (Beutler et al., 2002). Summaries aimed toward practice, practice reviews and practice-

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oriented books could all provide scientifically grounded and clinically useful resourcesfor practitioners. These would still require that practitioners apply the skills in analysisthat they learned in graduate school. In turn, that suggests that academics should activelyteach both summarizing and consuming research as valuable tools for practitioners.

As a final note in this section, good theory makes a bridge between science andpractice, drawing broader conclusions from each and creating a framework. Good theo-retical works, which are often more appealing to practitioners and provide guidance inthe complexities of the daily interactions of psychotherapy, are very useful, but shouldalso be offered in a way that is respectful of practice and of practitioners’ realities.

“Eclectic” Is a Theoretically and Practically Meaningful Term

It is very interesting that practitioners repeatedly endorse the theoretical description of“eclectic” as representing their approach. That is dutifully noted again and again. But Iposit that it is meaningful in the context of the scientist-practitioner model that practi-tioners claim to be “eclectic” and that the term “eclectic” as a theoretical description ismeaningful.

The choice of the term eclectic as most descriptive of one’s theory as applied inpractice means that none of the classic theories addresses all of the questions or experi-ence that a practitioner faces. By extension, then, practitioners are continually reviewingand revising their own theory of human behavior and change in the face of new anddifferent information received on a daily basis in the clinical exchange. With that as thecontext, it is abundantly clear that although practitioners turn to theory to provide guid-ance for clinical intervention and to organize thought for understanding the clinical pro-cess with this particular client, the organizer is undergoing constant revision based onboth discursive and intuitive processes. I would suggest that it would be extremely valu-able for us to understand better the process by which implicit theory is developed andrevised and how it is translated and utilized on a moment-by-moment basis in practice.Better understanding of eclectic as a theoretical term would likely enhance our ability tounderstand the underlying scholarly thought processes of practitioners and would offerrespect for those processes as valid and valuable. This is perhaps a model of the kind ofpsychotherapy integration that Lampropoulos, Spengler, Dixon, and Nicholas (2002)discuss.

In addition, the notion of “eclectic” as meaningful suggests something further. Althoughone must use standard diagnostic coding for participation in a larger health care deliverysystem, that does not mean that practitioners uniformly use DSM-type diagnostic catego-ries as particularly useful in the psychotherapy setting. Diagnoses of this sort are merelysuggestive of a symptom picture, but it is the theory bridge that is used to move from thesuggestions of a diagnosis to treatment planning and implementation—and that theory isusually an amalgamation of other theoretical approaches and data gathered in the practicesetting that practitioners are using to develop a general treatment approach for theirpractice overall and for particular patients in particular ways.

Summary

The serious attempts to understand and integrate science and practice in a more realistic,helpful, and respectful way that are offered in this series of articles are a welcome addi-tion to the dialogue that we engage in. Science and practice arise from the same wish tounderstand and affect human behavior and to alleviate human suffering. They can be

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significantly complementary, and yet we have continued to struggle over how to betterintegrate them. Ultimately it may be through a convergence of processes and respect forthe contributions of both, with continuous dialogue and collaboration, that bears mostfruit.

References

Asay, T.P., Lambert, M.J., Gregersen, A.T., & Goates, M.K. (2002). Using patient-focused researchin evaluating treatment outcome in private practice. Journal of Clinical Psychology, 58(10),1213–1225.

Beutler, L.E., Moleiro, C., & Talebi, H. (2002). How practitioners can systematically use empiricalevidence in treatment selection. Journal of Clinical Psychology, 58(10), 1199–1212.

Gelso, C.J., & Fretz, B.R. (1992). Counseling psychology. Fort Worth, TX: Harcourt Brace.

Lampropoulos, G.K., & Spengler, P.M. (2002). Reprioritizing the role of science in a realisticversion of the scientist-practitioner model. Journal of Clinical Psychology, 58(10), 1195–1197.

Lampropoulos, G.K., Spengler, P.M., Dixon, D.N., & Nicholas, D.R. (2002). How psychotherapyintegration can complement the scientist-practitioner model. Journal of Clinical Psychology,58(10), 1227–1240.

Lampropoulos, G.K., Spengler, P.M., Goldfried, M.R., Castonguay, L.G., Lambert, M.J., Stiles,W.B., & Nestoros, J.N. (2002). What kind of research can we realistically expect from thepractitioner? Journal of Clinical Psychology, 58(10), 1241–1264.

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