Beyond the limits

Psychotherapy between
practice and research
Practice

Omar C. G. Gelo

University of Salento (Italy)

Sigmund Freud University (Austria)

omar.gelo@unisalento.it

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Beyond the limits Beyond the limits

Research Research

Practice

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 Beyond the limits Beyond the limits
Research Research

Practice Practice

Dialogue NOT going beyond the limits:

• Pros: Safety, stability, identity
• Cons: May hinder exploration —> Adaptation

• Beyond the limits: we need to know “where” to go,

“how” and “why”
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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

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 Problem Problem (cont.)

• Most of psychotherapy theories: supported and
validated by means of professional practice (practice-
based knowledge).
• On the contrary, still few attempts to validate and
support psychotherapy theories by means of empirical
research (research-based knowledge)
• This situation is known as Science-Practice Gap, which
hinders the development and dissemination of
psychotherapy as a discipline
• Reasons for the Science-Practice Gap:
- Methodological complexity of research:
• research design, data collection, data analysis
- Misconceptions about research (from the side of
practitioners):
• research has little clinical relevance (RCTs; quantitative
research in general; etc.)
- Misconceptions about practice (from the side of
researchers):
• practice can be investigated by means of a few “elective”,
reductionistic research approaches (RCTs; quantitative
research in general; etc.)

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My aim today Summary

1) Theory and Psychotherapy
1) To address the science-practice gap in the 2) Practice and Research
field of psychotherapy
3) A short review
2) Suggest some strategies in order to reduce
this gap —> enhance te development and 4) Empirical strategies
dissemination of both psychotherapy
5) Conclusions
practice and research
6) Questions and discussion

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 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

- orient the way we perceive, describe, and explain different aspects of

3) A short review reality

• Theory and Psychotherapy:

4) Empirical Strategties
- theories of psychosocial functioning (i.e., how and why human beings
function)
5) Conclusions
- theories of professional intervention (i.e., how and why professionals
should handle with clients in order to alleviate their suffering and/or
6) Questions and discussion promote their well being)

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Summary 2) Practice & Research

1) Theory and Psychotherapy Practice
“What actually happens“
2) Practice and Research

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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Hierarchy of evidence Hierarchy of evidence

Meta-analysis Meta-analysis
(quant.) (quant.)

RCTs and N=1 RCTs and N=1

experiments (quant.) experiments (quant.)

Quasi-experiments (quant.) Quasi-experiments (quant.)

Naturalistic studies (qual. & quant.) Naturalistic studies (qual. & quant.)

Clinical case studies, theoretical studies Clinical case studies, theoretical studies
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 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

Hierarchy of evidence Hierarchy of evidence

Empirically Empirically
Supported Supported
Treatments Meta-analysis Evidence- Treatments Meta-analysis Evidence-
me

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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2) Practice & Research Ideal scenario

Practice Evidence-
“What actually happens“ Based Practice

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+

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Summary A short review

1) Theory and Transactional Analysis (TA)
2) Practice and Research
3) A short review
4) Empirical strategies
5)Conclusions
6) Questions and discussion
(2003-2013)
• Sample (N = 14684 -> N = 9796):
- American Journal of Psychiatry
- American Journal of Psychotherapy
- Archives of General Psychiatry
- Behavior Therapy
- Clinical Psychology and Psychotherapy
- Clinical Psychology: Science & Practice
- Counseling and Psychotherapy Research
- Journal of Clinical Psychology
- Journal of Counseling Psychology
- Journal of Consulting and Clinical Psychology
- Journal of Family Psychotherapy
- Journal of Psychotherapy Integration
- Psychology and Psychotherapy: Theory, Research and Practice
- Psychotherapy Research
- Psychotherapy: Theory, Research, Practice and Training

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 20,00%

1) Total sample (N=9796) 1) Type of article

18,81%

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%

THEORETICAL (n=2114) EMPIRICAL (n=7682)

33 THEORETICAL (n=2114)
34 EMPIRICAL (n=7682)

2) Empirical (N=7682) 30,00%

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%

QUANTITATIVE/MIXED METHOD (n=7265) QUALITATIVE (n=417)

QUANTITATIVE/MIXED METHOD (n=7265) QUALITATIVE (n=417)

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 Hierarchy of evidence
Summary
Meta-analysis
1) Theory and Psychotherapy
(quant.)
2) Practice and Research RCTs and N=1
experiments (quant.)
3) A short review

4) Empirical strategies Quasi-experiments (quant.)

5) Conclusion Naturalistic studies (qual. & quant.)

6) Questions and discussion
Clinical case studies, theoretical studies
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1) Theoretical studies 1) Theoretical studies (cont.)

• Epistemological paper: discussing about philosophical assumptions underlying

Aims:
psychotherapy theory, practice and research. (E.g.: “The debate between
quantitative and qualitative psychotherapy research”; “The social construction of
1. Theory construction/revision
psychopathology”)
• Methodological paper: discussing about principles governing psychotherapy 2. Epistemological/Methodological/Conceptual innovation
theory, practice and research. (E.g.: “Quantitative and qualitative methods in
psychotherapy research”; “The methodology of clinical intervention”)
Tools:
• Conceptual paper: presenting and discussing a specific theory and/or empirical
findings using as sources other papers/books which are not reviewed. (E.g.: a) Collect clinical and scientific literature
„Transference and attachment behavior”)
• Literature review: presenting and discussing an overview of theories and/or
b) Conceptual analysis (logically necessary truths,
empirical findings about a theory using as sources empirical papers that are coherence analysis, criticism)
reviewed - systematically or less systematically. (E.g.: „Transference and
attachment behavior: A review of the literature”) c) Draw conclusions

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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

• Clinical experience of therapist is reported and

Quasi-experiments (quant.) discussed by means of clinically-relevant examples
to sustain the ongoing argumentation
Naturalistic studies (qual. & quant.)
• Example: “An exceptional, efficient, and resilient
therapist: A case study in practice-based
Clinical case studies, theoretical studies evidence”
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2) Clinical (narrative) Hierarchy of evidence

case studies (cont.)
Aims: Meta-analysis
1. Preliminary evidence (quant.)
2. Increase understanding
3. Theory-building (discovery-oriented approach)
RCTs and N=1
experiments (quant.)
Tools:
a) Formulate a question
b) Go through the (clinical and scientific) literature Quasi-experiments (quant.)
c) Select and document a case
d) Review the case material and write a case narrative
e) Analyze the material (see the concept of “hermeneutic inquiry”) Naturalistic studies (qual. & quant.)
f) Sustain your argumentation by means of clinical examples taken from the
material

Clinical case studies, theoretical studies

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 3) Qualitative studies (cont.) 3) Qualitative studies (cont.)

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.

• Reflect a constructivist-interpretivist Tools:

paradigm: a) Formulate an explorative research question

b) Gather a small sample

- emphasize emphatic participation and c) Collect data by means of open-ended questions or observation (e.g., interviews, open
hermeneutic processes questionnaires)
d) Analyze data by means of methodical hermeneutics (e.g., content analysis, grounded
- focus on the individual, particular, in-depth, theory analysis, conversation analysis)

e) Sustain your argumentation by means of demonstrative rhetorics (use examples drawn

and contextual nature of meaning from the analyzed texts)

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Example: Helpful events within Hierarchy of evidence

eclectic short-time psychotherapy
Meta-analysis
(quant.)
What was helpful in the sessions?
• I am addressed personally RCTs and N=1
experiments (quant.)
•The presence of the therapist is helpful
•To talk helps me to distract myself Quasi-experiments (quant.)
•The „trances“ support me
•The “pain diary” contributes to alleviating solutions Naturalistic studies (qual. & quant.)
•Acknowledgment and praise help me in
recognizing my resources Clinical case studies, theoretical studies
!47
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 4) Quantitative 4) Quantitative
naturalistic studies naturalistic studies (cont.)

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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Example: Relational “resonance” Example: Relational “resonance”

in an outpatient clinic in an outpatient clinic
high
4,00 4,00
Relational “resonance”
Alliance convergence score

Alliance convergence score

3,00 3,00

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

Alliance convergence score

3,00 3,00

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

low Sessions Sessions

Relational “resonance” 53 54

Hierarchy of evidence 5) Randomized Clinical

Trials (RCTs)
Meta-analysis
(quant.)
• Use statistics in order to objectively test theories
RCTs and N=1 about psychotherapy (change) in experimental
experiments (quant.) settings

Quasi-experiments (quant.) • Reflect a positivist-postpositivist paradigm:

- emphasize experimental control and replicability
Naturalistic studies (qual. & quant.) - focus exclusively on the extensive nature of
general laws (although also individuality can be
Clinical case studies, theoretical studies studied; see N=1 studies)
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 5) Randomized Clinical Example: Hypnobehavioral vs.
hypnoenergetic therapy for obese
Trials (RCTs) (cont.) women
105
Aims:
=Hpno
HypnoBe
HypnoBE
• Specific hypothesis-testing generated from theory about therapy efficacy
=HypnoEN
HypnoEn
100
Tools:

Weight (Kg.)
a) Formulate a theory-driven hypothesis about efficacy
95
b) Gather a medium to large sample

c) Randomize the subjects to the treatment groups

d) Collect data by means of standardized outcome measures (e.g., 90

questionnaires, rating-scales)

e) Analyze data by means of statistics

85
f) Draw conclusions based on the refusal of the null hypotheses
Behandlungsbeginn Behandlungsende Stabilisierungssitzung
Pre Post Follow-Up
!58 (BB) (BE) (SS)
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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)

3) A short review 2. Be a dialogical pluralist:

• Do not rely only on EBP or PBE to legitimate clinical practice
4) Empirical strategies • Rely on each of them interchangeably (based on the needs)
• Engage with diversity (see the SFU PhD program):
5) Conclusions - If you endorse EBP, explore PBE (more theoretical, clinical cases,
qualitative, naturalistic quantitative)

6) Questions and discussion - If you endorse PBE, explore EBP (more RCTs, quasi-experiments)

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 Conclusions
2. Be a dialogical pluralist (cont.):
• For psychotherapy researchers:
- Do not ignore clinical complexity
• For psychotherapy practitioners:
- Do not underestimate methodological rigour
• Attend research workshops/summer schools
• Read about research
- Use research to inform your clinical practice (feedback systems)
• For psychotherapy trainers:
- Refine training curricula with research issues
Conclusions
2. Be a dialogical pluralist (cont.):
• For psychotherapy journals editors:
- review editorial policy
3. Create Networks:
• Set up/Get involved in Practice Research Networks (PRNs; i.e.,
multicentric practitioners-researchers collaborations)
- For example: SPR-PRN on “Therapist Training and
Development” (see our work here at the SFU)

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Conclusions Acknowledgments

Don’t be scared of diversity

I would like to thank my research assistant Gloria
Don’t be scared to challenge your identity Lagetto for the invaluable support she gave me
for the preparation of this Keynote
Don’t be scared of becoming

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Questions and discussion

• To be cited as:

Gelo, O.C.G. (2016, February).

Psychotherapy between Research and
practice. Keynote address presented at the
Connecting psychotherapy: Practice &
research conference of the European
Association for Psychotherapy, Vienna.

Beyond the limits

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