--------- Editorial note: This article was the first article reviewed under the new action editor process. The journal staff expresses thanks to Professor Jake Jacobs, Ph.D. of the University of Southern California Medical School for serving as the action editor for this article with no interaction with the Editor in the review process. ------------------------------------------------------------------------

The International Electronic Journal of Innovations in the Study of the Traumatization Process and Methods for Reducing or Eliminating Related Human Suffering

A Systematic Clinical Demonstration Methodology: A Collaboration Between Practitioners and Clinical Researchers

by Joyce L. Carbonell and Charles Figley

ABSTRACT

Research, quantification, and verification of treatment approaches are vital to any treatment field. This paper reviews the problems and challenges to testing new psychotherapy treatment procedures and suggests an innovative way to deal with the problems associated with researching new and innovative treatments. It is suggested that innovative practitioners be assisted in the demonstration and evaluation of their approaches by researchers, allowing the clinicians to demonstrate their method while researchers evaluate the effectiveness of the approach. This approach, the Systematic Clinical Demonstration (SCD) which combines the skills of clinicians and researchers, is described and discussed.
 
 

Background

A user friendly research methodology that is a collaboration between practitioners and researchers would provide an avenue for testing innovations in psychotherapy which might otherwise go unnoticed or remain the province of a few who had direct contact with the innovator. Recognition of this dilemma of the clinical innovator is not new. Halpert (1966) pointed out that many research findings that could improve clinical practice are virtually unknown to practitioners because they are either never published or never read by clinicians if they are published. In addition, there are traditionally numerous steps from innovation to adaptation: controlled clinical trials, archival data analysis, field testing, and systematic replications to other sites and populations that delay dissemination of the innovation (Backer, Liberman & Kuehnel, 1986). And, if either the research findings are known to the practitioner or the innovation has survived the gauntlet of evaluation, it must still pass the test most crucial to the practitioner: Is it appropriate to the practitioner's clinical environment? Thus, any evaluation of an innovative approach must also assess its utility. This requires, among other things, monitoring the appropriateness and quality of the adoption through competency-based and criterion-referenced scales and guidelines (Yeaton & Sechrest, 1981).

Liberman & Phipps (1987) have suggested one strategy for shortening the lag time between clinical innovation and dissemination. Although they were discussing the treatment of the chronically mentally ill, their suggestions are useful in this context also. They suggested that: (1) treatment units first nominate exemplary innovations; (2) researchers work with clinicians and service settings to develop other needed new procedures and techniques associated with these innovations; (3) learning modules be developed to convey the innovation and associated procedures and techniques; (4) treatment unit clinicians should be trained in the approach; (5) the impact of the innovation should be evaluated, and (6) model or demonstration programs in which all or part of the innovation is tested in vivo should be established.

Other attempts to focus on brief therapies through "large-scale omnibus studies" (e.g., Cross et al, 1982; Piper et al.,1984; Sloane et al., 1975, 1976; Strupp & Hadley, 1979) also included characteristics similar to the SCD design that will be described here. The characteristics included: (1) use of experienced therapists, (2) clients selected from a clinical population, (3) audio-recorded sessions for closer analysis, (4) multiple outcome measures, (5) appropriate controls, and (6) at least a one-year follow-up. But, given the cost of conducting such studies, few such studies have been conducted.

Koss, Butcher and Strupp (1986), have also noted the problems in much of the research on brief psychotherapy. They note that those participants excluded from studies are often those likely to be found among the caseload of many practitioners (e.g., suicidal, severely disturbed, older than 55). Thus, in their conclusion, they call for outcome research that explores "the impact of various brief psychotherapy approaches on a variety of homogeneous client populations" (p. 64). Such research is possible and can overcome these issues and others typically associated with psychotherapy research.

The design described below includes many of the suggestions noted above and attempts to avoid the problems commonly associated with such research, by using a clinical population, multiple measures of outcome and a six month follow up. Thus, many of the problems commonly noted such as reliance on client and therapist ratings as a sole outcome criteria, inability to correlate change in the client with number of sessions or total session time (Sifneos, 1975) are overcome.

The Systematic Clinical Demonstration Methodology

The approach suggested here expands on Liberman and Phipps (1982) suggestions. First, a specific problem to be studied is identified. Once the problem is identified, both the psychotherapy practice and research literature is surveyed and, most importantly, practitioners are surveyed for their input on the most efficient means to treat the identified problem. The leading experts in each of the approaches identified by the above methods then participate in a study of the effectiveness of the approach by treating pre-screened research clients who are evaluated prior to therapy and then are followed for six months. The critical factors to be studied are : How the client was functioning before treatment; how did they respond to treatment; and how long did the clinical treatment effects last? A detailed description of this methodology in practice is described below.

A study by Carbonell and Figley (1975) was the first to adopt this approach and will be used as the vehicle for demonstrating how the approach works. The problem identified by Carbonell and Figley involved the brief treatment of PTSD. The specific research questions posed were:

1. What PTSD treatment approaches are recommended by clinicians who have actually tried them with their clients because they cure PTSD?

2. What are the active ingredients in extremely efficient PTSD treatment approaches?

3. What do these approaches have in common that contribute to their effectiveness?

Step 1. Nominations for Efficient Treatments of PTSD

A review of the literature did not reveal answers to these questions, and so the second step in the methodology was pursued. First, the researchers designed an informal survey for practitioners. The survey was sent to the 10,000 members of the Internet special interest group consortium, InterPsych (Figley, 1994). The message was as follows:

"We are searching for a cure for PTSD and wish to find candidates for a study of treatments. The treatment approaches we want to study have four characteristics:

1. They are extremely efficient in that just a few sessions have an extraordinary impact on the clients progress in recovering from PTSD.

2. The clinical approach works under laboratory conditions, in that all clients will be carefully studied and all sessions video taped and observed by area clinicians as well as the research team.

3. The inventor would be willing to form a team and treat our research clients at our laboratory.

4. And the inventor would be willing to collaborate with us in finding a cure for PTSD and a theory about the trauma induction and reduction process."

In addition, Figley and Carbonell spoke to hundreds of practitioners personally to solicit nominations of treatment approaches. The treatments nominated were considered by an international scientific advisory board who made the final cut. The international scientific advisory board was made up of select traumatologists from around the world who are members of the Traumatology Forum. This Forum was started in April of 1994, in part, for the purpose of guiding this project.

Four of the nominated approaches appeared to satisfy all requirements. The innovators of each of these approaches was then contacted to determine if they would be willing to be part of the study. All four agreed to be part of the study, and the next step in the methodology began.

Step 2: Testing The Efficient PTSD Treatment Approaches

In the Figley and Carbonell (1995) study clients were recruited from newspaper stories and announcements and by word of mouth among area clinicians. Local radio stations made public service announcements about the study. Interested clients called the designated number, were told of the study and screened for suitability. Clients were told that the researchers were investigating various treatments for PTSD and that they would be assigned to one of the treatments. (The screening criteria would vary based on the treatment innovations being tested and on the problem being investigated). In this study, for example, clients with mental retardation were not appropriate, and were screened out. Clients were required to have some PTSD symptomology, although they were not required to have a diagnosis of PTSD.

If a client appeared suitable for the study, an appointment was made to complete the pre-testing protocol at the research laboratory. Clients were asked to sign an informed consent prior to any further interactions. If the client was willing to sign the informed consent, the pre-testing proceeded. The protocol included both paper and pencil testing and recording of physiological data ( skin temperature, blood pressure and GSR). At this time clients were given a "diary" and asked to keep a daily record of their "subjective units of distress" ( SUDS) on a scale of 1 to ten. The process of keeping the diary was explained and a set of instructions and the name of a contact person was attached to each diary. The Institutional Review Board (IRB) had reviewed and approved all procedures before the study began.

Following pre-testing, clients were scheduled for therapy with the treatment being evaluated. When they arrived for their therapy appointments they were introduced to their therapist who then escorted them into the therapy room. Each of the therapy rooms was equipped with audio visual recording equipment so that the therapist and the client would be recorded. The recordings were time stamped and labeled and retained for later analysis. Depending on the type of treatment, the time allotted for therapy sessions varied, but records were kept of the number of sessions and the time of each session. Although multiple sessions were scheduled for each client at the start of therapy, the therapist, in conjunction with the client ended therapy sessions when they decided that optimum improvement had been reached.

Immediately following treatment, a team member asked the research client the following questions: Did this treatment work? If so, how? If not, why not? What recommendations would you offer to improve the treatment? Physiological recordings were then repeated. Research clients were reminded to complete a daily diary of their subjective units of distress associated with the stress that brought them to treatment. Each was called by a research team member weekly to gather scores for the week, and to insure that some data would be available in the event that clients did not keep the diary as instructed. At the end of 6 months, research clients returned to the Clinical Laboratory to be re-tested on the original paper and pencil measures.

Community Involvement

In order to make the innovations accessible to the public, each of the innovators provided two workshops for the local mental health community. The first workshop was a presentation of their theory and of their treatment technique. A week later, a second workshop was presented where the innovator presented the results of their weeks' treatment and the researchers served as panel discussants. Initial findings were presented and the audience participated in the discussion. Thus, the innovations became known to the local mental health professionals who previously had little contact with these approaches.

Summary

The SCD methodology is a method for evaluating innovative techniques and can also be used to bring these techniques to mental health practitioners who might not have even known of the availability of the treatment. The methodology also avoids many of the pitfalls of psychotherapy research in that it uses "real" clients, experienced practitioners, has multiple measures of outcome, and follows clients for six months. It has the dual benefit of evaluating a new or innovative procedure and making it available for public scrutiny .

References

Backer, T. E., Liberman, R. P., & Kuehnel, T. G. (1986). Dissemination and adoption of innovative psychosocial interventions. Journal of Consulting and Clinical Psychology, 54:1, 111-118.

Carbonell, J. and Figley, C. (1995). The Active Ingredient Project: Initial Findings. Unpublished manuscript.

Cross, D. G., Sheehan P. W., & Khan, J. A. (1982). Short- and long-term follow-up of clients receiving insight-oriented therapy and behavior therapy. Journal of Consulting and Clinical Psychology, 50, 1103-112.

Figley, C. R.(1995) Editorial. TRAUMATOLOGY, Volume 1, Issue 1, 1-3.

Halpert, H. P. (1966). Communications as a basic tool in promoting utilization of research findings. Community Mental Health Journal, 2, (3), 231-236.

Koss, M. P., Butcher, J. N. & Strupp, H. H. (1986). Brief psychotherapy methods in clinical research. Journal of Consulting and Clinical Psychology, 54:1, 60-67.

Liberman, R. P. & Phipps, C. C. (1987). Innovative treatment and rehabilitation techniques for the chronically mentally ill. In W.

Menninger & G. Hannah (Eds.), The chronic mental patient. Washington, DC: American Psychiatric Press,1966,

Paul, G. L. (1967). Insight versus desensitization psychotherapy two years after termination. Journal of Consulting and Clinical Psychology, 31, 333-348.

Piper, W. E., Debbane, E. G., Bienvenu, J. P., & Garant, J.(1984). A comparative study of four forms of psychotherapy. Journal of Consulting and Clinical Psychology, 52, 268-279.

Sifneos, P. E. (1975). Criteria for psychotherapeutic outcome. Psychotherapy and Psychosomatics, 26, 49-58.

Sloane, R. B., Staples, F. R., Cristol, A. H., Yorkson, N. J., & Whipple, K. (1975). Psychotherapy versus behavior therapy. Cambridge, MA: Harvard University Press.

Sloane, R. B., Staples, F. R., Cristol, A. H., Yorkson, N. J., & Whipple, K. (1976). Patient characteristics and outcome in psychotherapy and behavior therapy, Journal of Consulting and Clinical Psychology, 44, 330-339.

Strupp, H. H., & Hadley, S. W. (1979). Specific versus nonspecific factors in psychotherapy: A controlled study of outcome. Archives of General Psychiatry, 36, 1125-1136.

Yeaton, W. H. & Sechrest, L. (1981). Critical dimensions in the choice and maintenance of successful treatments: Strength, integrity, and effectiveness. Journal of Consulting and Clinical Psychology, 49, 156-167.

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