Making Research Clinician-Friendly

Les Greene, PhD, FAGPA

“Translational” has not been a familiar word for me. However, I quickly became steeped in its meaning during my first meeting of an ongoing series of Open Sessions sponsored by the National Advisory Mental Health Council (NAMHC). In fact, “translational” seemed the core theme of this particular meeting, held in early February in Washington, DC. Both the Council and its parent organization—the National Institute of Mental Health (NIMH)—expressed considerable and repeated concern at this forum—perhaps rightly so—about insular tendencies within NIMH. Voices both inside and outside the nation’s premier mental health research funding organization, including such strange bedfellows as consumer advocacy groups and psychotherapy researchers, have increasingly criticized the provincial nature of the Institute’s research products. The essence of the mounting arguments is that the diverse studies funded by NIMH have remained relatively isolated within narrowly defined and discrete domains, with little cross fertilization vis-a-vis other scientific fields, and especially with little relevance to clinical matters.

To its credit, NIMH, now directed by Dr. Steven Hyman, seems quite attentive to the issue of boundary rigidification, a structural problem of organizational life that we as group psychotherapists can readily understand and appreciate. In response to such concerns, the NAMHC, a heterogeneous mix of some 20 academicians, executives of mental health organizations, and mental health consumer advocates, has been created as a conduit for the needs and values of the larger community, input that can vitally influence the course of NIMH’s research mission. Two or three times a year, the Council opens its doors to allow representatives of outside organizations a view, and to some modest degree, a voice, in its deliberations and consultations to NIMH. Much of the actual decision-making regarding allocations of research funding and calls for proposals takes place in closed sessions or in specially convened workgroups composed of staffs of NIMH and NAMHC and others recruited from the outside. The Open Sessions seem designed to showcase much of the recent work that has been done but also permit some further input from attendees.

In the meeting held at NIMH headquarters in Rockville, Maryland, Dr. Hyman’s emphasis on the complex, multi-determined nature of psychopathology was heartening. He reiterated that reductionistic models, such as the search for one defective gene, are not the prevailing view at NIMH. As a consequence, research conducted at and across many levels is needed. This refrain was echoed in a final report prepared by a workgroup focusing on the contributions of basic behavioral science research. The essential criticism here was of a “disconnect” between the specific domain, in this case the study of core psychological and behavioral variables (e.g., cognition, social process, affect regulation) and the treatment of mental illness. The workgroup urged that the highest funding priorities be given to those behavioral science grants that take a “translational” perspective, specifically a view that incorporates applications to the clinical arena, both in terms of etiology and treatment. In this context, there has been a recent program for research proposals aimed at investigating those basic behavioral mechanisms and processes that enhance or interfere with adherence to treatment interventions. It is interesting to note, as we have reviewed elsewhere (Greene, in press-b), that there is a small but developing body of research of this kind that has relevance to group psychotherapy, namely investigations that examine whether group processes can enhance compliance with substance abuse treatment.

A second major aspect of what amounts to a significant new directive for NIMH was the report by another NAMHC task force—the Clinical Treatment and Services Research workgroup. Highlights of “Bridging Science and Services,” (NAMHC’s Clinical Treatment and Services Research workgroup, 1999) were read at the meeting. Some 49 recommendations were offered by this workgroup, all designed to “increase the usefulness of NIMH research for individuals with mental illnesses, clinicians, purchasers and policymakers” and to achieve this in large measure by developing large scale, naturalistic studies in real-world clinical settings. In the jargon of research, the new emphasis is on effectiveness, as compared to efficacy, studies (Donenberg, Lyons & Howard, 1999; Norquist, Lebowitz, & Hyman, 1999). We have recently discussed (Greene, in press-a) how psychotherapy research to date has largely ignored clinical relevance for the sake of maximizing internal validity. The typical laboratory-based efficacy study, replete with randomized, double blind assignments, active comparison conditions, symptom focused, psychometrically sound measures, and as the latest requisite of the research protocol, manualized treatments, has aimed at eradicating sources of error variance (Greene, in press-a). Ironically, because this goal has been so successfully achieved, i.e. because the clinical-research enterprise has become so sanitized and tightly controlled, the findings obtained from these settings have lost applicability and generalizability to actual, less rarefied clinical contexts. Figure and ground will be reversed in these new “real-world” studies. What was considered error variance in the efficacy study will be embraced and explored within the large scale effectiveness investigations in order to discover what actually happens in the field and what really works. The ground-breaking recommendations of the NAMHC workgroup are just now being implemented. Dr. Hyman described the first two such large-scale studies that will follow what is dubbed “the public health model of intervention.” One of the studies, a $30 million grant to investigate refractory depression in adults, should have implications for psychotherapy in general and possibly group psychotherapy in particular, by assessing outcomes as a function of differing frequencies and modalities of psychotherapy.

In general, the essence of this Open Session, with its overarching emphasis on linking research and clinical practice (domains long split from each other), was encouraging. As group psychotherapists, we are faced with increasing pressures for bottom-line accountability in terms of demonstrating the effectiveness of our work. The current meeting suggests that researchers need to be more sensitive to what clinicians actually do and to conduct clinician-friendly investigations that study those actual processes and practices. 

The other side of the coin is that psychotherapists need to appreciate the increasingly influential role of research. The Surgeon General’s Report on Mental Health (U.S. Department of Health and Human Services, 1999), briefly discussed at the meeting, gives strong endorsement to psychotherapy as a viable treatment in major psychiatric disorders, but gives only passing reference to group psychotherapy as a specific therapeutic modality. In terms of “empirical validation” with which the report bases its recommendations and conclusions, group psychotherapy is far overshadowed by quantitative findings obtained from individual psychotherapy. Moreover, the only mode of group treatment that has received substantial empirical evidence is a short-term, cognitive-behavioral format. To keep our work viable, and reimbursable, we need to be more active—and perhaps the new funding direction of NIMH will help spur interest—in scientifically demonstrating what we know, or think we know, clinically.

References

Donenberg, G., Lyons, J. & Howard, K. (1999). Clinical trials versus mental health services research: Contributions and connections. Journal of Clinical Psychology, 55, 1135–1146.

Greene, L.R. (in press-b). Group psychotherapy research: Current status and future trends on the dawn of the new millennium. Group.

Greene, L.R. (in press-a). Research in group psychotherapy for substance abuse: Fiction, fact and future. In D.W. Brook & H.I. Spitz (Eds.) Group Psychotherapy of Substance Abuse. Washington, DC: American Psychiatric Press.

National Advisory Mental Health Council’s Clinical Treatment and Services Research Workgroup. (1999). Bridging science and service. Available on the web: www.nimh.nih.gov/research/bridge.htm.

Norquist, G., Lebowitz, B., & Hyman, S. (1999). Expanding the frontier of treatment research. Prevention & Treatment, 2, Article 00001a. Available on the web: www.journals.apa.org/prevention/volume2/pre0020001a.html.

U.S. Department of Health and Human Services (1999). Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

This article was published in the December 2000/January 2001 issue of The Group Circle.