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This article was downloaded by: [University of North Texas]On: 21 November 2014, At: 06:37Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T3JH, UK
Journal of Social ServiceResearchPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wssr20
Bridging the gap betweenclinical practice andresearch: An integratedpractice‐oriented modelA. Ka Tat Tsang aa Assistant Professor, Faculty of Social Work ,University of Toronto , 246 Bloor Street West,Toronto, Ontario, Canada , M5S 1A1 E-mail:Published online: 01 Jul 2009.
To cite this article: A. Ka Tat Tsang (2000) Bridging the gap between clinicalpractice and research: An integrated practice‐oriented model, Journal of SocialService Research, 26:4, 69-90, DOI: 10.1080/01488370009511337
To link to this article: http://dx.doi.org/10.1080/01488370009511337
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Bridging the GapBetween Clinical Practice and Research:An Integrated Practice-Oriented Model
A. Ka Tat Tsang
ABSTRACT. This paper addresses the gap between clinical practice andclinical research. Adopting a postmodern neopragmatic position, a prac-tice-oriented research model is proposed. This model cuts across the divi-sion between paradigmatic and narrative approaches to clinical practiceresearch and integrates quantitative and qualitative research methodolo-gies. Four guiding principles are operationalized: (1) clinical researchshould focus on practice-oriented questions, with the practitioner involvedin agenda setting and research question formulation; (2) the division be-tween empiricist and constructivist positions and that between quantitativeand qualitative methods can be resolved through epistemological andmethodological pluralism; (3) clinical research should be guided by adevelopmental perspective; and (4) collaboration between practitionersand researchers has to take place both on the program and the institutionallevels. [Article copies available for a fee from The Haworth Document DeliveryService: 1-800-342-9678. E-mail address: <[email protected]> Web-site: <http:llwww. ha worthpressinc, com >]
KEYWORDS. Practice-research gap, integrated practice-oriented model,postmodern neopragmatism, epistemological and methodological pluralism
The gap between research and practice has been well documented.Clinical practitioners generally do not read or utilize clinical research in
A. Ka Tat Tsang is Assiatant Professor, Faculty of Social Work, University ofToronto, 246 Bloor Street West, Toronto, Ontario, Canada M5S 1A1 (e-mail:[email protected]).
Submitted: 2/99; Revision Received: 6/99; Accepted: 7/99.
Journal of Social Service Research, Vol. 26(4) 2000© 2000 by The Haworth Press, Inc. All rights reserved. 69
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their practice (Morrow-Bradley & Elliott, 1986; Rosen, 1994) and seldomparticipate in research (Bednar & Shapiro, 1970; Norcross, Prochaska, &Gallagher, 1989; Vachon, Susman, Wynee, Berringer, Olshefsky, & Cox,1995; Wakefield & Kirk, 1996). Consequently, clinical research has littleimpact on practice (Anderson & Heppner, 1986; Barlow, 1981; Cohen,Sargent, & Sechrest, 1986; Falvey, 1989; Howard, 1985) and practitio-ners rely on value-based normative assertions, clinical training, personaland clinical experience, and clinical intuition to make clinical decisions(Kanfer, 1990; Rosen, 1994). The need to bridge the research-practicegap has been noted by a number of authors and a number of strategieshave been suggested (Howard 1985; Kanfer, 1990; Tally, Strupp, &Butler, 1994). This paper aims at contributing to the integration of prac-tice and research by examining critical research issues and proposing apractice-oriented approach to clinical practice research.
The perceived relevance or irrelevance of research is to a large extentrelated to whether the research program is practice-oriented. When re-searchers design their studies, methodological considerations such aswhether variables can be easily operationalized and measured or howclients are to be recruited and randomly assigned often take precedenceover relevance considerations such as what does the practitioner want toknow or how can the results be translated into practice procedures. Thefield of clinical practice research is sometimes more energized by academicdebates which divide researchers into opposing camps than by a commit-ment to address important practice issues (Padgett, 1998). For example, thedebates over positivism versus constructivism, and those over qualitativeversus quantitative method may not be seen as particularly relevant to thepractitioner who has to address a diverse range of questions which do notfit nicely into one of these divided categories (Fraser, Taylor, Jackson, &O'Jack, 1991). A major assumption of this paper is that clinical practiceresearch should support clinical practice by providing results which arerelevant to the practitioner. One of the first questions that the clinicalpractice researcher has to ask is what does the practitioner need to know.Taking such a practice-oriented position, issues in clinical practice researchwill be examined with regard to the practice agenda.
FROM EVALUATING OUTCOMETO INTENSIVE ANALYSIS OF PROCESS
A historical perspective will help us understand the current issues inclinical practice research. Systematic clinical practice research first
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flourished in the seventies when the value and effectiveness of clinicalpractice were questioned. Initial research findings were not encourag-ing (Fischer, 1973; Mullen & Dumpson, 1972; Segal, 1972; Wood,1978). This somehow set the tone for many practitioners when theythink of clinical practice research. Despite the subsequent emergenceof a substantial body of research studies that confirm the generaleffectiveness of clinical practice (e.g., Fischer, 1981; Reid & Hanra-han, 1982; Rubin, 1985; Thomlison, 1984; Videka-Sherman, 1988),research is still associated with the threat of negative evaluation formany practitioners.
The focus on evaluating outcome, though addressing the importantissue of effectiveness, is not sufficiently practice-oriented for a num-ber of reasons. First, the researcher assumes a secure external positionin relation to the practitioner whose competence is called into ques-tion, thus creating a skewed power relationship which is not conduciveto trust and collaboration. Another problem is that outcome evaluationin itself does not provide the practitioner with information for improv-ing practice competence. Findings based on correlational analysis ofaggregate baseline characteristics of clients often do not help clinicaldecision making. For example, the knowledge that a particular groupof clients sharing common characteristics such as age, gender, socio-economic status, psychiatric diagnosis, or ethnic background has ahigher chance of obtaining positive outcome than another group is notof much clinical relevance to the practitioner who has to work withthese clients. A third problem is that outcome research often demandsconditions which are very different from the practice realities of thepractitioner. The adoption of the classical randomized controlled trial(RCT) design, for example, requires the presence of a diagnosticallyhomogenous group of clients, control over the assignment of clients totreatment programs, and standardized application of a uniform clinicalpractice procedure. These conditions are rarely met in the actual prac-tice situation. Even when these conditions are met, the interventionbeing studied is so different from the everyday practice situation thatthe external validity of the study is questionable (Roth & Fonagy,1996). In clinical social work practice, similar experimental designsare very rarely adopted (Epstein, 1993; Marino, Green, & Young,1998).
In order to make clinical practice research more relevant to practice,researchers have to recognize the need to move beyond evaluation of
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outcome and start to examine the actual clinical process in order togenerate research findings relevant to the practitioner (Safran, Green-berg, & Rice, 1988; Videka-Sherman & Reid, 1990). This shift offocus is, at least in part, made possible by the consistently positivefindings generated by outcome studies in the last two decades (Whis-ton & Sexton, 1993). When the overall effectiveness of clinical prac-tice is no longer the most pressing issue, research efforts can be fo-cused on understanding the change processes. The primary objectiveof process-outcome research is to identify clinical procedures associ-ated with positive clinical outcome. The results will be immediatelyrelevant to the practitioner as the findings are about the effects ofspecific interventions undertaken by the practitioner (Rice & Green-berg, 1984).
The emergence of this new focus, however, finds itself amidst ma-jor epistemological and methodological debates. These debates areusually conducted along major lines of division among researchersand academics. They include the divisions between outcome and pro-cess research (Hill & Corbett, 1993; Orlinsky, Grawe, & Parks, 1994),between a positivist-empiricist and a constructivist epistemology(Fraser, Taylor, Jackson, & O'Jack, 1991; Schwandt, 1994; Sexton &Griffin, 1997), between paradigmatic and narrative approaches (Touk-manian & Rennie, 1992), between extensive and intensive research(Safran, Greenberg, & Rice, 1988), between quantitative and qualita-tive methods (McLeod, 1996; Sherman & Reid, 1994), and betweenexperimental and naturalistic designs (Hill, 1994). These divisions,though not identical, are often close parallels to one another. It is morelikely for outcome researchers to subscribe to a positivist-empiricistepistemological position, to follow a paradigmatic approach, to use anextensive sample, to use quantitative methods, and to employ an ex-perimental design such as the RCT (randomized controlled trials).Similarly, a process researcher is more likely to subscribe to aconstructivist epistemology, to follow a narrative approach, to performintensive analysis on a smaller number of cases, to use qualitativemethods, and to employ naturalistic designs. Methodological discus-sions in clinical practice research are usually conducted on the basis ofthese divisions. Many researchers are led to believe that one has tochoose between these alternative options in clinical practice research,and that these alternatives are incompatible with each other. A majorargument of this paper is that these epistemological and methodologi-
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cal divisions are not absolute and essential, and that synthesis andintegration are not only possible, but are potentially beneficial andmay even be necessary in the development of practice-oriented re-search programs.
POSTMODERN NEOPRAGMATISM
The notion that a researcher only needs to make the decision onceand can then stay on the chosen side of the division seems to be asimple and convenient one. To resign to a single way of making senseand a single way of doing research is, however, a strategy whichassumes that reality can only be seen as having one essential nature, beit socially constructed or objective and external. The heterogeneity ofour experiences of reality does not lend itself readily to such a simpleepistemological approach. In clinical practice, the variety of researchand professional issues demand answers of such a diverse nature thatthe adoption of a single epistemological and methodological positionis not commensurate with the demands of ethical and competent prac-tice. The practitioner needs to find answers to a diverse range ofquestions such as: Is my practice effective? Has the client reallychanged? Can the change be attributed to my intervention? Do I un-derstand what the client is trying to tell me? What is the meaning ofthe presenting issues to the client? How significant are these issues tothe client and people in his or her life? What can I do to engage betterwith the client? What is a better clinical strategy or procedure to adoptgiven my understanding of the client's situation? The answers to thesequestions are unlikely to be obtained through a single research proce-dure based on a single epistemological position.
Our engagement with reality is almost inevitably site-specific. Ourepistemology has to be connected with the purpose of the engagement.There are parts of our experience that we choose not to question, andtake as objectively real; and there are other parts that we activelyinterrogate and try to examine how they are constituted. Practitionersand researchers in different sites have diverse purposes and needs. Theknowledge that needs to be generated and the specific practice orresearch agendas to be pursued vary accordingly. In social work prac-tice research, the epistemological issue has to be considered in relationto what the research question is. The a priori determination of one'sepistemological commitment fosters the cart-before-the-horse phe-
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nomenon of choosing the method before the research question. It isnot unusual to find social work researchers to proclaim that they arecommitted to quantitative (and assume it to be necessarily positivist-empiricist) or qualitative (and assume it to be necessarily constructiv-ist) methods before they even know what they want to find out. Con-trary to conventional recommendation that the research questionshould determine the design (Proctor, 1990), this approach severelyrestricts the researcher's capacity to engage with the complex realitiesof clinical practice. A clinical practice unit trying to justify its funding,for example, has a different research question from that of a practitio-ner trying to understand the meaning and significance of client narra-tives. The adoption of a positivist-empiricist position and the produc-tion of quantitative data may be an appropriate strategy to demonstratethe cost-effectiveness of a clinical practice program whereas a narra-tive-based interpretive approach may be utilized to understand themeaning of stories told by clients.
The idea that epistemology is contingent upon practical purpose hasbeen asserted by Polkinghorne (1992) in his discussion of a postmod-ern epistemology of practice. He suggests that postmodern epistemol-ogy is characterized by a foundationlessness which means that we cannever claim that we have constructed a picture that perfectly reflectsan independent reality. Human knowledge is necessarily constructedin terms of the cognitive structures or interpretive schemas utilized tomake sense of our experiences. It can be argued that the positivist-em-piricist paradigm is one of these interpretive schemes shared by acommunity of social scientists. Kuhn (1970), in his discussion ofscientific paradigms, also emphasizes that paradigms are shared by acommunity of practitioners. Human realities do not present them-selves as a single integrated whole. The diversity and heterogeneity ofexperience produce knowledge which is fragmented. The possibilityof multiple or fragmented rendering of the same experience or phe-nomenon is compatible with the fluidity and indeterminancy of reality.Polkinghorne (1992) proposes a neopragmatism which emphasizes thedocumentation of courses of actions that accomplish intended ends.Instead of making the claim that one's research produces a picture thatcorresponds to reality, the neopragmatist aims at generating knowl-edge that guides action towards desired outcomes.
From a postmodern neopragmatic perspective, the positivist-empir-icist and the constructivist positions are not to be taken as incompat-
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ible epistemological commitments. Depending on the subject matter,the purpose of the research, and the practical purpose it is supposed toserve, methods developed from supposedly different epistemologicaltraditions can be employed in a program of research. In their review ofmethods in clinical research, Rennie and Toukmanian (1992) charac-terize the two major research approaches as the paradigmatic and thenarrative approaches. This classification can be traced back to Bruner(1986) who describes the paradigmatic and the narrative as two differ-ent modes of thought, or two ways of ordering experience andconstructing reality in the human sciences. The paradigmatic approachis logico-scientific, seeking to develop and test hypotheses about caus-al relationships among phenomena. These relationships are taken toreflect more general underlying laws. Following a positivist epis-temology, practitioners of the paradigmatic approach are committed tothe discovery of a reality external to the investigator which can beknown objectively. In this approach, reliability of observation is em-phasized while quantification is a preferred device for representing theunderlying order or lawfulness. In contrast, the narrative approach isinductive and hermeneutical. This approach emphasizes the representa-tion of experience by agents and the process of interpretation. Reality isseen as constructed, involving complicated processes of meaning gen-eration and transformation. In the narrative approach, words and theirmeanings are preferred to numbers in representing clinical reality.
The division between paradigmatic and narrative approaches over-lap significantly with the other divisions mentioned above. It is, how-ever, important to note that authors who describe these divisions oftensuggest that they are not incompatible but can be meaningfully com-bined. Bruner (1986), for example, maintains that the paradigmaticand the narrative modes of thought are complementary and irreducibleto one another. A number of clinical practice researchers (e.g., Safran,Greenberg, & Rice 1988; Sherman & Reid, 1994; Videka-Sherman &Reid, 1990) are in support of an integrated approach to psychotherapyprocess research, especially when different stages of study are beingconsidered. Sherman (1990) suggested that a change process approachshould be considered a necessary complement to the old paradigmwhich was focused on empirical evaluation of outcomes. Rennie andToukmanian (1992) recommended a methodological pluralism andepistemological synthesis. They proposed that the strengths of therespective approaches should be optimized. Methods seen as repre-
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senting different approaches might be incorporated at different stagesof a study, or used to address different aspects of a research question.Harrison (1994) even argues that integration is inevitable in socialwork research.
CLINICAL PRACTICE RESEARCH:AN INTEGRATED PRACTICE-ORIENTED MODEL
These recommendations for an integrative approach to clinicalpractice research have, however, not been systematically operational-ized. This section will introduce a model of integrative research whichis practice-oriented. This approach to research is capable of addressingthe critical issues in clinical practice and engaging the practitioner.Consistent with postmodern pragmatism, methodological decisionsare made with reference to the objective of the research project and thespecific research questions asked. Recognizing the fact that practitio-ners are a diverse group and do not share a single research agenda, theproposed model addresses the diverse knowledge needs of practitio-ners but also provides a conceptual structure to connect these researchagendas without unnecessarily dichotomizing or polarizing them. Anintegrative practice-oriented approach to research is, therefore, char-acterized by the following features: (1) focus on practice-orientedquestions; (2) epistemological and methodological pluralism; (3) de-velopmental perspective; and (4) collaboration between practitionersand researchers.
Formulating Research Questions
Following a postmodern neopragmatic approach, the first step inpractice-oriented research is the formulation of the research questionsand specifying the information or knowledge needed for practice.Instead of allowing the researcher's epistemological and methodologi-cal preferences to restrict the range of research questions asked, anintegrative practice-oriented research program brings in the appropri-ate methods and procedures to address practice issues. This orientationfacilitates responsiveness to the changing contexts of practice and theassociated demands. For example, within the current context of dimin-ished public funding and managed care, service providers are more
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often required to provide evidence of cost-effectiveness of specificservice units and programs. Funders and HMOs are increasingly in-volved in defining what are the desired outcomes of clinical practice(Hoyt, 1995; Jarman-Rhode, McFall, Kolar, & Strom, 1997; Strom,1992). In order to balance the demand for cost-effectiveness and theneed to provide adequate service to clients, practitioners need to haveresearch information which can inform clinical decision making aswell as satisfying the administrative and accountability requirementsof the funders. Simple outcome studies demonstrating that a givenintervention is superior to no treatment at the conventional level ofstatistical significance may not be adequate. The practitioner probablyneeds specific information on what intervention method works bestfor which group of clients as well as the duration of treatment neededto achieve positive outcome. These research questions require multi-ple outcome studies on specific interventions applied to specificgroups of clients, probably involving multiple group designs thatcompare different interventions (Roth & Fonagy, 1996). It is alsoexpected that studies that pay special attention to the effect of durationof treatment on outcome (e.g., Howard, Kopta, Krause, & Orlinsky,1986; Kadera, Lambert, & Andrews, 1996) will become increasinglyimportant.
Apart from establishing cost-effectiveness, another kind of researchdata which is likely to be relevant to the practitioner is information onspecific clinical procedures associated with positive client change.The relevance of process-outcome research for this purpose has al-ready been well documented (Harrison, 1994; Safran, Greenberg, &Rice, 1988; Toukmanian & Rennie, 1992). In the last two decades, awide variety of research procedures have been developed to addressdiverse practice issues (Hill, 1990; Hill & Corbett, 1993; Hill, Nutt, &Jackson, 1994). Given this positive development, one of the majorchallenges for the next decade will be the application of process-out-come studies to develop research-based clinical practice models for anincreasingly diverse population. The field of cross-cultural clinicalpractice is still dominated by studies investigating baseline variables,many of them using analogue designs rather than actual clinical data(Atkinson, 1983; Betancourt & Lopez, 1993; Ponterotto, 1988; Pon-terotto & Casas, 1991; Speight & Vera, 1997). Systematic process-out-come studies are rarely carried out, even though they have been rec-ommended by a number of reviewers (e.g., Speight & Vera, 1997; Sue,
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Zane, & Young, 1994). The area of cross-cultural clinical practicefurnishes numerous examples of the research agenda being drivenmore by the consideration of convenience with regard to subject re-cruitment, operationalization of variables, measurement and instru-mentation than by the consideration of what information is likely to beuseful to the practitioner. An integrative practice-oriented approachmay help to adjust the focus of research in this area.
Another major challenge for clinical practice which might havesignificant implication on the formulation of research questions is thetrend of psychotherapy integration. Comparative outcome studies inthe last three decades generally show positive post-interventionchanges regardless of the orientation of the tested clinical practicemodels; and between-model difference is rarely demonstrated (e.g.,Arnkoff, Victor, & Glass, 1993; Lambert, Shapiro, & Bergin, 1986;Smith, Glass, & Miller, 1980). Since research does not support therelative superiority of particular models, there is a growing trend in thefield towards integration (Glass, Victor, & Arnkoff, 1993; Lambert,1992; Newman & Goldfried, 1996). Integration practice requires aresearch program which supports clinical decision making which canmatch client circumstances and needs with specific clinical procedures,and monitoring of the change processes when procedures are adoptedfrom different clinical practice models. Such a research program islikely to involve intensive analysis of specific clinical procedures inrelation to their immediate clinical effects and final clinical outcome,thus requiring both outcome study and process study methods.
The above examples of possible research questions illustrate themultiple practice research agendas and the need to adopt varied re-search methods and procedures. The next section will explore howmultiple methods based on different epistemological positions can beintegrated into a practice-oriented research program.
Epistemological and Methodological Pluralism
Epistemological and methodological pluralism is a relevant issueeven when the research question appears to be simple and straightfor-ward. For example, when a service unit is interested in establishing theeffectiveness of its clinical programs, what constitutes positive out-come is a critical issue. Strict adherence to a positivist-empiricistposition will lead to a preference for objectively established measureswith satisfactory psychometric properties. Measures of mental health
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status, social adjustment, self-image, and the scaling of client satisfac-tion level will be considered key variables. Practitioners in actualpractice, however, rarely rely exclusively on psychometric measuresto assess the clinical outcome of their clients. A wide range of infor-mation is usually considered, including the clients' subjective state-ments, in-session behaviour of the clients, and the subjective assess-ment of the practitioner. The utilization of psychometric and narrativedata in a complementary manner is nothing new to most practitioners,and most of them try to synthesize both sources of information in theirclinical assessments and formulations (Shaw & Shaw, 1997). In doingso, practitioners negotiate with multiple constructions of reality, rang-ing from objectively quantifiable phenomena such as drug intake,frequency of abusive behaviour, to subjective experiences which maybe articulated through different narrative devices such as stories,dreams, and metaphors. The challenge for the researcher is to be ableto engage with these realities which are meaningful both to the clientand the practitioner. Dichotomizing human realities according to po-larized epistemological positions increases the risk of excluding infor-mation which is relevant to the practitioner and the client and thereforecreating a picture of reality that is not engaging and persuasive forthem. In establishing outcome, for example, it is possible for theclinical practice researcher to include multiple sources of informationand examine how they relate to each other.
A similar epistemological and methodological pluralism becomesparticularly relevant when the purpose of the research is not limited tooutcome and involves the investigation of process. Understanding thechange process with any given intervention model usually requiresnarrative methods as defined by Rennie and Toukmanian (1992). Theanalysis of clinical processes, however, almost always requires theengagement with multiple realities. The first reality is the actual clini-cal events, usually recorded electronically. These events representingthe interaction between the client and the practitioners are usuallytaken as facts and are transcribed, coded, or categorized. The physicalfeatures of these recordings such as time units, number of speechturns, or number of lines on the transcript are often taken as objectivefacts and dealt with as such by process researchers (e.g., Luborsky,Barber, & Diguer, 1992; Nye, 1994). The same researchers usuallysimultaneously engage with another reality which is the meaning ofthe narratives produced. This reality is usually accessed through her-
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meneutical and interpretive procedures. Through narrative analysis,researchers bring in a variety of analytic schemas which then interactwith the objective recordings to produce units or structures of mean-ings such as narrative categories (e.g., Nye, 1994), story components(e.g., Chambon, 1994), use of metaphors (e.g., Rasmussen & Angus,1997), or relationship episodes (e.g., Luborsky, Barber, & Diguer,1992). The use of narrative and discourse analysis procedures createsmultiple ways of constructing clinical reality which may focus onclient narratives, practitioner intervention, interaction patterns, or oth-er dimensions of the clinical engagement between client and practi-tioner. It should also be emphasized that studies of clinical processesthrough narrative method almost always refer to the relationship be-tween these processes and clinical outcomes. Most of these studies,sometimes explicitly and sometimes implicitly, attempt to show thatcertain sequences or patterns of clinical processes are differentiallyassociated with positive and negative clinical outcomes. Although acausal relationship is not always claimed, the pragmatic purpose ofnarrative analysis in clinical process research or process-outcome re-search connects the analysis with a practice-oriented agenda. Theresearch results that the practitioner needs are those which can informclinical decision making, usually with the anticipation that particularpractitioner actions are more likely to lead to desired changes in theclient.
Developmental Perspective
Accepting epistemological and methodological pluralism as a re-search orientation enables researchers to engage more fully with pro-grams of clinical practice research which are developmental in nature.Advocates of particular designs and methods, be they based on theempiricist experimental paradigm such as the RCT (e.g., Epstein,1993) or based on a more naturalistic orientation (Heineman Pieper,1994), usually emphasize the relevance of their approach by assuminga specific scope of research questions such as demonstrating a causalrelationship between intervention and outcome, or exploring naturallyoccurring clinical processes through heuristic procedures. It is clearthat any one of these approaches cannot address all the research needsof the practitioner. The necessity of some combination of methods andprocedures within epistemological and methodological pluralism be-comes more obvious when research programs, instead of specific
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studies, are considered. Using the area of cross-cultural clinical prac-tice as an example again, this section will illustrate how multiplemethods are necessary in developing a research program to address acritical practice issue.
The awareness of the increasing ethnic and cultural diversity inNorth American populations has led to a proliferation of publicationson cross-cultural clinical practice. Most of the recommended modelsof practice, however, are not based on empirical research (Tsang &Bogo, 1997). In order to develop a research-based model of cross-cul-tural clinical practice, both outcome study and process study proce-dures are needed (Speight & Vera, 1997; Sue, Zane, & Young, 1994).There are at least two alternative strategies for model development incross-cultural clinical practice. One is the application of empiricallyestablished models of practice to cross-cultural practice situations.The other is to use a discovery-oriented approach to practice modeldevelopment.
In the case of application of established models to cross-culturalpractice, a group comparison design is needed to investigate howethnocultural differences between client and practitioner affect clinicaloutcomes. If systematic differences in outcome are identified, processresearch is needed to examine how ethnocultural differences areplayed out in the actual clinical interaction between client and practi-tioner. This intensive analysis will then inform the development ofspecific guidelines for cross-cultural practice and may lead to modifi-cation of the original model. The revised practice model may then betested through an experimental design such as an RCT to see if it hassuperior effectiveness compared to existing practice.
Alternatively, researchers can follow a discovery-oriented ap-proach. Instead of testing the applicability of established modelscross-culturally, a discovery oriented method starts with what practi-tioners are actually doing in everyday practice. Since most practitio-ners tend to be somewhat eclectic in their practice and only a minorityis committed to following prescriptive models (Smith, 1982), thisapproach can be considered more practical. Given the argumentsagainst classifying clients into broad ethnocultural categories (Dyche &Zayas, 1995; Ho, 1995), researchers may choose not to use a groupcomparison experimental design which assumes that client-practitionerdyads can be neatly classified into ethnoculturally-similar and ethno-culturally-different categories. Taking these issues into consideration,
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a naturalistic research design may be adopted. This design allows theresearcher to study what practitioners are actually doing in their every-day practice. Multiple dimensions of ethnocultural differences be-tween client and practitioner can be assessed without inappropriatecategorization. A naturalistic design also has better external validitythan an experimental design using highly prescriptive manualized in-tervention procedures.
Following discovery-oriented naturalistic designs, the researchercan differentiate between positive and negative outcome cases andinvestigate if there are clinical processes systematically associatedwith different outcomes. As in the other alternative, intensive analysisof clinical processes is needed. Similarly, the process analysis willinform practice guideline generation and practice model development.The new model, as suggested for the alternative approach, can then betested for improved effectiveness using an experimental design.
The brief description of alternative approaches to clinical practicemodel development, using cross-cultural practice as an example, illus-trates the need for multiple designs, methods, and procedures at differ-ent stages of model development. The idea of developmental researchis not new in social work (Thomas, 1985, 1989). The present discus-sion, however, emphasizes a postmodern neopragmatic orientationand the relevance of epistemological and methodological pluralism.The proposed approach recognizes the principle of equifinality, alsosuggested by Polkinghorne (1992), which maintains that there aremultiple ways of achieving the same goal. The same principle can beapplied to understand both clinical practice and clinical research. Thecomparative research on intervention systems and the trend towardspsychotherapy integration reflects the principle of equifinality in clini-cal practice in that different pathways of therapeutic change are pos-sible. Recently, social work researchers have adopted a number ofprocess research methods which are particularly useful in practicemodel development because of their capacity for elucidating clinicalpractice procedures and associated change processes. One example istask analysis (Greenberg, 1992) which studies clinical tasks and theirsequential order by analyzing session transcripts. The focus is onunderstanding the underlying mechanism of clinical change in a step-by-step manner in order to delineate explanatory models for specificclinical procedures such as cognitive change (Berlin, Mann, & Gross-man, 1991) or intrapersonal conflict resolution (Greenberg, 1992;
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Greenberg & Foerster, 1996). Another example is interpersonal pro-cess recall (e.g., Naleppa & Reid, 1998) which involves reviewingtape-recordings of sessions with the practitioner and/or the client inorder to elucidate the implicit micro-theories of clinical change pro-cesses (Wiseman, 1992). The utilization of these research procedureswill help both practitioners and researchers achieve better understand-ing of the multiple pathways of positive clinical change in relation toboth established and developing practice models.
Practitioner-Researcher Collaboration
The above discussions have demonstrated how a practice-orientedresearch approach can make clinical research more relevant to practi-tioners. In order to bridge the gap between practice and research moresuccessfully, it is desirable to foster direct collaboration between prac-titioners and researchers in clinical research endeavours. Numerousmodels of collaboration have been recommended, including the col-laboration between social work faculties and direct practice units andthe institutional facilitation of practitioners' involvement in research(Adler et al., 1993; Bogo et al., 1992; Hall, Jensen, Fortney, Sutter,Locher, & Cayner, 1996; Kanfer, 1990; Sidell et al., 1996). Whereasthe exact format of collaboration can vary from setting to setting,depending on the research agenda and the expertise required, a num-ber of conditions are likely to be beneficial for the integration ofclinical research and practice. The overall strategy is to facilitate par-ticipation in research through increasing practitioners' ownership andcontrol of the research agenda, and to provide adequate support andrecognition on an institutional level.
First, practitioners should be involved in setting the research agendaand formulating the research question instead of only being asked tobecome research participants or respondents. This can be achievedeither through the formation of research teams composed of bothpractitioners and researchers or through the active engagement withpractitioners right from the early stages of the research program. Careshould be taken to ensure the collaborative effort is based on anequitable power relationship and mutual respect. Clinical researchershave to recognize that in most cases the researcher is learning from thepractitioner and that the value of clinical practice research has to beassessed by the practitioner. Practitioners should take part in settingthe research agenda. They can be involved in research funding propos-
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al review, in the determination of outcome criteria, and in the reviewof professional publications pertaining to direct clinical practice. Giv-en the fact that research is an activity created and carried out withininstitutional and organizational contexts, any significant change inresearch direction has to be supported by corresponding structuralchanges in these contexts.
Another organizational issue in practitioner-researcher collabora-tion lies in the differences in job nature and compensation structure.Currently researchers and practitioners are often employed by differ-ent institutions and charged with separate responsibilities. Schools ofsocial work often do not attach special value to direct practice re-search, and practice relevance is not necessarily a key criteria forevaluating scholarly work. Similarly, participation in research is usual-ly not in the practitioner's job description. Changes in institutionalagendas and reward systems are necessary to bring about more sys-tematic collaboration beyond isolated attempts of enthusiastic individ-uals and groups. For example, inclusion of research as part of the jobdescription for certain senior practitioner positions may provide incen-tive. Practitioners' participation in research can also be rewarded di-rectly through "buy-out" or "time purchase" arrangements integratedinto research budgets to recognize their contribution. Given the in-creasing number of practitioners entering into private or independentpractice which are outside of the conventional social service structure,the significance of research as an integral part of ethical and compe-tent practice has to be reinforced through institutional practice inprofessional education and professional development.
Social work education is a critical factor for successful integrationof practice and research. When research courses are mainly taught byresearchers who do not practice and practice courses taught by practi-tioners without focusing on research, students are socialized into aprofessional culture that separates the two areas instead of integratingthem. Moreover, most research courses and textbooks are organizedaccording to method and epistemology instead of areas of practice.There is also a strong tendency to keep qualitative and quantitativeresearch procedures as distinct and independent methods. The integra-tion of research and practice has to be modelled by instructors andarticulated in curriculum design. For example, the combination ofresearch and practice teaching in an integrated course taught byinstructors who have competence in both areas will convey a very
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powerful message to graduate students. The inclusion of researchknowledge and utilization in the evaluation of practice courses andfieldwork or practicum, and similarly the inclusion of practice rele-vance in the evaluation of research projects and graduate theses, canbe very effective pedagogical strategies.
CONCLUSION
In response to the challenges arising out of its changing social andprofessional contexts, clinical social work practice relies on the bestefforts of its practitioners and researchers to maintain its commitment toprovide ethical and competent service to clients. The gap between prac-tice and research has to be addressed within the current intellectual andprofessional context. This paper argues for an integrated practice-orientedapproach to clinical research by adopting a postmodern neopragmaticposition. The primacy of research agenda setting and research questionformulation is emphasized. Apart from bridging the gap between practiceand research, it is necessary to resolve the division and contestationbetween competing epistemological positions and methodological prefer-ences. This paper advocates an epistemological and methodological plu-ralism and operationalizes it into guiding principles. This results in thearticulation of a research strategy that integrates paradigmatic and narra-tive approaches as well as quantitative and qualitative procedures. It isexpected that the adoption of such a research strategy will facilitatepractitioner-researcher collaboration and focus clinical research attentionon research programs that support direct practice.
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