Journal of Marital and Family Therapy 1991, Vol. 17, No. 4, 349-353

BRIEF REPORT

CLINICAL RESEARCH AS A TRAINING OPPORTUNITY: BRIDGING THE GAP BETWEEN

THEORY AND PRACTICE

Sandra M. Stith Stephanie G. Barasch

Virginia Polytechnic Institute and State University

Karen H. Rosen Stephan M. Wilson

Although researchers and clinicians may recognize the importance of using science to guide clinical observation and using practical experience to inform science, these family professionals seldom work collaboratively (Olson, 1981; Schwartz & Bruenlin, 1983; Piercy & Sprenkle, 1986). Caught up in their own professional pursuits, research- ers and clinicians often fail to exchange ideas and to work together. Even though students in clinical training programs are exposed to research methods courses and are often required to complete empirical theses, many see research requirements as hoops to jump through rather than as vital parts of their training. Students often fail to see that research can offer them valuable learning opportunities, allowing them to observe the subtleties of family interaction in addition to providing them with valuable feedback about their own clinical work.

In order to stimulate student interest in clinical research, we involved practicum students in an empirical study of the relationship between domestic violence and sub- stance abuse in our university-sponsored family therapy clinic, which serves a diverse cross-section of families living in a metropolitan area. Although the practicum students had taken coursework in both substance abuse and domestic violence, they were sur- prised to discover how frequently families in our clinic came to therapy requesting help with a child behavior problem or marital conflict and revealed a substance abuse or domestic violence issue after therapy had begun. These insights gave rise to informal hypotheses about interrelationships. Students began to wonder how frequently these problems were occurring, either individually or together, in our clinic population and became interested in comparing our experience with national statistics. Thus, the present study was conducted in response to the curiosity of a group of practicum students.

Sandra M. Stith, PhD, is Assistant Professor, Department of Family and Child Development, Virginia Polytechnic Institute and State University, Northern Virginia Graduate Center, 2990 Telestar Court, Falls Church, VA 22042.

Karen H. Rosen, MS, is Assistant Clinical Director, Department of Family and Child Develop- ment, Virginia Polytechnic Institute and State University, Northern Virginia Graduate Center, 2990 Telestar Court, Falls Church, VA 22042.

Stephanie G. Barasch is a Masters Candidate, Department of Family and Child Development, Virginia Polytechnic Institute and State University, Northern Virginia Graduate Center, 2990 Telestar Court, Falls Church, VA 22042.

Stephan M. Wilson, PhD, is Associate Professor, Department of Family and Child Develop- ment, Virginia Polytechnic Institute and State University, Northern Virginia Graduate Center, 2990 Telestar Court, Falls Church, VA 22042.

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The study was undertaken less as an example of good research design than as an opportunity to involve students in relevant research and to encourage their interest and curiosity to be channeled (i.e., to use research as a tool to answer their own questions).

Domestic violence and substance abuse are both problems that can have cata- strophic effects on the lives of individuals and families. Clinical trainees must learn to diagnose, treat, andlor refer families dealing with these issues. Students who are not trained to help families with substance abuse and domestic violence issues will be ill- prepared to serve a large proportion of families in need of marital and family therapy services. Conducting this study allowed our students to see the value of combining research with their practice. It also gave them the opportunity to bring the “facts” regarding the incidence, interrelationship, and disguised presentation of domestic vio- lence and substance abuse into the realm of direct experience.

This exploratory study assessed the incidence of and relationship between substance abuse and domestic violence in our client population. The study also tested the hypothe- sis that most families who have substance abuse and domestic violence issues will not present with those issues a t the beginning of therapy.

METHOD

Practicum students examined all case records for clients seen in the clinic for more than one session (N = 262) between June 1986 and September 1989. Each student was responsible for gathering data from a proportional share of the clinic cases. Students examined standard clinic forms, including termination summaries, family background forms, and case notes and contacted the students or graduates who had been primary therapists for each case. They developed a code book and recorded the number of sessions, date of termination, case type (i.e., assessment, individual, relationship, marital, famil- ial), presenting problem (only one could be chosen), and whether or not during the course of treatment domestic violence andlor substance abuse had been identified as therapeutic issues in case notes or by intern’s report.

Domestic violence and substance abuse were considered to be therapeutic issues when the therapist andlor family defined their existence as problematic and in need of treatment. Domestic violence included spouse physical abuse, child physical or sexual abuse, and parent physical abuse. Substance abuse was defined as the problematic use of any form of psychoactive substance. Substance abuse and domestic violence were considered as separate dichotomous variables. That is, families were given a score of “1” if either the therapist or the families recognized that domestic violence or substance abuse was occurring and in need of treatment. If domestic violence or substance abuse was suspected but unconfirmed, the case was not considered to have family violence or substance abuse treatment issues. A graduate assistant independently coded 60% of the client records to provide some measure of reliability. The few discrepancies between the practicum students’ coding decisions and the graduate assistant’s were resolved by discussing the case and reaching consensus.

RESULTS

Analysis of the data by presenting problem revealed that 12% ( n = 31) of our clients originally presented with domestic violence as the main issue, and only 3% ( n = 6) originally presented with substance abuse as a main issue. When families did present with substance abuse as the main problem, only adolescents were identified as the substance abusing family member. None of our clients presented with an adult who had a substance abuse problem. As reflected in Table 1, clients most commonly presented with problems related to the behavior of children in the family, problems that appeared unrelated to either substance abuse or domestic violence.

350 JOURNAL OF MARITAL AND FAMILY THERAPY October 1991

Although only 12% of our clients came to therapy with domestic violence as the presenting problem, 40% (n = 103) had domestic violence as a therapeutic issue during the course of treatment. Although some form of abuse was occurring in these families, they most often presented for therapy with problems other than domestic violence, such as child behavior problems (37%), personal or relationship enrichment (14%), or marital problems (13%) (see Table 1).

Although less than 3% (n = 6) of the total cases examined originally presented with substance abuse as the main issue, 30% (n = 78) eventually revealed substance abuse as a therapeutic issue, and 18% ( n = 10) of these cases involved an adult's substance abuse problem as a therapeutic issue. As illustrated in Table 1, the largest number of these cases originally requested help for a problem unrelated to substance abuse, such as child behavior problem (41%), personal or relationship enrichment (13%), marital problems (9%), or divorce adjustment (6%) (see Table 1).

The students also found a statistically significant relationship between substance abuse and domestic violence ( r = .14; p < .01; N = 262). Of the 103 cases that had domestic violence as a treatment issue, nearly 38% (n = 39) also had substance abuse as a treatment issue. Of the 78 cases that had substance abuse as a therapeutic issue, 66% (n = 51) of the cases also involved some form of domestic violence as a therapeutic issue.

DISCUSSION

Our students learned a great deal from the basic research experience described above. In academic coursework they had learned that denial and minimization are often important therapeutic issues in working with both violent and substance abusing families. However, the implications of denial and minimization became more concrete after the students had conducted research with their own clientele. The students learned that their substance abusing or violent clients most often presented with problems unrelated to substance abuse and domestic violence, problems that may have been easier for families to discuss or recognize. When students identified the high incidence and disguised presentation of both substance abuse and domestic violence in this population and when they learned of the association between domestic violence and substance abuse issues in families, they became more committed to the importance of routinely assessing for use of drugs and alcohol and for the occurrence of domestic violence in their client families.

Table 1 Presenting Problem

Presenting Problem Cases Substance Abuse" Domestic Violenceh Overall Cases With Cases With

(N = 262) ( n = 78) ( n = 103)

Enrichment 37 (14%) 10 (13%) 14 (14% 1 Marital Problems 35 (13%) 7 ( 9%) 13 (13%) Domestic Violence 30 (12%) 14 (17%) 30 (30%) Divorce 1 5 ( 6%) 7 ( 6%) 5 ( 5%) Parenting 1 0 ( 4%) 4 ( 5%) 2 ( 2%) Child Behavior 128 (48%) 32 141%) 38 (37%) Substance Abuse 6 ( 3%) 6 ( 8%) 1 ( 1%)

"Breakdown of presenting problems for only those cases where substance abuse was a treatment issue.

bBreakdown of presenting problems for only those cases where domestic violence was a treatment issue.

October 1991 JOURNAL OF MARITAL AND FAMILY THERAPY 351

In addition, trainees developed an appreciation for the research process and the value of conducting research in a clinical setting. They were excited about the data they had gathered on their client families. When the graduate assistant working on the project (S.B.) brought completed data analyses to the practicum meetings, students were eager to examine and discuss the results and draw conclusions. Students made their own initial hypotheses based upon clinical impressions, followed a scientific protocol, and addressed their own questions by utilizing both clinical and empirical information. They also began to generate new questions to be explored in subsequent research. Involving students in data collection required them to look at their cases in new ways, to look for associations between treatment issues that they may not have looked for previously, and to clarify their initial and subsequent assessments of familial problems.

Although all students in practicum (12) were not equally involved in all phases of the research, they were all meaningfully involved. The procedure followed in this study could be easily approximated in a clinical setting where a treatment team might develop hypotheses and review records in order to gather data. A staff member might run analyses and write a first draft of the results. Of course it would be preferable in a setting in which clinical staff remain longer than one to two years for the clinical staff to develop hypotheses and include reliable and valid measures to test these hypotheses in future data collection procedures. However, if we had restrained the students from using research to answer their questions until they had included appropriate instrumen- tation in their data collection procedures and until a significant size group who had completed these measures had been amassed, many of the students asking the questions would have graduated and they would have lost the opportunity to see the results of their research efforts. The research was conducted, instead, at a “teachable moment” when it was relevant to the students’ work and to the questions they were asking.

Students also became aware of the problems with doing retrospective analyses of clinical data. Since the data had not originally been collected for research purposes, the students recognized the limitations ofthe subjectively collected data. Students concluded that the research would have been cleaner and the results more defensible if we had used standardized instruments, such as the Michigan Alcoholism Screening Test (Selzer, 1971) or the Conflict Tactics Scale (Straus, 1979) to measure alcoholism and violence. In fact, as a result of this study we have changed our family background form to include formal measures to assess substance abuse and domestic violence. Although many discussions emerged regarding the limitations of this exploratory research and what could have been done to improve the measurement and data reduction techniques, students were impressed with the direct relevance of clinical research for their clinical work. Involving marriage and family therapy trainees in research to answer their own questions helped them to understand research as a useful means to an end rather than as “merely” a formal requirement imposed upon them in order to graduate.

While the client population in our family therapy clinic can not be considered represen- tative of client populations in other mental health agencies or in other university-based clinics, the process of involving clinical trainees in data collection and evaluation is generalizable to other settings. Involving students and clinicians in ongoing research is a valuable training resource for all of those involved. The agency becomes more aware of the population it serves, trainees become more interested in improving their skills in important areas, and clients are more appropriately and perceptively served. Most importantly, students learn the value of combining theory, research, and intervention in their work. Family therapy trainees should have first-hand experiences with research to bridge their knowledge of research and their practice of family therapy appropriately. These skills will serve them well in their professional careers. Perhaps clinical training that involves students directly in empirical research on their clientele will be the first step toward an ongoing professional commitment to utilizing research in clinical

352 JOURNAL OF MARITAL AND FAMILY THERAPY October 1991

practice. Both clinical and research family professionals will gain a more complete understanding of family dynamics when they collaborate on empirical and clinical pursuits.

REFERENCES

Olson, D. H. (1981). Family research and family therapy: Bridging two different worlds. in E. E. Filsinger & R. A. Lewis (Eds.), Assessing marriage: New behavioral approaches. Beverly Hills, CA: Sage.

Piercy, F. P., & Sprenkle, D. H. (1986). Research in family therapy. In F. P. Piercy & D. H. Sprenkle (Eds.), Family therapy sourcebook. New York: Guilford Press.

Schwartz, R., & Bruenlin, D. (1983). Why clinicians should bother with research. Family Therapy Networker, 7, 4, 22-27.

Selzer, M. (1971). The Michigan Alcoholism Screening Test (MAST). Journal ofstudies on Alcohol,

Straus, M. (1979). Measuring intrafamily conflict and violence: The Conflict Tactic (CT) Scales. 36, 117-126.

Journal of Marriage and the Family, 41, 75-88.

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