ALL YOU EVER WANTED TO KNOW ABOUT RESEARCH!

By Nick Child

When I was AFT's Editor of Information Sheets, I tried to get someone to write one about Research and Family Therapy. I got other things, but not what I was looking for. So I had a go myself. This is it, rather dashed off , unpublished, and needing some critical feedback. "Family Therapy" is about everything to do with human life, hence my title's grand claim! The rationale is what I wanted to set out, and I'll get round to the referencing some day! Sorry.

Human Systems and Research
Research is for finding out things we don't know, and for firming up on things that we think we do know. Research takes many forms; it is not just the off-putting, high-profile, sophisticated, academically published, statistic-loaded stereotype that typically repels therapists and other workers who are more interested in helping people with personal problems. Ultimately, all research is a form of personal and interpersonal feedback and therefore a systemic matter. Its aim is always to persuade or dissuade oneself or other people of some view or explanation. The question "Who are we trying to persuade?" shapes the form of any research. (Throughout this document, the term Family Therapy (FT) is used to include related kinds of family systems approach to working in the helping professions, otherwise known as Systemic Practice.)

Psychotherapy - A Grey Area
Research in psychotherapy (including family therapy) is in a disputed grey area of research methods. Is it more like the material sciences (like physical medicine, where rationale and evidence can be more concrete)? It has emulated these by taking the medically connoted name 'therapy' and so naturally attracts inspection within a medical model. Or is it more like philosophy, art, politics or religion (where the methods of persuasion are pure discussion and not so easily grounded)? Or is it no more than a version of practical management and working in organisations with other humans, that is, one of the things human beings inherently have to get on with for love or money and without much extra proof of why we do?

Simple Research
If you trip over a stone, you will have proof enough of your discovery. "Watch out for that stone," you announce to your companions to communicate your findings more publicly. They will see what happened to you and see the stone. In seconds the research cycle has been completed satisfactorily enough for those involved - the fact and its significance will be discovered, evidenced, confirmed and published. If any doubt remains, the stone could be kicked or picked up or otherwise studied and experimented on to diminish that doubt. Another ten seconds research could explore ways of getting rid of the stone, or finding ways of avoiding it and ensuring that other people don't trip up. Though the word 'research' gets used for grander matters, this is simple research. We all do it all the time with hardly any effort or special awareness that it is the basic form of all research.

Research by Pure Discussion
Mathematicians, physicists, philosophers, priests and psychotherapists may deal with some less easily evidenced matters. But they still work to agree on shared rules by which they at least might work towards persuading each other to agree on something. So, after researching by thinking or discussion, some fields have to rely on methods of persuasion of others that also rely on pure thinking and discussion. This is particularly so when the object of the study is either abstract or is other people, and especially if the study is of those people's human experiences and actions, where the subjects of the study have as much right to a view or questions about their researcher. All kinds of research may be subject to prior discussion and persuasion - or politics (with a small and sometimes large 'p'). This is especially true where recruitment of any agreement is needed to fund it or the funding consequences that might arise from it. The massive legal drug industry sells drugs and so has funds; so drug research is more easily funded.

Management Pragmatics
Management, though characteristically governed ultimately by finance, has a commitment to quality thinking, communication and planning. This occurs when an organisation discusses and persuades its collective members what it wants to do within the evident limits of time, resources, personnel, and (therefore) funds. The management is simplest in a direct private practice relationship between therapist and client. Complications multiply when insurance agencies and/or larger service, managing and state agencies play major roles. The collaboration with managers may require only logic and words to be persuasive, but usually we are required to provide some descriptive data and evidence of what works better. This may be the hard evidenced kind of research, but usually it is the more practical version that is generally called 'stats' (numbers of referrals, appointments, staff etc) and audit. The newer idea of clinical governance in the British NHS is tightening a few screws more than just "stats" here, incorporating and using what used to be simply Audit.

Audit
Audit is local peer-group research on everyday aspects of what practitioners do. It is usually not to do with sophisticated or high level matters of cause or cure. Any effective working group will naturally identify what and how it does its task, will find and review things that aren't working as well as they could be, and will make changes to improve things that need it. Audit is about doing this collaboratively and more systematically with shared records of the stated aims and the evidence of problems and changes achieved. The audit cycle is simply to:
· decide how you think things should be (eg start appointments on time),
· find out what actually happens (eg jot down all timings over a couple of weeks and find that more often than you thought, people wait for ten minutes while you have your team discussion), then:
· either reset your aims or work out what factors could get your performance up to standard, which you check on by doing another two week's jottings, and so on.

Material Science
This is the most established and popularly known paradigm for research. Concrete processes and facts require to be identified, with concrete statistically rated evidence, all of which naturally attracts rather concrete thinking as a result.

FT Research as Simple Research
Family therapists like to characterise their methods and theories (of all kinds) as constant processes of feeding back between therapist and clients, with team colleagues, and with wider systems. Life and family therapy are both inherently such complex and ongoing matters, that most of the time, simple research is all that can be expected (I suggest). That is, we use the best simple clinical sense of what's happening and required, and what seems most agreed and helpful to those involved, in each particular instance. Since, as in life, this is often a search for human meanings, the evidence is not as concrete as tripping over a stone, even when it seems to be that solid. Since we are dealing with more complex matters than tripping over stones (that is, family interviews and problem stories), we benefit from having two or more heads on the job - that is, live team consultation of various kinds.

FT Research by Pure Discussion
Psychotherapy and family therapy can be seen as areas where research is conducted by pure discussion. Except for videoed family sessions, lots of new schools of FT thought have come (and gone) and attracted disciples with no more than skilled writing and presentation. There are probably more similarities in the ways of psychotherapeutic organisations compared with religious ones than with scientific ones. Alternatively, the therapy itself can be considered to be the research. Thus, analytical psychotherapy would not be criticised for its lack of more evident therapeutic results which raises questions about the value of such time and expense. Instead, it could be seen as a valid way for a person to research themselves thoroughly, the equivalent of doing a PhD. The family coming for therapy is researching itself and how to understand itself and develop its functioning.

FT Research as Management Pragmatics
Insofar as we usually require someone to pay for a psychotherapy service, it is at least like the pragmatic field of management. Psychotherapy, or at least some psychotherapies including family systems approaches, share with management the commitment to quality thinking, communication and planning. It has to be said that this value may be preached better than it is practiced.

In direct private practice, management and persuasion look much simpler since the patient and therapist have only to negotiate and agree their terms and fees; the therapist's concern need be no more than providing their client a service that the client is prepared to keep paying for, and ensuring enough clients to make themselves a living. Research here may be limited solely to the two-person client-therapist research into understanding and helping the client's problem within that twosome's own framework and criteria. The criteria may be simply a mutual sense of personal experience and growth which no outside researcher need know about.

The complications can be immense where adequate researched evidence for FT is required in more complex settings with the interacting demands and interests (mainly financial ones) of larger agencies, managements, purchasers, governments and insurance companies. Indeed, the forms of systemic approach known as business organisational methods are themselves appropriately indicated for the fast-moving and complex world of modern management. Evidence-based research is arriving, but until then the kind of research preferred by managers (since they would themselves have difficulty standing up to such scrutiny!) is of the softer variety than material science demands.

FT Research by Audit and Process Methods
If psychotherapy and family therapy are more pragmatic human or management matters, human systems looking for information and feedback to guide them, then audit is perhaps the form of research appropriate. Often such research is for local benefit and does not get published more widely. Good published examples of this form of research can be found in User-Friendly Family Therapy by Treacher and Riemers. Here, for example, families views about the use of live teams, one-way screen, and video, were recruited and led to changes in working practice. Other settings may have recognised these improvements by common sense, but it helps confirm the judgement of common sense to seek such feedback. Sometimes the solidest common sense is found to be mistaken, so research helps.

Other forms of FT research have included those from social science, where skilled participant observation methods are employed to study and explore the process and views of family and workers involved in family therapy. Anthropological methods and concepts address and respect the participants own interpretation of meaning and events. The collected or common aspects of such work provides more evidenced findings and interpretations of them that relate to established knowledge bases in the fields of social science. Examples of this approach are in Rudi Dallos's books.

FT Research as a Material Science
Psychotherapists could be far clearer than they are about the nature of psychotherapy, but they are more used to helping those with concrete thinking than being judged by them. The relationship between psychotherapy and material science remains problematic, even though it is material science that first required us to work with paradox and the uncertainty principle. It is even more difficult where there are theoretical matters being tested, since material science requires hypotheses to be stated in a way that can be concretely examined or experimented on. Even then, the degree of proof is limited to Popper's "not disproving your theory". Luckily for psychotherapy, some (though not all) clients like to be treated as other than just concrete objects. But there is little or no feedback in general or particular about which version of psychotherapy our clients feel best achieves even this basic aim. Anyway, how could there be proper comparative studies with serial or cross-over trials of psychotherapy?!

If psychotherapy and family therapy are more like a medical subject, even if it is just that they similarly claim to help the problems referred to them, then some more objective evidence is rightly expected. The degree of objectivity for evidence of improvement is flexible and may need only some kind of questionnaire feedback from the clients. Home grown questionnaires feel more relevant, but more validity is available from established questionnaires that have been properly developed, tried out and standardised with wider populations of people. This kind of research requires considerably more specialist personnel, skill and resources than audit. But in most fields of medicine, for example, such research is not expected to be conducted by the clinicians. Properly equipped specialist research teams are funded and established to do the job. There are few if any such specially dedicated research teams in the field of family therapy at present.

However, Family Therapy does have examples of more sophisticated research of this kind are Dare's work on anorexia nervosa, the extensive and widely replicated work on the benefits of some kinds of family therapy and EE education in reducing relapse rates for those suffering schizophrenic illnesses and other chronic physical disorders, and Eia Asen's meticulous work on depression and Family Therapy. In the work on expressed emotion in the families of those suffering schizophrenia, for example, this then creates new theory and information for the pure researchers in understanding the nature and causes of the illness itself.

Ethological analysis of the detailed behaviour in family interaction and therapy, perhaps categorising patterns after video analysis and inter-observer reliability might seem to be an appropriate scientific and objective method, but few researchers have used or gained much from such an approach. It is too open to all the subjeectivity and flow of meaning that the less objective approaches have.

Statistics in Perspective
Scientists have developed various rigorous methods to persuade each other of what they have found, notably using statistics. Statistical analysis provides an important framework for exploring the validity of claims and significance of evidence compared with chance. But statistics do not resolve what value to put on the results they may help confirm. For example, if a large enough population of people are used in the research, one anti-depressant can be confidently shown to be better than another at a 'highly significant' level of statistical confidence. But the difference itself, though confirmed, may only be that one drug has a 75% chance of reducing depression where the other has a 74% chance. In practical terms, this would be an insignificant difference. The choice of drug may be more significantly influenced by the side effects or cost of the drugs. Or, you might not use drugs at all even though they would work, if the depression could be seen as caused by more significant other factors that could be treated in their own right, such as cancer or marital violence.

Motives for Research
The researcher's motives for doing the more explicit forms of research can include one or more of the following:
· a simple wish to reflect on and improve their own work,
· a means of conveying information and its significance to colleagues
· an interest in pioneering innovation in knowledge and methods,
· a political battle for funds for a valued interest or career
· a campaign to bolster one valued field against another,
· a personal desire for fame and its emotional and material perks
· workaholism
· the expectation and need in some careers to have to be seen to have done research.

There are a range of kinds of research for family therapy to choose from. There is no agreement in the field which forms are most appropriate. Workers in this field have tended to move rapidly from one strong 'persuasion' to another with only the words of the proponent and one's own clinical experience as further evidence. It does not seem likely that the methods of material science are appropriate for family therapy. But, since we are claiming that, in addition to social and personal well-being, that life and health-threatening conditions will be helped if not cured by family therapy, this should be evidenced (and has been to some extent). In the USA, insurance companies increasingly want treatments to include marital or family work because of its efficacy from their financial point of view. Until greater specialist research resources can be established, the various forms of process research and audit remain the most useful and syntonic with the values and methods of the family therapy approach.

In the absence of references, I add this from February 2001. Rudi Dallos contributed this to an AFT List discussion on research and family therapy that covers some of the same ideas more authoritatively and elegantly :

"Coming in a bit late but I thought I would volunteer a few thoughts about narrative therapy and research. In my experience of research teaching in FT contexts there is a kind of word-association phenomenon: table - chair, research - statistics

I think this is a hard habit to kick. However, there are now a vast number of exciting books and papers on qualitative research methods which allow us to get a little bit nearer the heart of what happens in therapy not just counting some aspects of it.

Part of any research on any therapy has to be about how it is experienced by the participants. Especially if it is as collaborative form of therapy as narrative is then it is surely a nonsense not to include the family's experiences. We could turn some of their thoughts here into ratings if we want but preferably we would collaborate with them to construct what dimensions we might look at together.

We should bear in mind here perhaps what happens to therapies which do not work so collaboratively and how silly evaluations become. Elsa Jones and Eia Asen have just published their book reporting on a very tightly controlled (Randomised Control Group) design comparing the effectiveness of CBT, drug-based therapy and systemic couples therapy, for - yes depression. Remember this is the area in which CBT was developed within and was heralded as a clinical breakthrough. Let me quote if I may: ' Patients diagnosed as depressed by psychiatrists were randomly assigned to one of these three treatment modalities. However, the CBT arm of the trial had to be stopped in an early stage because the drop-out rate was so high ( 8 out of the 11 cases)' Jones and Asen, p. 3. 2000, Karnac Books

Now let me think how much would this tell us about CBT or anything if we did not talk to these patients about their experience of this therapy. Let's let go of the faith in 'scientific/statistical/quantitative' research giving us all, if any of the answers. But qualitative can tell us a lot and can tell our families a lot. In collaborative research there are at least two interested parties.

An interesting section on such research can be found in: Family Process , 1998 - special issue on evaluating narrative therapies! There is a lovely paper by Coulehan et al which looks at the process of narratve FT. Sessions are recorded and transcribed. Families are asked to comment on sections of the therapeutic conversation, for example in terms of transformational episodes. They are able to identify these but interestingly the study reveals just how much narrative therapists (and I include myself here) manipulate and direct the conversation. In effect we are still just about as strategic as we ever were but now with words rather then e.g. setting paradoxical tasks. Interesting finding - "we cannot not communicate (add: manipulate) when we converse".

So in my view really interesting and revealing research is possible into narrative therapies, especially if we regard our families as co-researchers not objects."

nick.child@virgin.net