Bridging the gap between scientists and practitioners: The challenge before us

BEHAVIOR THERAPy 27, 297-320, 1996

Bridging the Gap Between Scientists and Practitioners: The ChallengeBefore Us

LINDA CARTER SOBELI~

Addiction Research Foundation and

University of Toronto, Canada

The need to develop effective and efficient strategies for the dissemination of evidence-based health care has been recognized by governments, researchers, and clinicians alike. However, recognition and implementation are separate issues. If scientists are to have a significant impact on clinical practice, they will have to learn a new way of "doing business" Lessons from the business community and from the field of diffusion of innovations research (dissemination research) have direct applicability to disseminating science-based clinical procedures. This paper presents two examples of the successful integration of science and clinical practice. The goal in each case was to address problems fundamental to dissemination research, spe- cifically for addictions treatment. The first example demonstrates how scientists and practitioners successfully worked hand-in-hand to integrate science and practice, by creating a clinical protocol that subsequently served almost 300 clients. The second

Portions of thls i4ianus~6i']-pt were presented as a Presidential Address at the 27th Annual Con- vention of the Association for Advancement of Behavior Therapy in San Diego, CA, November, 1994. As with the talk, this paper is dedicated to the memory of Alan O. Ross, AABT's 18th president. Alan genuinely cared about his profession, and he was convinced it was important to unite science and practice (Ross, 1985). Alan touched the lives of many people, including myself. When I learned of his death, I decided to dedicate my talk to him, and I am pleased that my presentation addressed a theme about which Alan deeply cared.

This paper would not have been possible without the successful marriage of scientists and practitioners. That I had the courage to change how I practiced my science was aided by the following people who worked with me to bridge the gap between "our" science and "our" practice: Sangeeta Agrawal, Margaret Beardwood, Diane Benedek, E Curtis Breslin, Joanne Brown, Barbara Bruce, Giao Buchan, Carole Bush, Virginia Chow, Pat Cleland, John Cun- ningham, Judy Dobson, Doug Gavin, Kym Loates, Marilyn Herie, Joanne Jackson, Even Kwan, Kristine Lake, Gloria Leo, Garth Martin, Eric Rubel, Lorna Sagorsky, Kathy Sdao- Jarvie, Karen Singh, Mark Sobell, Joanne Spratt, and Peter Voros. Thanks to Joanne Jackson for her patience in typing multiple drafts of this manuscript, and to Kathy Sdao-Jarvie and Lizette Peterson for their valuable editorial comments.

Lastly, a special thanks to Kimberly, Stacey, and Mark for their support throughout the prepa- ration of the talk. Mark's editorial suggestions also greatly strengthened the paper.

Reprint requests should be sent to L. C. Sobell, Center for Psychological Studies, Nova Southeastern University, 3301 College Avenue, Ft. Lauderdale, FL 33314.

297 0005-7894/96/0297-032051.00/0 Copyright 1996 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

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example describes the successful dissemination of a clinical research intervention into community settings. The key to effective dissemination was to make practitioners true partners in the research, development, and dissemination process. For the effective wedding of clinical science and practice on a wide scale, dissemination must be adopted as a value and become a major objective of health care organizations. Current health care emphasis on evidence-based practice suggests that alli- ances between practitioners and scientists will point the way to clinical standards of practice for the next millennium.

Science-based practice is what distinguishes behavior therapy from other psychotherapies. When behavior therapy first became a field, the science- practice link was essential; it defined the heart of the area and described the values of those who practiced behavior therapy (i.e., the belief that clinical procedures should have a scientific basis). However, now that behavior therapy has matured and become mainstream, it is not clear that the field has continued to give the integration of science and practice the priority it deserves.

Although this paper focuses on bridging the gap between science and practice in behavior therapy, this topic is not new for clinical practice. Start- ing with the Boulder Conference, in 1949, the importance of a scientist- practitioner model has been stressed (Raimy, 1950). In the early 1960s, the Joint Commission on Mental Illness and Mental Health (Joint Commission on Mental Illness and Health, 1961) noted the split between practitioners and scientists. A decade later, Albee (1970) also noted the practitioner-scientist gap in an article in the American Psychologist. And in the early 1980s, Barlow summarized the relationship of clinical research to practice by stating, 'At present, clinical research has little or no influence on clinical practice" (Barlow, 1981, p. 147). With reference to psychology, Barlow asserted that "this state of affairs should be particularly distressing to a discipline whose goal over the last 30 years has been to produce professionals who would integrate the methods of science with clinical practice to produce new knowledge" (Barlow, p. 147). Likewise, Cyril Franks (1993), the Association for Advancement of Behavior Therapy's (AABT) first president, has argued that science and clinical acumen go hand-in-hand, asserting that "good behavior therapy must embrace both" (p. 133). Unfortunately, despite the passage of 16 years, and the proliferation of articles on this topic, Barlow's statement still rings t rue- rea l integration has yet to occur. Bridging the gap between science and practice remains a major challenge. This paper addresses issues that researchers and practitioners must face if they are to bridge the gap.

A Blueprint for a Bridge Although behavior therapy is no longer a passing fad, neither is it at center

stage (Lazarus, 1994; O'Leary, 1984). In discussing why behavior therapy is not more widely used, Lazarus asserted that "too many clinicians/practitioners erroneously believe that they have little to learn from top-notch re-

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searchers/scientists, and that many experimenters are impervious to 'clinical observations'" (p. 16).

The need to develop a working alliance between science and practice has often been described, but such an alliance has been elusive. Clearly, most in psychology and related fields, at some level, recognize that there is a gap between science and clinical practice. But recognizing a problem and solving it are two different matters. Building a good bridge takes more than identi- fying that a bridge is needed: One needs a blueprint where science and practice have solid and equal foundations. To illustrate that a successful bridge can be built, this paper describes a recent successful attempt at inducing community service providers to learn and use an empirically based treatment.

Professional Journals: A Poor Outlet for Dissemination

Before looking at what characterizes successful businesses, let us look at how most behavioral scientists, including myself, have attempted to disseminate our research-based treatments. Typically, our interventions are planned by a small cadre of scientists, and then reviewed by a small group of persons of similar persuasion. After a study is completed, it is written up for a professional journal using technical language and statistical reports and interpre- tations. Because of the time required for outcome evaluation and publication, results typically appear long after the study was performed, and often in more than one publication. Who reads these technical publications? Or conversely, who does not read them? Sadly, the answer was contained in a series of di- alogues that appeared in 1993 in various issues of the Behavior Therapist (Fensterheim, 1993; Raw, 1993; Suinn, 1993). Simply put, the respected peer reviewed journals in which scientists publish are not oriented to clinicians. They are not user friendly for practitioners. In almost all scientific articles, including my own, there has been little, if any, description of the intervention in a way that would allow therapists to replicate the treatment.

The problems go deeper than a lack of user friendliness, however. Often, research study procedures place serious limitations on the value of the findings (Seligman, 1995). A sizable percentage of persons in clinical treatment are excluded from research studies for one reason or another. Clinical trials often have so many exclusion criteria that it has been asserted that the problems addressed by researchers often are not those confronting practitioners (Fensterheim, 1993; Goldfried, 1983, 1993; Persons, 1991; Wolfe, 1994). If difficulties in generalization are not enough of a problem, imagine how prohibitive it is for clinicians to attempt to replicate research assessment procedures that involve a large number of instruments, sometimes requiring complicated scoring. Having used these practices to bring their products to market, scientists publish their clinical research findings and then wait for the "field" to adopt their "successful" interventions. If behavioral scientists were in business, their livelihoods would surely be in jeopardy! What I and other scientists have failed to do is seriously market our products to the practitioner community.

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Although some may take issue with the scenario I have just presented, the literature shows that when clinicians are asked to describe research, they char- acterize it as esoteric, technical, difficult to translate into clinical practice, often focused on narrow or superficial problems, seldom providing sufficient detail on treatment procedures, and relying to a disappointing degree on statistical significance as the criterion of "meaningful" effects (Dies, 1983). Miller (1987) argued that "It is senseless to decry a lack of utilization if we do not present our research results in language that is comprehensible, and that addresses the needs and interests of those whom we hope will utilize our findings" (p. 157). He further pointed out that our research journals are often inaccessible to practitioners, are jargony, make for laborious reading, include incomprehensible statistics, and are not formatted to be user friendly. Ogborne (1988) also reported that, in the addictions field, "many program planners and front-line clinicians find little of value in many research reports. To planners and clinicians, research reports often seem to be of doubtful rele- vance and lack generalizability" (p. 729). In summary, practitioners will continue to ignore our publications until they are seen as helpful and relevant (Fensterheim, 1993; Goldfried, 1983, 1993).

Alternative Paths to Dissemination

The above comments are not suggesting that rigorous, well-controlled research should not be undertaken. Indeed, in most businesses, this is the key to producing a reliable, high quality product. But once the product has been developed, there is considerable marketing to make the product appealing and easy to use. To be successful, the final product must be seen as having sufficient advantages over alternative products. It is these aspects of marketing in which behavioral scientists have been deficient. To be effective, dissemination efforts will have to seek new paths and transcend professional boundaries (Barlow, 1994).

One way of bridging the gap between scientists and practitioners is to have dissemination occur in outlets other than scientific journals (Barlow, 1994; Crosswaite & Curtice, 1994; Miller, 1987; Mutter, 1989; Ogborne, 1988). Although a recent survey confirms that clinicians do not read "research type" articles as frequently as scientists, they do read other clinical articles (Beutler, Williams, Wakefield, & Entwistle, 1995). Scientists need to learn to write for practitioners, and they need to publish in more relevant outlets, such as applied journals and clinical newsletters (Beutler et al.; Miller). Two new journals, Cognitive and Behavioral Practice (AABT) and IN Session (John Wiley & Sons), were founded to fill just such a gap. These two journals for practitioners are written by practitioners and by clinical scientists to directly serve practice through science by emphasizing the application of empirically documented treatment techniques.

Historically, the role of scientists in society has largely concerned reflective thought. Although this has value for both the individual scientist and society, dissemination researchers have asserted that it is important for re-

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searchers, particularly social scientists, to "realize that the focal point of your research must be the community and the dynamic social processes that are on-going there" (Fairweather, 1976). Social scientists must play an active role in the community. Barriers to effective dissemination must be identified and confronted (Crosswaite & Curtice, 1994). We need to listen to what practitioners say and make our products more clinically relevant (Dies, 1983). While this is not how most behavioral researchers have been trained, if we wish our science to have an impact, then we must learn "a new way of doing business." This theme resonates throughout the remainder of this paper.

What Can We Learn From Taking a Business Approach to Our Science?

America's best run companies successfully market their products to their customers (Peters & Waterman, 1984). Although scientists are typically not trained to market their products, there is no reason why they could not use a business approach to market their interventions and techniques. The utility of such an approach was evaluated in the two projects that will be described later in this paper.

One important lesson that can be learned from successful business is the maxim "Close to the Customer" (Peters & Waterman, 1984). In the dissemination of behavior therapy, our customers are the practitioners. To produce products practitioners want to buy, scientists must understand practitioners' needs. Successful businesses subscribe to the principle that customers "need to be part of the initial development team"; they need to feel bought into the product, that the product is theirs. Many innovative companies get their best product ideas by listening to what their customers say. If scientists want to see their science translated into wide-scale practice, they too need to listen to their customers-the practitioners. In a recent article, Beutler and his col- leagues (Beutler et al., 1995) discussed a number of strategies that may pro- mote better communications with practitioners.

Successful companies also develop and foster close working relationships with their customers. Scientists need to work directly with practitioners and in settings where their interventions will be adopted. For behavioral scientists, forming a partnership with practitioners involves having them field test our products and tailor them to meet their needs. Such efforts encourage practitioners to be more invested in the product, and ultimately will give them a feeling of ownership. Over a decade ago, Goldfried (1984) asserted that scientists and practitioners "desperately need each other. The experience and wisdom of the practicing clinician cannot be overlooked" (p. 46). Practitioners need to become real partners in the research, development, and dissemination process. One study, in fact, found that the best predictor of research findings being used in a clinical setting was when there was involvement by the practitioners in research-related activities (Bostrom & Sutter, 1993). The expected benefit of working together should be obvi-

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ous: practitioners will become more committed to implementing effective technologies.

Successful businesses trust and learn from their customers, something behavioral researchers need to do with practitioners. Like any customer, practitioners cannot be expected to make a purchase unless they feel what they buy will be useful; the products need to be clinically relevant, user friendly, and better than what is currently available. While scientists and practitioners need to understand each others' viewpoint and experiences, the responsibility for reaching out falls primarily on researchers because it is they who want their products disseminated. Lastly, researchers must recognize that clinical priorities, time constraints, and limited resources are real forces that affect clinical work every day, and these forces can be important determinants of whether a research-derived product has appeal.

In the end, "all business success rests on something labeled a sale, which at least momentarily weds company and customer" (Peters & Waterman, 1984). For clinical scientists, a "successful sale" would be the adoption of a therapeutic intervention. Successful businesses require their managers to have a "hands-on feel" for their products. The parallel for scientists would be to be involved in adapting their interventions to community settings and tailoring the product to fit the needs of the customer.

Because dissemination or diffusion of innovations is an area in which few scientists and clinicians have had much experience, factors considered essential to successful dissemination will be briefly reviewed. In business, successful partnerships typically yield multiple benefits. Similarly, a successful partnership between science and practice can also be expected to yield benefits (e.g., an immediate and continuing dialogue between scientists and practitioners). "Having practitioners as collaborators also lends authority to research on practice and to dissemination of findings, especially to other practitioners" (Phillips, 1989). Collaborating practitioners can help other practitioners become more receptive to scientifically based practice. Although implementation of dissemination projects may proceed more slowly than research trials because of the need to bring a product to market, it is also likely to yield more effective products as well as products that have a higher acceptance rate.

Historically, Dissemination Has Been a Slow Process Although dissemination involves getting new ideas adopted, this is not an

easy process. In 1781 Benjamin Franklin eloquently described the problems with dissemination: "To get the bad customs of a country changed and new ones, though better, introduced, it is necessary first to remove the prejudices of the people, enlighten their ignorance, and convince them that their interests will be promoted by the proposed changes; and this is not the work of a day" (Rogers, 1983). As Rogers, a well known scientist in dissemination

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research, noted, "There is a wide gap in many fields between what is known and what is actually put into use" (p. 1).

Contrary to what people might think, most innovations diffuse at a slow rate, and some not at all (Rogers, 1995a). To illustrate some of the factors that can affect the process of dissemination, Rogers provides several examples of innovations and their fates. One of these examples will be described to illustrate how good ideas or improved products are not always wel- comed with opened arms. The example, though historical, is nevertheless relevant. For over 400 years, from the late 15th century until almost the turn of the 19th century, scurvy, with a 62 % mortality rate, accounted for more deaths than wars among sailors. So many British sailors were dying aboard ship that, in the 1600s, one of the ships' captains decided to conduct what might be called an "experiment" Some sailors were given lemon juice, and the others, or "control crews" were not given lemon juice. The results were astounding: lemon juice effectively prevented scurvy. Apparently uncon- vinced, the British Navy wanted a replication. Unfortunately, this did not occur for more than 100 years when, in 1747, a British physician, aware of the earlier lemon juice experiment, carried out a "multi-factored" experiment with British seamen who came down with scurvy. To some he prescribed two oranges and a lemon; to others he gave one of five different diets not involving citrus fruits. In a few days, only those who received the citrus fruits were free of scurvy. With such evidence, one might conclude that the British Navy would have immediately prescribed citrus fruits for all of its sailors. Yet that did not happen for close to 50 years, at which time scurvy was eradi- cated. Why were naval authorities so slow to give their sailors citrus fruits? Although the specific reasons are unclear, at the time, competing remedies were being proposed; also, the physician who conducted the second experiment was not a prominent figure in naval medicine. This example illustrates that even good ideas, life-saving ideas, do not necessarily diffuse readily to clinical practice (Mattson & Donovan, 1994; Rogers).

Successful Dissemination What does it take to successfully disseminate (diffuse) an innovation?

Rogers (1995a) identifies four main elements of the process: innovation, communication channels, time, and the social system. An innovation is any idea, practice, or object perceived as new; the perceived newness determines a person's reaction to a product. If it is perceived as new, then it is an innovation. The second key element in diffusion research is communication channels. Diffusion occurs when information relating to new ideas or products is exchanged between two parties. The communication that is most important in diffusion is not formal communications, such as journal articles, but "word of mouth" communications. Credible statements by key individuals, particularly subjective evaluations conveyed by satisfied users, can have a powerful effect on people's opinions. For example, a computer software company's bro-

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chure may say wonderful things about its programs, but such advertising pales in comparison to comments from several well known, satisfied users. Rogers suggests that dependence on reports from others implies "that the heart of the diffusion process consists of the modeling and imitation by potential adopters of their network partners who have adopted previously" (p. 18).

Time, the third element in the process of dissemination, is important in terms of having realistic expectations. In successful dissemination, the rate of adoption is typically slow at first, with only a few individuals adopting the innovation. These early adopters are known as innovators. The next group to adopt an innovation is called "later adopters" As word spreads about a product, presumably because of satisfied customers, adoption starts to mush- room. As shown in Figure 1, as the diffusion, or rate of adoption, curve climbs steeply with more adopters, it takes on an S-shape. Rogers (1995a) stressed that "it is individuals' perceptions of an innovation that determine its rate of adoption" (p. 327). The three different curves (Innovations I, II, and III) in Figure I are intended to illustrate how perceived attributes (e.g., relative advantage, trialability) can affect an innovations adoption rate. For example, Innovation I reflects a relatively rapid adoption compared to Inno- vation III.

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FIG. 1. This figure shows the four elements of diffusion (innovation, communication channels, time, and the social system) and demonstrates the takeoff and acceleration in the rate of adoption of an intervention by members of the social system. The S-shaped curve reveals how a critical mass of adopters is necessary in the earlier stages. Source: Diffusion of Innovations, 4th Edition (Rogers, 1995a). Figure 1-1 on p. 11 reprinted with permission of The Free Press, a division of Simon & Schuster.


The fourth element in diffusion research is the social system. Although many individuals play key roles in the diffusion of innovations, two roles are particularly important-opinion leaders and change agents. Opinion leaders provide information and advice about innovations to others in the social system. These are individuals who influence other individuals' attitudes or behaviors. Change agents are individuals who purposely attempt to bring about change (e.g., teachers, salespeople, public health workers, consultants).

Although several factors can affect rates of adoption, past research suggests that the following perceived attributes will significantly affect an innovation's adoption rate: relative advantage, compatibility, complexity, trialability, and observability (Rogers, 1995a). With respect to relative advantage, the question is whether the new product or procedure is better than what it is intended to replace. In this regard, behavior therapy has always taken on the most effective, current method as a comparison condition. For example, behavioral treatments for anxiety or depression are not useful unless they can do at least as well as or amplify the effects of the current medications in those areas. Finally, the greater the perceived relative advantage, the more rapidly the innovation will be adopted.

The second factor, compatibility, relates to whether the new product or procedure is consistent with the existing values, past experiences, and needs of potential adopters. Ideas or products that are compatible with the current values and norms of a social system are more rapidly adopted than those that are not (Gates, 1995). In the present case, practitioners are the potential adopters. In the alcohol field, a prime example is moderation goals. When moderation goals were first introduced, they were in direct opposition to the norms and values of the field. Thus, they were not initially readily accepted (M. B. Sobell & Sobell, 1987; M. B. Sobell & Sobell, 1995).

The third factor to affect adoption rates, complexity, relates to how difficult the idea or intervention is to understand or use. Some innovations are readily understood by most members of a social system; others will be more complicated to adopt. Thus, i fa new treatment is too complicated, this may work against its adoption. An example of complexity might involve medication regi- mens or daily self-monitoring of problem behaviors where adherence and compliance problems have been observed in a sizable percentage of clients. Both procedures place more demands on clients compared to just attending a therapy session.

Trialability, the fourth factor, is the degree to which a product can be ex- perimented with on a limited basis. Being able to use the product or procedure on a trial basis makes adoption of the idea or product easier.

The last major factor that can affect adoption rates is the degree to which the results are visible to others, that is, its observability. The easier it is for others to see the results or to use a product, the more likely it is that it will be adopted and discussed with others. An excellent example of visibility involves the formats for videotape recorders. Although the Beta format was technically superior, the manufacturers of the competing format, VHS, mar-

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keted and sold their product such that VHS formats quickly outnumbered Beta formats in video stores (Gates, 1995). Consequently, consumers were reluctant to buy Beta video recorders because there were so few compatible movies to rent. Products and materials that are widely available will result in greater dissemination. In the disseminated intervention to be described below, all clinical materials and products were readily available to all programs.

Developing a Partnership--A New Way of Doing Business Although much of Rogers' work addresses general strategies for dissemi-

nation, at its core, dissemination takes place on an interpersonal level. Thus, getting practitioners to adopt a research product might be seen as an exercise in persuasion. In this regard, academic psychology and related disciplines can be of value in determining how we might be effective persuaders. General communication theory holds that personal interaction style can be a key vari- able in effective persuasion (Perloff, 1993). "The art of gentle persuasion" is more than a catchy phrase. People react cognitively and affectively to persuasive communications. When a persuasive message opposes an individual's beliefs, the natural response that occurs, almost reflexively, is resistance. If the message concerns an innovation that is inconsistent with the recipient's beliefs, then the content of the message can be adjusted to minimize resistance (i.e., acknowledging that the message goes against the grain, but providing reasons why it should not be discounted).

General communications theory also acknowledges that other aspects of the communication process are important (Perloff, 1993). For example, the credibility and authority of the source can strongly influence how people react to messages. A hard message delivered by a highly credible and well respected authority can change people's minds, or at least can compel recipi- ents to give the message a fair hearing.

Why Has Our Research Been Ignored?

Why has behavioral science's sphere of influence been so limited? Many have posed this question, but none so simply as B. E Skinner (1981), when, in an invited address, he asked, "We happy few, but why so few?" Although written in reference to the alcohol field, McCrady (1986) eloquently captured the frustrations experienced by behavioral scientists in disseminating their research: "Our research work is impeccable; our approaches to treatment as creative and effective as any other approach; our theory development careful and thoughtful. Unfortunately, our work is also invisible" (pp. 173-174). Simi- larly, O'Donohue and Szymanski (1994), in discussing the problem of clinicians using research in daily practice, asserted that "Clinicians agree that science is important for clinical decision making but in practice it is not frequently used" (p. 29). What accounts for this disparity? The most parsimoni- ous explanation is that scientists have not been good business people. We


have done a poor job of selling our wares; we have not been "close to our customers"

Developing a partnership between science and practice is not without its impediments. The effect of the separation of science and practice is evident in a very serious way in the alcohol field, where my own work has been con- centrated. A quarter of a century of research on alcohol problems has had little impact on practice and policy issues (Miller, 1987). In their review of empirically based alcoholism treatments, Miller and Hester (1986) con- cluded that 'American treatment of alcoholism follows a standard formula that appears to be impervious to emerging research evidence, and has not changed significantly in at least two decades" (p. 162). Most alcohol treatment programs in the U.S. do not have an empirical grounding.

Although there are several unique historical reasons for the separation of science and practice in the alcohol field (Pattison, Sobell, & Sobell, 1977), a perusal of the published clinical literature reveals that a similar state of affairs exists in other areas. For example, Paul and Menditto (1992) asserted that public psychiatric inpatient programs have been historically neglected, and "as in many other areas of psychology, medicine, and human services, it is astonishing that public policy and practices for inpatient treatment of the adult mentally ill developed and continue without being scientifically in- formed about program effectiveness" (p. 56). Arguing that the time for rap- prochement is now, Paul and Menditto asserted that years of mutual distrust and name calling must be set aside, although they also caution that respect and trust take time to develop. Experts in the field of psychotherapy also think that the time is right for developing a partnership (Goldfried, 1993).

Bridging the Gap: A Successful Personal Partnership For most scientists and practitioners, developing science and practice part-

nerships will require a new and different way of behaving and thinking. The following example based on personal experience illustrates the value of bridging the gap and conveys some of the experiences encountered in pre- paring for and disseminating research into the community. Until a few years ago, I had no background in dissemination research. I also had no idea how changing my behavior as a scientist might affect how my research would be received. It is important to recognize that the change process was not easy. It required a change in style, a new way of working together, and patience and perseverance.

My awareness of the importance of dissemination research began several years ago when the province of Ontario, Canada, began asking agencies it funded for accountability. One of those agencies was the Addiction Research Foundation (ARF), where I was employed. A small number of senior scientists at ARF, including myself, met with the President of ARF, who told us that we were going to have to do a better job of addressing the needs of the people of Ontario. Outpatient treatment was one of the areas he mentioned,

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and it was clear that area had been mentioned to him by staff at the Ministry of Health, which funds ARE I recall the scientists, including myself, telling him that we had already developed several successful outpatient interventions. Later we realized that it would not matter whether 3 or 9 or 20 treatments were available, if no one used them. The problem was not a lack of products, but rather that such products were being ignored by community programs and practitioners.

After the meeting with the President, we created a unit dedicated to dissemination research (Clinical Research Dissemination Unit). In 1992, the dissemination unit initiated a province-wide project called OPTIONS (Out- patient Treatment in ONtario Services). The project consisted of a team of researchers, practitioners, trainers, community development people, and representatives from community agencies. The goal of the project was to pro- mote the use of empirically validated, cost-effective outpatient treatments. The initial objective was to develop and make available, free of charge, two ARF treatment protocols and training packages: a Relapse Prevention (RP) treatment (a program designed for individuals with moderate to severe alcohol and drug problems) and a Guided Self-Change (GSC) treatment.

As discussed earlier, Rogers (1995a) has said that several processes are critical to the successful adoption of various innovations. One important factor is consulting with and actively involving others in the community in the project development, not as observers or as a token of respect, but as full collaborators. The OPTIONS project team did just that. The team consulted with and actively involved community service providers (i.e., our customers) in the development and dissemination of the treatments. This process initially involved four field tests, one in each of four designated target systems. Two of the target systems were addictions-specific (Assessment and Referral Centers for GSC and Outpatient Treatment Centers for RP), and two were not specific to the addictions field (College and University Health & Coun- seling Centers for GSC and Corrections Agencies for RP). The four target systems were identified through a market analysis that explored potential mar- kets for the treatments. The market analysis sought advice from four sources: (1) an External Advisory Committee established to advise and support the OPTIONS project; this committee provided a vehicle for constructive two- way communication between ARF and relevant community stakeholders; (b) six community forums were held throughout the province during 1993 and were attended by invited representatives of service agencies in each re- gion of the province; (c) an informal survey of "key informants" in the proposed target systems was conducted; and (d) representatives from the Provin- cial Ministry of Health were consulted about the proposed target systems.

After the market analysis, the next step was to collaborate with the identified target systems and tailor the interventions to their needs. The objectives of the field tests were two-fold: (a) to test the acceptability and impact of the two interventions in a representative service within each of four target systems; and (b) to tailor the two interventions to meet customer needs. There


were also two major outcome objectives: (a) to produce a customer-approved intervention package for each target system; and (b) to establish demonstra- tion services to assist in product dissemination.

Because I headed the GSC Unit, it is the dissemination of that treatment that is the focus of the remainder of this paper. GSC is a brief (4 sessions), motivationally based, cognitive behavioral treatment developed for use with individuals who have mild to moderate dependence on alcohol or drugs (L. C. Sobell, Sobell, Brown, & Cleland, 1995; M. B. Sobell & Sobell, 1993; M. B. Sobell, Sobell, & Gavin, 1995). A key feature of the GSC program is that clients direct their own treatment (e.g., select their own treatment goals).

OPTIONS: The process of dissemination. The experiences with one target group, the Assessment and Referral (A/R) Centers, will be described in detail. This target group is the most advanced in its adoption of the GSC intervention. Before looking at the temporal course of the dissemination process with A/R Centers, it is important to recognize, as noted by Rogers (1995a), that the process is laborious, and requires a large investment of effort over a long period. In the present case, this process took 21/2 years to enact.

Table 1 briefly outlines the outcomes of the dissemination process to date. In the summer of 1993, A/R Centers were identified as a target system for OPTIONS by participants who attended community forums held across On- tario. The community forums consisted of representatives from a variety of service settings. It was felt that A/R centers, whose primary business had been conducting assessments and referring clients to other community services, would be an ideal setting in which to offer a brief intervention to individuals with mild to moderately severe alcohol and drug problems, a type of service in short supply in Ontario. The next step was to obtain the endorsement of the entire A/R system to field test the GSC intervention. In October 1993, the OPTIONS program was presented to A/R Managers at their semi- annual conference. Not only did the managers endorse the project, they also formed a subcommittee to oversee the field process and to report the results of the field test back to the A/R managers group. In November 1993, an A/R Center in Ottawa was selected as the GSC field test site; a month later, staff from the Ottawa field test site visited the GSC Unit in Toronto and observed treatment sessions conducted by the GSC staff.

In April 1994, the A/R Center's clinical staff and the agency's director participated in 21/2 days of training in Ottawa. During this time, other community agencies in Ottawa were invited to a community information session to acquaint them with this new service. For the next 3 months, the OPTIONS staff made regular consultation visits to Ottawa, culminating in a final 2-day follow-up training session in June 1994. For 3 months, from July through September, the Ottawa staff recruited 34 clients into its field test. Satisfaction data were collected from each client. In October 1994, GSC staff made one last follow-up visit to Ottawa at which time all clinical staff completed several field test evaluation instruments to assess staff satisfaction with the GSC inter-

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TABLE 1 GUIDED SELF-CHANGE (GSC) TREATMENT DISSEMINATED TO ASSESSMENT/REFERRAL (A/R)

TARGET SYSTEM: OPTIONS OUTCOMES

Date Outcome

Summer 1993 October 1993 November 1993 December 1993 April 1994 April 1994

April-June 1994 June 1994 July-September 1994 October 1994 November 1994

1995-1996

A/R centers identified as one of four target systems A/R Managers endorsed the field testing of the GSC intervention Ottawa A/R center selected as field test site Ottawa staff observe GSC treatment in Toronto Ottawa staff and director participate in 21/2 days of training "Community information session" held to inform others in Ottawa

community about the new service Consultation visits to Ottawa Center by GSC staff 2 days of follow-up training in Ottawa by GSC staff 34 clients in Ottawa GSC field test Final follow-up visit and evaluation in Ottawa by GSC staff Evaluation report presented to A/R Managers followed by (1) full-

scale dissemination of GSC treatment to 39 of 42 A/R centers in Ontario, and (2) 10 2-day regional workshops offered across Ontario for A/R staff with over 200 people trained

After workshops clinical support available via telephone (toll-free number); telephone consultation provided by GSC staff at ARF.

Dissemination research: Compare different strategies to learn how to best disseminate innovations; GSC treatment also disseminated to several community service providers outside A/R Centers.

vention, as well as confidence in using specific elements of the GSC treatment protocol.

From endorsement to field setting. The final evaluation report was presented to the A / R managers group in November 1994. This group unani- mously endorsed the introduction of the GSC intervention to all their A /R Centers. The endorsement reflected strong support at the system level for the intervention's broad-scale dissemination. The next step was to disseminate a tailored version (i.e., designed to fit the needs of the A / R system) of the GSC intervention throughout the province of Ontario. All materials and training were free. Full-scale dissemination of the GSC treatment protocol was accomplished by conducting 10, 2-day regional training workshops from February through May o f 1995. Ninety-three percent (39/42) o f the centers participated, with slightly over 200 people attending the 10 workshops. Al- most all A /R counselors attending the workshops felt that the GSC treatment was appropriate for their center to offer. Another study also found that intensive workshops offered in multiple locations are important for getting alcohol and drug practitioners to understand the clinical significance o f research studies (Shanley, Lodge, & Mattick, 1996).

Continued support. After these workshops, clinical support and consultation was available in the form of a toll free number handled by therapists at


the GSC Unit in Toronto. Such consultation is especially useful for service providers in rural communities. Support materials such as clinical training manuals (L. C. SobeU & Sobell, 1995a, 1996a) and professional training videos (L. C. Sobell & Sobell, 1995b, 1996b) were made available to all community programs. When empirically grounded assessment and treatment materials are widely available, it is thought that this will result in broader dissemination and use of products (Miller, 1987; Wilson & Agras, 1992). Be- cause resource materials are often costly, funding, most likely in the form of grants, will be needed to facilitate dissemination.

As noted earlier, several factors can significantly affect an innovation's adoption rate (e.g., trialability). In this regard, community service providers were very pleased that they could tailor the GSC procedures to fit their needs. Acknowledging that materials and procedures developed at the GSC Unit may not necessarily reflect the particular needs of clients or staff at a community agency has been an extremely important factor in encouraging community practitioners to try things out. Without the ability to try the proposed intervention, and more importantly, to tailor it to their needs, wide-scale adoption by community programs may never have occurred. Another important element in bridging the gap has been the provision of ongoing clinical support. The easier it is for others to use a product, the more likely it is that it will be adopted (Rogers, 1995b).

OPTIONS Outcomes

Table 2 presents summary comments from 7 therapists and 21 clients from the first A/R Center to implement the GSC intervention. Both clients and staff were asked to report their evaluations using 5-point Likert scales. As shown in Table 2, very high levels of satisfaction with the GSC intervention were reported by staff and clients, with all staff reporting being very satisfied.

Client satisfaction. Clients were asked to rate how much the GSC program helped them, and staff were asked how well it had helped their clients with their alcohol or drug problems. All staff and all but 1 of the 21 clients rated the program as helping somewhat to very much [mean (SD) ratings of 1.6 (0.5) and 1.7 (0.7), respectively (1 = helped very much to 5 = did not help very much)]. As shown in Table 2, clients were very pleased and satisfied with both the quality of services received and with their therapists. When asked how well the GSC program fit into the framework of their center, all 7 staff members rated it as a very good fit. As noted earlier, the A/R Center counselors from the 39 other A/R Centers, which subsequently participated in the workshops, also rated the GSC treatment as a good fit with their re- spective centers. Of the 92 counselors who completed the posttraining survey, only 1 said the GSC program would not be an appropriate intervention for their A/R Center. These ratings show that when you take the time to understand your customers' needs, you can produce a product that the customer likes.

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T A B L E 2 STAFF (n = 7) AND CLIENT (n ----- 21) EVALUATIONS OF GUIDED SELF-CHANGE (GSC)

DISSEMINATED TREATMENT AT THE OTTAWA (A/R) CENTER

Mean (SD) Ratings

Staff Clients

Overall Satisfaction With GSC Treatment Program (1 --- very satisfied to 5 = not satisfied) 1.0 (1.0) 1.6 (0.8)

How Did GSC Program Help Your Client/You With A l c o h o l / D r u g Problem? (1 = helped very much to 5 = did not help at all) 1.6 (0.5) 1.7 (0.9)

Quality of Services Received (1 = excellent to 5 = poor) n.a. 1.4 (0.5)

Overall Satisfaction With Therapist (1 -- very satisfied to 5 = not at all satisfied) n.a. 1.4 (0.5)

How Does a Program Like GSC Fit Into Framework of A/R Service? (1 = very goodfit to 5 = very poorfit) 1.0 (1.0) n.a.

Quality of ARF Training to Provide GSC Treatment (1 = excellent to 5 = poor) 1.3 (0.5) n.a.

Would Recommend GSC Program to Other Agencies/ Friends With a Problem (1 = definitely to 5 = definitely not at all) 1.3 (0.6) 1.4 (0 .8)

Clinician training. A key element in the diffusion of innovations is the quality of training provided. In the present case, all 7 therapists rated the quality (1 = excellent to 5 = poor) of the training provided as very good to excellent, with a mean (SD) rating of 1.3 (0.5). Individual comments from the Ottawa staff not only support these ratings, but also reflect the practices of successful businesses reviewed earlier. Comments from the Ottawa staff included the following: (a) "I liked the professionalism of the ARF team; they were always well-organized and never patronized us"; (b) "I hope we continue our collaboration"; (c) "Great that the staff came to Ottawa"; (d) "Great that they allowed for adaptations if needed"; and (e) "Received lots of support; training was well presented, always room for questions-never made to feel 'stupid'" Lastly, when the Ottawa staff were asked if they would recommend the GSC intervention to other agencies, and when their clients were asked if they would recommend the program to a friend in need of similar help, the sentiment among all staff and clients was resoundingly positive, as illus- trated by the very high ratings in Table 2.

Community response. After the training and the field test evaluation, the Director of the Ottawa A/R Center stated that "What Guided Self-Change has offered our community is another way of looking at substance use and getting help. The evaluation showed that Guided Self-Change was a hit with


clients, counselors, and the community" (Drake, 1995, p. 1). Rogers (1995b) views this kind of message as a testimonial from a reCognized authority, and such testimonials, over time, will, it is hoped, decrease resistance to innovation.

After the GSC intervention was adopted by the A/R Centers, several other community programs also tailored the program to fit their needs. The Sioux Lookout Health Center, which provides services to Ojibway Indians, has translated the GSC materials in Ojibway. In response to implementing the GSC program, the Treatment Coordinator was quoted as saying "This has been a very educational experience. As you can see from the clients' quotes and their evaluations they completed, it was well received" (R. Johnson, personal communication, September 5, 1995). The introduction of the GSC intervention offered a type of treatment that otherwise would not have been available in that area. The Corporate Health Consultants, a Canadian national employee assistance firm, field tested a version of the GSC treatment, and 73 of their providers were trained. The 63 counselors who completed training evaluations felt that the GSC intervention would be very useful [SD = 4.3 (0.7); 1 = not useful to 5 = extremely useful]. Counseling Services at the University of Waterloo also field tested a modified version of the GSC intervention. Finally, National University of Mexico, supported by an Interna- tional Development Research Centre (Ottawa, Canada) grant, has translated the GSC intervention into Spanish and cross-culturally replicated the positive results demonstrated by the Canadian GSC intervention (Velazquez, Cardenas, Echeverria, & Gutierrez, 1995).

Guided Self-Change: An Example of Successful Integration of Science and Practice

A second set of personal experiences also demonstrates a successful attempt at bridging the gap between science and clinical practice. In 1992, the Clinical Research and Treatment Institute (CRTI) of ARF underwent a major change to better accomplish its dual mission: to conduct clinical research and to provide services to clients in an efficient and cost-effective manner. The previous clinical setting for outpatients was a centralized facility with a 6- to 8-week waiting list, and where the interventions offered bore little relationship to what the scientist at the very same facility had shown to be effective. The outpatient department was headed by a clinician with no formal relationship to research staff. To conduct clinical trials, scientists had to persuade clinical staff to participate in the studies. There were no incentives for clinical staff to participate, and although there was no outright sabotage of research, participating in research studies was not a priority for clinical staff.

The above circumstances were among the reasons why a major reorganization was implemented in the structure of the CRTI. The goal of the reorganization was to develop state-of=the-art clinical units where science and practice would truly be integrated. Each unit was also to provide clinical training to community service providers and to serve as a setting for clini-

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cal research. To accomplish this, each unit would be headed by a Unit Chief, who would be a senior scientist/clinician, and would also have a Unit Man- ager with a clinical background. The unit staff would include both research and clinically trained individuals, with the Chief and Manager responsible for getting the staff to work together as a team. The successful reorganization of the CRTI was acknowledged, in 1994, by the Institute of Public Admin- istration of Canada (IPAC), which ranked the CRTI 4th out of 113 agencies for its innovative management in reshaping a government agency.

The GSC Unit. One of the units that grew out of the reorganization was the GSC Unit, developed for individuals who are mild to moderately depen- dent on alcohol (M. B. Sobell & Sobell, 1993). Because of our work in the area of early interventions, I was asked to head this unit. Other units were also created, but are not relevant to this paper. The integration of science and practice on the GSC Unit followed most of the points reviewed earlier in relation to the diffusion of innovations as well as the development and marketing of products by successful companies. From the beginning, clinical staff were involved in the development of the unit research. Protocols were reviewed and revised several times. The entire staff spent countless hours working out the kinks of their first research protocol.

Successful implementation. Planning the protocol with so many people took a great deal of time and patience, but the results speak for themselves. In slightly less than a year, 287 alcohol (n = 232) and drug (n = 55) abusers were recruited into a clinical protocol evaluating the cost-effectiveness and outcome efficacy of a cognitive behavioral motivational intervention delivered in a group, versus individual, format (L. C. Sobell et al., 1995). Eight therapists, including myself, participated in, this project; 92.0% (264/287) of the clients who qualified for and consented to be in the study attended the first session, and of those attending the first session, 80.7% (213/264) completed the entire program. At the end of the treatment, 99.0% (207/209) of the clients reported being satisfied with the GSC program, 95.7% (200/209) said they would recommend the program to a friend, and 99.0% (207/209) said they were satisfied with their therapist. Twelve-month outcome results show that clients were significantly improved relative to pretreatment (Sobell et al.). Lastly, 1 year after the treatment, 98.5% (225/229) of the clients said they would recommend the GSC program be continued for other clients.

Bridging the gap: Staff comments. The GSC Unit represents an example of the successful integration between science and practice. How the staff felt about the process of bridging the gap between science and practice is reflected in their comments that have been categorized into five major themes: (a) facilitates understanding on both sides; (b) shared responsibilities-increased commitment; (c) better environment in which to work; (d) takes more to do it but it is worth it; and (e) testimonials. Below are two comments reflective of each theme.

Comments under the first theme suggest that integration facilitates understanding on both sides (staff, personal communications, May 1994). For ex-


ample, one therapist said "Collaboration in the planning stage permits both 'sides' to explain reasons for decisions-it helps greatly in preventing mis- understandings and assumptions?' Another therapist said "Involving clinical staff in the final development and refinement stage helps them gain a better understanding of research, of the importance of all aspects of clinical research, and the importance of adhering to the protocol?' The next two comments from therapists reflect the second theme, that with integration comes shared responsibilities and increased commitment. One therapist said that "if feedback is incorporated into the plan, the group takes ownership-there is increased commitment to a common goal?' Another said "It's important that people feel that they have some say in what is going on. Each of us could see the part that we contributed to the project and could really feel a part of it?'

The third theme suggests that integration of science and practice creates a better environment in which to work. For example, one therapist said that the "Collaborative process promotes mutual respect between the two sides. Decisions are made, not imposed?' A research associate said that "Participa- tion on both sides leads to a more positive approach to conducting the projects when people feel that their input is valuable and that they are contrib- uting" (staff, personal communications, May 1994).

Comments under the fourth theme reflect the fact that integration of science and practice takes more to do, but it is worth it. One staff member said, "It is labor-intensive on the part of both the scientist and the clinician; and on the part of the scientist it demands patience and respect for ideas from the front line workers?' Another research staff member said that "While it may take a little longer, suggestions made have been insightful and may not have been thought of if only clinicians or only researchers were involved" (staff, personal communications, May 1994).

Lastly, several comments (May 1994) about how staff felt about the integration of science and practice were testimonials. For example, one therapist said, "I know the history with respect to the 'we/they' impasse and how counter-productive it was?' Another comment came from a therapist who said that 'Although I have been working at the ARF for a good many years, I have never been involved in such a progressive event as what is happening on this Unit. This is the first time that I have been involved when researchers and clinicians have actually been working together, rather than at odds?'

Although the above examples are from Canada, there is no reason to think that the processes exemplified would operate differently elsewhere. In fact, the principles upon which the efforts were based were articulated by Ameri- can researchers in American publications.

Summary The integration of science and practice in the GSC Unit was successful in

two major respects. First, a large clinical trial was conducted over a short time with very low client attrition, very high client satisfaction with the inter-

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vention, and positive treatment outcomes (L. C. Sobell et al., 1995). Second, all staff, researchers and clinicians alike, felt the integration created a better working environment. A final example of the impact of fostering research and practice in a clinical setting is that from 1993 through the beginning of 1996, 90 practitioners were trained to implement the intervention by the GSC Unit, something that heretofore had not occurred. Comments from trainees reflect the value of this training: (a) "I feel that the following characteristics of the training program are particularly unique and valuable: flexibility, balance, openness, and instruction. Participation in the program was one of the best professional learning experiences I have ever had" (M. Zinatelli, personal communication, January 24, 1996); (b) "It was indeed a pleasure to be working with such a motivated and knowledgeable team of professionals who not only made my experience a very pleasant one, but who also extended themselves in every way to make available to me the educational resources, wealth of experience, and expert supervision that enabled me to learn about the Guided Self-Change philosophy and practice" (G. Liederman, personal communication, October 10, 1995); and (c) "The week I spent at the GSC Unit was an outstanding learning experience" (L. Mulvihill, personal communication, April 27, 1994). In many respects, the GSC Unit has allowed research to be conducted in a naturalistic therapeutic context, an event that Talley, Strupp, and Butler (1994) said would benefit both scientists and practitioners.

Because the process of bridging the gap takes time and considerable patience on both sides, the logical question is "Was it worth it?" My answer is a resounding "Yes!" I have learned a new and rewarding way of doing business that has benefits for scientists, for practitioners, and, most importantly, for our clients. My only regret is that I did not get here sooner. By adopting a new approach to the dissemination of my research, similar to that used in the business community, I have reached more agencies, more practitioners, and, ultimately, more clients than in my previous 25 years in the field. The rewards of effective disseminations are immense for everyone.

Bridging the Gap: We Are Halfway There This paper has presented the results of two successful examples of the inte-

gration of science and clinical practice. The key to successful integration was open two-way communication. Several strategies were found to be successful in promoting open communication including (a) involving practitioners in the planning, development, and implementation of clinical trials; (b) allowing for the intervention to be tailored to fit the needs of different community agencies and practitioners; (c) providing ongoing clinical support by the research team; (d) conducting infield training workshops; and (e) making relevant clinical materials readily available to practitioners and community agencies.

Although much has been written about cost-effective and efficient interventions, producing better treatments is only half of what behavior therapy, or


any therapy, is about. The other half is seeing that improved methods become the expected standard of care. To accomplish this, I have recommended that AABT adopt, as a value, the importance of diffusing empirically grounded behavioral techniques to clinical practice. For example, our graduate stu- dents should be trained in a new way of developing their science, in a new way of delivering their science, and in how to benefit from a partnership with practitioners.

To move innovations forward at all levels, pathfinders are needed. As in the adoption of innovations, the rate of adoption of dissemination, as a value, by AABT members can be expected to follow an S-shaped distribution. What are needed are more reports of effective demonstrations of the integration of practice and science, such as the ones in this paper. Testimonials from both sides, similar to the one by the A/R Center Director about the GSC intervention, are needed to convince people that the "new way" is a better way of doing business. To strengthen links between research and practice, it is crucial for key individuals, opinion leaders, to step forward and assume responsibility for "making it happen" (Mattson & Donovan, 1994).

Based on the experiences I have described in this paper, it is clear that when scientists and clinicians blend together as a team, each group finds considerable rewards in the relationship; together they can accomplish more than either could alone. As behavior therapy matures, if we institutionalize diffusion of knowledge as a value and a priority, we have the opportunity to work hand-in-hand with a changing health care system that will likely demand that practitioners seek to assimilate new knowledge and put it into practice. In this regard, AABT and other behavioral organizations need to develop ways to insure that what we learn gets diffused into everyday clinical practice. The two newly created journals, Cognitive and Behavioral Practice and IN Ses- sion, are good examples of such efforts.

As noted earlier, the gap between research and practice has often involved a lack of mutual respect and an atmosphere of distrust between researchers and practitioners. Because feelings on both sides have been portrayed as prejudices, it is important to recognize that prejudices do not disappear spontane- ously. Both parties have to work to remove them. The goal is to merge science and practice to achieve a harmonious alliance.

Finally, the effective transfer of research into practice is more than a prac- tical exercise. Behavior change is our forte, and theories of behavior, especially learning theory, apply to all behavior, not just disordered behavior. This means that they should apply to the behavior of scientists and practitioners as well (Wilson & Agras, 1992). Research studying the dissemination of behavior therapy can achieve two aims: (1) transfer of research-based procedures into community practice, and (2) generation of new knowledge about how to effectively disseminate our products. Effective dissemination is demonstrated by measurable behavior change. Therefore, what we learn about dissemination within our own ranks is likely to have some applicability to changing behavior in clinical situations. Likewise, what we learn about

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changing behavior in clinical research may have application to the dissemination process itself. Because dissemination research is, in the end, research into the process of changing human behavior, it follows that behavioral researchers should be major players in dissemination research.

The Challenge for Behavior Therapy and AABT I feel that it is critical that behavior therapy, as a field, and AABT, as an

organization, recognize the importance of effectively reuniting practice and science to form a strong and successful marriage. To do this, dissemination, as a value, must be adopted and made a major objective in the coming years.

To the extent that our work is seen as helping people, it will endure, but it will only be strong if we have the courage to change. In the end, I believe, effective transfer of research-based procedures for wide-scale community use holds the fate of behavior therapy. Behavior therapy has gained acceptance as a science-based practice, but our job is only half done. If we are convinced that our methods constitute a clinically significant improvement over alternative practices, then we have an obligation to disseminate those methods (Barlow, 1994; Strosahl, 1995). The health care field is facing radical and uncertain change. To successfully move into the next millennium, AABT as an organization and behavior therapy as a field need to develop a competi- tive edge. To do this, clinical scientists must reach out and work with their partners, the practice community.

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Bridging the gap between scientists and practitioners: The challenge before us