Academic journal article The International Journal of Behavioral Consultation and Therapy

Moving Behavioral Science from Efficacy to Effectiveness

Academic journal article The International Journal of Behavioral Consultation and Therapy

Moving Behavioral Science from Efficacy to Effectiveness

Article excerpt

Abstract

The gap between scientific knowledge and real world practice continues to be a major conundrum for the behavioral sciences. This paper briefly reviews the development of behavioral research and describes problems that have arisen in meeting the goal of improving behavioral interventions through science. Based on published literature and personal observations, the authors argue that behavioral research has followed too closely after the pharmaceutical research model, with reliance on small efficacy trials under optimal conditions. Specific problems are outlined along with three recommended solutions. In brief, real world feasibility testing is essential, and external validity must become as important as internal validity for evidence of effectiveness.

Keywords: Effectiveness, psychotherapy research, scientist practioner gap, alternative research paradigm.

Introduction

The gap between scientific knowledge and real world practice continues to be a major conundrum for the behavioral sciences. The promise that science can be brought to bear on vexing problems in American society, such as substance abuse and addiction, mental illness, crime and delinquency, obesity, and disease, has prompted an abundance of government initiatives to advance the development and effective use of "evidence-based" interventions (see, e.g., Coalition for Evidenced Based Policy (CEBP), 2002; 2003; Institute of Medicine, 1998; National Institute of Mental Health, 1998; Office of National Drug Control Policy, 1999). The consensus public policy goal is to improve prevention and treatment practice through implementation of interventions found to be effective through rigorous scientific research.

This paper briefly reviews the development of behavioral research and describes problems that have arisen in meeting the consensus goal. We then recommend several remedies for addressing these problems. Although behavioral science has used pharmaceutical research as a prototype, we contend that behavioral research needs to make its own way, a new way grounded more completely in the real world.

Randomized Controlled Trials (RCTs) are considered the "gold standard" for establishing causality and determining the scientific evidence for an intervention's effects. Although the RCT is widely accepted throughout behavioral science today, it is a relatively recent methodological innovation. In the early 1960s, the Food and Drug Administration (FDA) began requiring peer reviewed randomized trials demonstrating a pharmaceutical drug effectiveness before the FDA would allow the drug to be marketed (http://www.fda.gov/cder/about/history/). That policy change, along with parallel support by the National Institutes of Health (NIH) transformed the RCT in medicine from a rare and controversial phenomenon into the final standard for assessing the effectiveness of all new drugs and medical devices (CEBP, 2003). As evidence of impact, the number of clinical research articles based on RCTs surged from about 100 in 1966 to 10,000 in 1995 (Chassin, 1998).

In contrast to medicine, the RCT has been slower to take hold in education, crime, substance-abuse policy and in most areas of social policy, largely because it is more difficult to define and standardize protocols and more complicated to control environmental influences on behavior (CEBP, 2003). Likewise, pharmaceutical and medical research become more complex when applied to patients taking medication on a regular schedule in their homes, or to changing the way physicians practice medicine. Thus, even medical innovation has suffered from the chasm between what is known through research and what is practiced by physicians and patients (Wells, 1999; Braslow et al., 2005; Tunis et al., 2003).

Nevertheless, behavioral research followed pharmaceutical studies in making the RCT the cornerstone of evidence testing, and in particular, it became the sine qua non for testing efficacy. …

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