Framing the dialogue about Framing the dialogue about knowledge and practice in knowledge and practice in mental healthmental health

Reginald O. York, PhDReginald O. York, PhDProfessor and ChairProfessor and ChairDepartment of Social WorkDepartment of Social WorkUNC-WilmingtonUNC-Wilmington

Mental health practiceMental health practice

PsychotherapyPsychotherapy Case managementCase management Medication managementMedication management Specialized treatments like recreation Specialized treatments like recreation

therapy, art therapy, etc.therapy, art therapy, etc. OtherOther

PsychotherapyPsychotherapy

PsychotherapPsychotherapy is an interaction between y is an interaction between a qualified professional and a client with a qualified professional and a client with the purpose of improving the client's the purpose of improving the client's mental health through both the mental health through both the therapeutic relationship and consciously therapeutic relationship and consciously applied techniques supported by a applied techniques supported by a legitimate knowledge base.legitimate knowledge base.

The key issueThe key issue

How do we help practitioners navigate How do we help practitioners navigate the variety of knowledge bases that might the variety of knowledge bases that might be employed in the improvement of be employed in the improvement of practice?practice?

Specifically, how can we facilitate a Specifically, how can we facilitate a dialogue between two major approaches dialogue between two major approaches to knowledge and practice—evidence-to knowledge and practice—evidence-based practice and practice-based based practice and practice-based evidence.evidence.

What is evidence-based What is evidence-based practice? practice? [From Bruce Thyer][From Bruce Thyer]

““Evidence-based practice requires the Evidence-based practice requires the integration of the best research evidence integration of the best research evidence with our clinical expertise and our with our clinical expertise and our patient’s unique values and patient’s unique values and circumstances” circumstances”

From Strauss et al. (2005). From Strauss et al. (2005). Evidence-based medicine: How to practice Evidence-based medicine: How to practice and teach EBM (third edition). and teach EBM (third edition). New York: Elsevier.New York: Elsevier.

What is ‘Best Research What is ‘Best Research Evidence’? Evidence’? [From Bruce Thyer][From Bruce Thyer]

Clinically relevant research from basic Clinically relevant research from basic and applied scientific investigations, and applied scientific investigations, especially drawing from intervention especially drawing from intervention research evaluating the outcomes of research evaluating the outcomes of social work services, and from studies on social work services, and from studies on the reliability and validity of assessment the reliability and validity of assessment measures.measures.

Hierarchy of research evidenceHierarchy of research evidence

1.1. Studies that measured client growth using a Studies that measured client growth using a valid tool.valid tool.

2.2. Studies that also compared client growth with Studies that also compared client growth with a group that did not receive treatment.a group that did not receive treatment.

3.3. Studies that also randomly assigned persons Studies that also randomly assigned persons to the control group and the treatment group.to the control group and the treatment group.

4.4. Studies that also Studies that also [i.e., all of the above] [i.e., all of the above] included included a placebo treatment.a placebo treatment.

5.5. Studies that also included a comparison of Studies that also included a comparison of one treatment with another.one treatment with another.

Is “cherry picking” compatible Is “cherry picking” compatible with the scientific method?with the scientific method?

Cherry picking is intentionally selecting Cherry picking is intentionally selecting evidence that supports a given evidence that supports a given conclusion and avoiding evidence to the conclusion and avoiding evidence to the contrary.contrary.

What’s wrong with these What’s wrong with these pictures?pictures?

1.1. A clinician says “My 20 years of clinical A clinician says “My 20 years of clinical experience is my evidence?”experience is my evidence?”

2.2. A researcher appears to present a A researcher appears to present a systematic picture of the evidence that systematic picture of the evidence that supports a certain treatment model, but it supports a certain treatment model, but it is found that he left out several studies is found that he left out several studies that failed to support this model, and that failed to support this model, and these studies were relatively easy to find.these studies were relatively easy to find.

Steps in evidence-based Steps in evidence-based practicepractice

Determine the goal of intervention in Determine the goal of intervention in collaboration with the client.collaboration with the client.

Search for evidence of what methods are Search for evidence of what methods are best for achieving the goal.best for achieving the goal.

Collaborate with clients in determining Collaborate with clients in determining what interventions to apply.what interventions to apply.

Apply the selected intervention.Apply the selected intervention. Should outcomes be evaluated?Should outcomes be evaluated?..

Steps in practice-based Steps in practice-based evidenceevidence

1.1. Determine the goal of intervention in collaboration Determine the goal of intervention in collaboration with the client.with the client.

2.2. Decide on the intervention without being Decide on the intervention without being constrained or prejudiced by the kind of research constrained or prejudiced by the kind of research that seems to assert that a given model is the best that seems to assert that a given model is the best ((because systematic reviews of evidence normally do not because systematic reviews of evidence normally do not reach this conclusion)reach this conclusion)

3.3. Regularly monitor both therapeutic process and Regularly monitor both therapeutic process and client outcome.client outcome.

4.4. Adjust treatment in accordance with evidence on Adjust treatment in accordance with evidence on process and outcome, or refer client elsewhere.process and outcome, or refer client elsewhere.

How the perspectives treat How the perspectives treat collaboration with clientscollaboration with clients

They both suggest that practice goals They both suggest that practice goals and intervention approaches come from and intervention approaches come from a collaboration between client and a collaboration between client and therapist.therapist.

But emphasis on evidence in this But emphasis on evidence in this collaboration is somewhat different.collaboration is somewhat different.

How they treat evidenceHow they treat evidence

Both approaches utilize evidence.Both approaches utilize evidence. But their approach to evidence differs.But their approach to evidence differs.

EBPEBP a focus on evidence regarding a focus on evidence regarding treatment models or techniquestreatment models or techniques Defenders of EBP assert that they focus on the Defenders of EBP assert that they focus on the

best available evidence whether or not it relates best available evidence whether or not it relates to a treatment model.to a treatment model.

PBE PBE evidence on other factors is more evidence on other factors is more important than evidence on treatment modelimportant than evidence on treatment model

What we have learned from What we have learned from research on psychotherapyresearch on psychotherapy

(Wampold, The Great Psychotherapy Debate)(Wampold, The Great Psychotherapy Debate)

1.1. Psychotherapy is effective (standard forms of Psychotherapy is effective (standard forms of it). [it). [About 30% of people not treated get better as compared About 30% of people not treated get better as compared to 70% of those treated.]to 70% of those treated.]

2.2. Factors that different models have in common Factors that different models have in common are far more important in determining are far more important in determining outcome than specific methods. [outcome than specific methods. [Examples: Examples: helping relationship, client hope, goal agreement] helping relationship, client hope, goal agreement]

3.3. The chosen model of treatment has only a The chosen model of treatment has only a small effect on treatment outcome.small effect on treatment outcome.

How the two approaches How the two approaches treat measurement of client treat measurement of client progressprogress

The PBE group clearly includes regular The PBE group clearly includes regular measurement of client progress (and measurement of client progress (and session effectiveness) in the model.session effectiveness) in the model.

The classic EBP steps do not include The classic EBP steps do not include regular measurement of client progress, regular measurement of client progress, but some later advocates have included but some later advocates have included this step as a natural one that any good this step as a natural one that any good scientific practitioner would take. scientific practitioner would take.

Analyzing evidence-based practiceAnalyzing evidence-based practice

1.1. Can practitioners make reliable assessments Can practitioners make reliable assessments or diagnoses? If not, how can evidence help?or diagnoses? If not, how can evidence help?

Do you believe diagnosis is reliable?Do you believe diagnosis is reliable?

2.2. Can practitioners find evidence?Can practitioners find evidence? What has been your experience with evidence?What has been your experience with evidence?

3.3. Can practitioners apply the “evidence-based Can practitioners apply the “evidence-based practice”?practice”?

How many models can you employ right now?How many models can you employ right now?

4.4. Will this practice fit the client?Will this practice fit the client? How often do you find that a scientifically How often do you find that a scientifically

supported method does not fit this particular client?supported method does not fit this particular client?

My view on the question My view on the question about diagnosisabout diagnosis

My review of the evidence on diagnosis My review of the evidence on diagnosis suggests that it is reliable enough.suggests that it is reliable enough.

I am not saying it is perfect, but my I am not saying it is perfect, but my review tends to be more supportive than review tends to be more supportive than contrary. I am reminded of the old contrary. I am reminded of the old saying “Don’t throw the baby out with saying “Don’t throw the baby out with the bathwater!”the bathwater!”

My view on clinicians My view on clinicians finding evidence?finding evidence?

This is a big problem. This is a big problem. They need a user-friendly mechanism for They need a user-friendly mechanism for

finding it. finding it. I don’t believe the Campbell Collaboration is that I don’t believe the Campbell Collaboration is that

kind of mechanism.kind of mechanism.

They also need the ability to sort out the They also need the ability to sort out the better from the worse evidence.better from the worse evidence. I don’t believe the typical clinician has the ability to I don’t believe the typical clinician has the ability to

do this, given the nature of the sources available. do this, given the nature of the sources available.

My view on clinicians applying My view on clinicians applying evidence-based practices?evidence-based practices?

What if you found that dialectical behavioral What if you found that dialectical behavioral therapy was the only evidence-based practice for therapy was the only evidence-based practice for borderline personality disorder? Are you borderline personality disorder? Are you prepared to offer this model of treatment?prepared to offer this model of treatment?

I need more evidence on this one to give an I need more evidence on this one to give an opinion.opinion.

I do not believe that the pursuit of the one best I do not believe that the pursuit of the one best practice makes sense. But this is not the position practice makes sense. But this is not the position either of EBP or PBE, even though some have either of EBP or PBE, even though some have embraced this myth.embraced this myth.

Practitioner competence, Practitioner competence, continuedcontinued

I believe the major effect of the evidence-I believe the major effect of the evidence-based practice movement is that it has based practice movement is that it has encouraged practitioners to get training in encouraged practitioners to get training in models like cognitive-behavioral because of models like cognitive-behavioral because of the evidence that supports it. the evidence that supports it.

I also believe that the evidence typically I also believe that the evidence typically suggests there is more than one alternative suggests there is more than one alternative that is supported by evidence.that is supported by evidence.

Analyzing practice-based evidence Analyzing practice-based evidence

Can practitioners collaborate with clients in Can practitioners collaborate with clients in determining the goals? determining the goals? Any good therapist can.Any good therapist can.

With little attention to evidence about treatment With little attention to evidence about treatment approaches, how can practitioners find the approaches, how can practitioners find the place to start the intervention?place to start the intervention? What has been your experience?What has been your experience?

Will practitioners regularly monitor process and Will practitioners regularly monitor process and outcome? outcome? How likely are you to measure client’s in How likely are you to measure client’s in every session?every session?

Will practitioners modify practice or refer?Will practitioners modify practice or refer? What What has been your experience?has been your experience?

My view on the starting My view on the starting point for interventionpoint for intervention

Before considering the starting point for the Before considering the starting point for the structure of intervention, I believe you should structure of intervention, I believe you should consider the importance of the therapeutic consider the importance of the therapeutic relationship. If you don’t have this, you are not relationship. If you don’t have this, you are not likely to be very effective.likely to be very effective.

But you should be mindful of methods that have But you should be mindful of methods that have been found to be harmful.been found to be harmful.

Evidence should be considered, even if this Evidence should be considered, even if this means the recognition that there are five different means the recognition that there are five different models that have been found effectivemodels that have been found effective

Starting point, continuedStarting point, continued I believe the therapist should have I believe the therapist should have

several models or techniques in the several models or techniques in the toolbox and be prepared to experiment.toolbox and be prepared to experiment.

But these methods should be vetted by But these methods should be vetted by the evidence, with particular attention to the evidence, with particular attention to methods found to be harmful.methods found to be harmful.

Evidence should guide the practitioner’s Evidence should guide the practitioner’s pursuit of new training, but he/she should pursuit of new training, but he/she should be cognizant of what feels most natural.be cognizant of what feels most natural.

My tentative view of My tentative view of psychotherapy and psychotherapy and

sciencescience It is my hope that a study process in the It is my hope that a study process in the

coming year(s) will enlighten my view of coming year(s) will enlighten my view of psychotherapy and science and I will grow in psychotherapy and science and I will grow in the process.the process.

However, at present, here is where I seem However, at present, here is where I seem to stand, tentatively. This is based to stand, tentatively. This is based substantially on my review of the science of substantially on my review of the science of psychotherapy, but likely is influenced by my psychotherapy, but likely is influenced by my experience and inclinations.experience and inclinations.

Point 1 from my view:Point 1 from my view:Therapists should be trained in Therapists should be trained in the common factorsthe common factors

Much of what influences the outcomes of Much of what influences the outcomes of therapy are substantially beyond the control of therapy are substantially beyond the control of the therapist, such as client support, client the therapist, such as client support, client characteristics, environmental changes, and so characteristics, environmental changes, and so forth.forth.

Of those things potentially under the influence of Of those things potentially under the influence of the therapist, the ability to form a helping the therapist, the ability to form a helping relationship is most important. This requires relationship is most important. This requires empathic understanding, acceptance, positive empathic understanding, acceptance, positive regard, and so forth.regard, and so forth.

Point 2: Therapists should Point 2: Therapists should receive training in approaches receive training in approaches

with scientific validity with scientific validity There are a number of such approaches, There are a number of such approaches,

including behavioral, cognitive-behavioral, including behavioral, cognitive-behavioral, psychodynamic, and so forth.psychodynamic, and so forth.

Furthermore, the therapist should find the Furthermore, the therapist should find the methods where their greatest competence methods where their greatest competence lies, and recognize methods not comfortable lies, and recognize methods not comfortable and likely not to be effective if given by and likely not to be effective if given by them. They should use methods they really them. They should use methods they really believe in.believe in.

Point 2, continuedPoint 2, continued

They should also be cognizant of They should also be cognizant of methods that have been found to be methods that have been found to be harmful and avoid them. harmful and avoid them.

They should be cautious about trying They should be cautious about trying new methods that have not been tested.new methods that have not been tested.

Point 3: Therapists should seek Point 3: Therapists should seek the best available evidence.the best available evidence.

The best evidence seems to point to The best evidence seems to point to common factors like the helping common factors like the helping relationship and hope, rather than relationship and hope, rather than specific models or techniques. But if specific models or techniques. But if there is evidence of the superiority of one there is evidence of the superiority of one or two methods in the pursuit of the or two methods in the pursuit of the client’s goal, it should be prominently client’s goal, it should be prominently considered (but should not dictate).considered (but should not dictate).

Point 4: Therapists should Point 4: Therapists should collaborate with clients on collaborate with clients on treatment methodstreatment methods

Some research, and common sense, Some research, and common sense, suggests that the client’s preferred suggests that the client’s preferred paradigm for viewing behavior is related paradigm for viewing behavior is related to client preferences about methods. to client preferences about methods. Therapists should explore this fact in the Therapists should explore this fact in the dialogue about treatment methods.dialogue about treatment methods.

Point 5: Client progress should Point 5: Client progress should be systematically monitored.be systematically monitored.

The methods employed by Scott Miller The methods employed by Scott Miller and Barry Duncan are impressive. They and Barry Duncan are impressive. They have a tool for getting client feedback in have a tool for getting client feedback in every session about both process and every session about both process and outcome. This tool is simple and not as outcome. This tool is simple and not as intrusive as most instruments designed to intrusive as most instruments designed to measure client behavior.measure client behavior.

SummarySummary

If the therapist is comfortable with a If the therapist is comfortable with a scientifically supported method that is scientifically supported method that is compatible with the client’s behavioral compatible with the client’s behavioral paradigm, and the therapist has paradigm, and the therapist has relationship skills that work with this client, relationship skills that work with this client, I believe there is likely to be a good I believe there is likely to be a good outcome. And the fit of the method with outcome. And the fit of the method with the client diagnosis is not as important.the client diagnosis is not as important.