Transcript Evidence Based Practice in Psychology

Evidence Based
Practice in Psychology
Report of the APA Presidential
Task Force on EBPinP
Ronald F. Levant
2005 APA President
Evidence Based Practice
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Psychologists have been deeply and
uniquely associated with and evidencebased approach to patient care
Reflected in scientist-practitioner training
Consistent with the past 20 years of work
in evidence based medicine
Evidence Based Medicine
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Advocates for improved patient outcomes
by informing clinical practice with relevant
research
“...the conscientious, explicit, and
judicious use of current best evidence in
making decisions about the care of
individual patients…”
Gray, Haynes & Richardson (1996)
Role of Psychologists
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Development of guidelines for best
practice
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Importance of a comprehensive approach
Attend to the risk that guidelines may be used
inappropriately by commercial health care
organizations
APA formed a joint task force to develop
guidelines (1992)
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Approved by the APA Council of
Representatives (1995)
Criteria for Evaluating
Treatment Guidelines
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Evidence base for any psychological
intervention should be evaluated in terms
of
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Efficacy: strength of evidence pertaining to
establishing causal relationships between
interventions and disorders
Clinical utility: consideration of the
generalizability, feasibility, and costs and
benefits of interventions
Evaluation of Existing
Treatment Guidelines
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Wide variation was found in the quality of
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Coverage of relevant literature
Scientific and clinical basis
Specificity
Generalizability
Even educative guidelines did not always
accurately translate evidence into treatment
protocol
Concern about recommended use of medications
over psychological interventions in the absence
of data to support
Evidence Based Practice in
Psychotherapy
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General benefits of psychotherapy established in
reviews dating back to 1970s
Nonetheless, perception that drugs were
superior persisted
APA Division 12 (Clinical Psychology) Task Force
on Promotion and Dissemination of Psychological
Procedures
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Effort to promote treatments delivered by
psychologists
Published criteria for identifying empirically validated
treatments (subsequently labeled empirically
supported treatments)
Evidence Based Practice in
Psychotherapy
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Identified 18 treatments
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Tested in randomized controlled trials
With a specific population
Implemented using a treatment manual
Sparked a decade of enthusiasm and
controversy
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Concerns about brief, manualized treatments
Emphasis on specific treatment effects vs. common
factors
Applicability to a diverse range of patients
Additional Frameworks
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APA Division 29 (Psychotherapy)
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“empirically supported relationships”
APA Division 17 (Counseling Psychology)
Society for Behavioral Medicine
More recently APA Division 43 (Family
Psychology)
Health Care Policy
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Number of state level initiatives to
encourage or mandate specific list of
treatments for Medicaid
NIMH and SAMHSA focus on promoting,
implementing, and evaluating evidencebased mental health practices within state
systems
Health Care Policy
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Goals of EBP initiatives are laudable, but…
…The psychological community has
concerns over inappropriate restriction of
access to and choice of treatments
Appointment of the APA Presidential Task
Force on Evidence-Based Practice,
including a wide range of perspectives
from scientists and practitioners
2005 APA President Ronald Levant
Evidence Based Practice in
Psychology
EBPP was defined as:
“the integration of the best
available research with clinical
expertise in the context of
patient characteristics, culture,
and preferences”
Evidence Based Practice in
Psychology
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Closely parallels the definition of evidence-based
practice adopted by the Institute of Medicine
(2001)
Builds upon this definition by deepening the
examination of clinical expertise and broadening
the consideration of patient characteristics
Purpose: To promote effective psychological
practice and enhancing public health by applying
empirically supported principles
Evidence Based Practice in
Psychology vs. ESTs
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ESTs address specific treatments, for a specific
problems, under specific circumstances
EBPP starts with the patient and asks what
research evidence will assist in achieving the
best outcomes
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Encompasses a broader range of clinical activities
Articulates a decision making process for integrating
multiple streams of research evidence into the
intervention process
Outline of Remainder of
Presentation
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Best Available Research Evidence
Clinical Expertise
Patient Characteristics
Integration
Best Available Research Evidence
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A wide body of evidence testifies to the
effectiveness of psychological practice
Pays for itself in medical-cost offset,
increased productivity, and life satisfaction
Combines scientific commitment with an
emphasis on human relationships and
individual differences
Best Available Research Evidence
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Practice based on evidence and research
balancing internal and external validity
Must address
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Weighting of different methodologies
Representativeness of samples
Level of intervention
Generalizability and transportability
Decision making with limited research evidence
Appropriateness of treatments for racial/ethnic
minority and other marginalized populations
Best Available Research Evidence
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Effect sizes of psychological treatments
rival those of medical treatments
Important not to assume that treatments
that have not been studied are ineffective
Good practice and science calls for the
testing of practices
Barriers to conducting research should be
addressed
Multiple Types of Research
Evidence
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Clinical observation
Qualitative research
Systematic case studies
Single-case experimental designs
Public health and ethnographic research
Process-outcome studies
Effectiveness research in naturalistic settings
RCTs and their logical equivalents
Meta-analysis
Multiple Types of Research
Evidence
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In support of efficacy
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Clinical opinion, observation, and consensus
among experts
Sophisticated empirical methodologies
including quasi-experiments and randomized
controlled experiments (RCEs)
RCEs most stringent in establishing causality
Multiple Types of Research
Evidence
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In support of clinical utility
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Attention to generality of effects
Robustness of treatments across modes of
delivery
Feasibility with which treatments can be
delivered in real-world settings
Costs associated with treatments
Multiple Types of Research
Evidence
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Method, therapist, relationship, and patient all
contribute to outcome
Future directions should emphasize research on
the following
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Psychological treatments of established efficacy in
combination with and as an alternative to medication
Generalizability and transportability of interventions
shown to be efficacious
Patient x treatment effects (moderators)
Efficacy and effectiveness of treatments with
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Underrepresented groups
Children and youths at various developmental stages
Older adults
Multiple Types of Research
Evidence
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Future directions should emphasize research on
the following
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Common and specific factors of change
Characteristics/actions of therapists and of the
relationship that contribute to positive outcomes
Effectiveness of widely practiced but yet unstudied
treatments
Development of models of treatment based on
identification of practices of clinicians with the most
positive outcomes
Criteria for discontinuing treatment
Multiple Types of Research
Evidence
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Future directions should emphasize research on
the following
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Accessibility and utilization of psychological services
Cost-effectiveness and cost-benefits of psychological
services
Development and testing of practice research
networks
Effects of feedback regarding treatment progress of
psychologist or patient
Development of profession-wide consensus, rooted in
the best available evidence, on psychological
treatments that are considered discredited
Research on prevention
Clinical Expertise
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Refers to competence attained by education,
training and experience, and not extraordinary
performance by an elite group
Essential for identifying and integrating research
evidence with clinical data
Fostered by scientist-practitioner training
Allows for understanding and integration of
research literature into practice – the “local
clinical scientist” (Stricker & Terstweiler, 1995)
Clinical Expertise
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Cognitive science has shown that experts
recognize meaningful patterns, disregard
irrelevant information, and acquire and organize
information in ways that reflect a deep
understanding of their domain
There are inherent risks associated with
idiosyncratic interpretations, overgeneralizations,
confirmatory biases, and other errors in
judgment
Mechanisms of consultation and systematic
feedback from the patient can mitigate some of
these biases
Clinical Expertise
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Components:
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Assessment, diagnostic judgment, systematic
case formulation and treatment planning
Clinical decision making, treatment
implementation, and monitoring of patient
progress
Interpersonal expertise
Continual self-reflection and acquisition of
skills
Clinical Expertise
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Components of
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Appropriate evaluation and use of research
evidence in both basic and applied
psychological science
Understanding the influence of individual and
cultural differences on treatment
Seeking available resources
Having a cogent rationale for clinical
strategies
Clinical Expertise
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Future directions
 Studying practices of clinicians with best
outcomes in the community
 Identifying technical skills used by
experts
 Improving the reliability, validity, and
clinical utility of diagnoses and case
formulations
 Studying conditions that maximize
clinical expertise
Clinical Expertise
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Future directions
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Determining the extent to which errors and
biases are linked to decrements in outcomes
Developing well normed measures to quantify
diagnostic judgments, measure therapeutic
progress, and assess therapeutic process
Distinguishing expertise in common factors
and particular approaches
Providing clinicians with real-time patient
feedback and clinical support tools
Patient Characteristics, Culture,
and Preferences
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Treatment is most likely to be effective
when it is responsive to the patient’s
specific problems, strengths, personality,
sociocultural context, and preferences
EBPP considers patient characteristics
(values, beliefs, worldviews, goals and
preferences) along with psychologist
experience and understanding of research
Patient Characteristics, Culture,
and Preferences
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To what degree to cross-diagnostic patient
characteristics such as personality traits or constellations
serve as moderators?
Which social factors and cultural differences necessitate
different forms of treatment, or which treatments are
adaptable cross culturally?
To what degree do interventions attend to
developmental considerations?
What variable clinical presentations moderate treatment
effects (e.g., comorbidity)?
How do we best approach treatment with patients
whose gender, gender identity, ethnicity, race, social
class, disability status, sexual orientation and problems
forth differ from those of the research sample?
Patient Characteristics, Culture,
and Preferences
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Research indicates that some patient-related variables influence
outcomes:
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Functional status; Readiness to change; Level of social support
(Norcross, 2002)
Many others are important to consider
Clinical trials indicate that different strategies and relationships may
prove better suited for different populations
Symptoms or disorders that are phenotypically similar are often
heterogeneous with respect to etiology, prognosis, and the
psychological processes that create or maintain them
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Co-morbidities, personality variables
“Know the person who has the disorder in addition to knowing the
disorder the person has”
Patient Characteristics, Culture,
and Preferences
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Individual differences
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Developmental processes impact adult and child
psychopathology (e.g., attachment; socialization;
cognitive, social-cognitive, gender, moral and
emotional development)
Multiple variables (e.g., gender, gender identity,
culture, ethnicity, race, age, family context, religious
beliefs and sexual orientation) shape personality,
values, worldviews, relationships, psychopathology,
and attitudes towards treatment
Culture influences not only psychopathology but also
the client’s understanding of health and illness
Patient Characteristics, Culture,
and Preferences
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Consideration of race and its influence as a social
construct which groups people based upon physical
attributes, ancestry, and other factors
Also more broadly associated with power, status, and
opportunity, where European or White ancestry confers
advantage and opportunity
Exists as an interpersonal and political process with
significant implications for clinical practice and quality
health care
Power differentials between clinicians and their patients,
as well as systematic biases and implicit stereotypes,
contribute to inequitable care
Patient Characteristics, Culture,
and Preferences
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Social and environmental context can have an
enormous impact on mental health, adaptive
functioning, treatment seeking, and patient
resources
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Recent and chronic stressors
Sociocultural and familial factors
Social class
Broader social, economic, and situational factors
(e.g., unemployment, family disruption, lack of
insurance, losses, prejudice, immigration)
Patient Characteristics, Culture,
and Preferences
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Future directions
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Patient characteristics as moderators of treatment in naturalistic
settings
Studies attending to patients’ cross-diagnostic characteristics
Effectiveness of interventions widely studied on majority
populations
Examination of the nature of implicit stereotypes and successful
interventions for minimizing their activation or impact
Ways to make information about culture and psychotherapy
more accessible to practitioners
Maximizing psychologists’ cognitive, emotional, and role
competence with diverse patients
Identifying successful models of treatment decision making in
light of patient preferences
Conclusions
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EBPP is the integration of the best
available research with clinical expertise in
the context of patient characteristics,
culture, and preferences
It’s purpose is to promote more effective
psychological practice and enhance public
health
Requires the appreciation of the value of
multiple sources of scientific evidence
Conclusions
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Clinical decisions should be made in
collaboration with the patient
Consideration should be given to probable costs,
benefits, and available resources and options
Treatment decisions should never be made by
untrained persons unfamiliar with the specifics
of the case
Individual patients may require decisions to be
made that have not yet been addressed in
research
Ongoing monitoring of patient progress and
adjustment as needed are essential to EBPP
Conclusions
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Attend to a range of outcomes that may
suggest varying approaches
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Symptom relief
Prevention of future symptomatic episodes
Quality of life
Adaptive functioning in work and relationships
Ability to make satisfying life choices
Personality change
Reference
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APA Task Force on Evidence Based
Practice (2006). Report of the 2005
Presidential Task Force on EvidenceBased. American Psychologist, 61, 271285.