Pierre Desjardins , psychologist Director of quality and development of practice

1. evaluating the efficacy of psychological services Symposium presentation for the canadian society for psychotherapyresearchMontréal, october 2009 Pierre Desjardins, psychologistDirector of quality and development of practice pdesjardins@ordrepsy.qc.ca

2. Opqpolicystatement The purpose of evidence-based practice in psychology (EBPP) is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. Excerpt from the OPQ policy statement on evidence-based practice

3. Mental health Context: • Individuals suffering from significant mental illnesses • Identification of specific problems that have been thoroughly researched (e.g., anxiety disorders and depressive disorders) • Limited supply of services given a financial and human resources • Importance of protecting the public and assuring adequate services (in the wake of Bill 21)

4. Factors to consider Clinical decisions should be made in collaboration with the patient, based on the best clinically relevant evidence, and with consideration for the probable costs, benefits, and available resources and options. Excerpt from the OPQ policy statement on evidence-based practice

5. The importance of Professional judgment Treatment decisions should never be made by untrained persons unfamiliar with the specifics of the case. Excerpt from the OPQ policy statement on evidence-based practice The Trudeau report indicates that the initial assessment constitutes one of the key elements of psychotherapy. This applies equally to all services offered to clients.

6. Evidence-Based Practice:the one and only reference? It is important not to assume that interventions that have not yet been studied in controlled trials are ineffective. Excerpt from the OPQ policy statement on evidence-based practice Significant Risks: • Reducing the amount of services offered and the limiting the diversity of treatment modalities. • Affecting the quality of the services to clients who have comorbid diagnoses or clients who have an Axis II diagnosis.

7. TheoreticalModels OPQ: • Cognitive Behavioural • Existential-humanist • Psychodynamic-analytical • Systemic-interactional • Social-community Trudeau Report: • Cognitive Behavioural • Humanistic • Psychodynamic • Systemic and communication theories

8. Please, be rigorous! However, widely used psychological practices as well as innovations developed in the field or laboratory should be rigorously evaluated… Excerpt from the OPQ policy statement on evidence-based practice

9. Client characteristics Evidence-based practice in psychologyis the integration of the best availableresearchwithclinical expertise in the context of patient characteristics, culture, and preferences. Excerptfrom the OPQ policystatement on evidence-based practice

10. For Maximum EFFICACY The involvement of an active, informed patient isgenerally crucial to the success of psychological services. Excerptfrom the OPQ policystatement on evidence-based practice Adapting services to the client’s personality, specific problems and strengths, as well as to his or her socio-cultural context and personal preferences fosters the development of a stronger therapeutic alliance and the achievement of treatment goals.

11. Cliniciancharacteristics Integral to clinical expertise is an awareness of the limits of one’sknowledge and skillsand attention to the heuristics and biases—both cognitive and affective—thatcan affect clinicaljudgment. Moreover, psychologistsunderstand how theirowncharacteristics, values, and contextinteractwiththose of the patient. Excerptfrom the OPQ policystatement on evidence-based practice • Therebyreducing the relevance of third-partytreatmentdecisions

12. The key: Evaluation The treatingpsychologistdetermines the applicability of research conclusions to a particular patient. Individual patients mayrequiredecisions and interventions not directlyaddressed by the availableresearch. The application of researchevidence to a given patient alwaysinvolvesprobabilisticinferences. Therefore, ongoing monitoring of patient progressand adjustment of treatment as needed are essential to EBPP.

13. The key: evaluation Importance of evaluating available research data • In order to ensure the relevance and validity of research and evidence based practice Note: The competence research is one out of 7 that psychologists acquired during their curriculum (initial training) and it refers notably to the ability to read, understand and interpret research results and to be an informed consumer

14. The key: evaluation Importance of assessing the impact of various interventions • To go beyond probabilistic inferences • To counter any biased positions or personal prejudices • To adjust the services offered to clients, taking into account their progress, their reaction to services and their understanding of their treatment • As a measure of accountability vis-à-vis those requesting the services (e.g., the CSSS who expects that his psychologists provide services both effective and efficient)

15. Ethicalcommitments

16. Dignity and personal freedom 3- In their practice, psychologists must show respect for the dignity and freedom of persons. • Importance of recognizing that each client is a unique individual • Importance of providing the client with choice, and being sure not to ignore who the client is and what he wishes or requests • Importance of not imposing anything in the name of science, personal beliefs or convictions

17. In Support of science 5- In keeping with good practice in psychology, psychologists must practice according to generally recognized scientific and professional principles. • Professional practice depends both on scientific grounds as well as a professional foundation • The scientific mind should prevail in practice as it does in research • The scientific mind should be distinguished from the scientific method • Some approaches are more amenable to classical and current scientific measurement

18. The influence of Research: isthere a downside? 6- The psychologist takes into account all foreseeable consequences on society, research and practice • What is the impact of such extensive research focused on CBT, and widely spreaded, on the future of psychological practice? • On membership • On the diversity of services offered • On the development of innovative approaches • On insurance coverage

19. How to minimize the effects of subjectivity 7- Psychologists must discharge their professional obligations with competence, integrity, objectivity and moderation.Psychologists must avoid any misrepresentation with respect to their competence or the efficiency of their own services or those generally provided by the members of their profession. • Onlyworkingwithapproaches in which one istrained and competent • Having the necessaryknowledge to takethingsintoaccount • Being able to judge the relative effectiveness of services • Maintain up-to-date skillsbased on currentfindings

20. The framework, the client, & the psychologist 10- Before agreeing with a client to provide professional services, psychologists must consider the client's request and expectations and the extent of their skills and means at their disposal. Considerations: • Standards of practice and treatment methods that fit the mandate (referring to evidence based practice) • Scientific expertise, if required • The nature and extent of services that employer has to offer or that the client could afford

21. Evaluating the research Free and informed consent: 11,1- the objective, nature, relevance and main terms of the professional services, the advantages and disadvantages of the services and alternatives, the limits and mutual responsibilities of the parties, including any agreement on fees and terms of payment; • Clearlypresentwhat services canbeofferedbased on the framework, knowledge and research, in terms of the initial assessment and proposedtreatment plan

22. freedom of choice vs alliance ruptures (Free and informed consent) 11,2- the possibility of refusing the professional services offered or ceasing to receive professional services at any time; 42- Psychologists must acknowledge the client's right to consult another psychologist or any other competent person. Psychologists may not, by any means whatsoever, interfere with the client's freedom of choice. • Given the client’s right to leavetherapy, involve the client in ongoingevaluations of the services, therebyreducing the client’slikelihood of prematurelyceasingtherapy • Truefreedom of choicerequiresthat the client befullyinformed about the treatment, includingitspotentialeffectiveness

23. the client, a hostage? 23- Psychologists must subordinate their personal interests or, where applicable, the interests of their employer or colleagues to those of their clients. 30- Psychologists must not use the professional relationship established with a client for personal, political or commercial purposes. 66- In their practice, psychologists must preserve their professional autonomy and recognize that they are not required to perform any task contrary to their conscience or to the principles governing their practice… Because the employer’s (the province, CSST…) priorityis the client base and the psychologistworkswithindividual clients, theremaybeconflictsbetweentheseparites • Avoidfruitless confrontations (recommendedapproaches, otheravailablemethods) psychologist/employer, psychologistcontractworker/organismsgiving mandates • Provide the best possible services

24. The relevance of Measuringtreatmentefficacy 28- Psychologists must not, for the same client, intervene in a manner that is likely to affect the quality of their professional services. • Given the type of services provided, is a program evaluation of a service’s effectiveness appropriate? • Rather, positive effects on treatment outcomes result when the effectiveness of treatment is assessed with the client.

25. Not just a bunch of hot air!   38- Psychologists must establish a psychological diagnosis in respect of their client and give advice to the client only if they have sufficient professional and scientific information to be able to do so. 39- Psychologists must develop, perfect and maintain their knowledge and skills in the field in which they carry on their professional activities. • Necessity of knowing and properlyevaluatingresearchthat affects your clients and the specificproblemsthat are oftenencountered in your practice

26. Empowerment of clients 41- Psychologists must seek to establish or maintain a relationship of mutual trust and respect with their clients. • A good way to do this: empowerment. Giving voice to the client and proceed with him or her to assess the effectiveness of services.

27. DoingwHatwe have to: Not more, or Less 44- Psychologists may not persistently or unwarrantedly urge a person to have recourse to their professional services. 45- Psychologists may not perform unwarranted professional acts or unnecessarily increase the number of such professional acts, and must refrain from performing acts that are inappropriate or disproportionate to the client's needs. • Couldmisunderstanding of researchfindingsresult in a psychologistinappropriatelyinitiatingtreatment? • Is psychoanalytictreatmentappropriate first-line treatment? Or should first-line treatment for depressionbelimited to 6 sessions of CBT?

28. Measures of Efficacy:Using the right Tools 47- Psychologists must comply with the scientific and professional principles generally accepted in psychology when using, administering, correcting and interpreting psychological tests, and when publishing tests and information that must be provided with the related manuals and documents. 48- Psychologists must recognize the inherent limits of the measurement instruments they use and exercise caution in interpreting the psychometric material… • Avoidimprovising and resorting to rough guess • Rely on the use of valid instruments

29. A criticalview 59- Psychologists who give information to the public on psychological procedures and techniques must indicate the restrictions, limits and contraindications that apply to their use. 61- Psychologists acting as professional consultants informing the public must stress the relative value of the information or advice being given. • How can a psychologist do this if he has not learned to critically analyse research?

30. credibility of the profession and of the discipline 60- Psychologists must avoid publicly discrediting, without substantiation, any traditional or new psychological techniques that differ from those they use in their practice if the techniques are consistent with the professional and scientific principles generally accepted in psychology. 62- To the extent of their resources, qualifications and experience, psychologists must seek to promote the development and credibility of the profession. • The risks of discrediting a colleague or a specific approach leads to discrediting the discipline of psychology, undermining public confidence and creating a barrier to consultations

31. Assessing Progress: A necessity 76- Psychologists who are involved in the commercial distribution of instruments, books or other products related to psychology must base any statement concerning the operation, advantages and performance of such products on proof scientifically and professionally recognized in psychology. 77- Psychologists must be able to substantiate the special skills or qualities they claim to possess in their advertising, in particular as to the effectiveness or scope of their professional services and to those generally provided by other members of their profession, or as to their level of competence. • How can we comply with these provisions without either sacrificing scientific inquiry or the services we offer?

32. To think about! • How do we define scientific and professional? • Am I a scientist/professional or a believer? • Does objectivity exist? • Is the client held hostage to my beliefs and convictions? • Can the client decide which services he should receive? • Does professional autonomy mean that I can make all my own decisions? • Can a boss, a physician or another colleague decide what treatment I should use? • Are there limits to my creativity?

33. A few references • Les données probantes: science et dogmatisme, Psychologie Québec, novembre 2005 • Les données probantes en psychothérapie: pour qui, pourquoi?, Psychologie Québec, janvier 2007 • Psychologie Québec, septembre 2007 (numéro thématique intitulé: Évaluer ses interventions) • La psychothérapie: recherche et pratique, Psychologie Québec, mars 2008 • La recherche en psychothérapie: des échos du congrès, Psychologie Québec, janvier 2009

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