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 • Psychologists have been deeply and uniquely associated with and evidence-based approach to patient care • Reflected in scientist-practitioner training • Consistent with the past 20 years of work in evidence based medicine

Evidence Based Medicine • 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 • Development of guidelines for best practice • 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) • Approved by the APA Council of Representatives (1995)

Criteria for Evaluating Treatment Guidelines • Evidence base for any psychological intervention should be evaluated in terms of • 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 • Wide variation was found in the quality of • 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 • 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 • Effort to promote treatments delivered by psychologists • Published criteria for identifying empirically validated treatments (subsequently labeled empirically supported treatments)

Evidence Based Practice in Psychotherapy • Identified 18 treatments • Tested in randomized controlled trials • With a specific population • Implemented using a treatment manual • Sparked a decade of enthusiasm and controversy • Concerns about brief, manualized treatments • Emphasis on specific treatment effects vs. common factors • Applicability to a diverse range of patients

Additional Frameworks • APA Division 29 (Psychotherapy) • “empirically supported relationships” • APA Division 17 (Counseling Psychology) • Society for Behavioral Medicine • More recently APA Division 43 (Family Psychology)

Health Care Policy • Number of state level initiatives to encourage or mandate specific list of treatments for Medicaid • NIMH and SAMHSA focus on promoting, implementing, and evaluating evidence-based mental health practices within state systems

Health Care Policy • 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 • 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 • 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 • 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 • Best Available Research Evidence • Clinical Expertise • Patient Characteristics • Integration

Best Available Research Evidence • 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 • Practice based on evidence and research balancing internal and external validity • Must address • 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 • 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 • 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 • In support of efficacy • 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 • In support of clinical utility • 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 • Method, therapist, relationship, and patient all contribute to outcome • Future directions should emphasize research on the following • 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 • Underrepresented groups • Children and youths at various developmental stages • Older adults

Multiple Types of Research Evidence • Future directions should emphasize research on the following • 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 • Future directions should emphasize research on the following • 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 • 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 • 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 • Components: • 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 • Components of • 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 • 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 • Future directions • 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 • 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 • 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 • Research indicates that some patient-related variables influence outcomes: • 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 • 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 • Individual differences • 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 • 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 • Social and environmental context can have an enormous impact on mental health, adaptive functioning, treatment seeking, and patient resources • 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 • Future directions • 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 • 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 • 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 • Attend to a range of outcomes that may suggest varying approaches • 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 • APA Task Force on Evidence Based Practice (2006). Report of the 2005 Presidential Task Force on Evidence-Based. American Psychologist, 61, 271-285.

Evidence Based Practice in Psychology