estebtebpslides

www.heartandsoulofchange.com March 30, 2012

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Empirically Supported TreatmentsEvidence Based Treatments, &

Evidence Based Practice

A Rose by Any Other Name?

Barry Duncan, Barry Duncan, Psy.DPsy.D. www.heartandsoulofchange.com. www.heartandsoulofchange.com561.239.3640 [email protected] [email protected]


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Duncan & Reese, 2012Handbook of PsychologyDuncan & Reese, 2012

Handbook of Psychology

Examine ESTs, EBTs, and EBPs and describe Examine ESTs, EBTs, and EBPs and describe , ,two fundamentally different approaches to defining and disseminating evidence (Littell, 2010)—one that seeks to improve clinical practice via the dissemination of tx meeting a minimum standard of empirical support (EBT)

, ,two fundamentally different approaches to defining and disseminating evidence (Littell, 2010)—one that seeks to improve clinical practice via the dissemination of tx meeting a minimum standard of empirical support (EBT)minimum standard of empirical support (EBT) and another that describes a process of research application to practice that includes clinical judgment and client preferences (EBP).

minimum standard of empirical support (EBT) and another that describes a process of research application to practice that includes clinical judgment and client preferences (EBP).


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Evidence Based Treatment/PracticeWhat’s the Hubbub?

Evidence Based Treatment/PracticeWhat’s the Hubbub?

All approaches have valid ways to help clients

All approaches have valid ways to help clientsways to help clients. Makes sense to learn multiple ways.

Also makes sense to be “evidence based” I h

ways to help clients. Makes sense to learn multiple ways.

Also makes sense to be “evidence based” I h In truth, no one says, “Evidence, smevidence!”

Like not believing in Mom or apple pie. So what is the controversy about?

In truth, no one says, “Evidence, smevidence!”

Like not believing in Mom or apple pie. So what is the controversy about?

Evidence Based TreatmentA Little History: Good Intentions

Evidence Based TreatmentA Little History: Good Intentions

1993 apa guidelines 1995: Magic bullets to 1993 apa guidelines 1995: Magic bullets to1995: Magic bullets to

counter magic pills; Div 12: txs for specific dx via efficacy in 2 RCTs; Incr. recog. therapy efficacy, but

Promulgated gross misinterpretations & now

1995: Magic bullets to counter magic pills; Div 12: txs for specific dx via efficacy in 2 RCTs; Incr. recog. therapy efficacy, but

Promulgated gross misinterpretations & nowmisinterpretations & now often wielded as a mandate for competent, ethical, & reimbursable practice.

That’s the controversy. Intent is not to demonize

misinterpretations & now often wielded as a mandate for competent, ethical, & reimbursable practice.

That’s the controversy. Intent is not to demonize


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Even More RidiculousUnethical and Prosecutable

Even More RidiculousUnethical and Prosecutable

Such misinterpretations have only been made worse by those

Such misinterpretations have only been made worse by thoseonly been made worse by those suggesting that not using an EBT was not only unethical, but also “prosecutable!”

New York Times: Using vague, unstandardized methods to assist

only been made worse by those suggesting that not using an EBT was not only unethical, but also “prosecutable!”

New York Times: Using vague, unstandardized methods to assistunstandardized methods to assist troubled clients ‘should be prosecutable’ in some cases, said Dr. Marsha Linehan (Carey, 2005, p. 2).

unstandardized methods to assist troubled clients ‘should be prosecutable’ in some cases, said Dr. Marsha Linehan (Carey, 2005, p. 2).

Evidence Based TreatmentThree Empirical ProblemsEvidence Based TreatmentThree Empirical Problems

Emphasize model diff / ifi ff t

MST for you!

differences/specific effects when few are apparent.

Emphasize technical operations when other factors account for farfactors account for far more variance.

Pulling back the empirical curtain reveals little to be excited about


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The Dodo VerdictThe Dodo Verdict

••With few exceptions, partisan studiesWith few exceptions, partisan studiesd i d h i ffd i d h i ffdesigned to prove the unique effects designed to prove the unique effects of a given model have found no of a given model have found no differencesdifferences——nor has recent metanor has recent meta--analyses…analyses…The Dodo VerdictThe Dodo Verdict——the the most replicated finding in the most replicated finding in the psychological literaturepsychological literaturepsychological literature psychological literature

“Everybody has won and all“Everybody has won and allmust have prizes.”must have prizes.”

Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15.Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215.

What About Evidenced Based Treatment

What About Evidenced Based Treatment

••Dodo highlights fatal flaw: Efficacy Dodo highlights fatal flaw: Efficacy over placebo or TAU is not efficacyover placebo or TAU is not efficacyover placebo or TAU is not efficacy over placebo or TAU is not efficacy over other approaches & not saying over other approaches & not saying muchmuch——if if a friend went out on a date, you asked about the guy, yourfriend replied, “He was better than nothing—he was unequivocally

Rosenzweig, S. (1936). Some implicit common Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6Journal of Orthopsychiatry, 6, 412, 412--15.15.

g q ybetter than watching TV or washing my hair.” How impressed?How impressed?

••And the conclusion…And the conclusion…


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The Product View: Client & Therapist Interchangeable

The Product View: Client & Therapist Interchangeable

The product view is h th t

The product view is h th tperhaps the most

empirically vacuous aspect of EBT because the tx itself accounts for so little of outcome variance while the

perhaps the most empirically vacuous aspect of EBT because the tx itself accounts for so little of outcome variance while thevariance, while the client and the therapist—and their relationship—account for so much.

variance, while the client and the therapist—and their relationship—account for so much.

Client/Extratherapeutic Factors (87%)

Feedback Effects15‐31%

ll ffTreatment Effects

13%

Alliance Effects38‐54%

Model/Technique8%

Model/Technique Delivered:Expectancy/AllegianceRationale/Ritual (General Effects)

30‐?%

Therapist Effects46‐69%

Duncan, B. (2010). On becoming a better therapist.Washington DC: American Psychological Association


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Client is the of Change Client is the of Change

Client’s Resources, Client’s Resources, ,Resiliencies, and Relational Support

Client’s View of the Alliance

,Resiliencies, and Relational Support

Client’s View of the Alliance

Client’s View of Progress &Expectation of Success

Client’s View of Progress &Expectation of Success

Therapist count far more

Therapist EffectsIncredible Variation Among Providers

Therapist EffectsIncredible Variation Among Providers

Therapist count far more than the model practiced…46-69% v. 8%; TDCRP: clients of top third psych. giving placebo bested bottom third givingbested bottom third giving meds; clients of best therapists improve 50% more & drop out 50% less Wampold, B., & Brown, J. (2006). Estimating variability in

outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923.


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EBT does not eliminate

Therapist VarianceBottom Line

Therapist VarianceBottom Line

EBT does not eliminate the influence of the therapist on outcome. Great variability remains

Feedback or PCOMSFeedback or PCOMS improves therapist performance and reduces variability

Therapist Variables that Predict Change

Therapist Variables that Predict Change

Th i t ith thTh i t ith thTherapists with the best results:

Are better at the alliance across

Therapists with the best results:

Are better at the alliance across clients; alliance ability accounts for most of differences

clients; alliance ability accounts for most of differences

Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.; Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology, 78(5), 635-645.Owen, Duncan, Anker, & Sparks (2010). Therapist variability in couple therapy. Manuscript submitted for publication.


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Relationship FactorsRelationship Factors

The Alliance:The Alliance:

•• Relational Bond Relational Bond •• Agreement on Agreement on goals • Agreement on tasksAgreement on tasks

S TiS Ti th I t fth I t f

3838--54%54%

Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass

Seven TimesSeven Times the Impact of the Impact of Model/Technique…Accounts Model/Technique…Accounts for Most of for Most of Counselor Counselor VarianceVariance

Evidence Based TreatmentBottom Line

Evidence Based TreatmentBottom Line

EBT neitherEBT neitherEBT neither explains nor capitalizes on the sources of variance

EBT neither explains nor capitalizes on the sources of variancevariance known to effect outcome.

variance known to effect outcome.


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The AllianceThe of Change

The AllianceThe of Change

Alliance feedback enables a fit between client expectations, preferences, and services

Does not leave the alliance to chance—applying over 1000 studies showing the relationship of the alliance to positive outcomes

Be SkepticalLike My Little Friend

Be SkepticalLike My Little Friend

Can be tedious Can be tedious Can be tedious Worth it to counter

mandates & practice according to client preferences and benefit

Can be tedious Worth it to counter

mandates & practice according to client preferences and benefitpreferences and benefit

Two Issues: Allegiance and Unfair Contests

preferences and benefit Two Issues: Allegiance

and Unfair Contests



Whose Evidence Is It?Allegiance Effects

Whose Evidence Is It?Allegiance Effects

At least 40% of any b d ff i

At least 40% of any b d ff iobserved effect is

attributable to the belief in (allegiance to) the approach by the researchers…TDCRP

observed effect is attributable to the belief in (allegiance to) the approach by the researchers…TDCRP

Even meager Even meager differences disappear differences disappear when researcher when researcher allegiance is allegiance is controlled… controlled…

Even meager Even meager differences disappear differences disappear when researcher when researcher allegiance is allegiance is controlled… controlled…

How Much Allegiance Are We Talking About?How Much Allegiance

Are We Talking About?

As of 2004 founders of As of 2004 founders of MST have received $55 million in research funding

Earn $400-$550 per family served in licensing

MST have received $55 million in research funding

Earn $400-$550 per family served in licensingfamily served in licensing, training, and consultation fees; over 10,000 served or $5 million

family served in licensing, training, and consultation fees; over 10,000 served or $5 million

Littell, J.(2006) Evidence for Multisystemic Therapy: Evidence or Othodoxy? Children and Youth Services Review, 28, 458-472



When You Pull Back the CurtainCochrane Foundation

When You Pull Back the CurtainCochrane Foundation

No sig. diff. between MST and TAU obtained in the largest and most rigorous study: a multi-site trial conducted by ind. investigators with full ITT analysis (Leschied & y (Cunningham, 2002)Conclusion: MST is not consistently better or worse than other services

Littell, J, (2010). Evidence-based practice: Evidence or Orthodoxy. In B. Duncan et al (Eds.), The heart and soul of change (2nd Ed.). APA

No Data Supports MandatesThe Question: Is It a Fair Contest

No Data Supports MandatesThe Question: Is It a Fair Contest

Dodo: most replicated; no specific effects; efficacy over

Dodo: most replicated; no specific effects; efficacy overspecific effects; efficacy over placebo, sham, or no tx is not differential efficacy.

In few claiming superiority: Is it a fair contest?

Comparing 2 approaches

specific effects; efficacy over placebo, sham, or no tx is not differential efficacy.

In few claiming superiority: Is it a fair contest?

Comparing 2 approaches p g ppintended to be therapeutic administered in = amts by those who believe in what they are doing & equally supported—from same pool?

p g ppintended to be therapeutic administered in = amts by those who believe in what they are doing & equally supported—from same pool?



PMTO (Ogden & Hagan, 2008)

PMTO (Ogden & Hagan, 2008)

PMTO effective in reducing parent-rep child externalizing

PMTO effective in reducing parent-rep child externalizingparent rep. child externalizing problems, improving teacher-rep. social competence, & enhancing parental discipline over TAU.

“The findings thus indicate that

parent rep. child externalizing problems, improving teacher-rep. social competence, & enhancing parental discipline over TAU.

“The findings thus indicate that e d gs t us d cate t atPMTO is an effective treatment program…and moreover that an evidence-based treatment program can be transported successfully…” (p. 617).

e d gs t us d cate t atPMTO is an effective treatment program…and moreover that an evidence-based treatment program can be transported successfully…” (p. 617).

Ogden, T., & Hagen, K.A. (2008). Treatment effectiveness of Parent Management Training in Norway: A randomized controlled trial of children with conduct problems. Journal of Consulting and Clinical Psychology, 76(4), 607-621.

The Data—the Truth Is in the TablesPMTO v TAU

The Data—the Truth Is in the TablesPMTO v TAU

16 measures—only 4 found a difference

16 measures—only 4 found a differencedifference

On 1 of 4 (CBCL Total), the difference was 1.92 points.

On CBCL Ext., difference was 1.53 points. Clinical significance questionable at best.

difference On 1 of 4 (CBCL Total), the

difference was 1.92 points. On CBCL Ext., difference was

1.53 points. Clinical significance questionable at best. q

Differences by age. Superior finding for PMTO on 4/16 measures for 7 & younger only. None on 15/16 measures for 8 & older; 1 favored TAU.

q Differences by age. Superior

finding for PMTO on 4/16 measures for 7 & younger only. None on 15/16 measures for 8 & older; 1 favored TAU.



In Addition to These UnderwhelmingResults…Unfair Contest

In Addition to These UnderwhelmingResults…Unfair Contest

PMTO therapists: 18 months training & ongoing sup during

PMTO therapists: 18 months training & ongoing sup duringtraining & ongoing sup. during study: TAU therapists received no training, support, or sup.

Dose favored PMTO 40 v. 21 hrs. No findings on 12/16 measures,

no effects children 8 & over

training & ongoing sup. during study: TAU therapists received no training, support, or sup.

Dose favored PMTO 40 v. 21 hrs. No findings on 12/16 measures,

no effects children 8 & overno effects children 8 & over, combined with differential training& support of the 2 therapist groups & unequal doses of tx cast doubt on this study’s conclusions.

no effects children 8 & over, combined with differential training& support of the 2 therapist groups & unequal doses of tx cast doubt on this study’s conclusions.

Trauma Focused CBTUnfair Contests

Trauma Focused CBTUnfair Contests

Child Centered Treatment (CCT) the comparison tx is not

Child Centered Treatment (CCT) the comparison tx is not(CCT), the comparison tx is not a fair comparison—therapists did not see the kids & parents together, TF-CBT therapists saw kids and parents together 3 x out of the 12 sessions. Not reasonable care

(CCT), the comparison tx is not a fair comparison—therapists did not see the kids & parents together, TF-CBT therapists saw kids and parents together 3 x out of the 12 sessions. Not reasonable carereasonable care…

CCT condition did not provide advice or suggestions to kids or parents. Not a real tx.

Reactive measures; 5 of 13

reasonable care… CCT condition did not provide

advice or suggestions to kids or parents. Not a real tx.

Reactive measures; 5 of 13Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.



Lopsided ContestLook for YourselfLopsided ContestLook for Yourself

I have never seen anI have never seen an advantage of any approach over another

(or TAU) that wasn’t a lopsided contest

that had its winner predetermined.

Dialectical Behavior Therapy (DBT):

•Defined as, “a mode of treatment designed for people with borderline personality disorder (BPD)”;

•Aims to help people to validate their emotions and behaviors, examine the negative impact of emotions and behaviors on their lives, and make a conscious effort to bring about positive change.

http://www.medterms.com/script/main/art.asp?articlekey=34212http://www.apa.org/divisions/div12/cppi.htmlhttp://www.mhreform.org/policy/ebs.htm

•Currently identified by professional organizations, funding bodies, and government agencies as an “evidence-based,” “empirically-supported,” “best practice.”



•Currently 15 studies published DBT (1991 2006)

DBT:DBT:What do the data say?

on DBT (1991-2006);

•Nine of the fifteen qualify as “randomized clinical trials” (RCT);

http://depts.washington.edu/brtc/sharing/publications/research-and-articles-on-dialectical-behavior-therapy

•Three of the nine RCT’s were conducted by researchers othethan the developer.

•All of these studies but one compared the approach to “treatment


compared the approach to treatment as usual” or wait-list control;

•The one study compared DBT to an approach that “proscribed use of cognitive-behavioral change g gtechniques or any overt suggestion of new behaviors or advice about what to do.” (p. 16)…An example…

Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26.



•DBT therapists:•Received 45 hours of specialized


• Community experts:•Received no training, supervision, or

Received 45 hours of specialized training;•Pre- and during-study supervision.•Gave 95 (38 x 2½) more hours of contact dedicated to keeping people out of the hospital

Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766.

Received no training, supervision, or consultation;•No control of type, amount, or quality of services . •Provided significantly less direct service than DBT therapists.







The Truth Is in the Tables



Study RCT Comparision Group

Gender Race & Ethnicity Age Drop out rate (DBT/other)

Participants

Linnehan et al. 1991

BPD

Yes Treatment as usual

(Dosing not reported)

100% female Not reported 18-45 4/24 (16.7%) v. 6/12 (50%)

1 Suicide

24/24


BPD

Yes Treatment as usual

(Dosing not reported)

100% Female Not reported 18-45

Mean = 26

3/13 (23%)

1 suicide v. 0

13/13


BDP/Drug

Yes Treatment as usual (significantly lower dose)

DBT received 2X as much therapy

100% female 78% White

11% Unspecified

7% Black

4% Hispanic

18-45

Mean = 30

5/12 (41.6%)

1 death v. 0

D.O. in TAU dropped out prior to treatment

12/16

as much therapy


BPD/Drug

Yes DBT plus 12 steps 100% female 87% White

12% Unspecified

28-43

Mean = 36

4/11 (36%) v. 0/12 11/12

Koons et al. 2001

BPD


100% female 75% White

25% Black

31-46 3/14 (21%) v. 2/14 (14%)

14/14

Van den Bosch et al 2002

Verheul et al. 2003

BPD/Drug


100% Female Not reported Mean = 37.5 14/31 (45%) v. 20/27 (74%)

31/27

Telch et al. 2001

Binge Eating

Yes Wait list control 100% Female 94% White

6% Unspecified

Mean = 50 4/22 (18%) v. 6/22 (27%)

22/22

Safer et al 2001 Yes Wait list control 100% Female 87% White 18-54 2/14 (14%) v 1/15 (7%) 14/15

http://www.nrepp.samhsa.gov/programfulldetails.asp?PROGRAM_ID=72

Safer et al. 2001

Bulimia

Yes Wait list control 100% Female 87% White

13% Unspecified

18 54

Mean = 34

2/14 (14%) v. 1/15 (7%) 14/15

Lynch et al. 2003

Depression

Partial (n = 4)

Medication v. Meds plus DBT

(significantly higher dose)

85% Female

15% Male

85% White

9% Black

6% Hispanic

66-80

Mean = 66

Not reported 17/17


BPD

Yes Community nominated experts

100% Female 86% White

3.8% Black

Asian 1.9%

Other 5.8%

18-45

Mean = 29

11.5% v. 28.6% 52/49

TOTALAllegiance

8.5 1 semi-direct comparison

BPD = 100% Female 81.5% White 18-45

Mean = 31.725.9 v. 35.6% BPD =

157

Smoke and MirrorsReal World Applications

Smoke and MirrorsReal World Applications

DBT for “BPD”DBT for “BPD”DBT for BPD In a large CMHC serving

SPMI clients: Of 382 eligible by dx, only 25 (6.5%) thought it was for them; 25% of those

DBT for BPD In a large CMHC serving

SPMI clients: Of 382 eligible by dx, only 25 (6.5%) thought it was for them; 25% of thosethem; 25% of those dropped out before program started; another 25% dropped out…is it worth the cost?

them; 25% of those dropped out before program started; another 25% dropped out…is it worth the cost?

Haynes, M. (2006). Real world applications of evidence based practice. Heart and Soul of Change 3. Bar Harbor, ME.



It Never StopsWeisz, Jensen-Doss, & Hawley (2006)

It Never StopsWeisz, Jensen-Doss, & Hawley (2006) Meta-analysis of 32 studies

comparing EBT to UC found Meta-analysis of 32 studies

comparing EBT to UC foundcomparing EBT to UC found an ES of 0.30. Conclusion: “Our findings support the view that EBTs have outperformed UC in direct, randomized comparisons”

comparing EBT to UC found an ES of 0.30. Conclusion: “Our findings support the view that EBTs have outperformed UC in direct, randomized comparisons” p

Warrants a closer look because it bears importantly on value added to clinical practice by EBT implementation.

p Warrants a closer look

because it bears importantly on value added to clinical practice by EBT implementation.

Unfair ContestsOf Course!

Unfair ContestsOf Course! Consider Kazdin et al.,

1987)…produced the largest ES Consider Kazdin et al.,

1987)…produced the largest ES ) p gfavoring EBP (d = 1.12).

Problem-solving skills training, the EBT, delivered twice the dose (45 minutes, 2-3 times/wk v. 20 minutes 2-3 times/wk); UC not a real therapy (avoided in-depth discussion of affect-laden material the therapists

) p gfavoring EBP (d = 1.12).

Problem-solving skills training, the EBT, delivered twice the dose (45 minutes, 2-3 times/wk v. 20 minutes 2-3 times/wk); UC not a real therapy (avoided in-depth discussion of affect-laden material the therapistsaffect laden material… the therapists discussed routine activities with no attempt to probe the child’s feelings or clinical problems).

The UC was distinctly disadvantaged; not surprising the EBT elicited superior outcomes.

affect laden material… the therapists discussed routine activities with no attempt to probe the child’s feelings or clinical problems).

The UC was distinctly disadvantaged; not surprising the EBT elicited superior outcomes.



EBT and UCApples and Oranges

EBT and UCApples and Oranges

If the dose of EBT was not greater than UC, the effect nonsignificant.

If the dose of EBT was not greater than UC, the effect nonsignificant. , g

Several of the comparisons were between EBT and a UC that was not a therapy (case management or the minimal contact in Kazdin et al., 1987)—when the UC was a psychotherapy, the effect was not significantly different from zero

, g Several of the comparisons were

between EBT and a UC that was not a therapy (case management or the minimal contact in Kazdin et al., 1987)—when the UC was a psychotherapy, the effect was not significantly different from zerosignificantly different from zero.

Further, many comparisons did not draw the therapists for EBT and UC from the same pool. When therapists were drawn from the same pool, the superiority of EBT was small and nonsignificant.

significantly different from zero. Further, many comparisons did not

draw the therapists for EBT and UC from the same pool. When therapists were drawn from the same pool, the superiority of EBT was small and nonsignificant.

FFT Completers Vs. TAUFFT Completers Vs. TAU



Is It Worth the Cost?Is It Worth the Cost?

Begs the question of the cost of implementing approaches only

Begs the question of the cost of implementing approaches onlyimplementing approaches only better than no tx or TAU. Eg., FFT training costs are $47,500 excl. expenses for but one group.

Considering turnover rates and alleg. challenges the practicality of implementing EBT Perhaps money

implementing approaches only better than no tx or TAU. Eg., FFT training costs are $47,500 excl. expenses for but one group.

Considering turnover rates and alleg. challenges the practicality of implementing EBT Perhaps moneyimplementing EBT. Perhaps money better spent on lower caseloads, more supervision, reliable feedback about outcome, & training in the models that fit therapist preferences.

implementing EBT. Perhaps money better spent on lower caseloads, more supervision, reliable feedback about outcome, & training in the models that fit therapist preferences.

Reminds Me of Animal FarmReminds Me of Animal Farm

Some therapies are more equalh h

Some therapies are more equalh hthan othersthan others



EBT and The EBT and The Medical Model Medical Model EquationEquationDoes it Really FitDoes it Really Fit

EBT and The EBT and The Medical Model Medical Model EquationEquationDoes it Really FitDoes it Really Fit

DiagnosisDiagnosis+ +

Prescriptive Treatment Prescriptive Treatment ==

DiagnosisDiagnosis+ +

Prescriptive Treatment Prescriptive Treatment ==

Cure or Symptom Cure or Symptom AmeliorationAmelioration

Cure or Symptom Cure or Symptom

AmeliorationAmelioration

The Medical Model Fighting the Borg?The Medical Model

Fighting the Borg? MM is not the Borg, nor am

I Captain Picard MM is not the Borg, nor am

I Captain PicardI Captain Picard. Psychotherapy, however, is

not a medical, it is relational.

Yet, MM rules as a d i ti f h t d

I Captain Picard. Psychotherapy, however, is

not a medical, it is relational.

Yet, MM rules as a d i ti f h t ddescription of what we do as evidenced by EBT. Ironically, its assumptions and practices are not supported by the data.

description of what we do as evidenced by EBT. Ironically, its assumptions and practices are not supported by the data.



Medical Model: Doesn’t Fit Me, My Experience, or the Data

Medical Model: Doesn’t Fit Me, My Experience, or the Data

Not pts with illnesses requiring Not pts with illnesses requiring tx from experts w/powerful interventions. Not best described by Killer Ds. Therapy is not model & technique.

Identity lies outside dx, i ti t &

tx from experts w/powerful interventions. Not best described by Killer Ds. Therapy is not model & technique.

Identity lies outside dx, i ti t &prescriptive tx, cure, &

reflects the interpersonal nature of the work & the consumer’s perspective of the benefit & fit of services.

prescriptive tx, cure, & reflects the interpersonal nature of the work & the consumer’s perspective of the benefit & fit of services.

EBTs offers choices for li b l

EBTs offers choices for li b l

No Silver Bullet Cures

clients—but are merely lenses that may or may not fit the client’s frame and prescription. Methods and models are neither deity nor demon but are useful

clients—but are merely lenses that may or may not fit the client’s frame and prescription. Methods and models are neither deity nor demon but are usefulnor demon, but are useful metaphorical accounts of how people can change.

But any mandates…

nor demon, but are useful metaphorical accounts of how people can change.

But any mandates…



A Mountain of ManureA Mountain of Manure

APA Definition of EBPAPA Definition of EBP

Evidence-based i i h

Evidence-based i i hpractice is the

integration of the best available research with clinical expertise in the context of client

practice is the integration of the best available research with clinical expertise in the context of clientcontext of client characteristics, culture, and preferences(American Psychologist, May 2006).

context of client characteristics, culture, and preferences(American Psychologist, May 2006).



EBP Now Accommodatesthe Common Factors

EBP Now Accommodatesthe Common Factors

First part (integration of th b t il bl

First part (integration of th b t il blthe best available research) includes ESTs but does not grant privilege—now consists of a range of empirical findings: the dodo

the best available research) includes ESTs but does not grant privilege—now consists of a range of empirical findings: the dodo

FeedbackAlliance

M/T

M/T Delivered:Th i tfindings: the dodo verdict, alliance, common factors, emergent findings about feedback…

findings: the dodo verdict, alliance, common factors, emergent findings about feedback…

M/T Delivered:General Effects

Therapist

Evidence Based PracticeThe Therapist

Evidence Based PracticeThe Therapist

Next (with clinical Next (with clinical expertise), or sum total of who the therapist is—highlights what the th i t b i

expertise), or sum total of who the therapist is—highlights what the th i t b i

Therapist

therapist brings consistent with findings of clinician variability

therapist brings consistent with findings of clinician variability

46-69%



Evidenced Based PracticeThe Client

Evidenced Based PracticeThe Client

And finally (in the And finally (in the context of client characteristics, culture, and preferences)rightfully emphasizes what the client brings as

context of client characteristics, culture, and preferences)rightfully emphasizes what the client brings as

87%

13%

gwell as the acceptability of any intervention to the client’s sensibilities and expectations.

gwell as the acceptability of any intervention to the client’s sensibilities and expectations.

APA RecommendationsAPA Recommendations

Decisions should be made in collaboration with the client

Decisions should be made in collaboration with the clientcollaboration with the client, based on the best evidence

Most effective when responsive to the client’s strengths, cultural context, and preferences.

collaboration with the client, based on the best evidence

Most effective when responsive to the client’s strengths, cultural context, and preferences. a d p e e e ces

Responses are variable. Therefore, ongoing monitoring of client progress and adjusting as needed is essential

a d p e e e ces Responses are variable.

Therefore, ongoing monitoring of client progress and adjusting as needed is essential



Outcome and Alliance FeedbackOutcome and Alliance Feedback

The O.R.SThe O.R.S The S.R.SThe S.R.SDownload free working copies at: Download free working copies at: http://www.heartandsoulofchange.comhttp://www.heartandsoulofchange.com

ConclusionsThe Differences

ConclusionsThe Differences

EBT: confidence in the available evidence and li t th h b li th t

EBT: confidence in the available evidence and li t th h b li th tappealing to those who believe that more

structure and consistency and less clinician judgment is needed for positive outcomes.

EBP: scientific evidence is tentative, outcome is dependent not only on applying research but

appealing to those who believe that more structure and consistency and less clinician judgment is needed for positive outcomes.

EBP: scientific evidence is tentative, outcome is dependent not only on applying research butdependent not only on applying research but also on the participants. EBP appeals to those who value clinician autonomy and individualized tx decisions based on unique presentations of clients.

dependent not only on applying research but also on the participants. EBP appeals to those who value clinician autonomy and individualized tx decisions based on unique presentations of clients.



NOT ANTI-EBTNOT ANTI-EBT

Calling for a more sophisticated clinician who Calling for a more sophisticated clinician who g pchooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches there is indeed differential

g pchooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches there is indeed differentialamong approaches, there is indeed differential effectiveness for the client in the room now—therapists need expertise in a broad range of intervention options, including ESTs.

among approaches, there is indeed differential effectiveness for the client in the room now—therapists need expertise in a broad range of intervention options, including ESTs.

Conclusions and theBottom Line

Conclusions and theBottom Line Outcome not guaranteed

dl f id Outcome not guaranteed

dl f idMandates regardless of evidence Challenge statements that

use EBTs to mandate or reimburse.

Know about dodo verdict &

regardless of evidence Challenge statements that

use EBTs to mandate or reimburse.

Know about dodo verdict &

Mandates don’t make

i i l Know about dodo verdict & unfair contests in research.

Educate others about APA definition & importance of measuring client response.

Know about dodo verdict & unfair contests in research.

Educate others about APA definition & importance of measuring client response.

empiricalsense

estebtebpslides

Education