Understanding

Evidence-Based Practices

Ventura County Behavioral Health

April 29, 2009

Presented by Todd Sosna, Ph.D.

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Topics• MHSA Prevention and Early Intervention

• Research Informed Practice

• Levels of Effectiveness

• Rating Criteria Examples

• Implementation Considerations

• Intervention Categories

• Examples of EBPs

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MHSA Spectrum of Services

Extended Treatment for Known Disorders

Early Intervention

Selective

Universal

Prevention

Early InterventionPEI

CSS

Recovery and Resilience

Supports

MENTAL HEALTH SERVICES ACT (MHSA ) SPECTRUM OF SERVICES

Source : Adapted from Mrazek & Haggerty (1994) and Commonwealth of Australia (2000)

Treatment & Recovery

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Prevention• Services provided to individuals who do not have any

signs of a mental illness – Universal: Provided to the general public or a whole

population group that has not been identified on the basis of individual risk.

– Selective: Provided to individuals or subgroups whose risk of developing mental illness is significantly higher than average.

• Promotes and supports emotional well-being • Prevents the development of mental illness• No time limits imposed

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Early Intervention• Services for individuals with minimal signs of

mental illness• Short duration (less than 1 year*) and low

intensity

* except services for treatment of early signs of severe mental illness

• Prevents mental health condition from worsening

• Supports return to well-being• Avoids need for more costly services

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Research Informed Practice • The effectiveness of a service is one important

consideration in care planning, sometimes referred to as evidence-based practices--planning that integrates– Professional expertise and judgment– Consumer and family values and preferences– Best research evidence on the effectiveness of

services

– Based on the definition used in “Crossing the Quality Chasm: A New Health System for the 21st Century” (2001), by the Institute of Medicine

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Why is Research Informed Practice?

• Mental health disorders can be complicated, severe, and difficult to prevent and treat

• The causes of these disorders are not fully understood

• Prevention and early intervention models are not effective for all individuals in all situations

• However, some interventions are more successful than others

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Why Research Informed Practices?• Evidence-based practices result in more

individualized and hopeful treatment decisions, and– Reduce adverse consequences of imprecise

care– Are more likely to be effective– Achieve outcomes sooner– Outcomes that last longer – Are ethical and cost effective, allowing limited

resources to be used to serve more children and their families

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Levels of Effectiveness

• The degree to which research indicates that a service is effective, or responsible for achievement of an outcome

• Levels of evidence are on a continuum

• Level of evidence is related to the quality of the research

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Quality of Research • There is a tendency to assume that if a treatment was

provided and there is improvement then the treatment caused the improvement

• However, positive outcomes may be achieved as a result of a number of factors unrelated to treatment– Spontaneous recovery: Individuals naturally strive for

health, try strategies and seek social support to reduce distress and achieve their goals; often this is successful!

– Placebo effect: Improvement associated with non-specific aspects of treatment, for example, the expectation of improvement, that is independent of the unique characteristics of the specific practice; also can be successful!

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Other Unrelated Factors• Non-specific factors

– Treatment leads to outcomes but for reasons unrelated to the theory or active components

• Independent factors– Employment– Friends

• Bias– Selection bias

• More hope and motivation– Consumers bias

• Want to be helpful– Providers bias

• Want to show success

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Quality of Research

• Research is helpful in clarifying the effect of a practice independent of other factors that promote health, and independent of a proponent’s bias in favor of the practice

• Quality of research studies vary• The higher the quality of research, the

greater the confidence in the conclusions of the study

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Quality of Research • Qualitative studies

– Anecdotal observations– Case studies

• Quasi- or partially controlled experimental studies– Within-subjects or longitudinal (pre and post

comparison) studies– Between groups comparisons without assignment

• Controlled experimental studies– Random clinical trials (between groups)– Random clinical trial-longitudinal studies

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Quality of Research• Qualitative studies are especially helpful in

developing theories and practice elements• Quasi-experimental studies provide support for the

effectiveness of a practice but do not control for the influence of important factors

• Controlled studies provide the strongest evidence that the practice, and not other factors, is responsible for achievement of specific outcomes

• Studies vary in their ability to answer questions about if the intervention works (internal validity) and with whom (external validity) the intervention works

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Internal Validity• Level of confidence that the practice is

responsible for the outcome

• Answers the question “Does it work?”– Typically involves highly controlled research

studies– Homogenous populations (for example, to

diagnosis, gender, ethnicity)– Standard, verified application of the practice

(for example, practitioner is highly trained and supervised by the developer)

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External Validity• Level of confidence that the practice will be

effective across diverse groups of individuals

• Answers the question “Will it work in my community?”– Also, involves highly controlled studies– Heterogeneous populations (for example, dual

disorders, both genders and diverse ethnicities)– Replication in diverse (public mental health)

usual care settings with diverse clients and practitioners

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Levels of Effectiveness• Evidence-based practice

– Clearly articulated model– Substantial and credible evidence of positive

outcomes based upon experimental or equivalently strong research methods (replication)

• Promising practice– Clearly articulated model– Generally consistent evidence of positive outcomes

based upon qualitative or quasi-experimental research methods (may have replications)

• Emerging– Clearly articulated model, sound theory, intention to

evaluate

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Reviews of Effectiveness

• SAMHSA National Registry of Evidence Based Practiceshttp://www.nrepp.samhsa.gov/index.htm

• SAMHSA--A Guide to EBPs on the Web

• http://www.samhsa.gov/ebpWebguide/index.asp

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Confidence in a Practice

• No practice works with all individuals

• Confidence in achieving a positive outcome is increased when controlled research has demonstrated that the practice is effective, in real world settings and with individuals from diverse backgrounds

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Fidelity or Model Adherence

• Degree to which there is adherence to the model (high quality)

• Model adherent programs are most likely to result in achievement of similar outcomes to those reported in the research

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Model Adherence or Fidelity• Degree to which there is adherence to the

model (high quality)• Model adherent programs are most likely to

result in achievement of similar outcomes to those reported in the research

• Drift from the model (poor fidelity) can jeopardize achievement of outcomes

• Achieving fidelity or model adherence is an important consideration

• Requires the practice be ready to disseminate

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Fidelity or Model Adherence• Requires the community be ready to adopt

– Consumer and family readiness

– Staff readiness

– Agency readiness

– Service system readiness• Implementing and sustaining an intervention with

model adherence requires--– Training– Coaching (ongoing)– Monitoring and evaluation (ongoing)

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Causes of Program Drift• Insufficient training or supervision• Staff are not interested in or oppose the

practice • Practitioners with multiple or competing duties • Failure to adhere to practice specific workload

standards• Insufficient intra- and inter-agency coordination

around referrals, related services, and so forth

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Causes of Program Drift• No administrative level champion• Little or not attention to fidelity monitoring• Increased scrutiny and accountability• Interest in adapting the practice before it is

well-established • Attrition of practice-proficient practitioners• Delays between training and service provision• Competing initiatives

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Implementing• Designate an administrator/manager lead to

champion learning and using the model• Develop a concrete intervention-specific

implementation plan• Select providers/staff based on a full

understanding of the intervention requirements and commitment to achieving and maintaining fidelity

• Adhere to practice workloads and related intervention characteristics

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Implementing

• Focus on fidelity from the outset• Support fidelity thorough training, coaching,

monitoring, and evaluation• Maintain momentum• Expect and plan for interrupted progression• Expect and plan for staff turnover

(replacement training)

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Selecting• Fit with target population including cultural relevance

• Fit with intended outcome(s)

• Level of demonstrated effectiveness

– Level of research support

– Internal and external validity

• Readiness to be implemented and sustained with model adherence

– Tried and proven training protocols

– Tools for monitoring model adherence and outcomes

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Selecting• Select a practice with a high level of demonstrated

evidence • Select a practice that is valued by consumers,

families and community• Select a practice with a history of successful

implementation across diverse communities– Relevant to MHSA PEI priority populations and

intended outcomes – Suitable for use in Ventura County– Culturally sensitive and responsive to the diverse

communities that comprise Ventura County

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Intervention Categories• Education campaign --Universal Prevention

– Triple P Parenting– Adolescent Transition Program

• Regular education curriculum --Universal Prevention– Incredible Years– Promoting Alternative Thinking Strategies

• Parenting program– Incredible Years– Triple P Parenting– Parent-Child Interaction Therapy– SafeCare

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Intervention Categories• Family therapy

– Functional Family Therapy– Multisystemic Therapy– Multidimensional Family Therapy– Brief Strategic Family Therapy

• School-based parent/child program– Family and Schools Together– Strengthening Families Program– Adolescent Transition Program

• Comprehensive– Nurse Family Partnership

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Intervention Categories• Disorder specific early intervention

– Trauma• Trauma Focused Cognitive Behavior Therapy• Cognitive Behavioral Intervention for Trauma in

Schools– Depression

• Depression Treatment Quality Improvement– Psychosis

• Early Detection and Intervention for the Prevention of Psychosis

• Foster Care– Multidimensional Treatment Foster Care

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Triple P Parenting• Children 0-16 years of age• Parenting program• Five levels of intervention • Universal prevention, early intervention, and treatment• Individual and group modalities• Numerous random clinical trials• Real world (South Carolina) trial

– Improves parenting skills– Decrease in parental stress and depression– Decrease in child behavior problems– Improves parent anger management skills– Decreases social isolation

• www.triplep.net/

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Incredible Years• Children 0-12 years of age• Three sets of comprehensive developmentally based

curriculums for parents, teachers and children to promote emotional and social competence

• Universal prevention, early intervention, and treatment• Strengthens parents’ and teachers’ competence in

communication, child directed play, clear limit setting, effective (nonviolent) discipline

• Numerous random clinical trials• Use with diverse populations and settings

– Less behavior problems– Increases in effective parenting– Less parental depression and increase in esteem

• www.incredibleyears.com/

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PATHS• Children in elementary school• Classroom curriculum to promote social-emotional

competence and reduce behavior problems• Self-control, feelings and relationships, interpersonal

cognitive problem solving units• Universal prevention• Random clinical trials• Use with diverse populations and settings

– Improved self-control and ability to tolerate frustration– Use of more effective conflict resolution strategies– Decreased report of conduct problems and symptoms of

depression and anxiety• http://www.prevention.psu.edu/projects/PATHS.html

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Parent Child Interaction Therapy• Children 2-8 years of age and their parents, at risk of or

presenting conduct problems

• Parent guided (by therapist) in interacting with their child

• Early intervention and treatment

• Numerous random clinical trials

• Use with diverse populations and settings

– Improved parenting skills

– Improved child behavior

– Improved quality of parent-child relationship

– Improved parental affect and personal distress

• Developed by Eyberg at University of Florida

• UC Davis http://www.pcittraining.tv/Default.asp

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Functional Family Therapy• Youth 11-18 years of age, and their families, showing family

conflict or serious delinquency, violence and/or substance use

• Strength-based, phasic family therapy involving 12-16 sessions

• Numerous random clinical trials• Use with diverse populations and settings

– Low treatment drop out rate– Reduction in violent behavior and criminal activity – Improved family interactions – Reduced younger siblings’ high risk behaviors

• www.fftinc.com

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Strengthening Families Program• Children 3-17 years of age• Parent and family skills training program• 14 weekly child and parent (individual and combined) skills

building sessions• Early intervention and treatment• Random clinical trials• Use with diverse populations and settings

– Improved parenting skills– Improved child behavior– Improved family communication, and child problem

solving and anger control• http://www.strengtheningfamiliesprogram.org/

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Nurse-Family Partnership• First time, low-income mothers (any age) • Selective prevention involving home visitation, by public health

nurses, intensively supporting maternal-prenatal and early childhood health, and well-being, over a 2 year period

• Focus on parental roles, family and friend support, physical and mental health, home and neighborhood environment, and major life events (e.g. pregnancy planning, education, employment)

• Random clinical trials• Use with diverse populations and settings

– Improved prenatal health– Increased maternal employment– Reduced childhood injuries

• www.nursefamilypartnership.org

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TF-CBT• Children 4-18 years of age with trauma symptoms• Individual sessions (weekly) with the child, parent and joint

child-parent (12-16 sessions) • Therapeutic relationship, psycho-education, emotional

regulation, stress management, connecting thoughts-feelings and behaviors, gradual in vivo exposure, cognitive and affective processing of trauma experiences, personal safety and skills training

• Numerous random clinical trials • Use with diverse populations and settings

– Decreases PTSD symptoms– Decreases negative attributes (self-blame) – Decreases externalizing problem behaviors– Improves parent-child relationship

• http://tfcbt.musc.edu/

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DTQI• Adolescents to young adults (ages 13-22) with depression• Comprehensive approach to managing depression• Screening and assessment, CBT psychosocial treatment,

symptom monitoring and management, relapse prevention, individual and group formats

• Random clinical trials• Use with diverse populations and settings

– Improved mood– Decrease in depression symptoms– Decrease in suicide ideation and behaviors

• Developers Joan Asarnow (UCLA) & Maggie Rea, (UC Davis)

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EDIPP• Teenagers to adults at-risk of psychosis• Universal prevention, early intervention, and treatment• Educational campaign to reduce stigma and barriers to

treatment, and increase identification of individuals showing signs of psychotic disorders by community members (e.g teachers, doctors, nurses, police officers, parents), and use of assertive case management model

• Promising practice• Several community-based trials in process

– Delayed onset of psychotic disorders– Reduced symptoms– Improved functioning

• http://preventmentalillness.org/

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MTFC• In lieu of group home care for children ages 3-5

(preschool), 6-11 (child), and 12-17 (adolescent)• Multi-level child and family-focused behavioral foster care

program• Numerous random clinical trials • Use with diverse populations and settings

– Increase foster parent competencies– Decrease in child behavior problems– Improved parenting– Decreases parental stress and depression– Increase in social support– Promotes reunification and reduces juvenile crime

• http://www.mtfc.com/http://www.mtfc.com/

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EBP Common Features• Clearly articulated models

– Curriculum or phases or strategies– Specific intervention goals– Defined start and end– Can be replicated

• Emphasis on engagement as an early goal of intervention and responsibility of practitioner

• Specific target populations• Specific target outcomes• Grounded in research-based theory

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Contact Information

• California Institute for Mental Health– web: www.cimh.org– Todd Sosna– email: tmq@verizon.net – Phone: (916) 549-5506