Chapter 11 Flashcards
Origin and Goal of Evidence-Based Practice (Institute of Medicine (IOM), 2001)
- The IOM emphasized the importance of integrating research evidence, clinical expertise, and patient values into HC decision-making
- Τhe goal of EBP is to improve patient outcomes by using the best available evidence rather than relying solely on tradition, intuition, or personal experience
- This approach ensures that HC is not only effective but also personalized and scientifically sound
- Not a new concept; it has historical roots
Three parts of EPB
- Best research evidence
- Clinical expertise
- Patient Preference & Values
Best research evidence
Refers to the most current and high-quality scientific studies available; this includes randomized controlled trials, systematic reviews, and meta-analyses
Clinical Expertise
Incorporates the knowledge and skills of HC professionals developed through experience and education
Patient Preference & Values
Acknowledging that HC decisions should respect individual patient needs, beliefs, and circumstances
Early example of EBP - Scurvy and Vasco de Gama
- Scurvy: Greater mortality in early European navies than due to shipwrecks and naval battles
- Vasco de Gama (1497): 100/160 sailors die of scurvy on voyage from Portugal, around Africa, to India
- Benefitted from local remedies
- Controlled experiments were conducted on scurvy
Early example of EBP - Jacques Cartier (1535) to James Cook (1776)
- Jacques Cartier (1535): Iroquois provide assistance to sailors over-wintering on St Lawrence River
- James Lancaster (1601): 4 ships from England to India, 3 with regular diet, 4th with 3 teasponss of lemon juice a day
- At hald-point, 40% of sailors on ships 1-3 had died; none on ship 4 died
- James Cook (1776): “early adopter” of EBP, required all sailors to have fresh water, fresh food, and foods with atiscorbutic properties (ex. citrus fruits, sauerkraut)
Early example of EBP - 1795 to 1865
- 1795: British Navy (Royal Navy) finally implemented a routine diet including citrus fruits to prevent scurvy
- 194 years since Lancaster data available
- The adoption drastically reduced scurvy cases in the Navy
- 1865: British Board of Trade (Merchant Navy) adopted citrus-based prevention much later, in 1865
- 264 years since Lancaster data available
- The delay highlights the slow translation of scientific evidence into widespread medical and policy changes
- This case serves as a critical lesson in EBP - even with strong data, implementation can be slow due to cultural resistance, lack of awareness, and institutional inertia
Timeline for adoption of anti-scurvy practices
- 1497-1500s (anecdotal reports demonstration)
- 1600-Mid 1700s (evidence of intervention and prevention)
- 1795-1865 (implementation of policy on consumption of vitamin C in navy voyages)
Psychotherapy
Informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting ppl to modify their behaviours, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable
Psychotherapy in practice
- It involves clinical methods and interpersonal techniques grounded in psychological principles
- The goal is to support individuals in achieving desired personal changes, improving mental health, and enhancing well-being
- Psychotherapy can be applied in various forms, including CBT, psychoanalysis, and humanistic approaches
- Emphasizes collaboration between therapist and client to tailor treatment to individual needs
- Two-way street: should be conversation not preaching out the client
APA Resolution on Effectiveness of Psychotherapy
- In 2012, the APA officially recognized psychotherapy as an effective and cost-effective HC service; The resolution emphasizes that psychotherapy is evidence-based and should be integrated into the HC system
- Benefits of the resolution included validating psychotherapy as a scientifically supported treatment
- Promotes insurance coverage and accessibility for mental HC (not all therapies are covered)
- Reinforces psychotherapy’s role in reducing HC costs by preventing more severe mental health issues
Potential Shortcomings of Resolution
- The resolution alone does not guarantee policy changes or insurance reimbursement
- Implementation depends on HC providers, policymakers, and insurers
- Some still question effectiveness across different ppns and conditions
- This highlights the ongoing challenge of translating research into widespread HC adoption
Psychotherapy Code
- Within professional relationship (ethical and structured interaction, one sided and professional)
- Emphasis on psychological principles
- Broad: Affect, behaviour, cognition
- Acknowledges client/patient goals
- But does not address whether services are EB, there is a need for researched approaches
Alternative Definition as Psychological Treatment
- Unlike general psychotherapy, psychological treatment explicitly requires an EB approach
- It focuses on treating clinically significant emotional and behavioural problems; emphasizes scientific validation and structured interventions
- This definition aligns with the principles of EBP, ensuring that treatments are backed by research
- need to be 100% research based unlike psychotherapy
Ethics of intervention
- Informed consent is a fundamental ethical requirement in psychological treatment; before starting treatment, individuals have the right to be informed about available EB options
- Psychologists must discuss medication options when relevant; (any out of all) psychological treatments they can provide; treatments they are NOT trained in, ensuring referrals to qualified professionals when necessary
- This ensures ethical practice, patient autonomy, and access to appropriate care
Psychotherapy as a controlled act - What is the practice of psychotherapy (Ontario Psychotherapy Act, 2007)
Assessment and treatment of cognitive, emotional or behavioural disturbances by psychotherapeutic means (silence, active listening), delivered through a therapeutic relationship based primarily on verbal or non-verbal communication
Psychotherapy as a controlled act
- In many jurisdictions, psychotherapy is not a controlled act, meaning it can be practiced without strict regulatory oversight
- The lack of regulation in some areas concerns about quality control, practitioner qualifications, and patient safety; some regions regulate psychotherapy to ensure ethical standards and EBP
Examples of Discredited Psychotherapies - Neurolinguistic Programming (NLP)
Claims to enhance communication and change behaviour but lacks empirical support (which is what it is discredited for)
Examples of Discredited Psychotherapies - Rebirthing
A dangerous practice involving forced breathing techniques, linked to fatalities
Examples of Discredited Psychotherapies - DARE (Drug abuser resistance education)
Shown to be ineffective in preventing substance abuse among youth
Examples of Discredited Psychotherapies - Scared Straight
Exposing at-risk youth to prison environments; research indicates it increases criminal behaviour rather than deterring it
What is there is no EBT that matches client needs exactly?
- Adopt the one that is closest (similar clientele, diagnosis); applying principles from existing EBT that share similarities with the client’s concerns
- Adapt and change development if necessary; Monitoring client progress and adjusting interventions based on their response
- Abandon if evidence shows it does not fit and replace with another EBP (need a tailored treatment); Integrating clinical expertise and patient preferences while ensuring ethical practice (treatment remains evidence informed)
Theoretical Approaches - Short-Term Psychodynamic Therapies (STPT)
Focus on unconscious conflicts and emotional processing in a brief, time-limited format
Theoretical Approaches - Interpersonal Psychotherapy (IPT)
Addresses relationship patterns and social roles to improve mental health
Theoretical Approaches - Process-Experiential Therapy (P-ET)
Uses emotion-focused strategies to deepen self-awareness and personal growth
Theoretical Approaches - Cognitive-Behaviour Therapy (CBT)
A structured, EB approach that focuses on changing maladaptive thoughts and behaviours
Theoretical Approaches - Eclectic
Therapists may use a single approach or integrate multiple methods based on client needs
STPT - What is it
- Weekly or biweekly sessions for 16-30 weeks
- Structured, time-limited therapy with weekly or biweekly sessions for 16-30 weeks
STPT - Goals
- Develop positive transference and establish themes
- Analyze transference relationship through clarification and confrontation
- Dealing with loss; dealing with the unexpected
STPT - Focus and Area of Effectiveness
- Focuses on unconscious conflicts, emotions, and interpersonal patterns that influence present behaviour
- Effective for depression, anxiety, and relationship issues, offering a focused alternative to LT psychoanalysis
STPT - Process
- Therapy follows a structured process
1. Develop positive transference and establish themes; building a therapeutic alliance and identifying core emotional issues
2. Analyze transference through clarification and confrontation; examining the therapist-client relationship to reveal unconscious patterns
3. Dealing with loss and the unexpected; helping clients process emotions related to unresolved conflicts and adapt to change (what’s not working and how can we fix it)
IPT - What is it
A structured, time-limited therapy (12-16 sessions) focusing on how interpersonal relationships impact MH (looking inwards to see how it impacts the individual and their surroundings); designed to change relational functioning
IPT - Three main phases
- Initial (sessions 1-3)
- Intermediate (Sessions 4-12)
- Termination (Sessions 13-16)
IPT - Initial Phase
Assessment and case formulation to identify key relationship patterns affecting distress
IPT - Intermediate Phase
- Addressing specific interpersonal themes, like:
- Grief (loss of a loved one)
- Role disputes (conflicts in a relationship)
- Role transitions (life changes like divorce, job loss)
- Interpersonal deficits (difficulty forming/maintaining relationships)
IPT - Termination Phase
Acknowledges progress, reinforce skills, and prepare for future challenges (how to slowly terminate therapy, how do we feel about it, how to maximize independence)
IPT - Area of Effectiveness
Evidence-based support for depression and other mood disorders helping clients build stronger social support
PET - What is it
- Emotion-approach that helps clients explore and transform their emotional experiences
- Emphasizes awareness of emotions, understanding & expressing emotions, & transforming maladaptive to adaptive emotions
- Encourages clients to process feelings deeply rather than suppress or avoid them
- Combine therapeutic relationship, client self-determination, and therapist empathy to explore emotions and experiences
PET - Key principles
- Enhancing emotional awareness (identifying and understanding emotions)
- Expressing emotions safely (encouraging clients to communicate feelings effectively)
- Regulating emotions (learning how to manage overwhelming emotions)
- Transforming maladaptive emotions (changing harmful emotional patterns into healthier responses)
PET - Area of Effectiveness
Useful for trauma, depression, and relationship difficulties, helping clients create meaningful emotional change
CBT - What is it
Structured, goal-oriented therapy that focuses on changing unhelpful thoughts and behaviours
CBT - Key stages of treatment
- Assessment & Case Formulation
- Cognitive & Behavioural Skill-building
- Review & Maintenance
Assessment & Case Formulation
- Assessment to develop case formulation and client goals
- Identifying cognitive distortions and behavioural patterns
Cognitive & Behavioural Skill-building
Cognitive and behavioural skills and techniques modeled and practised in sessions, reinforced and generalized through homework tasks and assignments
Review & Maintenance
- Review goals and skills, evaluate progress
- Anticipate and prepare for future challenges
- Booster sessions as required
CBT - Area of Effectiveness
Highly EB for treating depression, anxiety, PTSD, and more, making it one of the most widely used psychotherapies (the most important changes happen between sessions)
Seeking Psychological Treatment - Psychotherapy vs Medication
Individuals may choose therapy, medication, or a combo based on condition severity, personal preference, and accessibility
Seeking Psychological Treatment - Growth in psychotropic medication use
There has been a rise in antidepressants and anti-anxiety medications, sometimes prescribed instead of or alongside therapy
Seeking Psychological Treatment - Barriers
Accessibility and stigma remain barriers to seek treatment
Seeking Psychological Treatment - Who seeks psychotherapy based on Age
Young adults and middle-aged individuals are more likely to seek therapy
Seeking Psychological Treatment - Who seeks psychotherapy based on Gender
Women tend to seek psychotherapy more often than men
Seeking Psychological Treatment - Who seeks psychotherapy based on Education
Higher education levels are linked to greater use of therapy
Seeking Psychological Treatment - Who seeks psychotherapy based on Use of Other HC services
Those already engaged in medical care are more likely to seek therapy
Seeking Psychological Treatment - Who seeks psychotherapy based on Urban vs Rural
Urban residents have greater access to MH services compared to rural ppns
The Duration and Impact of Psychotherapy
- Most therapy treatments are ST, with an average of fewer than 12 sessions
- Many clients (most) attend only 1-2 sessions, which may limit effectiveness
The Duration and Impact of Psychotherapy - Treatment as Usual (TAU) vs EBT
- TAU is general clinic-based therapy with varying quality and structure
- EBT is structured, research-supported methods
- Hansen et al. (2002): 67% recovery rate with EBT vs 35% with TAU
- Wampold & Brown (2005): Only 29% recovery with TAU
Blais et al. (2012)
- 800 patients in university-based clinic
- Results showed that 50% improved or recovered after psychotherapy alone, while 56% improved when psychotherapy was combined with medication
- Raised important questions on whether this improvement reflected a growing use of EBT in clinical practice or whether these results were specific to this particular clinic and its methods?
- The findings highlight the potential impact of psychotherapy but also suggest that context matters - different clinics may have different success rates based on their approach and treatment models
Enhancing Attendance at Psychotherapy - Oldam et al. (2012)
Conducted a meta-analysis examining strategies to improve psychotherapy attendance
Enhancing Attendance at Psychotherapy - Key strategies identified
- Allowing clients to choose their therapist and appointment time (increases comfort and engagement)
- Motivational interviewing (helps client explore their reasons for seeking therapy, boosting commitment)
- Preparing clients for what to expect (reduces anxiety and improves follow-through)
- Appointment reminders (simple yet effective in reducing no-show rates)
- Case management for highly distressed clients (Extra support can help those at risk of dropping out)
Alternative Modes of Service Delivery
- Group Therapy
- Couples Therapy
- Family Therapy
- Self-help
- Telepsychology
- Each mode offers unique advantages, and the best approach depends on the client’s needs, preferences, and the severity of the issue being addressed
Alternative Modes of Service Delivery - Group Therapy
- Involves multiple clients with similar concerns
- Provides peer support and shared experiences
- Cost-effective and helps clients learn from others
Alternative Modes of Service Delivery - Couples Therapy
- Focuses on improving communication and resolving conflicts in relationships
- Addresses issues such as trust, intimacy, and relationship dynamics
- Can be beneficial for married or unmarried couples
Alternative Modes of Service Delivery - Family Therapy
- Involves multiple family members to improve relationships and resolve conflicts
- Helps address family dynamics, parenting issues, and communication problems
- Often used for issues like substance abuse, behavioural problems, and MH disorders
Alternative Modes of Service Delivery - Self-help
- Clients use books, online resources, and self-guided programs
- Can be effective for mild psychological issues and personal growth
- Often complements formal therapy
Alternative Modes of Service Delivery - Telepsychology
- Involves delivering therapy via video calls, phone calls, or online platforms
- Increases accessibility for clients in remote or underserved areas
- Convenient and flexible but may have limitations in rapport-building and crisis management
Evidence-Based Self-Help - Anger
Cognitive-behavioural techniques for managing outbursts
Evidence-Based Self-Help - Anxiety
Mindfulness, relaxation, and exposure-based strategies
Evidence-Based Self-Help - ADHD
Organizational skills training and self-monitoring
Evidence-Based Self-Help - Dementia
Memory enhancement exercises and caregiver support
Evidence-Based Self-Help - Eating Disorders
Self-monitoring of food intake and body image therapy
Evidence-Based Self-Help - Mood Disorders
Behavioural activation and cognitive restructuring
Evidence-Based Self-Help - Schizophrenia
Coping strategies and relapse prevention techniques
Evidence-Based Self-Help - Sexual Abuse
Trauma-informed self-help resources
Evidence-Based Self-Help - Sexual Functioning
Behavioural interventions for performance anxiety and intimacy issues
Evidence-Based Self-Help - Assertiveness
Techniques for expressing thoughts and needs confidently
Evidence-Based Self-Help - Communication skills
Enhancing interpersonal effectiveness
Evidence-Based Self-Help - Couple Relationships
Strengthening emotional bonds and conflict resolution
Evidence-Based Self-Help - Managing Stress
Mindfulness and relaxation techniques
Evidence-Based Self-Help - EBTs vs routine Psychotherapy services
EBTs perform better than routine psychotherapy services, and patients receiving EBT in randomized controlled trials are often more severely distressed
Telepsychology
- Involves delivering therapy via video calls, phone calls, or online platforms
- Increases accessibility
- Convenient and flexible but may have limitations in rapport-building and crisis management
Telepsychology - Various Approaches
- Videoconferencing (live sessions via Zoom, Skype, or other platforms)
- Virtual Reality Therapy (Immersive environments for exposure therapy)
- Online Services (Therapy delivered through chat-based or text-based interactions)
- Smartphone Apps (MH support tools, mood tracking, and guided exercises)
Telepsychology - Common uses
CBT, coaching, and MH support apps
Stepped Care
- Graduate Dosage
- Efficient Resource Use
- Pyramid Approach
- Adaptability
Graduate Dosage
Providing the least insensitive but effective intervention first
Efficient Resource Use
Ensures clients receive only the level of care necessary
Pyramid Approach
Ranges from self-help to more intensive therapy options as needed
Adaptability
Adjusts care based on individual progress and response to treatment
