EBTs

Question 1

what does evidence-based mean

Answer 1

EBT = any psychotherapy, intervention or mental health treatment which has been shown to be effective.
- “Shown” = proof. Evidence based on scientific (empirical) research.
- Effective/efficacious = it works / causes a change that did not occur by chance/randomly.
Evidence = empirical data (information acquired from sensory observation) showing that a phenomenon exists. Provides reasons for believing something is true or untrue.
How data is observed and measured = through the ‘scientific method’
‘Evidence-based’ means interventions are supported by empirical, scientific research to consistently show improved outcomes

Question 2

what are the origins of the EB movement

Answer 2

-medical movement in the early 1980’s by Canadian epidemiologist, David
Sackett.
-Sacket’s definition: the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”
-Encouraged clinical decision-making that was grounded in best-available evidence
-This idea spread throughout the field of medicine, including psychiatry. Became a buzzword that is still very much heard within medicine.

Question 3

what are the origins of the EB practice in psychology

Answer 3

-the 1970’s a meta-analysis found that most psychotherapies work for most people – very little discrimination between methods/techniques.
-Gave rise to the idea of common therapeutic practices considered to be crucial to therapy, rather than a specific technique
- psychiatry had tended to somewhat underplay the value of therapy in guiding mental disorders, instead favouring medication.
-In order to make psychotherapies look more valid in the field of medicine, the EBT movement in psychology adopted the FDA evidence model: using clinical trials to show that a treatment doesn’t cause harm, and is effective.
-Focus was on brief, focal treatments for specific disorders.

Question 4

what is the gold standard in the EBTs

Answer 4

RCTs

Question 4

what is the policy of EB practice in psychology

Answer 4

In 2006, (APA) released their policy on EB practice in psychology:
^ Emphasis on “integrating the best-available research with clinical expertise in the context of the patient’s culture, individual characteristics, and personal preferences”.
-“This policy makes clear that the effectiveness of any psychotherapy is influenced by the unique characteristics of each patient, such as: - developmental history and life stage,personal problems, strengths.
-The policy also highlights consideration of the patient’s environment when choosing an evidence-based psychotherapy modality”.
-This policy was intended to maximize patients’ choices about their treatment.
Choices for treatment should also be framed by best evidence
-What the APA identified as the best treatments came from a wide range of research methodologies - E.g. meta-analyses, randomised controlled trials
-But RCTs have come to be seen as the best evidence, and retained as the only way of “proving”efficacy

Question 4

what is the difference between efficacy and effectiveness

Answer 4

Efficacy = evidence derived from trials where the threat to internal validity is minimized. Data is derived from a well-controlled trial which has tried, as far as possible, to eliminate confounding
variables.
- Evidence which comes from RCTs, which are considered the ‘gold standard’.
- Enables researchers to establish cause and effect.
- EB treatment has become synonymous with efficacy.
Effectiveness = performance under real-world conditions. Less-controlled.
- Therefore might not be as generalisable or internally valid.
Efficacy studies are considered superior to effectiveness studies within most of science.
-Testing pharmacological treatments is a little different to testing psychotherapy: pharmacological placebos look basically identical to the real treatment; In therapy, a person is involved – introduces a lot more variability

Question 4

what is the global health movement

Answer 4

-in 2007: Global Mental Health (GMH) movement started to address global inequalities in mental health care and lack of access to services.Especially in LMICs.
-A global network of agencies, NGOs, universities, government departments etc. that produce a large amount of research in international publications.
Host international conferences, advocate in governments, participate in policy-making at national and global levels.

Question 5

why is important to intervene when it comes to evidence-based treatments and prevalence in sa

Answer 5

There was simultaneously increased recognition of the impact and prevalence of mental disorders.
- Common mental disorders (CMDs) like anxiety and depression were being shown to be highly prevalent.
- Mental disorders also lead to greater impairment than chronic medical disorders do.
- E.g. Depression predicted to be the leading cause of disability worldwide by 2030 (it’s currently the second).
- Also greater recognition of the impairment and expense caused – lost productivity and
income, cost associated with treatment.
- Direct and indirect costs to individuals, communities and economies are enormous. Also, research shows how unequal access to treatment is (i.e. the treatment gap). Up to 90%
of people in LMICs who need services don’t/can’t access them.
The gap is 75% in SA.
“By incorporating research into clinical practice, providers use research-driven evidence rather
than rely solely on personal opinion.” (Cook et al., 2017)

Question 6

what are the two fundamental principles of the Global mental health movement

Answer 6

scientific evidence (ensuring that the care is empirically grounded) + human rights (access to care and the right to be treated with dignity).

Question 7

what are Kazdin’s 6 criteria of EB pschotherpay

Answer 7

According to Kazdin (2014), it is a treatment that has been tested and:
1. Clearly specifies patient characteristics
2. With participants randomised to intervention and control groups
3. Using a manualised intervention
4. Multiple outcome measures
5. Statistically significant effect size
6. Outcomes can be replicated
These criteria show how the idea of evidence-based has changed since the original conceptualisation in 2006.
Criteria 2+3 are particularly emphasised today. What has come to be known as EB therapy is that it’s based on data from RCT, it’s supported by that data, and is manualised.
-According to Shelder (2018): EB “is now used as a code word for manualized therapy - most often brief, one-sie-fits-all forms of cognitive behaviour therapy”.
The rest of the criteria are in fact all part of RCTs.
- Evidence-based therapy has become conflated with RCTs.
Based on these criteria, there are over 320 EB interventions

Question 8

what are RCTs

Answer 8

-Randomised controlled trials
-Considered the quintessential ‘evidence generators’. Need to understand how they work in order to understand what is meant by ‘evidence’.
-A population is chosen, and certain people are included or excluded according to criteria such as age, gender, mental disorders etc.
-The study sample is then randomly allocated to a ‘treatment group’ and ‘control group’.
- They must be matched and equal in size.
Ideally, the research should be double-blinded: nobody will know who’s in which group, including the researchers themselves. Not really possible when studying therapy though.
Both groups are then measured with the same set of baseline questionnaires.
- Looking at demographics, experiences, mental health etc – depends on what it is you’re studying. Everyone is then assigned to their condition.
- The control group is either wait-listed, given treatment as usual (TAU), or nothing at all.
- The treatment group is given the actual intervention or treatment. After the specified period of time, everyone is assessed and measured again.
Then look at whether there’s a difference between baseline and outcome measurements (for both groups).
- Statistics can determine whether any change is significant or not. The control group allows you to show cause and effect.
The goal is to try simulate laboratory conditions as far as possible – excluding any confounding variables in order to have valid results.

Question 8

explain Kazdin’s 1st criterion: Clearly + carefully specifying patient populations and what are the critical challenges of this criterion

Answer 8

-RCTs require careful specification of participants. Inclusion and exclusion criteria
are clear.
-NB to reduce in-group variability.
More than 1 diagnosis/problem often leads to exclusion.
- May also be excluded due to suicidality, being considered unstable, or
having a personality pathology. “In other words, they are the patients we
treat in real-world practice” (Shadler, 2018)
Certain socio demographic groups, or patients with particular psychosocial
stressors, may also be excluded (Cook et al, 2017)

BUT (Critical challenges)
This is unrealistic. Comorbidities are the norm. 66%-80% of people may be
excluded due to this.
● This means that the intervention has only been shown to be effective for
people with only that problem (and no others).
In other words: “…concerns have been raised about the generalizability of the findings,
given that the conditions and characteristics of randomized controlled treatment outcome
research versus those of real-world clinical practice differ significantly.” (Cook et al,
2017)
“Until efficacy and effectiveness studies include treatment conditions that resemble
practice in the real world, it is challenging to draw conclusions from the existing data that
can meaningfully affect clinical practice”
● “The higher the exclusion rates, the better the outcomes”.

Question 9

what does “evidence based” really mean today/now

Answer 9

-Evidence = empirical data (observed through the senses). Has come to mean gathered through the ‘scientific method’.
And the scientific method has come to be conflated with RCTs.
-‘Evidence-based means interventions are supported by scientific research (i.e. RCTs) to consistently show improved outcomes:
“Those psychological interventions that have been shown by means of empirical research to reduce symptomatology and increase functioning among clients, at a rate that is beyond what would have occurred by chance” (Kagee & Lund, 2012, p.103).
- People can improve due to reasons other than the intervention, such as due to natural improvement over time, changed circumstances, falling in love etc

Question 10

explain Kazdin’s 2nd criterion: Randomisation to intervention + control groups and explain what are the critical challenges of this criterion

Answer 10

Randomising participants reduces (conscious/unconscious) bias.
Using a control group allows for suitable comparison.
Different types of control groups: no-treatment, TAU, attention as placebo.

CRITICAL CHALLENGE
-But… ““evidence-based” therapies are almost never compared to legitimate alternative therapies
-The bar for the no-treatment group is far too low. Early research has shown that most therapies are effective for most people.
● There’s no standard for TAU in psychology (unlike in medicine). Could even mean “no
psychotherapy”.
● Comparison studies often use undertrained therapists. The “other” therapy is conducted
by less experienced/trained therapists. The playing fields aren’t level, so the comparison is not valid.

Question 11

explain Kazdin’s 4th criterion: Using multiple outcome measures and explain the critical challenges

Answer 11

-A range of different measures are applied at baseline (prior to intervention starting) so that outcomes can be determined.

There is the primary outcome measure e.g. assessing levels of depression before the
intervention in order to measure possible improvement as a result of theintervention.
But there are a range of other variables, symptoms etc. at play that need to be measured. Other, secondary outcome measures will therefore be applied.
- E.g. substance use/abuse, everyday functioning level, levels of perceived distress, levels of social support.
Most studies thus use many outcome measures.

BUT
● Slanted reporting of outcomes: Some measures may show improvement, whereas others may not: effects are therefore mixed. Researchers may only report on the measures that show improvement, making it look like the intervention has been completely successful.
I.e. literature bias and the “file-drawer effect”, which sees the published benefits of CBT being exaggerated by up to 75% (Shedler, 2018).
● No guidelines regarding appropriateness of measures. Not all measures are equally:
○ Psychometrically valid (does it measure what it’s supposed to measure?)
○ Psychometrically reliable (are outcomes consistent?)
○ Important/relevant
○ Sensitive to change

Question 11

explain Kazdin’s 3rd criterion: Manualised interventions, and explain what are the critical challenges of this criterion

Answer 11

““Manualized” means the therapy is conducted by following an instruction manual.”Facilitates consistency in application (i.e. intervention fidelity). Prevents drift (going off-course). Clear procedures are important for replication of results. NB for task-sharing (training people who aren’t specialists to carry out interventions).

BUT
Manualised therapy is most often a brief form of CBT (Shedler, 2018)
● Manuals can be obstacles to relating to the patients. “when evidence-based
psychotherapies are applied too rigidly, there is risk of diminishing their value”. “Such over-reliance on rules may result in psychotherapeutic practice that is management driven, rather than patient-centered” (Cook et al., 2017)
● Highlights the assumption that the technique is curative, despite evidence for the importance of non-specific factors common to most therapies: compassion, warmth etc.
“the therapeutic relationship accounts for why patients improve, or fail to improve, at
least as much as the particular treatment method.”. Cook et al., thus recommend paying attention to “evidence-based relationships.”
● Manuals focus on addressing one problem, which is unrealistic. We therefore don’t know whether the intervention works for multiple problems e.g. anxiety AND depression, PTSD and substance-use disorders.
● Assumes one-approach fits all. What works for one person doesn’t necessarily work for another. There are many factors which matter e.g. being invested in the process.
● Manuals are based on assumptions about what good mental health means, that it
means the same thing universally – such as ‘being happy’ all the time

Question 11

explain Kazdin’s 5th criterion: Significant effect sizes and explain the critical challenges

Answer 11

Evidence must show ‘statistically significant’ outcomes: difference between baseline and
outcomes must be significantly different.
Statistical significance means that the change didn’t occur by chance.
- “In statistics, significant is a term of art with a technical definition, pertaining to the
probability of an observed finding.”
Also interested in effect size: the size of the pre- and post-intervention difference / amount of benefit.
-Comparing point A (start) to point B (end) for both groups, AS WELL as point B across both groups, to see whether the changes are statistically significant.
-Allows us to establish cause and effect

BUTT
-Statistical significance is often seen as evidence of efficacy. But all it shows is that there has been a change which is significant.
● But that change may have little bearing on functioning (i.e. has no clinical significance). May not actually improve their life.
● Also, improvement does not mean recovery. A reduction in symptoms doesn’t
automatically mean you’re completely better

Question 12

explain Kazdin’s 6th criterion: Outcomes can be replicated and explain the challenges

Answer 12

Repeating methods in other studies will produce the same results.
Following manuals faithfully will produce the same outcomes

BUTT
Assumes a ‘cookbook’ approach to therapy: if you follow the steps, you’ll get the same
results.
● Suggests a one-size-fits-all approach, that there’s one type of therapy which will work for everyone.
● Reflects assumptions about what it means to be mentally ‘healthy’. Psychological health is not universally understood the same way

Question 12

according to shedler 2018 what does empirical research actually show

Answer 12

-“Empirical research actually shows that “evidence-based” therapies are ineffective for most patients most of the time.”
-“Their benefits are trivial. Most patients do not get well. Even the trivial benefits do not last.”- I.e. the benefits are often temporary.
- “Treatment outcome is typically measured the day treatment ends.”
- Many seek treatment later. Those who don’t may have gotten well or they may have simply given up.
-Statistically significant doesn’t mean effective. It just means that the findings were unlikely to have occurred by chance.
-“There is a mismatch between the questions studies of “evidence-based” therapy tend to ask versus what patients, clinicians, and health care policymakers need to know.”
- Researchers usually don’t know whether the patients’ everyday lives have changed in a way that makes a difference (clinical significance)

Question 13

what is tasking sharing/shifting

Answer 13

-The GMHM is driven to develop interventions and treatments grounded in scientific evidence and aimed at closing the treatment gap.
- Remember, evidence-based interventions are based on Kazdin’s 6 criteria.
-The HIV/AIDS pandemic highlighted SA’s shortage of resources and unnecessary reliance on specialists to deliver services that someone with lesser qualifications could deliver.
-Hospitals were terribly under-staffed and under-resources, unable to provide services to the hoards of people in need.
-This crisis led to the birth of task-shifting / task-sharing: “shifting” certain tasks from specialists to ordinary people or staff with less qualifications.
According to the WHO (2008), task shifting is defined as: “…involv[ing] the rational redistribution of tasks among health workforce teams. Specific tasks
are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available
human resources for health” (p. 7).
- The time and skills of specialists are freed up so they can attend to tasks requiring them alone.
-The WHO envisioned an ‘optimal mix of services’ that would reduce pressure on specialist services, by developing non-specialist services in community and primary health care settings
further.
-The need for highly specialised and limited professional services might arguably be reduced, as those needs are met elsewhere.
-The traditional model means the person has to be very unwell to access care, so services were generally not accessible to the average person.
-In the mental health field, task-shifting has largely meant inventing new tasks to make mental health services more accessible. The name “task-shifting” is therefore a little misleading.
-Also involves increasing awareness and helping with general psychological distress, even if it’s not diagnosable.
-Evidence-based treatments (basically versions of CBT) were adapted for delivery by non-specialists to treat CMDs.
- Short, structured, manualized types of therapy such as problem-solving therapy.
Generally, evidence for these interventions has been very positive

Question 14

what are the advantages/positives of EBTs

Answer 14

-Supporting evidence suggests they are effective (but what is meant by ‘evidence’ and ‘effective’ needs to be interrogated)
-Addresses GMH movement’s mandate of ensuring cost-effective and accessible interventions, grounded in science.
-EBTs provide frameworks from which to build on our knowledge of what works and what doesn’t work.
- Qualitative research helps us improve our understanding.
-Allows for development of interventions that can be task-shifted/shared.

Question 14

what are the disadvatages/negatives of EBTs

Answer 14

-EB treatments often ignore cultures within which treatment occurs e.g. making assumptions about what good mental health means.
- These assumptions are not interrogated.
Treatments can assume a one-size-fits-all approach.
- But the treatment should differ according to the individual, as well as the type of therapist and technique they use.
-Little to no acknowledgment of the relational or intersubjective context in which therapy happens, the relationship that shapes the therapeutic work.
- Little emphasis on developing counselling skills, and more on implementing the actual
therapy. Assumptions about what constitutes ‘evidence’ are grounded in the scientific method, and that it
can only be derived from RCTs .Compared to other therapies, the evidence for EBT is not all that good.
- There is a lot of consistency across therapies, and many are effective for most people.
-We should therefore be looking more at patient choice and different types of evidence, thus returning to the original APA’s policy.
-Not saying that there shouldn’t be EBTs, but that what we call evidence and how we derive it needs to be reconsidered.