Lecture 5 - Evidence-Based Practice

Question 1

The problem

Answer 1

➢Research takes a nomothetic approach
▫How well does a therapy work, on average, for a population of people
➢Therapy is idiographi
c▫Conducted one-on-one with a person who may or may not be represented in research studies4

Question 2

What is evidence-based practice?

Answer 2

➢Evidence-based practice is a comprehensive concept
▫Not equivalent to empirically-supported treatment5
-Empirically supported treatment only one component of evidence-based practice

3 legs:
1. Best evidence from research (best scientific evidence)
-results of experiments and quantitative studies
2. Clinical expertise and experience
-expert panels
-practice groups
-consensus statements
3. Client/patient perspective and input (patient preferences)
-satisfaction
-quality of life
-treatment burder
-qualitative studies

Question 3

Leg 1: Best evidence from research (best scientific evidence)

Answer 3

➢Best available research evidence
▫Not all research evidence is equivalent
▫Upper levels minimize sources of error
Ones we want to turn to first

1. Systematic reviews
2. Randomized Controlled Trials (RCTs)
3. Cohort studies
4. Case control studies
5. Case series, case reports
6. Editorials, expert opinion

➢Sources of evidence
▫Treatment efficacy:
Strength of evidence pertaining to causal relationship between intervention and disorder
From rigorously designed studies in research settings
-RCTs
▫Treatment effectiveness/clinical utility:
How well does the therapy work in “real world” clinical settings
E.g., Generalizability, feasibility, costs and benefits of intervention
▫Basic psychological processes relevant to treatment
E.g., memory, attention, problem-solving, emotion, personality

➢Research studies must move beyond what treatment has best outcome and consider:
▫Patient diversity
▫Mode of delivery
▫Feasibility of delivery in real world settings
▫Treatment costs
▫Therapeutic relationship

Question 4

Leg 2: Clinical expertise and experience

Answer 4

▫Competence attained by psychologists through education, training, and experience that results in effective treatment
Clinical case conceptualization
Treatment planning
Treatment implementation
Interpersonal expertise
Self-reflection
Knowledge and use of research literature
Understanding influence of diversity and culture on treatment
tSeeking consultation and resources

➢Research evidence not available to dictate every decision in a therapy session
▫Make use of clinical judgement and past experience
➢BUT…
▫Should always start with the research evidence when planning a treatment

Question 5

Leg 3: Client/patient perspective and input (patient preferences)

Answer 5

➢Patient Characteristics, Culture, and Preferences
▫“What works for whom”
▫Research can examine patient moderators of treatment effects
▫Do treatments tested on majority groups generalize to minority groups?
▫How do comorbid conditions affect effectiveness of treatment?
▫Phenotypically similar symptoms can have different etiological and maintenance factors

Question 6

CPA report on evidence-based practice

Answer 6

(see slide)

Question 7

Advantages and criticism

Answer 7

Advantages:
▫Improve quality and cost effectiveness of treatment
▫Enhance accountability (of the therapist)… if client is aware of how therapy works (because guidelines made public), can make sure it’s been done correctly. Informed consumers.
Criticisms:
▫Treatments amenable to research more likely to be included (aka traetments that are easier to study in a lab more likely to be studied. Ex: CBT is short, so easy to study in lab, vs. psychodynamic therapy long, so not as often included)
▫Inappropriately restrict access to certain treatment

Question 8

Moving forward

Answer 8

➢Requirement for clear relationship between guiding theoretical base and treatment outcome
▫First, proposed mechanisms of change should be validated in basic research
▫Second, proposed mechanisms of change should be related to proposed mechanisms of disorder
▫Third, change in proposed mechanisms should relate to change in symptoms in treatment studies

➢Difference between unvalidated treatments and invalidated treatments
▫Unvalidated = not examined sufficiently in controlled study
Not listed as evidence-based, but doesn’t mean that it might not work
▫Invalidated treatment = shown not to work
➢Suggestion to make list of invalidated treatments▫Make it clear what not to do

Question 9

Case example - Alissa

Answer 9

(see full description)

➢Leg 1: Best available research evidence
▫CBT is the only treatment with strong research support for Panic Disorder and Generalized Anxiety Disorder
▫CBT for Panic Disorder
Cognitive techniques to modify catastrophic thinking related to bodily sensations
Interoceptive (i.e., bodily) exposures
▫CBT for Generalized Anxiety Disorder
Cognitive techniques to modify catastrophic thinking related to likelihood of negative outcomes as well as the adaptive function of worry
Behavioural techniques including worry time, relaxation training

➢Leg 2: Clinical Expertise
▫Case conceptualization
Genetic predisposition towards mental health problems activated in context of school stress
Anxiety about school linked to past perceptions of low intelligence and effort, first in family to potentially graduate from college
Irritable moods more prominent than anxiety based on self-monitoring
Very few “I” statements when monitoring thoughts; blames others for psychological symptoms
Difficulty with “mentalization” –making sense of emotions and mental processes of self and others
Difficulty trusting others, including therapists

➢Leg 3: Patient Characteristics, Culture, and Preferences
▫Alissa presented for treatment for help with anxiety symptoms
Make this target of treatment
▫Personality and emotional characteristics may impact effectiveness of treatment
▫Patient’s sexual identity judged by previous therapists
Believes this to be unrelated to symptoms

➢Treatment Approach
▫Focus on building therapeutic alliance
Demonstrate interest in things unique to Alissa
▫Mood monitoring and thought restructuring
Point out predominant irritable moods and thoughts related to other people’s behaviour
▫Exposure for panic symptoms and worry
Client not interested in relaxation techniques
▫With time, incorporate mentalization-based therapy techniques
Modest research support for borderline personality disorder
Ask questions to clarify emotion in the moment; ask about what others might have been feeling and thinking in a particular situation