Module 6

Question 1

What is evidence based practice (EBP)?

Answer 1

• EBP is the integration of best available research with clinical expertise in the context of the client
  
  • Start with client and apply research evidence
  • Not EB treatment (starts with treatment, used until 90s)
• EBP can be operationalised as a combination of 3 factors inside the context of practice:
  
  1. Best research evidence
  2. Clinical expertise (tacit and explicit)
  3. Client values, characteristics, preferences)

Question 2

What is the 6-step process of EBP?

Answer 2

1. Assess your patient; Define the problem, gather information regarding client history, distress, etc
2. Ask the right question; What are you looking for? Have clients expressed a preference or aversion for a particular treatment?
3. Assess the evidence; What is the current empirical support?
4. Appraise the evidence; Critically analyse the research
5. Apply the evidence; Consider the evidence in relation to the client circumstances (cultural, personal factors etc)
6. Audit clinical practice; reflect on practice and modify what is and isnt effective

Question 3

What is the NHMRC heirachy of evidence?

Answer 3

• I: Systematic review of RCTs
• II: At least one RCT
• III-1: Well designed pseudo RCT
• III-2: Comparative studies with current controls, cohort study
• III-3: Comparative studies with historical control, 2-arm studies
• IV: Case studies

Question 4

How can we define best research evidence (in RCTS)?

Answer 4

• Best evidence involves RCTs which show:
  
  • Statistical significance
  • Clinical significance
  • Reasonable effect sizes
• Characteristics of RCTs:
  
  • Primarily medical model
  • Involve large sample sizes (issues with dropouts and small effect sizes)
  • Randomisation balances variance due to extraneous variables

Question 5

What are some sources of research evidence?

Answer 5

• Cochraine Collaboration;
  
  • Produces highest standard systematic reviews in health care
  • PICO (participants, interventions, comparisons, outcomes)
• National Institute for Clinical Evidence
  
  • Produces standards of excellence (short, evidence based statements for practitioners)
• World Health Organisation
  
  • ​Publishes systematic reviews
  • Note context roles (cost of studies are often a barrier in non-western countries)
• Moriana, Galvaz-Lara, Corpasa Review
  
  • Recent review of standards of evidence across organisations incl APS, NICE, Cochraine. Noted inconsitencies

Question 6

What are some limitations to the EBP model?

Answer 6

• Critiques of Evidence Based Medicine Model
  
  • David Healy; criticism of role of bias in evidence based medicine, particularly BigPharma in SSRI research
  • Effects of funding, publication bias and mishandling of data
• Dodo effect; there is evidence that no form of psychological treatment is actually any more beneficial than another
  
  • Common factors
  • Problem when considering harmful side effects of aversive techniques

Question 7

What is Practice-Based Evidence (PBE)?

Answer 7

• Evidence of efficacy is generated by the practitioner rather than the treatment framework (a bottom up rather than top down approach)
  
  • Recent response to backlash against trustworthiness of observer led approach of EBP
• Based on asking psychologists to employ universal outcome measures to allow systematic comparison
  
  • Health of the Nation Outcome Scales (HoNOS): 12-item likert scale (score out of 48). Rated at end of each session.
• Clinical Implications:
  
  • Therapy should be collaborative, weight cost vs benefits
  • Client should be informed, evolved and consulted in treatment plan

Question 8

What are POR and PRN?

Answer 8

• Practice Oriented Research (POR) or practice-based research
  
  • Conducting research in a routine practice setting (naturalistic)
  • Research conducted with a group not on a group
  • Provides opportunities for 2way learning
• Practice Reseach Networks (PRN)
  
  • Developed to enable smooth trasition from research to practice
  • Collaborative enterprise between students, faculties, clinicians, administrators etc
  • eg Centre for Collegiate Mental Health

Question 9

What potential approaches of the Science-practitioner model are outlined in Stricker (2002)?

Answer 9

1. Local Clinical Science Model (LCS): Define science as an attitude carried into clinical practice (critical inquiry)
   
   • Question, Apply findings, Reflect, Produce research
2. Systematic Treatment Selection (STS); distinguish effective parts of treatments and apply them systematically to individual patients
   
   • Combine approaches to tailor treatment
   • Caveat; few practitioners equally strong in all areas, practice in same way
3. Patient Focused Research; Focus on progression of treatment for individual client, tracking progress relative to similar clients
4. Psychotherapy Integration; Umbrella concept, consumate example of SP thinking. Struggles with actualization due to clash of manualisation and flexibility requirements.
5. Practitioner-Initated Research; Context of discovery (usually practioners) vs context of confirmation (usually researchers). Focus on fostering connection between the two.
6. Practice Informed Research; Regardless of primary interest, effectiveness is more important than efficacy. Clinical outcomes are primary concern,

Question 10

What reasons did Moriana et al (2017) suggest for discrepencies between levels of treatment evidence across organisations?

Answer 10

• High levels of disagreement: Only 4 disorders had excellent agreement (GAD, phobias, Bulimia, OCD), 3 good agreement (Anorexia, Schiz, ADHD)
• Potential causes:
  
  • Bias in procedures/committees: information not provided for ineffective treatments, bias to own studies
  • Different RCTs, meta-analysis reviewed; particularly for BPD and schizophrenia
  • Different criteria on what consititutes effective
• Limitations of study:
  
  • ​Heterogeneity of levels of evidence hinders comparisons
  • Only compared 4 international organisations
  • Only examined a small proportion of disorders

Question 11

What 9 foci do Homlqvest et al outline as arguments for practice-based studies?

Answer 11

1. Patients; Many clients have more complex and heterogenous situations than are captured in research settings
2. Therapists; Often have heterogenous competences, trained in combinations of multiple approaches
3. Treatment length; Actual practice duration may differ significantly from manual recomendations
4. Under-represented treatments; Non-manualised treatments are rarely studied in RCTs.
5. Therapist effects and training; Therapists in RCTs controlled for training level and background
6. Patient-treatment matching; Assigning a patient to a treatment based on personal factors may be different to randomising
7. Dropouts; Include dropouts as an outcome measure in routine practice dropout rates are high.
8. Service effects: examine differences in delivery context (not controlled)
9. Benefits for clinicians: May find feedback more useful

Question 12

What challenges do Holmqvist et al identify for practice-based studies?

Answer 12

• Therapist participation rates:
  
  • Concern over increased administrative demands, difficulty in defining “therapeutic” interactions, what feedback would be obtained.
• Being fit for purpose and fitting the political space
  
  • Balancing measures that are useful for research and practitioners, but also adheres to political requirements around health delivery (over-valuing symptom specific outcomes)
• Empirical and conceptual mapping; How to best map and examine ther relationships between different outcome measures

Question 13

What is the Neremberg Code?

Answer 13

• Set of principles for human research finalised during the Nuremberg Trials. 10 Principles:
  
  1. Voluntary consent of participant
  2. Experiment is justified
  3. Experiment designed with knowledge of area
  4. Avoid all unnecessary suffering/injury
  5. Never conduct an experiment with forseeable risk of death or disablement (except maybe on self)
  6. Risk should never exceed benefits
  7. Ensure adequate protection for subject even for low risk
  8. Only scientifically qualified persons may conduct experiment
  9. Subject free to leave at any time
  10. Scientist prepared to end experiement immediately if there is risk

Question 14

What are some of the strengths and limirtations of the Nuremberg Code?

Answer 14

• Strengths and significance:
  
  • A turning point in medical and biological research
  • Underlying values of justic, respect and informed consent first articulated
• Limitations:
  
  • Origin led many to believe it to have nothing to teach non-nazi physicians
  • Over-emphasis on informed consent at expense of other principles
  • Incomplete guidance

Question 15

What is the Declaration of Helsinki?

Answer 15

• Official policy document of the World Medical Association
  
  • First developed in 1964, from similar circumstances to the Nuremberg Code
  • Regularly updated, most widely known and available guideline, scope beyond human concerns
• Ashmond Controversy surrounding recent versions
  
  • Debate of ethical authority of declaration, and of the WMA to regulate worldwide
  • Concerns over impractical requirements in resource-poor settings
  • Inconsistencies and undue restrictions/biases
  • Has become politicised
  • No explanatory notes or discussion points, reliance on interpretation is risky

Question 16

What is the Belmont Report? What are some applications?

Answer 16

• Released in 1979, building upon Nuremberg and Helsinki. Tied together code under 3 principles;
  
  • Respect for persons; Right to autonomy, and right of vulnerable populations to protection if they cannot exercise autonomy.
  • Beneficence; Do no harm, increase potential benefits and decrease potential adverse effects. Informed consent.
  • Justice; No discrimination, patients still have right to care if they refuse participation in studies
• Examples of application to unethical studies:
  
  1. Watson baby albert;
  2. Monster study; long term psychological damage to children with stutters
  3. Milgram shock experiment
  4. Bystander effect studies
  5. Zymbardo prison experiment

Question 17

What is research misconduct and why does it occur?

Answer 17

• Academic wrongdoing which takes many forms, monitored through HREC, Peer Review, and community (Retraction Watch)
• Many reasons for misconduct:
  
  • Inexperience/ignorance re ethical issues, plagiarism
  • High pressure for research output
• Examples of misconduct
  
  • Fabrication (inventing data) & Falsification (‘twisting’ data)
  • Plagiarism, failure to acknowledge conflict of interest
  • Incompetence (methods/stats) and careless work habits (record keeping)
  • Questionable publication practices/authorship, biased reporting
  • Failure to provide ethical research environment

Question 18

What did Franco find regarding the ‘file drawer’ publication problem?

Answer 18

• Study Rationale: Examining the effect of publication bias on null results hindered by lack of access to unpublished studies, quality of unpublished studies
  
  • Cannot distinguish bias on publisher or reserchers part
• Study details: Examined TESS (time sharing experiments in social sciences). 4 benefits:
  
  • Known population of conducted studies
  • All studies meet minimum quality standards
  • All conducted via same format
  • All have sufficient statistical power
• Findings: Evidence of null-result publication bias
  
  • Half studies were published, only 20% of null results
  • Majority of null results never written up 65%
  • Researchers abandon low publication odds for other projects

Question 19

What is ethical drift?

Answer 19

• Ethics is an active, sometimes difficult process.
  
  • Ethics needs to be constantly maintained to avoid drift
• A slippery slope of ethical drift can occur when
  
  • there is intense competition for your resources, e. g. time
  • there is little tangible reward for making an ethical decision and acting on it
  • you perceive others acting in ways that are ethically compromised
  • you are coerced by others, in power, to act in an ethically compromised manner

Question 20

What did Koocher and Keigth Spiegel find regarding the effects of colleague reporting on ethical drift?

Answer 20

• Recommendations; keep notes, increase checkups and conversations re ethics
  
  • Avoid discussion with those who will priotise your wellbeing over ethical concerns
  • Formal action is often preferble, if informal, ensure a tone of education
• Reporting Rates:
  
  • 63% of respondents took action when they observed ethical violations
  • Majority of action taken was informal
  • Of those that didn’t report, most felt they were too far removed or the matter was already being handled
  • More likely to report if senior to colleague, and less likely if friends with colleague
• Outcomes of reporting:
  
  • 39% satisfied or highly satisfied
  • 35% disatisfied or highly disatisfied
  • 25% neutral

Question 21

What are the most common ethical transgressions identified by Koocher and Keith Speigel’s survey?

Answer 21

Question 22

What are Norcross and Barnet’s 12 strategies for self care?

Answer 22

1. Valuing yourself: Apply the skills used for clients to yourself.
2. Refocusing on why you chose this work: Remember to focus on the benefits and privileges of working as a psychologist.
3. Recognising the hazards: Acknowledge and accept the occupational challenges that are endemic to working as a psychologist.
4. Minding the body: Remember to practice the essentials of healthy living; sleep, eat and exercise well.
5. Nurturing relationships: Cultivate support among colleagues, family members, friends and mentors.
6. Setting boundaries: Establish and maintain boundaries between yourself and others; between your personal life and your professional life.
7. Restructuring cognitions: Notice perfectionistic and self-critical thoughts; manage them with compassion.
8. Sustaining healthy escapes: Seek restorative activities that keep you vital and engaged.
9. Creating a flourishing environment: Intentionally create a positive environment for yourself in terms of setting, colleagues and comfort.
10. Undergoing personal therapy: Engage in personal therapy on a periodic basis as a form of positive self-development. Consider alternative approaches such as taking a yoga or mindfulness meditation (Activity 3.6)
11. Cultivating spirituality and mission: Connect to sources of meaning and values in your life.
12. Fostering creativity and growth: Diversify your professional activities; seek growth, development, change and renewal in your work.

Question 23

What 5 questions does Packham recommend asking yourself to check for burnout?

Answer 23

1. Have there been changes in my behaviour/attitude in the past 6 months to a year?
2. Have there been any changes in my thinking style in the past 6 months or a year?
3. Have there been any comments from others about their observations of me, specifically as it relates to family members, friends, or colleagues?
4. Have you noticed any differing reactions from others who know you well?
5. Have there been any particular differences in my clients’ response to me as a therapist in the past 6 months or a year?

Question 24

What points of consideration does Pakenham identify to adress burnout on an industry level?

Answer 24

1. The need to distinguish between psychology trainees and practising qualified psychologists when addressing stress and self-care requirements in the profession;
2. the importance of developing a culture of self-care among psychologists by providing self-care instruction during training;
3. the need to temper research findings on stress and mental health among psychologists by the methodological weakness of the studies in this area;
4. adhering to the recent call from colleagues to shift from a focus on pathology and punishment to a positive acceptance, mindfulness, and values-based approach for encouraging self-care among psychologists;
5. the use of a systematic framework for organising the presentation of self-care strategies that makes them more accessible; and
6. an appeal to professional bodies to take their responsibility in promoting self-care in the profession