Friday, October 28, 2011

Evidenced Based Practice; Knowing When a Treatment Fits an Individuals Needs.

Over the past 10 or so years, the focus of mental health treatment for the support of individuals and families has increasingly been on “evidence based practices (EBP's).” EBP's are treatments that have been shown through clinical research to produce positive outcomes for individuals and their families. In short, the practices have been shown through research to be effective.  I like this shift in our field and you should too.

Back in the 80's a common question I received from my peers was "what's your therapeutic orientation?"  I have to laugh now as I look back.  For me, being trained in both applied behavior analysis and clinical psychology often meant I had t o choose my answer based more on the characteristics of who was asking the question than on any particular merits of the elements of the treatment procedures themselves.  This also meant the needs of the assumed client took a backseat position to the need to appear competent in the eyes of the person asking the question.  The most often heard response by ethical but sensitive clinicians was a confident exclamation that one was "eclectic."

I'd like to say with confidence that the situation has truly changed however I can say the situation is quickly evolving and with some help from consumers, will change greatly in the next few years.  With that in mind lets take a closer look at EBP's, how the research works and why it benefit's consumers so significantly.

This focus on EBPs in mental health follows the release of a series of national reports calling for the broader dissemination of EBPs.  These reports include those by the U.S. Surgeon General (1999), the Institute of Medicine (2001), the President’s New Freedom Commission Report on Mental Health (2003), and more. Also, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for
Mental Health Services (CMHS) released Evidence-Based Practice Implementation Resource Kits for the mental health system regarding children and adolescents.

Before going farther, one word of caution.  Although there is a growing emphasis on the use of EBPs, individuals and families must maintain their right to choose the most appropriate treatment that meets their unique needs. Choice is necessary and highly valued by individuals and families because proposed EBP treatments may conflict with an individuals or family’s beliefs, may have been tried and failed, or an individual or family may know that a proposed treatment will not work for the current situation based upon other previous experiences.

How was the research done to determine the best EBP's?  The research in this area is ongoing so we tend to know more about the current best treatment procedures than we do about the all-time best treatment procedures.  In a typical study, participants are assigned to one of two groups. One group receives the treatment that is being studied to better understand its effectiveness, while the second group does not receive that treatment, and may instead be given usual treatment, placed on a wait list, or given an alternative treatment. The two groups are compared to see whether the outcomes for the group receiving the treatment being studied are better than the outcomes for the group that did not receive that treatment.

The studies typically use uniform training and a treatment manual to guide providers (psychiatrists, therapists, social workers, and other health care providers) in the treatment. They also provide supervision
and oversight to help ensure that providers follow the treatment protocol or procedures.  In general, those treatments qualify as an EBP that produce positive outcomes in two or more studies and are preferably conducted by more than one research group.

The outcomes typically measured in studies include some combination of the following:

1. Symptom Reduction and Improved Functioning
                • Improved school attendance and/or work performance;
                • Improved significant other, family and peer relationships;
                • Decreased involvement with law enforcement or the juvenile justice system;
                • Decreased rates of substance use and abuse; and
                • Reduction in self-harm and suicide related behaviors.
2. Prevention of Deep End Service Use
                • Decreased hospital admissions, institutional care, and other types of out-of-home placement.

Cautions About EBPs.  Much has been learned in the last decade about evidence-based practices in mental health and more remains to be done. First, the development of EBPs does not mean that these practices are widely available. There are many EBPs that are only available in a limited number of communities around the country. Many mental health providers have not been trained in EBPs and thus lack the training to provide these interventions for individuals and their families. Some providers also resist change in the way they practice, often believing that their clinical judgment, based on years of experience, produces the best outcomes. Individuals and Families need to find providers that are open to change and are willing to partner with them to provide the most effective and appropriate interventions.

Just because a individual or family is receiving treatment that has not been recognized as an EBP, does not mean that the intervention will not be effective. Many factors lead to successful service outcomes, and some of them can be difficult to evaluate. For example, the benefit of a strong therapeutic relationship between a provider, individual, and family can be a factor leading to positive outcomes as long as the provider uses the skills necessary to change concerning behaviors. Families highly value mental health providers who respect the family’s expertise about their child or loved one, and spend adequate time with the family through a thoughtful needs assessment and in developing and implementing an effective treatment plan. How these factors play into positive outcomes for the individual and family can be hard to measure, but are important factors in positive change.

Not all, but many EBPs have been studied in culturally and racially diverse communities. Consequently, the existing research base for some of the interventions in children’s mental health does not address the effectiveness of the practices in all communities. Fortunately, more attention is being paid to the need to adapt EBPs, whenever possible, to better meet the values, needs, and culture of individuals and families in diverse communities.

Co-occurring disorders are common in mental illnesses. This is especially true for substance abuse disorders, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder. It is important for families to understand whether research supporting an EBP includes studies with children, adolescents, and adults with co-occurring disorders. If not, families may want to request several interventions which are likely to improve the outcomes for the disorders that are impacting them.

Research gaps persist in effective treatment for a number of serious mental illnesses that impact the lives of children and adolescents, including bipolar disorder, early-onset schizophrenia, and eating disorders. There is limited research on child use of psychotropic medications, outside of research on the use of stimulants to treat attention deficit/hyperactivity disorder. The limited research that has been done on medications tends to focus on the short-term effects of medication, without examining the long term safety and effectiveness of medications. Fortunately, the scientific understanding of medications continues to grow, with increased information about combining medication with other therapeutic interventions—often involving parents and families as co-therapists, to produce the best results.

New research is being conducted so that more EBPs will be available to treat early-onset mental illnesses. Unfortunately, there is currently not a central clearinghouse or single resource for families to access to learn more about EBPs in mental health and the availability of those EBPs in communities.  We will get there so stay tuned and ask questions in the meantime.

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