Evidence Based Practice in a Generalist Setting Implications

Evidence Based Practice in a Generalist Setting: Implications for Training Donna Mc. Donald, Ph. D Counseling and Testing Center The University of Akron

Me and “Evidence Based Practices” � My own training ◦ “Stand on your head” therapy ◦ “Susie” � Changes � Are in trainees? we becoming technicians? � Where is the “art? ”

SOA “The competent practice of psychology requires attention to the empirical basis for all methods involved in psychological practice, including a scientific orientation toward psychological knowledge and methods. ”

SOA Profession Wide Competencies: Intervention � Establish and maintain effective relationships with the recipients of psychological services � Develop evidence-based intervention plans specific to the service delivery goals � Implement interventions informed by the current scientific literature, assessment findings, diversity characteristics, and contextual variables � Demonstrate the ability to apply relevant research literature to clinical decision making � Modify and adapt evidence-based approaches effectively when a clear evidence-base is lacking � Evaluate intervention effectiveness, and adapt intervention goals and methods consistent with ongoing evaluation

Evidence-Based Practices: My Questions � We are generalists. How are we supposed to train in Evidence Based Practices for every situation we encounter? � Are we ready and able to supervise using Evidence Based Practices? � Maybe Common Factors offers us a way to provide “generalist” training? � But specific intervention/psychotherapy research is helpful. Which ones make sense to use in a UCC? � What are Evidence Based Practices anyway?

Evidence Based Practice in Psychology

Evidence-Based Practice in Psychology (EBPP) (APA 2005, 2006) � EBPP is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences. � “The purpose of EBPP is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. ”

EBPP: Best Research Evidence � Scientific results related to intervention strategies, assessment, clinical problems, and patient populations in laboratory and field settings � Clinically relevant results of basic research in psychology and related fields. � Is drawn from a variety of research designs and methodologies � Should be based on systemic reviews, reasonable effect sizes, statistical and clinical significance and a body of supporting evidence � Should recognize gaps and limitations in the existing literature

EBPP: Clinical Expertise � Expertise develops from clinical and scientific training, theoretical understanding, experience, self-reflection, knowledge of current research, and continuing education and training � Clinical expertise is used to integrate the best research evidence with clinical data � Integral to clinical judgment is an awareness of the limits of one’s knowledge and skills and how one’s characteristics and values interact with those of the patient

EBPP: Patients’ Characteristics, Values, and Context � Responsiveness to the patients’ specific problems, strengths, personality, sociocultural context, and preferences

EBPP: Clinical Implications � Clinical decisions should be made in collaboration with the patient, based on the best clinically relevant evidence, and with consideration for the probable cost, benefits, and available resources and options. � It is the treating psychologist who makes the ultimate judgment regarding a particular intervention or treatment plan.

EBPP: Federal Policy Statement (Institute of Medicine/National Academy of Medicine, 2015) Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence Based Practices Five Steps to bring EBP into clinical practice � Support research to strengthen the evidence base � Identify key elements that drive an intervention effect � Conduct reviews to inform clinical guidelines � Develop measures of the structure, process and outcomes � Establish training methods ◦ based on the specific and non-specific or common factors ◦ and paying attention to contextual/environmental and individual patient factors

EBPP Policy: An Elements Model (IOM, 2015) � “Uncovering therapeutic elements that cut across existing interventions and address therapeutic targets across disorders and consumer populations may allow psychological interventions to become far more streamlined and easier to teach to clinicians, and potentially make it possible to provide rapid intervention for consumers. ” (p. 38) � “Training in the elements [of therapy] has the potential to be more efficient as practitioners would learn strategies and techniques that can be applied across target problems/disorders or contexts. ” (p. 65)

So, � EBP’s include both common and specific factors � EBP’s are grounded in research, which can take varied forms � EBP’s include clinical expertise or judgment as well as self-awareness � EBP’s include client factors ◦ Individual differences ◦ Multicultural factors/diverse identities � EBP’s include contextual or factors related to the setting � The purpose of EBP’s is to enhance public health � Public policy suggests that training in EBP’s common elements of therapy would be beneficial

Common Factors and Evidence Supported Treatments

Common Factors and EST’s � Common Factors (CF): ingredients or elements that exist in all forms of psychotherapy � Empirically Supported Treatments (EST): ◦ Focus on a single diagnosis ◦ Have a manual or well-outlined ritual to validate specific techniques ◦ Randomized control trials (RCT’s) represent “gold standard” ◦ Repeatedly demonstrate effectiveness in pre-and post tests

CF: Therapeutic Relationship (Duncan, Miller, Wampold, Hubble. (2010). The Heart and Soul of Change: 2 nd Edition; Brown, 2015) � Clients are most like to refer to the relationship when asked what helped � Factors associated with successful treatment: ◦ ◦ ◦ ◦ Empathy Working Alliance Goals Consensus and Collaboration Unconditional Positive Regard Congruence/Genuineness Therapist Feedback Repair of alliance ruptures Instilling hope

CF: Client Factors (Duncan et al. , 2010) � Client involvement and participation � Client perception of psychotherapy ◦ Therapeutic alliance ◦ Therapist empathy ◦ Collaborative nature � Readiness for Change � Implications: ◦ Strength based approach ◦ Therapy should be collaborative ◦ Therapist should illicit client feedback and adjust services

CF: Contextual Model ( Laska, Gurman & Wampold, 2014; Wampold & Imel, 2015) � An emotionally charged bond between therapist and patient � A confiding healing setting in which therapy takes place � A therapist who provides a psychologically derived and culturally embedded explanation for emotional distress � An explanation that is adaptive and is accepted by the patient � A set of procedures or rituals engaged by the patient and therapist that leads the patient to enact something that is positive, helpful, or adaptive

CF/Contextual Model: Core Predictions � Any therapy that contains all of the ingredients of the CF approach will be efficacious for the presenting problem being treated � Relationship factors such as empathy, goal consensus and collaboration, therapeutic alliance and positive regard should predict the outcome of psychotherapy ◦ More effective therapists will more skillfully apply these factors � Treatments intending to be therapeutic will be superior to “supportive control” or psychological placebo conditions

Criticism of Common Factors (Baker & Mc. Fall, 2014; Asnaani & Foa, 2014 Relational factors etc. aren’t well defined – not sure if training is important or what training is important � Ad hoc design and doesn’t use multiple measures– derived from existing research using meta-analysis, thus, it is less rigorous � Doesn’t take into consideration dose/duration and delivery systems – not as helpful from a public health standpoint � Criticism of EST’s methodological concerns are an overstatement and miss crucial studies � Some studies don’t support the importance of the alliance � Clinicians still have to decide what “procedures and rituals” to use � Questions I have: efficiency? long term effects? �

Microskills: Common Technique? (TCP: Training in Counseling psychology , August 2011 � Microskills and CF share common ground (Nutt, 2011) ◦ Therapeutic relationship important ◦ Microskills are aimed at improving therapeutic relationship ◦ CF may support need for microskills training � Microskills training has received lots of empirical support � Criticized for not being tied to theory, methodological flaws, ignoring cognitive appraisal processes

EST’s � Propose that psychotherapeutic treatments contain specific elements that remediate a specific diagnosis � Mid 90’s: Division 12: Clinical Psychology task force examined EST’s � Now thousands of EST studies for hundreds of EST approaches � Current focus ◦ dismantling – what elements are important ◦ moving in to real-world settings

Choosing EST’s: � Division 12 (Clinical Psychology): http: //www. div 12. org/psychological-treatments/ ◦ Chambless, et al. (1998). Established criteria for modest treatments and strong treatments based on type of study, number of studies, and how many different researchers (two different researchers for strong) � Different entities have developed different criteria to evaluate rigor of EST’s – no standardization

Choosing EST’s (Baker et al. , 2008; Baker & Mc. Fall, 2014) � The scientifically trained clinician should use interventions that are: ◦ Effective across multiple types of outcome measures ◦ Can be implemented and disseminated easily ◦ Are relatively cost-effective � Thus, the choice of EST’s also involves clinical judgment and setting characteristics

Criticism of EST’s (Laska et al. , 2014, Beutler, 2014; Duncan et al. , 2010 � � � Dodo bird verdict: “Everybody has won, and all must have prizes” – EST’s don’t produce unique outcomes when compared to each other Different EST’s for the same problem/diagnosis propose that different mechanisms create change The mechanisms of action postulated by EST’s generally have not been confirmed Relational factors have stronger effects sizes than the type of therapy – some therapists have better outcomes than others Based more on political or theoretical bias Does not consider comorbidity Clients who join EST research are motivated for change Erosion of therapist autonomy Not transferrable to real-world settings - UCC concerns: breaks in service due to academic calendar, short term models Ignores multicultural issues Rather than straight adherence to the manual, flexibility within the model appears beneficial

Other Interesting Things I Found Or, A New Direction?

Transdiagnostic Methods (Mc. Hugh, Murray & Barlow, 2009) � ◦ ◦ Identifying common symptoms within a class of disorders and developing various unified treatment protocols Emotional Regulation as a transdiagnostic factor (Aldao, 2016) Barlow et al. , 2008: Exposure-based cognitivebehavioral treatment that focuses on changing maladaptive responses to emotional experiences for anxiety and unipolar mood disorders

Transtheoretical Integration (Brown, 2015) � Facilitative and supportive behavior leads to less client resistance than teaching and confronting (Motivational Interviewing) � Exposure for anxiety, or any uncomfortable thought, feeling or situation (paradoxical intention, systematic desensitization, Emotion Focused Therapy, Interpersonal Therapy) � Emotional Regulation (ACT, EFT, DBT, Mindfulness approaches)

Importance of Treatment Planning and Treatment Outcome Measures (Lambert in the Heart and Soul of Change, 2010; Mozdzierz et al. 2011; IOM, 2015) � Failure to improve and deterioration rates remain high in routine care � Therapists, despite their confidence in their clinical judgment, are not alert to treatment failure � Regular measurement of treatment outcomes can be an important part of EBP. � Policy (IOM, 2015) advocates for outcome measures also supported in research

SO, What To Do? What Should Training Encompass?

EBPP Training � Common factors ◦ Relational/Therapeutic Alliance ◦ Collaborative approach ◦ Microskills � EST’s � Transdiagnostic/Transtheoretical � Clinical Judgment and Self-Awareness � Treatment Planning and Treatment Outcomes � Individual and cultural diversity � Should be embedded within the context of each setting

Where to Start � EST’s start with a treatment and ask whether it works for a certain disorder or problem under specified circumstances. EBP starts with the patient and asks what research evidence (including relevant results from EST’s) will assist the psychologist in achieving the best outcome (APA, 2006, p. 273)

Client and Setting Characteristics � Who are your clients? � What do you do? � Owen, Tao, & Rodolfa, 2005: advocate each UCC develop EBP protocols for their typical client population Ideas for Training: Review of common client characteristics Use of case examples from your work Review of your mission, vision Policy considerations: session limits, billing, standards of care, scope of service

Common Factors/Relational � Training Seminars: ◦ Common Factors Research ◦ the Therapy Relationship �Empathy training �Importance of collaboration �Repair of ruptures �Boundaries ◦ Motivational Interviewing � My ideas: ◦ Multi-cultural therapy ◦ Relational-Cultural therapy ◦ Therapeutic presence � Incorporate in to group and individual supervision

Specific EST’s � � What EST’s fit your population? What does your staff already know? EST’s that show promise for more than one client concern/diagnosis typically seen in a UCC (DIV 12): ◦ ◦ � CBT: Anxiety, Depression, Eating Disorders, ADHD ACT: Anxiety, Depression Interpersonal: Depression, Eating Disorders Motivational Interviewing: Substance Use and is considered a transtheoretical model My Ideas: ◦ Emotion Focused Therapy: Depression (transdiagnostic? ) ◦ DBT: I find helpful for “maladaptive coping” such as chronic SI, SIB’s, eating disordered behaviors, substance use (transdiagnostic? ) ◦ Trauma therapies ◦ Suicide assessment and treatment ◦ Biofeedback

Individual and Cultural Diversity Training � Who are your clients? � Separate trainings or Integrated? � What does your staff know? � Diversity training/Exercises also work to: ◦ increase understanding and empathy ◦ Increase self-awareness � Individual Characteristics; perfectionism, reactance, grit

Clinical Judgment/Expertise Critical Thinking (Beidas & Kendall, 2010; Rousseau and Gunia, 2016; Mozdzierz, et al. 2011) � Knowing yourself: biases, values, assumptions, culture � Hypothesis testing: teach the scientific method ◦ ◦ ◦ Developing a question Researching: empirical, case studies, consultation Creating a hypothesis Testing hypothesis Evaluating results � Teach lifelong learning

Treatment Planning and Monitoring � Training on conceptualization and treatment planning skills � Use of a written treatment plan? � Ways to monitor ◦ Asking ◦ CCAPS. OQ-45, or other measures � Tracking planning and progress in supervision

Supervisory Considerations (Chwalisz, 2003; Owen et al. , 2005; Beck et al, 2014) � Gaining competence in a particular skill or EST requires practice not just didactic training � Should include more guidance about searching and incorporating research � Modeling critical thinking, hypothesis testing � Judgment of trainee competency varies by therapist – we don’t seem to have a common method of evaluating � My Ideas: ◦ Interpersonal Process Recall ◦ Socratic teaching ◦ Group Supervision to model hypothesis testing and coaching in EST’s ◦ Tracking clients/Monitoring progress in a different way

Proposed Training Model � “Foundational” training seminars ◦ Who we are – our students, policies, staff, modalities ◦ Common factors � Specific EST’s seminars that fit your population � Transdiagnostic/Transtheoretical/Elements models? � Integrated throughout training and supervision: ◦ Clinical judgement ◦ Individual and cultural diversity ◦ Use of scientific method and how to use research � With a focus on practice ◦ Seminars include discussions of adaption to your population ◦ Case examples from your setting ◦ Video of examples when possible ◦ Follow-up in group and/or individual supervision

My Questions and Continued Struggles: � � � � � What EBP practices are you using? Creating training seminars is time consuming – how do you manage the task? Do you teach relational skills – How? How teach empathy? Does anyone teach microskills? How to increase clinical judgment? The role of Counseling Center policy and procedures? Use of transdiagnostic/transtheoretical approaches – I think this holds promise. Are you doing any treatment planning or monitoring treatment outcomes? What about therapist? Development of theoretical orientation? Different therapists choose different theories. This is not discussed in the EBPP literature. How to move didactic training into practice? Supervisory issues? Not all of the staff know EST’s I may train on. Do I attempt to train the staff?

For More Info: � On EBPP and policy ◦ American Psychological Association Presidential Task Force on Evidence-Based Practice (2006). Evidence 0 bsed practice in psychology. American Psychologist, 61, 271 -285. ◦ Institute of Medicine (2015). Psychosocial Interventions for Mental and Substance Abuse Disorders: A Framework for Establishing Evidence-Based Standards, National Academies Press: Washington DC. � On Common Factors vs. EST’s ◦ Duncan, B. , Miller, S. , Wampold, B. , Hubble, M. (2010). The heart and soul of change. APA: Washington DC. ◦ Wampold, B. , & Imel, Z. (2015). The great psychotherapy debate. Routledge: NY. ◦ Vol. 51 (2014) of Psychotherapy (Laska, Gurman & Wampold) � On Transdiagnostic/transtheoretical ◦ Aldao, A. (2016). Introduction to the Special Issue: Emotion regulation as a transdiagnostic process. Cognitive Therapy and Research. 40. 257 -261. ◦ Brown, J. (2015). Specific techniques vs. common factors? Psychotherapy integration and its role in ethical practice. American Journal of Psychotherapy, 69, 301 -316 ◦ Mc. Hugh, K. , Murray, H. , Barlow, D. (2009). Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions. Behavior Research and Therapy. 47, 946 -953.

For More Info: � On Training in EBPP ◦ Beck, J. , Castonguay, L. , Chronis-Tuscano, A. , Klonsky, E. Mc. Ginn, L. , Youngstrom, E. (2014). Principles for training in evidence-based psychology: Recommendations for the graduate curricula in clinical psychology. Clinical Psychology: Science and Practice, 21, 410 -424. ◦ Beidas, R & Kendall, P. (2010). Training therapists in evidence-based practice: A critical review of studies from a systems-cultural perspective. Clinical Psychology: Science and Practice, 17, 1 -30. ◦ Chwalisz, K. (2003) Evidence-based practice: A framework for twenty-first -century scientist-practitioner training. The Counseling Psychologist, 31, 497 -528. ◦ Mozdzierz, G. , Peluso, P. , Lisiecki J. , (2011). Evidence-based psychological practices and therapist training: At the crossroads. Journal of Humanistic Psychology, 51(4), 439 -464. ◦ Owen, J. , Tao, K. , & Rodolfa, E. (2005). Supervising counseling center trainees in the era of evidence based practices. Journal of College Student Psychotherapy, 20, 67 -77. ◦ Rousseau, D. , & Gunia, B. (2016). Evidence-based practice: The psychology of EBP implementation. Annual Review of Psychology, 67, 667 -692.