Evidence-Based Practice and Interprofessional Education

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Evidence-Based Practiceand Interprofessional
Education

• Bruce A. Thyer, Ph.D., LCSW, BCBA-D
• College of Social Work, Florida State University
• Visiting Fulbright Specialist, Kings College,
  UWO, 416 March 2013

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What is Evidence Based Practice?

• Evidence-based practice requires the integration
  of the best research evidence with our clinical
  expertise and our patients unique values and
  circumstances
• From Strauss et al. (2005). Evidence-based
  medicine How to practice and teach EBM (third
  edition). New York Elsevier.

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Note the equivalent importance of ALL these
factors in the EBP process

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What is Best Research Evidence?

• Clinically relevant research from basic and
  applied scientific investigations, especially
  drawing from intervention research evaluating the
  outcomes of health and human services, and from
  studies on the reliability and validity of
  assessment measures.

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• Higher End of Internal Validity
• (in terms of causal inference)
• Systematic Reviews (highest form of evidence)
• Meta-analyses
• Multi-site Randomized Clinical Trials
• Individual RCTs
• Quasi-experiments
• Pre-experiments
• Single Subject Studies
• Correlational Studies/Epidemiological Studies
• Qualitative Research
• Narrative Case Studies
• Basic Science Studies
• Expert or consensus opinion, Theory (lowest form
  of evidence)
• Lower End of Internal Validity

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Best Evidence Means Best Available

• Look for relevant systematic reviews, then
  meta-analyses, then RCTs, then quasi-experiments,
  etc. Integrate this best available evidence into
  your decision-making practice. EBP does NOT
  depend on having a large body of RCTs available
  to consult. It does depend on one examining the
  best available evidence.
• There is ALWAYS evidence, even if it is of low
  quality.

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What are Client Values?

• The unique preferences, concerns and expectations
  each client brings to a clinical encounter with a
  practitioner, and which must be integrated into
  practice decisions if they are to serve the
  client.
• A thorough consideration of ethical
  considerations and client considerations is
  integral to the EBP model.

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What is Clinical Expertise?

• Our ability to use our education, interpersonal
  skills and past experience to assess client
  functioning, diagnose mental disorders and/or
  other relevant conditions, including
  environmental factors, and to understand client
  values and preferences.
• Clinical expertise factors, costs, available
  resources, etc. are integral to the EBP model.
• Research findings are NOT accorded greater
  weight. All are compellingly important.

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What are the Major Steps of Evidence-based
Practice?

1. Convert the need for information into an
   answerable questions(s).

2. Track down the best available evidence to
answer each question.

1. Critically evaluate this evidence in terms of its
   validity, impact, and potential relevance to our
   client.

4. Integrate relevant evidence with our own
clinical expertise and client values and
circumstances.

5. Evaluate our expertise in conducting Steps 1-4
above, and evaluate the outcomes of our services
to the client, especially focusing on an
assessment of enhanced client functioning and/or
problem resolution.
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What are Answerable Questions?

• 1. A question with a verb, as in
• What has been shown to help.? Or
• What psychosocial treatments work.?
• What community-based interventions reduce.?
• What group therapies improve.?

• 2. A question including some aspect of the
  clients or condition. As in
• What psychosocial interventions reduce the risk
  of teenage pregnancy?
• What individual therapies are the most successful
  in getting clients to stop abusing crack cocaine?
• How can schools reduce student absenteeism?
• What treatments are effective in improving
  prenatal care adherence?

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How Can You Track Down the Best Available
Evidence?

• There are LOTS of resources!
• Evidence-based Practice-research journals, as in
• Research on Social Work Practice
• Journal of Consulting and Clinical Psychology
• Evidence-based Mental Health

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• Evidence-based Textbooks, as in
• Social Work in Mental Health An Evidence-based
  Approach
• Effective Interventions for Child Abuse and
  Neglect An Evidence-based Approach to Planning
  and Evaluating Interventions
• Evidence-based Social Work Practice with Families
• Clinical Applications of Evidence-based Family
  Interventions
• Substance Abuse Treatment for Criminal Offenders
  An Evidence-based Guide for Professionals
• A Guide to Treatments that Work,
• and some invaluable websites (next slides)

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• 3. How Can You Critically Evaluate the Available
  Evidence?

• Develop critical appraisal skills in evaluating
  research yourself. (a bottom-up search)
• Seek out and rely on credible groups which have
  already done this (e.g. Cochrane and Campbell
  Collaboration, APAs Division 12s lists of ESTs,
  SAMSHA, California Clearing Houseetc.) (a
  top-down search)

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In the last 30 years, social work has seen three
major initiatives intended to better integrate
scientific findings within the human services.

• Empirical Clinical Practice (1979)
• by Siri Jayaratne and Rona Levy
• Empirically Supported Treatments
• by APAs Division 12, Section III, early 90s
• Evidence-based Practice (early 90s)
• by Evidence-based Medicine Work Group

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Empirical Clinical Practice involved

• Encouraging practitioners to make use of
  psychosocial interventions supported by credible
  outcome studies,
• Encouraging practitioners to evaluate clinical
  outcomes using single-system designs
• See The empirical practice movement, by William
  J. Reid (1994).
• Social Service Review, June, 165 184.

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What are Empirically-Supported Treatments and
Where Do They Come From?

• Division 12 (Clinical Psychology of the APA)
  organized a Task for on Promotion and
  Dissemination of Psychological Procedures in the
  early 1990s. Its purpose was to publish
  information for both the practitioner and the
  general public on the random assignment,
  controlled outcome study literature of
  psychotherapy and of psychoactive medications.

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The Task Force had Two Sequential Tasks

1. To develop evidentiary standards to be used to
   designate a given treatment/assessment methods as
   empirically validated (later changed to
   empirically supported.
2. To review the literature and publish lists of
   treatments that met or did not meet these
   evidentiary standards.

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What Evidentiary Standards Did They Develop?

• They (APA, Division 12)came up with two sets of
  standards or evidence benchmarks, one to
  designate an treatment as empirically
  supported(hence ESTs) or well supported, and
  another, less stringent one, used to
• designate an intervention as promising or
• probably efficacious.

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OK Where are these lists of approved
treatments?

• Two major publication pathways emerged from the
  Task Forces efforts
• Initially, one book -
• Nathan, P. E. Gorman, J. M. (Eds.) (2007). A
  Guide to Treatments That Work (third edition).
  New York Oxford University Press

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And a series of articles

• These are available for free at
• http//www.apa.org/divisions/div12/journals.htmlE
  STs
• You can also find their current lists of ESTs on
  this website, broken down by Treatments and by
  Disorders (this list is focused on so-called
  mental disorders only). See

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See also

• A new Division 12 developed, edited and supported
  book series titled
• Keeping up with the Advances in Psychotherapy
  Evidence-based Practice, published by Hogrefe
  Huber.
• Note the crucial terminology change from
  empirically supported to evidence-based
• This is a problem. These are different things.

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The EST movement remains alive and well through
the efforts of the Committee on Science and
Practice, Society of Clinical Psychology (e.g.,
Section III of Division 12 of the APA), Chaired
by David Klonsky, Ph.D.E.David.Klonsky_at_stonybroo
k.edu
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Individuals who wish to participate in this
initiative to update lists of ESTs are welcome to
contact Dr. Klonsky. He is especially interested
in competent people who will review draft
documents.
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While the EST movement remains alive and well, it
has largely been overtaken by theEvidence-based
PracticeMovement
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WARNING!

• Folks who wish to intelligently discuss
  evidence-based practice should be very familiar
  with the primary source readings on EBP. It is
  NOT the SAME as Empirically Supported Treatments!

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EBP is a PROCESS of learning, it is NOT A
LISTING OF EFFECTIVE TREATMENTS!

• Crucial Definitional Terms such as
• Best Research Evidence,
• Clinical Expertise
• Patient Values and
• Patient Circumstances
• are all operationalized reasonably well.

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What Should Social Work Do and NOT Do?

• When we talk about interventions that are
  supported by credible research, please use the
  language of empirically-supported treatments, and
  call these ESTs.
• When we are talking about evidence-based
  practice, lets keep in mind that this is a
  process, not a listing of interventions.

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There is no such thing asEVIDENCE-BASED PRACTICES

• It is mixing apples and oranges to refer to
  evidence-based practices, when we really mean
  empirically supported treatments! See Thyer
  Pignotti (2011). Evidence-based practices do not
  exist. Clinical
• Social Work Journal,
• 38, 328-333.

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In fact, nowhere in the Campbell or Cochrane
Collaborations do you see lists of endorsed
treatments. Such lists would actually be
antithetical to EBP, since these ignore clinical
variables, ethics, and clinical expertise, other
elements valued equally with scientific support.
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The EST program is less scientifically and
professionally credible than EBP. When we talk
about EBP in terms only of lists of approved
therapies, we tar EBP with the deficiencies of
the EST model, distorting EBP.
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Some Problems with lists of ESTs

• One legitimate criticism is that the EST list is
  based on an overly simple all or none model of
  effectiveness A treatment is either empirically
  supported or it is not. Yet the true state of
  affairs is likely far more more complex (ABCT
  website, on ESTs)
• Such lists of ESTs ignore ethical considerations,
  client preferences, resource consideration and
  the adequacy or clinical expertise.
• They also focus on positive studies and ignore
  negative outcome studies. (a treatment with two
  positive studies and 8 negative ones could be
  considered empirically supported!)
• They are based on p-values in determining
  effectiveness and ignore effect sizes of
  treatments.

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Also, the EBP Process does NOT involve recourse
to Practice Guidelines. Some Problems with
Practice Guidelines include

• They are usually created by members of one
  discipline, and fail to adequately take into
  account interdisciplinary literature.
• Disciplinary prejudices are rife (PGs prepared by
  psychiatrists tend to ignore effective
  psychosocial treatments)
• Expert consensus sometimes overrules scientific
  considerations.
• They are usually not too comprehensive, and
  ignore the gray literature.

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Other Misconceptions

• EBP is only applicable to clinical practice. For
  example, studies relating to macro level,
  social change are less likely to be encouraged by
  those advocating for more scientific approaches
  to practice. (EBP) thus privileges micro-level
  approaches that focus on problems (Furman,
  2009, Social Work, 54, p. 83)
• Rebuttal?
• See the Coalition for Evidence-based Policy,
  which evaluates social programs in terms of their
  effectiveness.
• http//www.evidencebasedprograms.org/

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And the special issue of the Journal of
Evidence-based Social Work

• Devoted to EBP and macro-level practice.
• 2008, 5(3/4).
• The journal Evidence and Policy

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Other Misconceptions

• If outcome research becomes the most important
  factor guiding social work services provision, a
  focus on client empowerment and autonomy may
  become at risk (Furman, 2009, p. 82)
• In reality, in EBP outcome research is one
  required consideration but it is not elevated in
  importance relative to ethics, client
  preferences, etc.

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Other Misconceptions

• (EBP) has naturally focused on issues and
  concerns that are relatively easy, or quick, to
  measure (Furman, 2009, p. 82)
• EBP as a process is applicable to all problems
  of concern to social workers, simple or complex.
  Look over the complex problems that have been the
  focus of systematic reviews, found within the
  Campbell and Cochrane websites, to find examples
  (e.g., the effects of welfare-to-work programs
  or improving the conditions of slum
  neighborhoods)
• List of ESTs do tend to focus on discrete
  DSM-defined disorders, but this limitation of the
  EST movement is inapplicable to the EBP process
  model.

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Other Misconceptions

• EBP will increase social workers stress,
  workload, and monetary output. This will likely
  force many social workers to leave the social
  work profession and look for other jobs. As a
  result, the status of social work in the
  hierarchy of the professions will become much
  lower.
• the present adoption of EBP in social work
  makes people who might not be professional in
  practice the judges of practice.
• adopting EBP may merely serve to provide a
  source of legitimacy that contributes to the
  authority of social work managers. This is
  likely to put frontline social workers under
  increased managerial control and thus damage
  their incentives to remain social workers
• (c.f. Yunong Fengzhi, 2009, Social Work, 54, p.
  177-181)!
• EBP actually is PRACTITIONER-driver, not
  managerial in nature. Again, the authors seem to
  be confusing EBP with empirically supported
  treatments.

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Other Misconceptions

• According to this view, social work decisions
  should rest solely on evidence leading to
  effective outcomes. (emphasis added)
• undermines professional judgment and discretion
  in social work
• By underplaying the values and anticipations of
  social workers
• Evidence-based practice assumes that social work
  is decontextualized.
• (c.f. Webb, S. Some considerations on the
  validity of evidence-based practice in social
  work. British Journal of Social Work, 31,
  57-59).
• See prior commentary on what the EBP process is
  really like.

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Other Misconceptions

• There is an inadequate foundation of high
  quality evidence regarding the problem of XXX.
  Therefore, we cannot be expected to make use of
  the EBP model.
• EBP does not require the existence of lots of
  high quality evidence. It does require the
  practitioner to seek out, appraise, and judge the
  applicability of the highest quality available
  evidence.
• There is always evidence, even it is consists of
  informed clinical opinion, or theoretical systems.

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Summary

• It is possible that the EBP process model
  represents a significant positive step in the
  professional maturation of social work and in our
  ability to genuinely help clients, and to
  implement effective social policies and programs.
• It is also possible that it represents simply
  another conceptual fad which will enjoy a brief
  flurry of interest, and then fade from view. We
  have had many examples of this latter scenario.
  Time will tell.

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Summary

• When the primary sources describing EBP are
  consulted, it is troubling to see the numerous
  misconceptions that are being promulgated about
  this potentially useful model.
• Social workers are urged to acquaint themselves
  with this approach, make their own informed
  decisions as to its usefulness, and take steps to
  adopt it, if moved to do so.
• EBP represents the most sophisticated model to
  date that has been developed to guide our
  practice and improve the services we provide.

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Copies of this powerpoint presentation are
available from the author, via

• Bthyer_at_fsu.edu
• Bruce Thyer, Ph.D., LCSW
• College of Social Work
• Florida State University
• Tallahassee, FL 32306 USA