Evidence-Based Practice: Introduction and Overview Joanne Yaffe, PhD, ACSW University of Utah College of Social Work

What is “Evidence-Based Practice” (EBP)? Originated with “Evidence-Based Medicine” Now “the buzz” in helping professional education Model is commonly misunderstood and misinterpreted within helping professions. There is still much disagreement even among proponents as to what the term means.

What is EBP not? The “Scientist/Practitioner Model” “Empirical Clinical Practice” “Best Practice” “Evidence-Based Practices” “Eminence-Based Practice”

What is“The Scientist/Practitioner Model?” Boulder Conference on Graduate Education in Clinical Psychology (1949). Practitioners adhere to scientific methods, procedures, and research in day-to-day practice. Core tenets: scientifically-based protocols for assessment and intervention; integration of scientific findings; hypothesis testing in practice; contributing to practice-based R&D to improve practice. Criticisms: Is it possible to expect practitioners to adhere to the ideals and tenets of the Scientist-Practitioner model? Clinicians find it difficult to complete their practical duties let alone conduct research or to remain up-to-date with cutting edge science.

What is “Empirical Clinical Practice?” Technology transfer from psychology to social work in early 1970s. Grew out of joint program at University of Michigan. Jayaratne, S. & Levy, R. (1979). Empirical Clinical Practice. NY: Columbia University Press. Involved incorporation of scientific methods, including behavioral assessment and single-case design to document outcomes of practice. Resisted by many who saw the model as “too behavioral for social work.”

What is “Best Practice?” Assumption: There is a clinical technique or menu of techniques that is more effective at delivering a particular outcome than other techniques. Has evolved to lists of acceptable practices, e.g., Oregon. Considered by some as a buzzword used to describe the process of developing and following a standard way of doing things that multiple organizations can use for management, policy, and reimbursement. Criticisms: No one intervention has been shown to be effective in every case. We aren’t all trained the same way. Systematic reviews challenge accepted efficacy. Reification??

What are“Evidence-Based Practices?” More formally known as “Empirically Supported Treatments.” Division 12 (Clinical Psychology of the APA) “Task Force on Promotion and Dissemination of Psychological Procedures” in the early 1990s. Purpose: “publish information for both the practitioner and the general public on the random assignment, controlled outcome study literature of psychotherapy and of psychoactive medications.”

What was the mandate for the Task Force? The Task Force had 2 sequential tasks: To develop evidentiary standards to be used to designate given treatment/assessment methods as “empirically validated” (later changed to “empirically supported”). To review the literature and publish lists of treatments that met or did not meet these evidentiary standards.

What evidentiary standards did they develop? Two sets of standards or evidence benchmarks: one to designate an intervention as “empirically supported” (hence ESTs) or “well-supported”, and another, less stringent one, used to designate an intervention as “promising” or “probably efficacious.”

Where are these lists of ‘approved’ treatments? Two major publication pathways emerged from the Task Force’s efforts: : Book: Nathan, P. E. & Gorman, J. M. (Eds.) (2007). A Guide to Treatments That Work (third edition). New York: Oxford University Press Series of articles: http://www.apa.org/divisions/div12/journals.html#ESTs Nothing has been added to this list since 1998.

Is there anything else? New Division 12 developed, edited and supported book series titled “Keeping up with the Advances in Psychotherapy: Evidence-based Practice”, published by Hogrefe & Huber. http://www.hhpub.com/books/series/apt_flyer_may_2007_e.pdf Note the crucial terminology change from ‘empirically supported’ to ‘evidence-based’

What is “Eminence-Based Practice?”

What is Evidence-Based Practice then? Evidence-based practice (EBP) began in medicine in the early 1990s. Its primary source document is: Sackett et al. (1997). Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingstone. EBP “…requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstance” (Straus et al., 2005, p. 1).

What is EBP as commonly conceptualized? Converting information needs into well-formulated answerable questions. Tracking down with maximum efficiency the best evidence with which to answer the questions. Critically appraising the evidence for validity and applicability. Applying the results of this evidence appraisal to policy/practice. Evaluating performance. From: Gibbs, L. E. (2003). Evidence-based practice for the helping professions: A practical guide with integrated multimedia. Pacific Grove, CA: Thomson/Brooks/Cole. Pp. 8-9.

“Evidence-based Practice” is really “Evidence-informed Practice.” Professional ethics and the EBP model call for shared decision-making with client, taking into account their wishes, preferences, and values. Intervention is constrained by agency and social policy. Professionals must practice within their competencies.

Evidence-Informed Practice Model Intersection is EBP

Deconstructing EBP: Asking well-formed questions “converting information needs related to practice decisions into well-structured answerable questions; Practitioners bring questions from the field and learn to develop well-formed questions from which they can derive keywords for their evidence searches (PICO)

Deconstructing EBP: Finding the evidence tracking down with maximum efficiency, the best evidence with which to answer them, Practitioners select keywords based on their questions, make use of methodological locators to find the best evidence available Can use university library indexes and databases, as well as other resources, to quickly locate evidence relevant to their questions. Gibb’s website provides helpful suggestions: (http://www.evidence.brookscole.com/)

Deconstructing EBP: Selecting the best evidence available critically appraising that evidence for its validity, impact (size of effect) and applicability (usefulness in practice) Practitioners utilize basic criteria of sound science to appraise the articles that they find. Some tools are publicly available from Bandolier (http://www.medicine.ox.ac.uk/bandolier/learnzone.html )

Deconstructing EBP: Applying the evidence to practice and policy decisions applying the results of this appraisal to practice-policy decisions. This involves deciding whether evidence found (if any) applies to the decision at hand (e. g., is a client similar to those studied? Is there access to services described?) and considering client values and preferences in making decisions as well as other application concerns Practitioners utilize the results of their evidence search and together with clients select the most appropriate interventions.

Deconstructing EBP: Evaluating the effectiveness of evidence-informed interventions evaluating our effectiveness and efficiency in carrying out steps 1-4 and seeking ways to improve them in the future (Sackett, et al., 2000, pp. 3-4, cited in Gambrill, 2006). Practitioners evaluate the effectiveness of their interventions using both clinical and program evaluation tools.