What is best practice – is evidence based practice the answer? Tor-Johan Ekeland Professor, Volda University College Professor II, Molde University College Nordic Conference New perspectives – best mental health practice Akureyri May 7-8, 2009

Akureyri May TJE Evidence based…….. Comes from medicine A world wide trend not specific to mental health Driven by: Accountability What works

Akureyri May TJE Evidence based excitement: n Government n Politicians n Managers and payers n Researchers n Clinicians ?

Akureyri May TJE What does it mean that a treatment are evidence based? Evidence based knowledge: –That a diagnosed group of patient getting a specific treatment, in average get better results compared to the average effect in a comparable group not getting the treatment (or another) Evidence based practice: –Implementing this knowledge through diagnose based procedures

Akureyri May TJE The Logic of Evidence Based Practice Research literature Selection -filtering Management Clinical practice Gold standard Manuals

Akureyri May TJE Hanne Foss Hansen

Akureyri May TJE n What is new and what is old? n What is good and what is the problems? n Is evidence based synonymous with scientific? Evidence based practice

Akureyri May TJE This is old: Evidence based knowledge –The idealization of context-independent and universal knowledge –The aspiration to transform knowledge into technology This is new: Evidence based practice –Narrowed and authorized criteria of what counts as knowledge (gold standard) –The use of evidence based knowledge are not a matter of professional autonomy alone, but come with manuals implemented in new strategies for governing

Akureyri May TJE Archibald Leman Cochrane ( ) n Can it work? n Does it work in practice? n Is it worth it?

Akureyri May TJE ……but: Why does it work? EBP is a kind of empirical pragmatism….. May foster pseudoscience…………

Akureyri May TJE From science to technology: n Science: If A, then B (i.e. with p=x) n Technology: If you want B, do A Implicit premises: –Stable relation between A and B –Can be replicated –That the action (A) is independent of the acting person –That the response (B) is independent of the person who is the target for the action When is this premises valid?

Akureyri May TJE Intervention and prediction in different worlds physicalbiologyhumane Responses are: Stable Universal Causal Unhistorical Responses are: Distributed System dependent Functional Adaptive Responses are: Language dependent Based on reason Relational Historical/Contextual Do we have a map (epistemology) which fit the territory (ontology)? Confusion create epistemological errors Prediction is: Precise Prediction is: Statistical known variance Prediction is: Statistical Unstable variance

Akureyri May TJE Experts showed strong agreement that research did support following assertions: n Therapy is helpful to the majority of clients n Most people achieve some change relatively quickly in therapy n People change more due to common factors than to specific factors associated with therapies n In general, therapies achieve similar outcome n The relationship between the therapist and client is the best predictor of treatment outcome n Most therapists learn more about effective therapy techniques from their experience than from the research (Charles Boisvert & David Faust, 2003)

Akureyri May TJE Despite volumes devoted to the theoretical differences among different schools of psychotherapy, the result of research demonstrate negligible differences in the effects produced by different therapy types. (Smith og Glass, 1977, s.760)..., there is massive evidence that psychotherapeutic techniques do not have specific effects, yet there is tremendous resistance to accepting this finding as a legitimate one (Bergin & Garfield, 1994, Handbook of Psychotherapy and Behavioral Change, s. 822).

Akureyri May TJE What works? Implication from research outside the evidence paradigm n Difficult to predict good outcome n Equal efforts for the equal problems gives different experiences n Formal treatment variables not so important n Timing: small causes may give great effects (turning points) n A sense of life – functional daily life n A home, work – meaningful activities n A sense of being – identity, respect and acceptance n Involved, trustworthy and dedicated helpers n Regaining responsibility – a speaking I

Akureyri May TJE Summing up…. n EBP are therapies which are relatively independent of context and therefore can be standardized (= technology): –In medicine evidence based can function well when the diagnostic validity is high and the working theories are adequate n Empirical evidence on psychotherapy and social methods show that this is contextual methods and therefore should not be standardized (= praxis) –The effects of such methods are dependent on individual and contextual conditions –The practice should therefore be tailor-made rather than standardized

Akureyri May TJE Best practice as I see it…… The main perspective should be the mental suffering person, not the mental illness Implications: n Contextual Model instead of Medical Model: perspective on life world and restoring life-functions rather than focus on pathology and cure. Organizational level n An integrated local service, low thresholds n User oriented and user cooperated services and resources n Ambulant specialists Escalation of: n Common human language, cooperation and Care Reduction of: n Expert language, medicalisation/psychologization and Cure This will move us towards a better practice

Akureyri May TJE Thank you!

Akureyri May TJE Challenges in practice n Get access with the patients subjectivity n Create hope and belief in coping n Create experience of coping n Create trust in ability to cope n Create trust and recovery of a speaking I The medical model restrain this because: n It focus on pathology/problems instead of resources n Ignore context (local and cultural) n Objectify the service users n Ignore the patient agency

Akureyri May TJE n Diagnosis-driven, illness model n Prescriptive Treatments n Emphasis on quality and competence n Cure of illness n Client-directed (Fit) n Outcome-informed (Effect) n Emphasis on benefit over need n Restore real-life functioning The Medical Model: The Contextual Model:

Akureyri May TJE Summing up…. n In medicine evidence based can function well when the diagnostic validity is high and the working theories are adequate n In mental health and addiction therapy evidence based gives wrong focus Implication –Reduce complexity –Foster medical and mechanical methods –Exaggerate the technical on behalf of the relational and communicative in treatment

Akureyri May TJE Some problems n Standardization not efficient if best treatment is individualization n Many health problems without evidence based treatment n The average patient does not exist in practice n Absence of evidence is not evidence of absence n Weak relation between diagnose and therapy method n Marginalization of other kinds of knowledge n Increase the danger to objectify the patient n Less creative practice n Disguise the contextual difference between practice and research n Research informed practice a better strategy than research governed practice

Akureyri May TJE Forty years with empirical research on psychotherapy n Therapy works (80% compared to no therapy) n Enduring effects for most patients n No difference between different methods (Dodo- verdict) n Diagnose alone doesn't predict best treatment n The method explain little variance (3-15 %) n Therapists and patients belief in the method explain 2-3 ganger more variance than the method alone n No stable relation between specific technique and outcome n Best predictors are relation and early improvement

Akureyri May TJE I medisinen er EBM eit heitt debattema: The initially refreshing educational approach of clinical epidemiology has been horribly transformed into the bureaucratic monster of evidence based medicine (Fowler,1997)

Akureyri May TJE Bergin og Garfield (1994) held det som eit viktig funn at «...it is the client more than the therapist who implements the change process» (s.824)

Akureyri May TJE «Despite volumes devoted to the theoretical differences among different schools of psychotherapy, the result of research demonstrate negligible differences in the effects produced by different therapy types». (Smith og Glass, 1977, s.760)

Akureyri May TJE Systematic use of a human relationship «What appears to matter most in psychotherapy is the interaction of patient`s interpersonal style with the therapist`s skill in managing the interpersonal climate. (....) In this view, psychotherapy is defined as the systematic use of a human relationship for the therapeutic purpose». (Butler og Strupp, 1986, s.36)

Akureyri May TJE A new deal? Instead, greater scientific promise lies in the recognition that psychotherapy cannot be meaningfully reduced to «factors» independent of a particular interpersonal context. (......) What is needed is a new approach or paradigm through which to conceptualize and investigate psychotherapy (Butler og Strupp, 1986, s.31 og s. 37)

Akureyri May TJE Min konklusjon n Dette er kunnskap basert på ein objektivert brukar n Der er ingen evidens for evidensbasert behandling når det gjeld kommunikativ praksis n Slik praksis må vere skreddarsaum n Vi treng kunnskap som styrker den relasjonelle og kommunikative kompetansen

Akureyri May TJE Konklusjon på behandlingsforskinga Frå behandling Til Samhandling Frå Det andre (sjukdomen) Til Den andre (den sjuke personen)

Akureyri May TJE Noen implikasjoner av den empiriske forskningen: n Den terapeutiske teorien (modellen) fungerer terapeutisk først og fremst for terapeuten n En terapeutisk metode kan være virksom uavhengig av dens empiriske eller vitenskaplige grunnlag n Psykoterapi er kontekstuell medisin (metamodell)

Akureyri May TJE Jerome Frank (1961): n An emotional and trusting relationship n A healing setting in which the client or clients meet a professional whom they believ can help them n A rational group of concepts or the creation of a myth that is able tyo provide a plausible explanation n A belief in the treatment itself ( Persuasion and healing )

Akureyri May TJE To eksistensielle grunnvilkår n Vi er relasjonelle vesen – avhengigheit er føresetnaden for identitet og sjølvoppleving n Vi er meaning makers – sjølvfortolkande vesen – og meining er føresetnad for ontologisk tryggleik n All meiningsdanning er relasjonell

Akureyri May TJE Davidson et al 2007 Bedringsprosessen dreier seg om å gjenskape en opplevelse av tilhørighet i sitt lokalmiljø samt en positiv følelse av identitet utenfor ens problemer, i arbeidet med å skape seg et liv på tross av eller innenfor begrensningene ved situasjonen man er i.

Akureyri May TJE Etiologiske mønster ved psykiske lidelser n Ekvifinalitet: ulike årsaker, samme virkning n Multifinalitet: samme årsaker, ulike virkninger n Store årsaker gir små virkninger n Små årsaker gir store virkninger

Akureyri May TJE Bakgrunn n Høgt tempo i kunnskapsproduksjonen n Informasjonsoverload og motseiande bodskap frå kunnskapsverda n Behov for oversikter, sortering, syntetisering og formidling av kunnskapsstatus om gitte forhold, t.d. effekten av ulike tiltak (medisinske, sosialpolitiske osv....)

Akureyri May TJE Gullstandard Hierarki av evidens (Geddes & Harrison, 1997) n Metaanalyse av RCT-studiar n Minst eit RCT-studie n Minst ein kontrollert studie utan randomisiering n Minst ein annan type kvasieksperimentell studie n Ikkje-eksperimentelle deskriptive studiar n Ekspertrapportar/eksperterfaringar

Akureyri May TJE Empirisk pragmatisme Kunnskapssenterets rolle vil særlig være knyttet til det å evaluere og måle og ikke det å forstå mer grunnleggende mekanismer eller fortolke opplevelser og sammenhenger. (Nasjonalt kunnskapssenter for helsetjenesten, 2005)

Akureyri May TJE Metodemetafysikk Når det gjelder spørsmål om effekt av tiltak, er det Kunnskapssenterets syn at det finnes et hierarki hvor kunnskap fremskaffet med gode randomiserte kontrollerte studier (RCT) er bedre og mer gyldig enn annen kunnskap. (Nasjonalt kunnskapssenter for helsetjenesten, 2005, s. 7).

Akureyri May TJE Dessutan: n Kvar er evidensen for at implementering av EBP gir betre praksis enn vanleg praksis? n Dette er ein empirisk påstand som ikkje er godt dokumentert

Akureyri May TJE Litt presisering: Det uproblematiske: n Bruk av vitenskap - evidensbasert og annen n At forskning etterprøver og evaluerer praksis n At forholdet mellom forskning og praksis er basert på dialog Det problematiske: n Misbruk av vitenskap - pseudovitenskap n At skillet mellom vitenskap og praksis blir tilslørt n At vitenskapen opptrer monologisk (styring) n Evidensbasert praksis

Akureyri May TJE INPUT THROUGHPUT OUTPUT THE MARKET Logic: To transform the input to a desired or acceptable output Aim: Develop throughput (technology) by the markets control/selection of output.

Akureyri May TJE How to Improve by 65%: Pop Quiz Question #6: The bulk of change in successful treatment occurs earlier rather than later. True If a particular approach, delivered in a given setting, by a specific provider is going to work, there should measurable improvement in the first six weeks of care.

Akureyri May TJE How to Improve by 65%: Pop Quiz Last Question! The best way to insure effective, efficient, ethical and accountable treatment practice is for the field to adopt and enforce: Evidence-based practice;Evidence-based practice; Quality assurance;Quality assurance; External management;External management; Continuing education requirements;Continuing education requirements; Legal protection of trade and terminology.Legal protection of trade and terminology. False

Akureyri May TJE How to Improve by 65%: Pop Quiz Question #6: The bulk of change in successful treatment occurs earlier rather than later. True If a particular approach, delivered in a given setting, by a specific provider is going to work, there should measurable improvement in the first six weeks of care.

Akureyri May TJE Old and new heroes Emil Kraepelin ( ) Sigmund Freud ( ) That other Objectification Explain causality Treatment The other Subjectification Understand Intentionality Cooperation

Akureyri May TJE Part of a world wide trend not specific to mental health and independent of any particular type of reimbursement system.Part of a world wide trend not specific to mental health and independent of any particular type of reimbursement system. Accountability, Stewardship, & Return on Investment the buzzwords of the day.Accountability, Stewardship, & Return on Investment the buzzwords of the day.

Akureyri May TJE Evidens n Eit pluss-ord: Evidensbasert praksis, evidensbasert politik, evidensbasert medisin, sjukepleie, sosialt arbeide, pedagogik, leiing, fangebehandling...….. n Evidens i tydinga systematiske kunnskapsoversikter n Nye internatsjonale og nasjonale organisasjonar som spesialiserer seg på å produsere og formidle systematiske kunnskapsoversikter, f. eks. Cochrane, Campbell, EPPI, SCIE... n Ofte semistatlege med rådgivingsoppgåver (f.eks. Nasjonalt kunnskapssenter for helsetjenesten),