Implementing Evidence-Based Practice Training in a Scientist-Practitioner Program David DiLillo Director of Clinical Training University of Nebraska-Lincoln Will talk about our efforts at UNL to integrate EBP into our training program at UNL. We see this as an evolving process – not something that has been accomplished and presented here in a completed form.

Clinical Psychology at the University of Nebraska-Lincoln History Seven core clinical faculty Scientist-practitioner model Clinical Intervention I & II Have been continuously accredited since 1948, the year accreditation began. In the early 1990’s, with the retirement of several faculty and the hiring of others, the program made a shift from being more clinically oriented to one that placed an increasing emphasis on research, was more CBT oriented, and embraced the empirically supported treatments. This has been the case for the past 10 or so year and is not something we want to abandon. Rather we see the integration of EBP as a way for the program to maintain existing strengths while continuing to evolve. Normally have seven core faculty as well as the director of our training clinic the PCC. Faculty interests include adult anxiety, severe mental illness, substance abuse, to child maltreatment, family violence We are a good representation of the s-p model. Well balanced training with lots of integration of research and clinical activities. Many faculty maintain combined service delivery and research programs that provide clinical training and also generate data that fuels research programs. Students begin formal clinical work in their second year through a two-semester course sequence called Clinical Intervention , which occurs in our training clinic. Each intervention team consists of 4-5 students whose sessions are observed by their peers and a faculty member who provides live supervision from behind a mirror. Variety of paid practicum placements, which begin third year. At any given time, half or more of our students are funded by these placements.

Training Context for EBP Clinical psychology as a health care profession Focus on “psychological treatments” EBP is consistent with the notion that psychology is a health care profession. APA declared us so a few years ago (2001) as a way to be part of the various developing health care schemes in the country. One goal is for parity for the reimbursement for the treatment of mental and behavioral health problems. Part of the justification for psychology being considered a health care profession is the evidence demonstrating that our interventions are as efficacious, if not more so, than pharmacological treatments when evaluated in the context of specific disorders. You can point to a number of problems, form depression to panic disorder, to insomnia and stress-related incontinence and find clear data showing that PTs are superior to medication or the usual medical treatments. This has led David Barlow to make the distinction between: Psychological treatments = techniques directed at different manifestations of psychopathology or psychological components of physical disorders. Includes a strong therapeutic alliance, support of client, positive expectation of change, but focuses on specific procedures or techniques that are applied to treat the psychopathology at hand. This is the core identity of most practicing psychologists. Psychotherapy = promotion of better adjustment, resolution in problems of living, personal growth—has a long and distinguished history and can be very enriching but fall outside the parameters of the healthcare system. One implication of this distinction is that—if we are to be part of the healthcare system—doctoral programs oriented toward EBP will emphasize training in the implementation of psychological treatments for manifestations of psychopathology. Most of us would universal health care, full parity for psychological disorders as a part of that coverage.

Best available research evidence Patient preferences and values The EBP Model Best available research evidence EBP Patient preferences and values In integrating EBP into our training, we rely on Sackett et al (2000) tripartite model: Best available research evidence – clinicians must avail themselves of the best available research evidence when making treatment decisions. RCT is still the gold standard but other evidence may be considered as well, for example effectiveness data. Patient preference and values – considering role of patients’ individual characteristics in treatment; includes a consideration of diversity issues as well as the need to involve the patient fully in treatment planning including analysis of the chances they will benefit or not from the evidence-based approach (using quantitative presentations when possible). Clinical expertise - Advanced clinical skills to diagnose, assess, and treat clients. How does one translate the best available research evidence, which may have been developed for the average or a prototypical client, for use with a particular patient? Clinical expertise

Best available research evidence The EBP Model Relevant Abilities: Adopt a scientific view of clinical psychology Knowledge of clinical research design and methods Strategies for accessing best available research Ability to evaluate relevant evidence Best available research evidence An question in implementing EBP in training is: How can the three components just described be operationalized in the training context. For example, how do we ensure that students avail themselves of the best available research evidence? This involves things like (read list)

Patient preferences and values The EBP Model Relevant Abilities: View therapy as a collaborative endeavor Knowledge of specific diverse groups Ability to ascertain patient values and preferences Respond effectively to patient preferences and values Patient preferences and values Patient preferences and values (read list and elaborate)

The EBP Model Relevant Abilities: Clinical expertise Understand role and limits of clinical judgment Skills in relationship building Assessment and diagnostic skills Skills to implement EST’s (e.g., specific therapeutic techniques) Integration of EST with client characteristics Clinical expertise Clinical expertise and judgment

Infusion of EBP Into Training Highlight existing consistencies Coursework Introduce EBP early and often Review course content Evidence-Based Clinical Interviewing Given these ideas about how to operationalize the components of EBP, the next question is how to integrate these into the training curriculum. In many respects what we were doing was already consistent with EBP so it is a matter of highlighting these or “connecting the dots” with things we were already doing. In other cases, we are making tangible changes to the training program. The efforts are occurring in different domains, including the classroom, clinical practicum, and

Infusion of EBP Into Training Practicum training Clinical Intervention Clinic procedures Clinical Comps Given these ideas about how to operationalize the components of EBP, the next question is how to integrate these into the training curriculum. In many respects what we were doing was already consistent with EBP so it is a matter of highlighting these or “connecting the dots” with things we were already doing. In other cases, we are making tangible changes to the training program. The efforts are occurring in different domains, including the classroom, clinical practicum, and

Measuring Outcomes: Clinical Comps Identify relevant empirical literature for the case Understand the relevant empirical literature and is able to apply it appropriately to the case. Identify client’s values and individual characteristics that should impact assessment and treatment planning. Incorporate client values and individual characteristics into the conceptualization Demonstrate clinical expertise appropriate to this point in training to the case conceptualization, assessment and treatment planning. Clinical comprehensive examines. End of second year. Previously was a demonstration of Rogerian counseling skills, such as active listening and rapport building, presented to a committee with an actual client on videotape. Now re-designed as an exercise to demonstrate integration of EBP with an actual client. It’s more of a case presentation…still with video clips but now more of a case presentation within EBP framework. Grading criteria include: Student has identified the relevant empirical and/or clinical literature for the case. _____1. Student has identified the relevant empirical and/or clinical literature for the case. _____2. Student understands the relevant empirical and/or clinical literature and is able to apply it appropriately to the case. _____3. Student identifies client(s)’s values and individual characteristics that should impact assessment and treatment planning. _____4. Student is able to incorporate the client(s)’s values and individual characteristics into the conceptualization. ______5. Student uses a level of clinical judgment and expertise appropriate to this point in training to the case conceptualization, assessment and treatment planning. ______6. Student develops a case conceptualization that follows from the empirical literature, clinical judgment and client characteristics that can guide assessment and treatment planning and implementation. _____7. Student identifies risk factors (e.g., suicidal/homicidal ideation or intent, need to consult or refer), and handles them in an ethical manner as needed for the case. _____8. Student develops and implements an appropriate treatment plan (implementation may not have occurred yet). _____9. Student demonstrates how therapy progress is monitored and modifies treatment as needed in light of the data.

Measuring Outcomes: Clinical Comps Develop a case conceptualization that follows from the empirical literature, clinical judgment and client characteristics that can guide assessment, treatment planning, and implementation. Clinical comprehensive examines. End of second year. Previously was a demonstration of Rogerian counseling skills, such as active listening and rapport building, presented to a committee with an actual client on videotape. Now re-designed as an exercise to demonstrate integration of EBP with an actual client. It’s more of a case presentation…still with video clips but now more of a case presentation within EBP framework. Grading criteria include: Student has identified the relevant empirical and/or clinical literature for the case. _____1. Student has identified the relevant empirical and/or clinical literature for the case. _____2. Student understands the relevant empirical and/or clinical literature and is able to apply it appropriately to the case. _____3. Student identifies client(s)’s values and individual characteristics that should impact assessment and treatment planning. _____4. Student is able to incorporate the client(s)’s values and individual characteristics into the conceptualization. ______5. Student uses a level of clinical judgment and expertise appropriate to this point in training to the case conceptualization, assessment and treatment planning. ______6. Student develops a case conceptualization that follows from the empirical literature, clinical judgment and client characteristics that can guide assessment and treatment planning and implementation. _____7. Student identifies risk factors (e.g., suicidal/homicidal ideation or intent, need to consult or refer), and handles them in an ethical manner as needed for the case. _____8. Student develops and implements an appropriate treatment plan (implementation may not have occurred yet). _____9. Student demonstrates how therapy progress is monitored and modifies treatment as needed in light of the data.

Challenges to Implementing EBP Evolving model of EBP Faculty know how and “buy in” Integration of outside supervisors Measuring long-term outcomes