1 Evidence-Based Practice and Interprofessional Education Bruce A. Thyer, Ph.D., LCSW, BCBA-D College of Social Work, Florida State University Visiting Fulbright Specialist, King’s College, UWO, 4–16 March 2013

2 What is Evidence Based Practice? “Evidence-based practice requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances” From Strauss et al. (2005). Evidence-based medicine: How to practice and teach EBM (third edition). New York: Elsevier.

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

4 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.

5 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

6 ‘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 RCT’s available to consult. It does depend on one examining the best available evidence. There is ALWAYS evidence, even if it is of low quality.

7 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.

8 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.

9 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. 3.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.

10 What are ‘Answerable Questions’? 2. A question including some aspect of the client’s 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? 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….?

11 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

12 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)

13 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, APA’s Division 12’s lists of ESTs, SAMSHA, California Clearing House…etc.) (a top-down search)

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29 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 APA’s Division 12, Section III, early 90s Evidence-based Practice (early ‘90s) by Evidence-based Medicine Work Group

30 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.

31 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.”

32 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.

33 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.

34 OK – Where are these lists of ‘approved’ treatments? Two major publication pathways emerged from the Task Force’s 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

35 And a series of articles These are available for free at: tml#ESTs 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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40 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.

41 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.

42 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.

43 While the EST movement remains alive and well, it has largely been overtaken by the Evidence-based Practice Movement

44 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!

45 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.

46 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.

47 There is no such thing as EVIDENCE-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,

48 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.

49 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.

50 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.

51 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.

52 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.

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56 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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59 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.

60 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.

61 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 )! EBP actually is PRACTITIONER-driver, not managerial in nature. Again, the authors seem to be confusing EBP with empirically supported treatments.

62 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.

63 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.

64 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.

65 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.

66 Copies of this powerpoint presentation are available from the author, via Bruce Thyer, Ph.D., LCSW College of Social Work Florida State University Tallahassee, FL USA