Transcript The Evidence-Based Practice Tells Me So!

The Evidence-Based
Practice Tells Me So!
Cody Jeffries, M.A.
Jennifer Halpin, B.A.
Dr. Judith R. Gonzalez, LMFT, PsyD
As the field of Marriage and
Family develops,
practitioners have
experienced increasing
pressure to engage in
evidence-based practice
(EBP).
This break-out session will
review the original definition
of EBP, and then new
systemic approaches will be
presented which
demonstrate to the
participants the steps of the
EBP process toward making
clinical decisions.
1.
Participants will review the original definition of EBP and
compare it to the new systemic definitions and
approaches.
2.
Participants will collaborate with the presenters in the
application of the EBP process toward making clinical
decisions in two case studies using government agencies
and initiatives, and databases for research.
3.
Participants will be able to witness how clinicians may use
the EBP process in their clinical work to provide better
services for their consumers.
Evidence-Based
Practice
EBP is a process for making
practice decisions in which
practitioners integrate the best
research evidence available
with their practice expertise
and with client attributes,
values, preferences , and
circumstances (Rubin, 2008).
Original EBP Model
Practitioner’s .
Individual
.
Expertise
. EBP
Best Evidence
Client Values
& Expectations
Rubin, A. (2008). Practitioner’s guide to using
research for evidence-based practice. Hoboken, NJ:
John Wiley & Sons.
Newer EBP Model
Clinical State
& Circumstances
PRACTITIONER
EXPERTISE
Client
Preferences
& Actions
Research
Evidence
Rubin, A. (2008). Practitioner’s guide to using
research for evidence-based practice. Hoboken, NJ:
John Wiley & Sons.
The Cycle of EBP
Appropriate for
this client?
Contextual
assessment
Clinical State
& Circumstances
Valid
assessment
PRACTITIONER
EXPERTISE
Client’s
preferred
course or at
least willing to
try?
Client
Preferences
& Actions
Barriers (e.g.,
cultural conflict)
Research
Evidence
Effective
services
Rubin, A. (2008). Practitioner’s guide to using
research for evidence-based practice. Hoboken, NJ:
John Wiley & Sons.
Steps in the EBP
Process
Rubin, A. (2008). Practitioner’s guide to
using research for evidence-based
practice. Hoboken, NJ: John Wiley &
Sons.
STEP ONE: Question Formulation

A research question serves as:


A starting point for a given line of inquiry.
A compass, providing direction so the
researcher stays on track and on topic.
STEP ONE: Question Formulation

One of the most common types of
questions in EBP research:

“In the treatment of W in X, is Y superior to
Z?”

Example: “In the treatment of infidelity in a
cohabitating couple, is Solution-Focused Family
Therapy superior to Narrative Family Therapy?”
STEP ONE: Question Formulation

Forming the question:

First, identify the presenting issue you wish to treat, or
treatment goal you wish to reach.

This may require a “diagnosis”: An objective label assigned to a
specific cluster of reported symptoms.


The “diagnosis” need not be DSM- or ICD-based; it may be a more
mundane, but empirically studied issue like “infidelity.”


CONSIDER  Why would you first need to land on a “diagnosis” before
you can engage in the EBP process?
CONSIDER  Many MFT’s hesitate to “diagnose” because they are
diametrically opposed to the notion of unnecessarily “labeling” their
clients. What are the implications of this aspect of EBP on MFT practice
and conceptualization?
Looking into a specific treatment goal is a way of navigating around
the need for “diagnosing” a client (E.g., “Decreasing the frequency
of communication danger signs in the couple’s communication.”)
STEP TWO: Evidence Search

Second, identify the most similar population to your client who
was studied with the presenting issue.

Demographic qualifiers:

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Context


Marital status (cohabiting, married, polyamorous arrangement, etc.?)
Race (White couple, interrace couple, etc.?)
Stage of life (young adult, older adult, different stages of life, etc.?)
Family formation (adoptive children, family with young children, etc.?)
Sexual orientation (heterosexual couple, gay/lesbian couple, etc.?)
Other considerations (gender identity concerns, intersex partner in the
dyad, child with special needs, others?)
Efficacy (Does it work in this setting?) vs. Effectiveness (Does it work?)
studies
Find the most salient, relevant qualifiers to find the research that
will be most helpful for treating your client.

Consider  Each of these qualifiers constitute a label, and sometimes
labels have little relevance to a presenting issue. How do you decide
which labels to use, when, in conducting EBP research?
STEP ONE: Question Formulation

Third, decide which treatments you should compare.


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Treatments you are trained and competent to use.
Treatments about which you know, for which you can
receive training and supervision to use.
Treatments about which you know, for which you cannot
presently receiving training and supervision to use, but
which are competently used by a colleague to whom you
could refer the client.

CONSIDER  Why might you forgo researching a treatment
that neither you nor your colleagues use, even if you have
background knowledge to suggest it may be a viable, if not
preferable treatment for Z?
STEP ONE: Question Formulation

If you are unsure even about which treatments
can address a specific presenting issue, your
initial question may begin one step earlier:

“Which modalities/interventions/programs [m/i/p]
have been empirically studied in the treatment of W
with X?”

Example: “Which forms of marriage and family therapy been
used in the treatment of grief issues surrounding a
miscarriage with an interracial couple?”

NOTE  This question is framed broadly, but it is possible to
frame this question in such a way as to investigate only one
m/i/p a time.
STEP ONE: Question Formulation

Forming the question:


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First, identify the presenting issue you wish to treat
(same as if you were employing the previous question
formulation).
Second, identify the most similar population to your
client who was studied with the presenting issue.
Third, decide whether to frame the question broadly,
or to investigate research pertaining to specific
m/i/p’s you or a colleague already knows.

CONSIDER  When might it be more effective to frame the
question in more broad terms? When might it be more
effective to investigate a single m/i/p?
STEP TWO: Evidence Search

There are different avenues one could take at
this point:

Conducting an exhaustive literature search in a
scholarly fashion.

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Pros: Thorough, publishable, reputable sources
Cons: Timely, costly
Conducting a quick search using popular search
engines

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Pros: Faster, more convenient
Cons: Less reputable sources, may not have ready access to
every hit, requires more skepticism/critical thought to
determine validity, reliability, etc.
STEP TWO: Evidence Search
http://www.cochrane.org/
http://www.campbellcollaboration.org/
http://nih.gov/
http://www.nlm.nih.gov/medlineplus/
http://www.tripdatabase.com/
http://scholar.google.com/
http://www.nrepp.samhsa.gov
http://jamanetwork.com
STEP TWO: Evidence Search

Search terms

Regardless of approach used or sites accessed, the
process of searching for relevant studies varies little.

Search terms should be related to the research question.


What are the key terms in the research question?
 Presenting issue/treatment goal
 Population/demographic qualifiers
 Treatment modalities
Other considerations for advanced searches:
 Limiting dates of publication (recent as well as relevant)
 Peer reviewed (increases reputability of findings)
 Articles or books
STEP THREE: Critically Appraising
Studies and Reviews
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Participants:
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Data collection:
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Sampling/selection
Number
Demographics
Qualitative: Basic assumptions, Instruments
(validity/reliability), etc.
Quantitative: Biases of researchers, Methods, etc.
Analysis:

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Appropriate methods to the research question?
Appropriate execution of analyses?
STEP FOUR: Selecting and
Implementing the Intervention
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Which empirical evidences will you use to make
your decision?

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Include only those studies that have withstood your
critical appraisal in STEP THREE…
From among the studies you considered in STEP
TWO…
Which adequately and appropriately addressed the
initial research question you posed in STEP ONE.

Remember: “No matter how scientifically rigorous a study
might be and no matter how dramatic its findings might be in
supporting a particular intervention, there always will be
some clients for whom the intervention is ineffective or
inapplicable” (p. 28).
STEP FOUR: Selecting and
Implementing the Intervention

Additional considerations:

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Don’t forget about your treatment context!
How many studies are needed?
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“If you find that Intervention A is supported by one or two
very strong studies and you find no studies that are equally
strong from a scientific standpoint in supporting any
alternative interventions, then your findings would provide
ample grounds for considering Intervention A to have the
best evidence” (p. 31).
But… EBP is an ongoing process, and different interventions
than “Intervention A” may become best practice 5 or 10
years down the road.
Don’t forget client informed consent!
STEP FIVE: Monitor Client
Progress
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This step is all about having mutually agreed upon,
measurable goals to help your client work on their
presenting issue.
How to monitor progress?
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Notes
Objective assessment
Subjective (client self-report in-session) assessment
Outcome questionnaires
Monitoring helps you assess effectiveness of treatment,
can be therapeutic if you share progress with the client,
and can contribute to your own “local research” into
which treatments work best for which presenting issues
in the area in which you are serving.
Case Example #1
Cody Jeffries, M.A.
“Anakin and Padme Skywalker”

Demographic Information

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Presenting Concern
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Infidelity on husband’s part with wife’s best friend
Contemplating divorce
Treatment History
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Caucasian, Young Adult, Highly Religious, Heterosexual
Initial treatment agreement with original therapist by husband to
terminate all contact with wife’s best friend.
About 6 sessions in, the wife discovers and then reports in
therapy that husband violated therapeutic contract by keeping in
contact with her best friend throughout treatment
Wife now serious about divorce
Conceptualization

Bowenian/Structural
STEP ONE

Question Formulation:

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“Is there a research basis for highly religious
clients involving a personal God in negative
ways in their marital conflict?”
“Are there evidenced-based treatments a
presenting issue such as this?”
STEP TWO

Evidence Search:

“What do I look for?”

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“Where do I look?”
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Clinician factors: Theoretical Orientation and Training
Client factors: Highly religious, White, heterosexual, married
PsychINFO (via EBSCOHost)
Google Scholar
“How do I look?”

Search Terms:
 “God and religious couples” in the PsychINFO database and
Google Scholar, limiting the search to peer-reviewed journals
published in the past 10 years.
 “Attachment to god + correspondence model + adults +
attachment theory” and “Attachment to god + compensation
model + adults + attachment theory” using Google Scholar to
find peer-reviewed journals published in the past 10 years.
STEP THREE

Critically Appraising Studies and Reviews:

Comparison of issues being explored

Research subject vs. presenting concern
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Comparison of demographic info
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Study participants vs. Clients
Analyzing methods
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Theistic triangulation
Attachment to God research
Participant selection
Research method
Data analysis
Consideration of results

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Validity and reliability
Applicability
STEP FOUR

Selecting and Implementing the Intervention:

What if there are no evidence-based interventions to
select from?
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Research-informed interventions
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Theory-informed interventions
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Object-relations for addressing the attachment to God concerns
Bowenian family therapy for addressing theistic triangulation
Implementation

Devising a research-informed strategy

Theoretical rationale
STEP FIVE

Monitor Client Progress:

Importance of assessing progress
We want the client to improve
 We want to inform our rationale for continuing the
intervention or seeking an alternative

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Methods of assessment
Objective measure vs. subjective report
 Quantitative vs. Qualitative assessment

Case Summary

Couple terminated therapy before completion of
treatment goals.
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But before they did, the couple had begun to speak more in
terms of their own thoughts, feelings, and preferences rather
than appealing to God in-session to substantiate or validate their
respective views (per client observation).
Padme declared she was no longer willing to remain in the
marriage purely for God’s or her children’s sake, and began to
explore her personal motives for staying or wanting to leave.
Anakin began speaking more about his own preferences about
how they navigate the separation and continue to explore the
possibility of their reunification, rather than simply defaulting to
asking for and appealing to Padme’s desires.

However, he continued to assert a strong belief that God wanted
them to be together as a central component of his argument to
continue to work to heal the relationship.
If they had continued…
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What would be the primary treatment goal
(from an EBP- or theoretically-based
perspective) for Anakin? For Padme?
What would be the best form(s) of
treatment according to EBP?
What would I, as the therapist, want to do
as I continued to treat them to ensure I
was operating according to best EBP
practice?
Case Example #2
Jennifer Halpin, B.A.
“Bob MethMaker”

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Demographic information
Presenting Concern
Treatment History
Conceptualization
STEP ONE

Question Formulation:

“Are there effective evidence-based
treatments for relapse prevention treatment in
individuals with Polysubstance dependence?”
STEP TWO

Evidence Search:

“What do I look for?”
Clinical factors: CBT and Systems Training
 Client factors: White, heterosexual, single,
unemployed, recent multiple drug abuse and
extensive history, probation, mandated treatment
through probation

STEP TWO

“Where do I look?”

Start with SAMHSA - substance abuse and
mental health services administration
National Database for Substance Abuse treatments
with national funding
 Findings:

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Everyone has a different path to recovery
Recent publication of Mindfulness based Cognitive
Therapy pdf on their website
Mindfulness-Based Cognitive Therapy
nrepp.SAMSHA.gov
STEP TWO

“Where do I look?”


When looking for specific evidenced based
research, one can look in the National
Registry of Evidenced Based Programs
and Practices
Findings: Four main EBP for relapse
prevention
Relapse Prevention Therapy (RBT)
 Motivational Enhancement Therapy
 Living in Balance (LIB) Therapy
 Network Therapy

Relapse Prevention Therapy
(RPT)
nrepp.SAMHSA.gov
Motivational Enhancement Therapy
nrepp.SAMHSA.gov
Living in Balance (LIB)
nrepp.SAMHSA.gov
Network Therapy
nrepp.SAMHSA.gov
STEP TWO
 “Where
to look?”
EBSCO Host (PsychInfo, PsychArticles,
PsychBooks)
 Search Terms:

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“relapse prevention” AND substance
“relapse prevention” AND individual therapy
Substance AND individual therapy AND relapse
prevention
Substance dependence AND relapse prevention
Preventing relapse AND substance
STEP THREE
JAMA Psychiatry 2014
 Title: Relative efficacy of mindfulness-based
relapse prevention, standard relapse
prevention, and treatment as usual for
substance use disorders: A randomized
clinical trial

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Compared MBRP, CBT RP, and TAU(12 step +
psychoeducation)
MBRP and RP significantly reduced relapse risk
RP delayed time to first drug use
MBRP reducing drug use and heavy drinking
STEP THREE
Substance Abuse Treatment, Prevention,
and Policy 2011
 Title: Relapse prevention for addictive
behaviors

 Relapse
Prevention (RP) model
STEP THREE
Journal of Clinical Psychology 2012
 Title: Between-Session Practice and
Therapeutic Alliance as Predictors of
Mindfulness After Mindfulness-Based
Relapse Prevention

 Mindfulness-based
treatments
STEP THREE
Substance Abuse Jan 2014
 Title: Training addiction professionals in
empirically supported treatments:
Perspectives from the treatment community

 Multidimensional
Family Therapy, Motivational
Enhancement Therapy, Relapse Prevention
Therapy, “Seeking Safety,” and broad
addiction-focused pharmacotherapy.
STEP THREE
STEP FOUR

Selecting and Implementing the
Intervention:

Research-informed interventions

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Mindfulness-based Cognitive Therapy
Implementation

Devising a treatment plan for the client with his
specific characteristics in mind

E.g. unemployment, probation, rural area
STEP FIVE

Monitor Client Progress:
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Client’s progress was monitored by assessing
the client’s past week in terms of stress,
cravings, and substance use or lack their of
Methods of assessment

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Subjective report, Qualitative
Objective measure, U.A. done by Probation
Officer
Case Summary

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Client completed 13 weeks of treatment
with a slip after week one of treatment
Client reported lower stress overall and
zero cravings in the last month of
treatment
Client is free of substance use by
subjective report and no reports of use by
probation officer
Summary & Conclusions
of Workshop
Questions?
References
Bowen, S. & Kurz, A. S. (2012). Between-session practice and therapeutic alliance as
predictors of mindfulness after mindfulness-based relapse prevention. Journal of
Clinical Psychology, 68(3), 236-245. doi: 10.1002/jclp.20855.Epub2011Dec1.
Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H. … & Larimer, M.
E. (2014). Relative efficacy of mindfulness-based relapse prevention, standard
relapse prevention, and treatment as usual for substance use disorders: A
randomized clinical trial. JAMA Psychiatry, 71(5), 547-556.
Hartzler, B. & Rabun, C. (2014). Training addiction professionals in empirically supported
treatments: Perspectives from the treatment community. Substance Abuse, 35(1),
30-36. doi: 10.1080/08897077.2013.789816.
Hendershot, C. S., Witkiewitz, K., George, W. H. & Marlatt, G. A. (2011). Relapse
prevention for addictive behaviors. Substance Abuse Treatment, Prevention and
Policy, 17(6),. Doi: 10.1186/1747-597X-6-17.
Rubin, A. (2008). Practitioner’s guide to using research for evidence-based practice.
Hoboken, NJ: John Wiley & Sons.
Turner, N., Welches, P. & Conti, S. (2013). Mindfulness-based sobriety: A clinician’s
treatment guide for addiction recovery using relapse prevention therapy, acceptance
& commitment therapy & motivational interviewing. Oakland, CA: New Harbinger
Publications, Inc.