Transcript Slide 1

Life-Line Annual Community Luncheon
The New Evidenced-Based Practice
Ellen Behrens, Ph.D.
[email protected]
Outline:
1.the “new” evidence-based practice (EBP)
2. “NEW” EBPs for intensive adolescent
care
Family
Spiritual
Leaders
Educators
Teen
Success
Juvenile
Justice
System
Mental Health
Professionals
Good
Friends
Proponents of EBP
Promoted by federal policy authorities:
-National Advisory Mental Health Council Workgroup on Child
and Adolescent Mental Health, 2001;
-President’s New Freedom Commission on Mental Health 2003;
-Department of Health and Human Services, 1999
Implemented at:
-National Institute of Mental Health,
-Substance Abuse and Mental Health Service Administration,
-Medicare and Medicaid,
-most state mental health authorities
(Panzano & Herman, 2005).
Goal of EBP = RECOVERY

What is the way to the goal?

Originally = narrow focus: research supported
interventions. Empirical position.

Now= broader focus: interventions AND broad
factors that are research supported, clinically
informed, and matched to client. Contextual Position.
“Old” EBP in Mental Health Care

Paid relatively little attention to the role of
the client and therapist

Focused on “evidence”
Hierarchy of
Evidence
Effective
Solid research
Assumption was that
only Level 1’s (or 2’s)
were legitimately EBP.
Level 1
Level 2
Probably Effective
good preliminary research
Level 3
Possibly Effective
Isolated research studies, anecdote,
standard practice, individual opinion .
Lists of Level 1 interventions were
the primary focus
SAMHSA
http://www.modelprograms.samhsa.gov/template_cf.cfm?
page=model_list
Office of Juvenile Justice and Delinquency
Prevention (OJJDP) and Center for
Substance Abuse Prevention
http://www.strengtheningfamilies.org/html/programs_199
9/programs_list_1999.html
Lists of Level 1 interventions were
the primary focus
Cochrane Library
http://www.update-software.com/cochrane/
British Medical Association
http://www.clinicalevidence.com/ceweb/conditions/index jsp.
APA
http://www.apa.org/divisions/div12/rev_est/index.html
Level 1’s “work”…sort of

Meta-analytic reviews show EBPs
outperformed “usual care”.

However, the magnitude of the differences
are in the small to medium range.

…What does that mean?
Weisz, J.R. et al., 2006, Evidence-Based Youth Psychotherapies
Versus Usual Clinical Care: A Meta-Analysis of Direct Comparisons.
American Psychologist, 61, 671–689.
“New” evidence-based practice?
1. 3-legged stool
EBP is a process of blending 3 factors
 Research
 Care Provider
 Client
Research evidence for interventions is necessary, but
not sufficient.
“The integration of the best available research
evidence with clinical expertise in the context of
patient characteristics, culture, and preferences.”
(APA Task Force on Evidence-Based Practice, 2006).
3 Legged Stool

Client factors: expectations, readiness for
change, active effort, and problem severity
(25% of the variation in outcomes)

Therapist factors: Personal attributes
(e.g., flexibility, honesty, respectfulness,
trustworthiness, confidence, warmth),
professional judgment and expertise
(10% of the variation in outcomes)

Therapeutic relationship:
(10% of the variation in outcomes)
Norcross, J.C., & Lambert, M.J. (2006). In Norcross, J.C., Beutler, L.E., &
Levant, R.F. (Eds.), Evidence-based practice in mental health: Debate
and dialogue on the fundamental questions.
Therapeutic Relationship

Critical factors appear to be:

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Instilling hope
Sense of mastery/success
Feeling understood
Empathy
Rapport with therapist
Confronting the problem
Support
Bergin & Lambert,
1994
Weinberger, 1995
“New” EBP

2. “Common factors”


Looks beyond research supported interventions
and manualized treatment programs,
“common factors” can predict positive
outcomes and can be Level 1
“Common Factors”

Vast bodies of research show that
adolescent mental health & substance
abuse care is optimal when treatment is
individualized and when
community,
education, and
family resources are integrated.

These are “common factors” in programs like
Multi-systemic therapy, case management,
and wrap-around.
Confer: SAMHSA, NIMH, President’s New Freedom Commission, OJJDP, etc.
“Common Factors”
Community-based
Family-based
Individualized treatment
Research supported
interventions
Henggeler, S.W. (2006). Juvenile Drug Court:
Enhancing Outcomes by Integrating Evidence-Based
Treatments. Journal of Consulting and Clinical
Psychology,74, 42–54
Transforming Mental Health Care for Children and
Their Families, Huang, L, et al., 2005, American
Psychologist, 60, 615–627
Why do “common factors” work?
Youth do not necessarily generalize
learning from intensive treatment to more
normalized settings unless they have
ample opportunity to practice new skills in
their day-to-day contexts (i.e., school,
work, peer groups, church, family),
especially because those contexts are
often the determinants of clinical
problems.
“Common Factors”

Outcomes with Family- & CommunityFocused mental health treatment
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Juvenile Justice: Reduced re-arrest rates longterm
Family: Improved functioning, Reduced “out-ofhome” placements
Education: Improved performance
Therapy: High retention rates
Youth: Decreased externalizing, oppositional
behaviors, & substance use
Community-Based Treatment
Family
Improve outcomes?
Comprehensively address
the known determinants
of clinical problems
Spiritual
Leaders
Educators
Teen
Success
Juvenile
Justice
System
Mental Health
Professionals
Good
Friends
Spiritual Community

Research

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New (1990’s) and growing
Reviews conclude that spirituality is
associated with improved sobriety and
mental health and physical health (Level
2?) (Larimore, Parker, & Crowther, 2002)
Educational Community

school connectedness = belief by students
that adults in the school care,

…is positively related to academic,
behavioral, and social success in school
(Blum & Libbey, 2004; McNeely, Nonnemaker,& Blum, 2002).
Peer Community
Longitudinal studies on the development
of adolescent problem behavior provide
compelling evidence that such
behavior is embedded within the peer
group
Deviancy Training
(Dishion et al., 1999) deviant
talk is a tool high-risk youth use to formulate and
establish friendship networks, during adolescence
Juvenile Justice Community

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adult drug courts research found close
collaboration of criminal justice professionals and
treatment providers has positive outcomes (i.e.,
retention in treatment, closer and comprehensive
supervision, reduces substance use, produces
cost savings).
treatment promoted by some juvenile drug
courts are intended to address an array of the
correlates of adolescent substance abuse
(Belenko, 2001; Parnham & Wright, 1998)
Mental Health Community

Outcomes are maximized when youth are not
required to “navigate” numerous mental health
systems -- when they experience a “seamless
continuum of care”.
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All providers, past, present, future, are integrated.
Progress from more to less restrictive care matched for
“readiness”.
Levels of care are part of a larger treatment program
that operates in an integrated manner.
Common Factors only “work”….
when they work together.
 Integrated services are EBP.

Family
Spiritual
Leaders
Educators
Teen
Success
Drake et al.,2001
Juvenile
Justice
System
Mental Health
Professionals
Good
Friends
Family-Based Treatment
Family
Spiritual
Leaders
Educators
Teen
Success
Juvenile
Justice
System
Mental Health
Professionals
Good
Friends
Paradigm shift
Remove from family
Restore the family
Family involvement is a strong
predictor of outcomes
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Parent-focused interventions
… more effective than child-focused programs
…are the most extensively tested and
supported form of treatment for conduct
problems, substance abuse, and mental health
problems such as ADHD, anxiety, and
depression.
…quality?
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parents as partners
collaborate in entire process
(Huan et al., 2005; Kumpher, 1999; Sunseri, 2004)
Level 1 Family therapies
Common Therapeutic Mechanisms=
Alliance
Negativity reduction
Reattribution (reframing)
Competency development (parenting, communication etc)
Common Programmatic Aspects:
Articulate the therapeutic process
Structured yet clinically responsive & relationally sensitive
Integrated into overall program
Sexton, Hollimon, Mease, 2002
Self-Study Guide, Treatment Improvement
(2004) Reclaiming Futures National
Program Office Graduate School of Social
Work.
www.reclaimingfutures.org/documents/tre
atment_guide.pdf Based on:
• U.S. Department of Justice, Office of
Justice Programs (OJP), “Promising
Strategies to Reduce Substance Abuse.”
• National Council for Juvenile and Family
Court Judges Curriculum, “Effective and
Innovative Approaches to Adolescent
Substance Abuse Treatment.”
• National Institute of Drug Abuse (NIDA),
“Principles of Effective Treatment: A
“Families, in their many
forms and structures,
are openly, actively and
respectfully included in
all aspects of their
child’s treatment
experience. They are
assumed to have
strengths, to be capable
of growing and
responding to their
challenges in a positive
manner, and to be
involved in their child’s
treatment plan.”
Take Home Message
In the “new” EBP, research supported
interventions are necessary, but not
sufficient,
For EBP to be sufficient it must:
 be a 3 legged stool (client, therapist,
relationship),
 be Family-focused and Communityfocused
Recommended Reading
Psychiatric Clinics of North America 13 (2) 2004, 13 (4)
2004, 14 (2) 2005. http://www.psych.theclinics.com/
Special Issues devoted to “Evidence-Based Practices” &
“Residential Treatment” Excellent primers. Each $41
What Works for Whom? A Critical Review of Treatments
for Children and Adolescents. Fonagy et. al., (2002).
$30
&
Evidence-Based Psychotherapies for Children and
Adolescents. Kazdin & Weisz, Eds. (2003).
order at: http://www.guilford.com/cgibin/cartscript.cgi?page=pr/fonagy.htm&dir=pp/cpap&cart_id=57
9565.22624