Beyond Evidence-Based Practice to Practice-Based Evidence

It's crucial to evaluate the effectiveness of your mental health treatment.

Posted May 14, 2018

Research has identified many highly effective psychological treatments for a wide array of presenting problems, also referred to as Evidence-Based Psychological Treatments (EBPT).

While we are inundated with ads on TV touting pharmaceutical agents, most people are less aware of the huge body of research indicating what works for whom and under what circumstances in psychotherapy. This body of published research that continues to grow must inform the treatment decisions of individual practitioners.

In addition to the limited information publicly available about EBPT, there is often limited access to these treatments. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 60 percent of people with a mental disorder do not receive treatment and only 32 percent of the treatments were categorized as minimally adequate. 

Client factors such as cultural considerations, preferences, work schedules, travel, and childcare impact the application of EBPT, outside of the initial randomized control trials providing evidence of treatment efficacy. Most practitioners find juggling between accommodating these very real barriers and providing treatment fidelity is a major challenge. Using digital and online educational and practice tools through platforms such as TAO Connect (www.taoconnect.org) can provide more insurance of treatment fidelity. With online education and practice materials, patients are assured of learning and practicing the ideas and skills recommended in the EBPT following the protocol. Therapist dashboards allow the clinician to review the patient activities, reaction, engagement and response.

Often in controlled studies, people with complex or multiple problems were excluded from the subject pool, yet these more complicated presenting problems are ubiquitous in most clinics and practice. Clinicians often adapt EBPT to individual circumstances without knowing how those changes will impact treatment effectiveness. When one is working with a patient, the primary consideration must be the individual needs of that person and always working within a supportive therapeutic relationship. 

The only way to truly know the effectiveness of a treatment any individual provider delivers to any individual patient is through practice-based evidence. Assessment needs to be an integral part of service delivery and can be helpful in a number of ways: 

  • Assessment can ensure the appropriateness of the treatment and treatment modality. Patients can be asked at the beginning about problems and symptoms, but also about potential barriers (work, cost, child care) and about their expectations about treatment duration and intensity.
  • Assessment can improve risk management and client safety. Asking about risk at both the beginning of treatment and at intervals throughout can help manage risk.
  • Assessing progress regularly throughout treatment has been shown to improve outcomes regardless of the treatment delivered. Many studies have found that measuring progress and response to treatment weekly actually improves treatment effectiveness. We are better therapists when we measure progress.
  • Assessment of progress at regular intervals improves client engagement. Seeing progress is very motivating and helps keep clients engaged. Conversely, if treatment is not working well, this can be identified quickly, discussed and treatment plans can be changed in real time.
  • Assessment of progress at regular intervals increases treatment efficiency. Some studies have shown when therapists use a progress measure and review their assessment results change happens more quickly with fewer sessions.
  • Assessment of progress, satisfaction and engagement at regular intervals helps us to effectively respond to individual preferences without reducing treatment effectiveness. When therapists find themselves diverting from the EBPT protocol they can monitor the effectiveness of these variations.

There are many useful tools available. Some examples include Scott Miller’s PCOMS, the BHM-20 from CelestHealth, the CCAPS for college student mental health, Michael Lambert’s OQ-45. All are well researched and effective measures with varying benefits and limitations.

References

Harvey, A. G., & Gumport, N. B. (2015). Evidence-based psychological treatments for mental disorders: Modifiable barriers to access and possible solutions. Behaviour Research and Therapy, 68, 1–12. http://doi.org/10.1016/j.brat.2015.02.004

Lambert, M.J., C. Harmon, K. Slade, J.L. Whipple, and E.J. Hawkins. "Providing Feedback to Psychotherapists on Their Patients' Progress: Clinical Results and Practice Suggestions." Journal of Clinical Psychology, vol. 61, no. 2, 2005, pp. 165-174.

Laska, K.M., A.S. Gurman, and B.E. Wampold. "Expanding the Lens of Evidence-Based Practice in Psychotherapy: A Common Factors Perspective."Psychotherapy, online ahead of print. doi: 10.1037/a0034332.

McAleavey, A.A., S.S. Nordberg, D.R. Kraus, and L.G. Castonguay. "Errors in Treatment Outcome Monitoring: Implications of Multidimensional and General Measurements for Real-World Psychotherapy." Canadian Psychology, vol. 53, 2012, pp. 105-114.

McHugh, R.K., H.W. Murray, and D.H. Barlow. "Balancing Fidelity and Adaptation in the Dissemination of Empirically-Supported Treatments: The Promise of Transdiagnostic Interventions." Behaviour Research and Therapy, vol. 47, no. 11, 2009, pp. 946-953.

Schoenwald, S.K. "It's a Bird, It's a Plane, It's...Fidelity Measurement in the Real World." Clinical Psychology: A Publication of the Division of Clinical Psychology of the American Psychological Association, vol. 18, no. 2, 2011c, pp. 142-147.