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Evidence-Based Practice and Interprofessional Education

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Title: Evidence-Based Practice and Interprofessional Education


1
Evidence-Based Practiceand Interprofessional
Education
  • Bruce A. Thyer, Ph.D., LCSW, BCBA-D
  • College of Social Work, Florida State University
  • Visiting Fulbright Specialist, Kings College,
    UWO, 416 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 patients 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.

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  • 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 RCTs available
    to consult. It does depend on one examining the
    best available evidence.
  • There is ALWAYS evidence, even if it is of low
    quality.

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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.
  1. 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.
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What are Answerable Questions?
  • 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.?
  • 2. A question including some aspect of the
    clients 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?

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)

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  • 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, APAs Division 12s lists of ESTs,
    SAMSHA, California Clearing Houseetc.) (a
    top-down search)

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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 APAs 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 Forces 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

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And a series of articles
  • These are available for free at
  • http//www.apa.org/divisions/div12/journals.htmlE
    STs
  • 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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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.E.David.Klonsky_at_stonybroo
k.edu
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 theEvidence-based
PracticeMovement
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.

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There is no such thing asEVIDENCE-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, 328-333.

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.

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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.

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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.
  • http//www.evidencebasedprograms.org/

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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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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.

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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.
    177-181)!
  • EBP actually is PRACTITIONER-driver, not
    managerial in nature. Again, the authors seem to
    be confusing EBP with empirically supported
    treatments.

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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.

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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.

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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.

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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.

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Copies of this powerpoint presentation are
available from the author, via
  • Bthyer_at_fsu.edu
  • Bruce Thyer, Ph.D., LCSW
  • College of Social Work
  • Florida State University
  • Tallahassee, FL 32306 USA
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