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Title: The%20Evidence-Based%20Practice%20Tells%20Me%20So!


1
The Evidence-Based Practice Tells Me So!
  • Cody Jeffries, M.A.
  • Jennifer Halpin, B.A.
  • Dr. Judith R. Gonzalez, LMFT, PsyD

2
  • 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.

3
  • 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.

4
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).
5
Original EBP Model
EBP
Rubin, A. (2008). Practitioners guide to using
research for evidence-based practice. Hoboken,
NJ John Wiley Sons.
6
Newer EBP Model
PRACTITIONER EXPERTISE
Rubin, A. (2008). Practitioners guide to using
research for evidence-based practice. Hoboken,
NJ John Wiley Sons.
7
The Cycle of EBP
Appropriate for this client?
Contextual assessment
Valid assessment
PRACTITIONER EXPERTISE
Clients preferred course or at least willing to
try?
Effective services
Barriers (e.g., cultural conflict)
Rubin, A. (2008). Practitioners guide to using
research for evidence-based practice. Hoboken,
NJ John Wiley Sons.
8
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9
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10
Steps in the EBP Process
  • Rubin, A. (2008). Practitioners guide to using
    research for evidence-based practice. Hoboken,
    NJ John Wiley Sons.

11
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.

12
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?

13
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.
  • CONSIDER ? Why would you first need to land on a
    diagnosis before you can engage in the EBP
    process?
  • The diagnosis need not be DSM- or ICD-based it
    may be a more mundane, but empirically studied
    issue like infidelity.
  • CONSIDER ? Many MFTs 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 couples
    communication.)

14
STEP TWO Evidence Search
  • Second, identify the most similar population to
    your client who was studied with the presenting
    issue.
  • Demographic qualifiers
  • 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?)
  • Context
  • 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?

15
STEP ONE Question Formulation
  • Third, decide which treatments you should
    compare.
  • 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?

16
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.

17
STEP ONE Question Formulation
  • Forming the question
  • 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/ps 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?

18
STEP TWO Evidence Search
  • There are different avenues one could take at
    this point
  • Conducting an exhaustive literature search in a
    scholarly fashion.
  • Pros Thorough, publishable, reputable sources
  • Cons Timely, costly
  • Conducting a quick search using popular search
    engines
  • 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.

19
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
20
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

21
STEP THREE Critically Appraising Studies and
Reviews
  • Participants
  • Sampling/selection
  • Number
  • Demographics
  • Data collection
  • Qualitative Basic assumptions, Instruments
    (validity/reliability), etc.
  • Quantitative Biases of researchers, Methods,
    etc.
  • Analysis
  • Appropriate methods to the research question?
  • Appropriate execution of analyses?

22
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23
STEP FOUR Selecting and Implementing the
Intervention
  • Which empirical evidences will you use to make
    your decision?
  • 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).

24
STEP FOUR Selecting and Implementing the
Intervention
  • Additional considerations
  • Dont forget about your treatment context!
  • How many studies are needed?
  • 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.
  • Dont forget client informed consent!

25
STEP FIVE Monitor Client Progress
  • This step is all about having mutually agreed
    upon, measurable goals to help your client work
    on their presenting issue.
  • How to monitor progress?
  • 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.

26
Case Example 1
  • Cody Jeffries, M.A.

27
Anakin and Padme Skywalker
  • Demographic Information
  • Caucasian, Young Adult, Highly Religious,
    Heterosexual
  • Presenting Concern
  • Infidelity on husbands part with wifes best
    friend
  • Contemplating divorce
  • Treatment History
  • Initial treatment agreement with original
    therapist by husband to terminate all contact
    with wifes 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

28
STEP ONE
  • Question Formulation
  • 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?

29
STEP TWO
  • Evidence Search
  • What do I look for?
  • Clinician factors Theoretical Orientation and
    Training
  • Client factors Highly religious, White,
    heterosexual, married
  • Where do I look?
  • 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.

30
STEP THREE
  • Critically Appraising Studies and Reviews
  • Comparison of issues being explored
  • Research subject vs. presenting concern
  • Theistic triangulation
  • Attachment to God research
  • Comparison of demographic info
  • Study participants vs. Clients
  • Analyzing methods
  • Participant selection
  • Research method
  • Data analysis
  • Consideration of results
  • Validity and reliability
  • Applicability

31
STEP FOUR
  • Selecting and Implementing the Intervention
  • What if there are no evidence-based interventions
    to select from?
  • Research-informed interventions
  • Object-relations for addressing the attachment to
    God concerns
  • Theory-informed interventions
  • Bowenian family therapy for addressing theistic
    triangulation
  • Implementation
  • Devising a research-informed strategy
  • Theoretical rationale

32
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
  • Methods of assessment
  • Objective measure vs. subjective report
  • Quantitative vs. Qualitative assessment

33
Case Summary
  • Couple terminated therapy before completion of
    treatment goals.
  • 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 Gods or her
    childrens 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
    Padmes 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.

34
If they had continued
  • 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?

35
Case Example 2
  • Jennifer Halpin, B.A.

36
Bob MethMaker
  • Demographic information
  • Presenting Concern
  • Treatment History
  • Conceptualization

37
STEP ONE
  • Question Formulation
  • Are there effective evidence-based treatments
    for relapse prevention treatment in individuals
    with Polysubstance dependence?

38
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

39
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
  • Everyone has a different path to recovery
  • Recent publication of Mindfulness based Cognitive
    Therapy pdf on their website

40
Mindfulness-Based Cognitive Therapy
41
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

42
Relapse Prevention Therapy (RPT)
43
Motivational Enhancement Therapy
44
Living in Balance (LIB)
45
Network Therapy
46
STEP TWO
  • Where to look?
  • EBSCO Host (PsychInfo, PsychArticles, PsychBooks)
  • Search Terms
  • 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

47
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
  • 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

48
STEP THREE
  • Substance Abuse Treatment, Prevention, and Policy
    2011
  • Title Relapse prevention for addictive behaviors
  • Relapse Prevention (RP) model

49
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

50
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.

51
STEP THREE
52
STEP FOUR
  • Selecting and Implementing the Intervention
  • Research-informed interventions
  • Mindfulness-based Cognitive Therapy
  • Implementation
  • Devising a treatment plan for the client with his
    specific characteristics in mind
  • E.g. unemployment, probation, rural area

53
STEP FIVE
  • Monitor Client Progress
  • Clients progress was monitored by assessing the
    clients past week in terms of stress, cravings,
    and substance use or lack their of
  • Methods of assessment
  • Subjective report, Qualitative
  • Objective measure, U.A. done by Probation Officer

54
Case Summary
  • 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

55
Summary Conclusions of Workshop
56
Questions?
57
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.Epub2011De
    c1.
  • 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). Practitioners guide to using
    research for evidence-based practice. Hoboken,
    NJ John Wiley Sons.
  • Turner, N., Welches, P. Conti, S. (2013).
    Mindfulness-based sobriety A clinicians
    treatment guide for addiction recovery using
    relapse prevention therapy, acceptance
    commitment therapy motivational interviewing.
    Oakland, CA New Harbinger Publications, Inc.
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