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Evidence-based Practice in Psychology: Epistemological Diversity*

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Evidence-based Practice in Psychology: Epistemological Diversity* Steven D. Hollon Member, Presidential Task Force on EBPP Vanderbilt University – PowerPoint PPT presentation

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Title: Evidence-based Practice in Psychology: Epistemological Diversity*


1
Evidence-based Practice in Psychology
Epistemological Diversity
  • Steven D. Hollon
  • Member, Presidential Task Force on EBPP
  • Vanderbilt University
  • Email steven.d.hollon_at_vanderbilt.edu
  • Based upon Report of the 2005 Presidential Task
    Force on Evidence-Based Practice Policy
    statement http//www.apa.org/practice/ebpstatemen
    t.pdf
  • Complete report http//www.apa.org/practice
    /ebpreport.pdf

2
2005 Presidential Task Force on Evidence-Based
Practice (APA)
  • Ronald F Levant EdD (Chair) Carol D Goodheart EdD
    (Chair)
  • David H Barlow PhD Frederick L Newman PhD
  • Jean Carter PhD John C Norcross PhD
  • Karina Davidson PhD Doris K Silverman PhD
  • Kristofer J Hagglund PhD Brian D Smedley PhD
  • Steven D Hollon PhD Bruce E Wampold PhD
  • Josephine D Johnson PhD Drew I Westen PhD
  • Laura C Leviton PhD Brian T Yates PhD
  • Alvin R Mahrer PhD Nolan W Zane PhD
  • APA Staff
  • Geoffrey M Reed PhD
  • Lynn F Bufka PhD
  • Ernestine Penniman

3
Basic Definition and Process
  • Based on IOM definition that emphasized
    integration of research evidence with clinical
    expertise and patient values
  • Drew on diverse group with range of expertise and
    interests from research scientists through
    clinical practitioners
  • Produced draft policy statement and position
    paper that was then posted for comments and
    subsequently revised
  • Approved by vote of council at the 2005 APA
    convention

4
EBPP Defined
  • Evidence-based practice in psychology (EBPP) is
    the integration of the best available research
    with clinical expertise in the context of patient
    characteristics, culture, and preferences.
  • Closely parallels the definition adopted by the
    Institute of Medicine (2001) as adapted from
    Sackett and colleagues (2000, p. 14)
    Evidence-based practice is the integration of
    best research evidence with clinical expertise
    and patient values.

5
Best Research Evidence
  • Evidence drawn from basic and applied research
  • Hierarchy from clinical observation through
    randomized controlled trials with respect to
    efficacy
  • Address efficacy and effectiveness (utility)
  • Absence of evidence not evidence of absence
  • Untested does not mean ineffective
  • Claims for efficacy should be tested

American Psychological Association (2002).
Criteria for evaluating treatment
guidelines. American Psychologist, 57, 1052-1059.
6
Clinical Expertise
  • Encompasses number of competencies
  • positive therapeutic relationships
  • integration of diverse information
  • recognizes own bias and limitation
  • Derived from clinical and scientific training
  • Used to integrate research evidence with clinical
    data in context of patient preference

7
Patient Characteristics, Values, and Context
  • Services most effective when responsive to
    patient problems, strengths, and preferences
  • Important variations in age, gender, race and
    ethnicity, and culture (among others)
  • EBPP seeks to maximize patient choice among
    effective alternative interventions

8
Integration
  • Psychologist determines applicability of research
    evidence to particular patient
  • Application of research to given patient always
    involves probabilistic inferences
  • Continuous monitoring of patient progress and
    adjustment of treatment as needed
  • Clinical decisions made in collaboration with
    informed patient and in consideration of costs,
    benefits, and options available (never by
    untrained persons unfamiliar with specifics of
    the case)

9
In Defense of RCTs
  • RCTs best way to detect causal influence
  • far from perfect but still the best we have
  • uncontrolled trials confound patients and
    procedures
  • hormone replacement therapy just latest example
  • need not do therapy like a scientist to evaluate
    effects
  • Carl Rogers one of the first to do controlled
    trials
  • good data best way to keep the critics at bay
  • no controlled trials before Eysencks critique
  • hundreds of subsequent trials show that
    psychotherapy works
  • some leading therapies still not adequately tested

10
In Defense of ESTs
  • ESTs one reasonable way to see what works
  • look for well done studies that show effects
  • need not sacrifice external validity for internal
    validity
  • need not exclude representative patients (and no
    longer do)
  • can be used to test long-term treatments (and
    starting to do so)
  • do not mandate specificity but can detect it
  • treatment needs to work but not for reasons
    specified
  • special case for medications not for
    psychotherapy
  • treatment manuals neither necessary nor
    sufficient
  • need not constrain clinicians unduly if integrity
    maintained
  • merely useful aid for training and dissemination

11
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12
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13
In Defense of ESTs
  • ESTs one reasonable way to see what works
  • look for well done studies that show effects
  • need not sacrifice external validity for internal
    validity
  • need not exclude representative patients (and no
    longer do)
  • can be used to test long-term treatments (and
    starting to do so)
  • do not mandate specificity but can detect it
  • treatment needs to work but not for reasons
    specified
  • special case for medications not for
    psychotherapy
  • treatment manuals neither necessary nor
    sufficient
  • need not constrain clinicians unduly if integrity
    maintained
  • merely useful aid for training and dissemination

14
Must RCTs Exclude Representative Patients?
  • 805 patients evaluated
  • 240 (30) randomized
  • 565 (70) excluded
  • 235 (29) low severity
  • 240 (30) diagnostic
  • 96 (12) psychosis
  • 63 (08) sub abuse
  • 17 (02) axis I
  • 19 (02) axis II
  • 45 (06) medical
  • 95 (10) med refusal
  • 08 (01) suicide risk

From DeRubeis et al., 2005
15
Must RCTs Exclude Complicated Patients?
  • 240 patients randomized
  • 40 (16) depressed only
  • 200 (84) comorbid
  • 146 (73) axis I
  • 127 (53) anxiety disorder
  • 86 (36) sub abuse
  • 40 (16) eating disorder
  • 125 (52) axis II
  • 10 (04) cluster a
  • 10 (04) cluster b
  • 84 (35) cluster c
  • 37 (16) pd nos

From DeRubeis et al., 2005
16
In Defense of ESTs
  • ESTs one reasonable way to see what works
  • look for well done studies that show effects
  • need not sacrifice external validity for internal
    validity
  • need not exclude representative patients (and no
    longer do)
  • can be used to test long-term treatments (and
    starting to do so)
  • do not mandate specificity but can detect it
  • treatment needs to work but not for reasons
    specified
  • special case for medications not for
    psychotherapy
  • treatment manuals neither necessary nor
    sufficient
  • need not constrain clinicians unduly if integrity
    maintained
  • merely useful aid for training and dissemination

17
CPT III
Maintenance/Follow-up (36 months)
Acute Treatment (1-18 months)
Continuation (6-18 months)
ADM and CT (N225)
ADM (N90)
(monthly/ quarterly)
(twice weekly/weekly)
(monthly)
No ADM (N90)
1st R a n d o m i z a t i
o n
2nd R a n d o m i z a
t i o n
Response
Relapse
Recurrence
ADM (N225)
ADM (N90)
(monthly/ quarterly)
(weekly/biweekly)
(monthly)
No ADM (N90)
Remission
Recovery
18
79
64
19
79
69
20
71
41
19
09
21
Sustained Recovery pRemit x cpRecover x
1-cpRecurrence
22
In Defense of ESTs
  • ESTs one reasonable way to see what works
  • look for well done studies that show effects
  • need not sacrifice external validity for internal
    validity
  • need not exclude representative patients (and no
    longer do)
  • can be used to test long-term treatments (and
    starting to do so)
  • do not mandate specificity but can detect it
  • treatment needs to work but not for reasons
    specified
  • special case for medications not for
    psychotherapy
  • treatment manuals neither necessary nor
    sufficient
  • need not constrain clinicians unduly if integrity
    maintained
  • merely useful aid for training and dissemination

23
Response to Treatment as a Function of Condition
24
Continuation
Followup
25
Sustained Improvementfor All Assigned to
Treatment
26
Cumulative Direct Costs of ADM and CT
27
In Defense of ESTs
  • ESTs one reasonable way to see what works
  • look for well done studies that show effects
  • need not sacrifice external validity for internal
    validity
  • need not exclude representative patients (and no
    longer do)
  • can be used to test long-term treatments (and
    starting to do so)
  • do not mandate specificity but can detect it
  • treatment needs to work but not for reasons
    specified
  • special case for medications not for
    psychotherapy
  • treatment manuals neither necessary nor
    sufficient
  • need not constrain clinicians unduly if integrity
    maintained
  • merely useful aid for training and dissemination

28
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29
Summary and Conclusions
  • Multiple components contribute to outcome
  • Patient, therapist, relationship also matter
  • Validate treatments to improve patient care
  • New methods emerge over time
  • Pursue other ways to improve care
  • Emphasize that which we can reliably teach

30
Putting Things in Perspective
  • No one pretends that democracy is perfect or
    all-wise...indeed, it has been said that
    democracy is the worst form of Government except
    all those other forms that have been tried from
    time to time Winston Churchill
  • The first principle for being a good psychologist
    is to not kid yourself, the second principle is
    to not kid anybody else Paul Meehl
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