1. Framing the dialogue about knowledge and practice in mental health Reginald O. York, PhD Professor and Chair Department of Social Work UNC-Wilmington

2. Mental health practice  Psychotherapy  Case management  Medication management  Specialized treatments like recreation therapy, art therapy, etc.  Other

3. Psychotherapy  Psychotherapy is an interaction between a qualified professional and a client with the purpose of improving the client's mental health through both the therapeutic relationship and consciously applied techniques supported by a legitimate knowledge base.

4. The key issue  How do we help practitioners navigate the variety of knowledge bases that might be employed in the improvement of practice?  Specifically, how can we facilitate a dialogue between two major approaches to knowledge and practice—evidence- based practice and practice-based evidence.

5. What is evidence-based practice? [From Bruce Thyer]  “Evidence-based practice requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances” From Strauss et al. (2005). Evidence-based medicine: How to practice and teach EBM (third edition). New York: Elsevier.

6. What is ‘Best Research Evidence’? [From Bruce Thyer]  Clinically relevant research from basic and applied scientific investigations, especially drawing from intervention research evaluating the outcomes of social work services, and from studies on the reliability and validity of assessment measures.

7. Hierarchy of research evidence 1.Studies that measured client growth using a valid tool. 2.Studies that also compared client growth with a group that did not receive treatment. 3.Studies that also randomly assigned persons to the control group and the treatment group. 4.Studies that also [i.e., all of the above] included a placebo treatment. 5.Studies that also included a comparison of one treatment with another.

8. Is “cherry picking” compatible with the scientific method?  Cherry picking is intentionally selecting evidence that supports a given conclusion and avoiding evidence to the contrary.

9. What’s wrong with these pictures? 1.A clinician says “My 20 years of clinical experience is my evidence?” 2.A researcher appears to present a systematic picture of the evidence that supports a certain treatment model, but it is found that he left out several studies that failed to support this model, and these studies were relatively easy to find.

10. Steps in evidence-based practice  Determine the goal of intervention in collaboration with the client.  Search for evidence of what methods are best for achieving the goal.  Collaborate with clients in determining what interventions to apply.  Apply the selected intervention.  Should outcomes be evaluated?.

11. Steps in practice-based evidence 1.Determine the goal of intervention in collaboration with the client. 2.Decide on the intervention without being constrained or prejudiced by the kind of research that seems to assert that a given model is the best ( because systematic reviews of evidence normally do not reach this conclusion) 3.Regularly monitor both therapeutic process and client outcome. 4.Adjust treatment in accordance with evidence on process and outcome, or refer client elsewhere.

12. How the perspectives treat collaboration with clients  They both suggest that practice goals and intervention approaches come from a collaboration between client and therapist.  But emphasis on evidence in this collaboration is somewhat different.

13. How they treat evidence  Both approaches utilize evidence.  But their approach to evidence differs.  EBP  a focus on evidence regarding treatment models or techniques  Defenders of EBP assert that they focus on the best available evidence whether or not it relates to a treatment model.  PBE  evidence on other factors is more important than evidence on treatment model

14. What we have learned from research on psychotherapy (Wampold, The Great Psychotherapy Debate) 1.Psychotherapy is effective (standard forms of it). [ About 30% of people not treated get better as compared to 70% of those treated.] 2.Factors that different models have in common are far more important in determining outcome than specific methods. [ Examples: helping relationship, client hope, goal agreement] 3.The chosen model of treatment has only a small effect on treatment outcome.

15. How the two approaches treat measurement of client progress  The PBE group clearly includes regular measurement of client progress (and session effectiveness) in the model.  The classic EBP steps do not include regular measurement of client progress, but some later advocates have included this step as a natural one that any good scientific practitioner would take.

16. Analyzing evidence-based practice 1.Can practitioners make reliable assessments or diagnoses? If not, how can evidence help?  Do you believe diagnosis is reliable? 2.Can practitioners find evidence?  What has been your experience with evidence? 3.Can practitioners apply the “evidence-based practice”?  How many models can you employ right now? 4.Will this practice fit the client?  How often do you find that a scientifically supported method does not fit this particular client?

17. My view on the question about diagnosis  My review of the evidence on diagnosis suggests that it is reliable enough.  I am not saying it is perfect, but my review tends to be more supportive than contrary. I am reminded of the old saying “Don’t throw the baby out with the bathwater!”

18. My view on clinicians finding evidence?  This is a big problem.  They need a user-friendly mechanism for finding it.  I don’t believe the Campbell Collaboration is that kind of mechanism.  They also need the ability to sort out the better from the worse evidence.  I don’t believe the typical clinician has the ability to do this, given the nature of the sources available.

19. My view on clinicians applying evidence-based practices?  What if you found that dialectical behavioral therapy was the only evidence-based practice for borderline personality disorder? Are you prepared to offer this model of treatment?  I need more evidence on this one to give an opinion.  I do not believe that the pursuit of the one best practice makes sense. But this is not the position either of EBP or PBE, even though some have embraced this myth.

20. Practitioner competence, continued  I believe the major effect of the evidence- based practice movement is that it has encouraged practitioners to get training in models like cognitive-behavioral because of the evidence that supports it.  I also believe that the evidence typically suggests there is more than one alternative that is supported by evidence.

21. Analyzing practice-based evidence  Can practitioners collaborate with clients in determining the goals? Any good therapist can.  With little attention to evidence about treatment approaches, how can practitioners find the place to start the intervention?  What has been your experience?  Will practitioners regularly monitor process and outcome? How likely are you to measure client’s in every session?  Will practitioners modify practice or refer? What has been your experience?

22. My view on the starting point for intervention  Before considering the starting point for the structure of intervention, I believe you should consider the importance of the therapeutic relationship. If you don’t have this, you are not likely to be very effective.  But you should be mindful of methods that have been found to be harmful.  Evidence should be considered, even if this means the recognition that there are five different models that have been found effective

23. Starting point, continued  I believe the therapist should have several models or techniques in the toolbox and be prepared to experiment.  But these methods should be vetted by the evidence, with particular attention to methods found to be harmful.  Evidence should guide the practitioner’s pursuit of new training, but he/she should be cognizant of what feels most natural.

24. My tentative view of psychotherapy and science  It is my hope that a study process in the coming year(s) will enlighten my view of psychotherapy and science and I will grow in the process.  However, at present, here is where I seem to stand, tentatively. This is based substantially on my review of the science of psychotherapy, but likely is influenced by my experience and inclinations.

25. Point 1 from my view: Therapists should be trained in the common factors  Much of what influences the outcomes of therapy are substantially beyond the control of the therapist, such as client support, client characteristics, environmental changes, and so forth.  Of those things potentially under the influence of the therapist, the ability to form a helping relationship is most important. This requires empathic understanding, acceptance, positive regard, and so forth.

26. Point 2: Therapists should receive training in approaches with scientific validity  There are a number of such approaches, including behavioral, cognitive- behavioral, psychodynamic, and so forth.  Furthermore, the therapist should find the methods where their greatest competence lies, and recognize methods not comfortable and likely not to be effective if given by them. They should use methods they really believe in.

27. Point 2, continued  They should also be cognizant of methods that have been found to be harmful and avoid them.  They should be cautious about trying new methods that have not been tested.

28. Point 3: Therapists should seek the best available evidence.  The best evidence seems to point to common factors like the helping relationship and hope, rather than specific models or techniques. But if there is evidence of the superiority of one or two methods in the pursuit of the client’s goal, it should be prominently considered (but should not dictate).

29. Point 4: Therapists should collaborate with clients on treatment methods  Some research, and common sense, suggests that the client’s preferred paradigm for viewing behavior is related to client preferences about methods. Therapists should explore this fact in the dialogue about treatment methods.

30. Point 5: Client progress should be systematically monitored.  The methods employed by Scott Miller and Barry Duncan are impressive. They have a tool for getting client feedback in every session about both process and outcome. This tool is simple and not as intrusive as most instruments designed to measure client behavior.

31. Summary  If the therapist is comfortable with a scientifically supported method that is compatible with the client’s behavioral paradigm, and the therapist has relationship skills that work with this client, I believe there is likely to be a good outcome. And the fit of the method with the client diagnosis is not as important.