What is best practice – is evidence based practice the answer? Tor-Johan Ekeland Professor, Volda University College Professor II, Molde University College

What is best practice – is evidence based practice the answer?

Tor-Johan Ekeland

Professor, Volda University College

Professor II, Molde University College

Nordic ConferenceNew perspectives – best mental health practice

Akureyri May 7-8, 2009

Akureyri May 7-8 2009 TJE

Evidence based……..• Comes from medicine • A world wide trend not specific to mental health• Driven by:

• Accountability• What works


Evidence based excitement:

Government Politicians Managers and payers Researchers Clinicians ?


What does it mean that a treatment are evidence based?

Evidence based knowledge:– That a diagnosed group of patient getting

a specific treatment, in average get better results compared to the average effect in a comparable group not getting the treatment (or another)

Evidence based practice:– Implementing this knowledge through

diagnose based procedures


The Logic of Evidence Based Practice

Research literature

Selection -filtering

Management

Clinical practice

Gold standard

Manuals


Hanne Foss Hansen


What is new and what is old? What is good and what is the problems?

Is ”evidence based” synonymous with scientific?

Evidence based practice


This is old:Evidence based knowledge– The idealization of context-independent and universal

knowledge – The aspiration to transform knowledge into

”technology”

This is new:Evidence based practice– Narrowed and authorized criteria of what counts as

knowledge (gold standard)– The use of evidence based knowledge are not a matter

of professional autonomy alone, but come with manuals implemented in new strategies for governing


Archibald Leman Cochrane (1909 - 1988)

Can it work? Does it work in

practice? Is it worth it?


……but:

Why does it work?

EBP is a kind of empirical pragmatism…..

May foster pseudoscience…………


From science to ”technology”:

Science: If A, then B (i.e. with p=x)

Technology: If you want B, do A

Implicit premises:– Stable relation between A and B– Can be replicated– That the action (A) is independent of the acting person – That the response (B) is independent of the person who

is the target for the action

When is this premises valid?


Intervention and prediction in different “worlds”

physical biology humane

Responses are:• Stable• Universal• Causal• Unhistorical

Responses are:• Distributed• System

dependent• Functional• Adaptive

Responses are:• Language dependent• Based on reason• Relational•

Historical/Contextual

Do we have a map (epistemology) which fit the territory (ontology)?

Confusion create epistemological errors

Prediction is:• Precise

Prediction is: • Statistical • known variance

Prediction is:• Statistical• Unstable variance


Experts showed strong agreement that research did support following assertions:

Therapy is helpful to the majority of clients Most people achieve some change relatively quickly in

therapy People change more due to “common factors” than to

specific factors associated with therapies In general, therapies achieve similar outcome The relationship between the therapist and client is the

best predictor of treatment outcome Most therapists learn more about effective therapy

techniques from their experience than from the research

(Charles Boisvert & David Faust, 2003)


“Despite volumes devoted to the theoretical

differences among different schools of psychotherapy, the result of research demonstrate negligible differences in the effects produced by different therapy types”. (Smith og Glass, 1977, s.760)

”..., there is massive evidence that psychotherapeutic techniques do not have specific effects, yet there is tremendous resistance to accepting this finding as a legitimate one” (Bergin & Garfield, 1994, ”Handbook of Psychotherapy and Behavioral Change”, s.

822).


What works? Implication from research outside the evidence paradigm

Difficult to predict good outcome Equal efforts for the equal problems gives different

experiences Formal treatment variables not so important Timing: small causes may give great effects (turning points) A sense of life – functional daily life A home, work – meaningful activities A sense of being – identity, respect and acceptance Involved, trustworthy and dedicated helpers Regaining responsibility – “a speaking I”


Summing up…. EBP are therapies which are relatively independent of

context and therefore can be standardized (= technology):– In medicine ”evidence based” can function well when the

diagnostic validity is high and the working theories are adequate

Empirical evidence on psychotherapy and social methods show that this is contextual methods and therefore should not be standardized (= praxis) – The effects of such methods are dependent on individual

and contextual conditions– The practice should therefore be “tailor-made” rather than

standardized


Best practice as I see it……The main perspective should be the mental suffering person, not the

mental illness Implications: Contextual Model instead of Medical Model: perspective on life

world and restoring life-functions rather than focus on pathology and cure.

Organizational level An integrated local service, low thresholds User oriented and user cooperated services and resources Ambulant specialists

Escalation of: Common human language, cooperation and ”Care”Reduction of: Expert language, medicalisation/psychologization and ”Cure”

This will move us towards a better practice


Thank you!


Challenges in practice Get access with the patients subjectivity Create hope and belief in coping Create experience of coping Create trust in ability to cope Create trust and recovery of ”a speaking I”

The medical model restrain this because: It focus on pathology/problems instead of resources Ignore context (local and cultural) Objectify the service users Ignore the patient agency


Diagnosis-driven, “illness model” Prescriptive Treatments Emphasis on quality and competence Cure of “illness”

Client-directed (Fit) Outcome-informed (Effect) Emphasis on benefit over need Restore real-life functioning

The Medical Model: The Contextual Model:


Summing up…. In medicine ”evidence based” can function

well when the diagnostic validity is high and the working theories are adequate

In mental health and addiction therapy ”evidence based” gives wrong focus

Implication– Reduce complexity– Foster medical and mechanical methods– Exaggerate the technical on behalf of the

relational and communicative in treatment


Some problems Standardization not efficient if ”best treatment” is

individualization Many health problems without evidence based treatment The average patient does not exist in practice ”Absence of evidence is not evidence of absence” Weak relation between diagnose and therapy method Marginalization of other kinds of knowledge Increase the danger to objectify the patient Less creative practice Disguise the contextual difference between practice and

research Research informed practice a better strategy than research

governed practice


Forty years with empirical research on psychotherapy

Therapy works (80% compared to no therapy) Enduring effects for most patients No difference between different methods (Dodo-

verdict) Diagnose alone doesn't predict ”best treatment” The method explain little variance (3-15 %) Therapists and patients belief in the method explain

2-3 ganger more variance than the method alone No stable relation between specific technique and

outcome Best predictors are relation and early improvement


I medisinen er EBM eit heitt debattema: ”….the conscientious, explicit, and judicious use of current best evidence in making decisions about the care og individual patients” (Sackett et al, 1996)

”The initially refreshing educational approach of clinical epidemiology has been horribly transformed into the bureaucratic monster of evidence based medicine” (Fowler,1997)


Bergin og Garfield (1994) held det som eit viktig funn at «...it is the client more than the therapist who implements the change process» (s.824)


«Despite volumes devoted to the theoretical differences among different schools of psychotherapy, the result of research demonstrate negligible differences in the effects produced by different therapy types».

(Smith og Glass, 1977, s.760)


Systematic use of a human relationship

«What appears to matter most in psychotherapy is the interaction of patient`s interpersonal style with the therapist`s skill in managing the interpersonal climate. (....) In this view, psychotherapy is defined as the systematic use of a human relationship for the therapeutic purpose».

(Butler og Strupp, 1986, s.36)


A new deal?

Instead, greater scientific promise lies in the recognition that psychotherapy cannot be meaningfully reduced to «factors» independent of a particular interpersonal context. (......) What is needed is a new approach or paradigm through which to conceptualize and investigate psychotherapy

(Butler og Strupp, 1986, s.31 og s. 37)


Min konklusjon Dette er kunnskap basert på ein ”objektivert”

brukar Der er ingen evidens for evidensbasert

behandling når det gjeld kommunikativ praksis

Slik praksis må vere skreddarsaum Vi treng kunnskap som styrker den

relasjonelle og kommunikative kompetansen


Konklusjon på behandlingsforskinga

Frå behandling

Til

Samhandling

Frå

Det andre (sjukdomen)

Til

Den andre (den sjuke personen)


Noen implikasjoner av den empiriske forskningen:

Den terapeutiske teorien (modellen) fungerer terapeutisk først og fremst for terapeuten

En terapeutisk metode kan være virksom uavhengig av dens empiriske eller vitenskaplige grunnlag

Psykoterapi er kontekstuell medisin (metamodell)


Jerome Frank (1961):

An emotional and trusting relationship A healing setting in which the client or

clients meet a professional whom they believ can help them

A rational group of concepts or the creation of a myth that is able tyo provide a plausible explanation

A belief in the treatment itself (Persuasion and healing)


To eksistensielle grunnvilkår

Vi er relasjonelle vesen – avhengigheit er føresetnaden for identitet og sjølvoppleving

Vi er ”meaning makers” – sjølvfortolkande vesen – og meining er føresetnad for ontologisk tryggleik

All meiningsdanning er relasjonell


Davidson et al 2007

Bedringsprosessen dreier seg om å gjenskape en opplevelse av tilhørighet i sitt lokalmiljø samt en positiv følelse av identitet utenfor ens problemer, i arbeidet med å skape seg et liv på tross av eller innenfor begrensningene ved situasjonen man er i.


Etiologiske mønster ved psykiske lidelser

Ekvifinalitet: ulike årsaker, samme virkning

Multifinalitet: samme årsaker, ulike virkninger

Store årsaker gir små virkninger Små årsaker gir store virkninger


Bakgrunn Høgt tempo i kunnskapsproduksjonen Informasjonsoverload og motseiande

bodskap frå kunnskapsverda Behov for oversikter, sortering,

syntetisering og formidling av kunnskapsstatus om gitte forhold, t.d. effekten av ulike tiltak (medisinske, sosialpolitiske osv....)


GullstandardHierarki av evidens (Geddes & Harrison, 1997)

Metaanalyse av RCT-studiar Minst eit RCT-studie Minst ein kontrollert studie utan

randomisiering Minst ein annan type kvasieksperimentell

studie Ikkje-eksperimentelle deskriptive studiar Ekspertrapportar/eksperterfaringar


Empirisk pragmatisme

”Kunnskapssenterets rolle vil særlig være knyttet til det å evaluere og måle og ikke det å forstå mer grunnleggende mekanismer eller fortolke opplevelser og sammenhenger.”

(Nasjonalt kunnskapssenter for helsetjenesten, 2005)


Metodemetafysikk

”Når det gjelder spørsmål om effekt av tiltak, er det Kunnskapssenterets syn at det finnes et hierarki hvor kunnskap fremskaffet med gode randomiserte kontrollerte studier (RCT) er bedre og mer gyldig enn annen kunnskap”.

(Nasjonalt kunnskapssenter for helsetjenesten, 2005, s. 7).


Dessutan:

Kvar er evidensen for at implementering av EBP gir betre praksis enn ”vanleg” praksis?

Dette er ein empirisk påstand som ikkje er godt dokumentert


Litt presisering:Det uproblematiske: Bruk av vitenskap - ”evidensbasert” og annen At forskning etterprøver og evaluerer praksis At forholdet mellom forskning og praksis er

basert på dialogDet problematiske: Misbruk av vitenskap - pseudovitenskap At skillet mellom vitenskap og praksis blir

tilslørt At vitenskapen opptrer monologisk (styring) Evidensbasert praksis


How to Improve by 65%:Pop QuizHow to Improve by 65%:Pop Quiz

Question #6:

The bulk of change in successful treatment occurs earlier rather than later.

TrueIf a particular approach, delivered in a given setting, by a specific provider is going to work, there should measurable improvement in the first six weeks of care.



Last Question!The best way to insure effective, efficient, ethical and accountable treatment practice is for the field to adopt and enforce:

• Evidence-based practice;• Quality assurance;• External management;• Continuing education requirements;• Legal protection of trade and

terminology.

False



Question #6:

The bulk of change in successful treatment occurs earlier rather than later.

TrueIf a particular approach, delivered in a given setting, by a specific provider is going to work, there should measurable improvement in the first six weeks of care.


Old and new heroes

Emil Kraepelin (1856-1926)

Sigmund Freud

(1856-1939)

That other• Objectification• Explain• causality• Treatment

The other• Subjectification• Understand• Intentionality• Cooperation


• Part of a world wide trend not specific to mental health and independent of any particular type of reimbursement system.

• “Accountability,” “Stewardship,” & “Return on Investment” the buzzwords of the day.


Evidens........ Eit pluss-ord: Evidensbasert praksis, evidensbasert

politik, evidensbasert medisin, sjukepleie, sosialt arbeide, pedagogik, leiing, fangebehandling...…..

Evidens i tydinga systematiske kunnskapsoversikter Nye internatsjonale og nasjonale organisasjonar som

spesialiserer seg på å produsere og formidle systematiske kunnskapsoversikter, f. eks. Cochrane, Campbell, EPPI, SCIE...

Ofte semistatlege med rådgivingsoppgåver (f.eks. Nasjonalt kunnskapssenter for

helsetjenesten) ,

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What is best practice – is evidence based practice the answer? Tor-Johan Ekeland Professor, Volda University College Professor II, Molde University College