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APA  Presidential Task Force on Evidence-Based Practice  defined evidence based practice (EBP) as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (Task Force 2006, p. 273).  The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280). (From Barry Duncan)

For several years there has been an impetus for the use of evidence based practice in counseling and psychology. The logic is simple enough. In a medical model, you diagnosis and you base the treatment on the best practices care for that diagnosis. The symptoms and lab work show a specific disease with a specific treatment that works, and you prescribe that treatment.

This sounds very simple and straightforward but there are a couple of problems with it.  First of all, diagnoses in the Diagnostic and Statistical Manual are behavioral diagnoses, not medical diagnoses.  There is no lab work, there are no x-rays.  There is only comparison to a list of behaviors associated with each diagnosis.  To come up with these diagnoses, psychiatrists and other mental health professionals review research, make proposals and vote. What is a disorder in one edition of the DSM may not be a disorder in the next edition. There are proposed changes for substance use disorders in the upcoming DSM V. Among them are dropping the term “dependency” and using the word “addiction.” Problems with law enforcement as a symptom will be dropped. Gambling will be added as an addiction. You can read more about the proposed changes at http://www.jointogether.org/news/features/2010/dsm-v-draft-includes-major.html. To quote Shirah Vollmer, MD,No matter how DSM V will be written, it will be flawed. There is no psychiatric diagnosis which has an objective measure. At the moment, all diagnoses are clinical diagnoses, meaning they are subjective. This is a field of humility. There is a lot that we do not know.” (http://www.psychologytoday.com/blog/learning-play/200912/dsm-v-plea-skepticism)

There are cultural biases in how mental health diagnoses are made. A black male in America is much more likely to be diagnosed as schizophrenic than a white male with the same symptoms. (http://drvitelli.typepad.com/providentia/2010/01/is-race-a-factor-in-diagnosis.html).  After the Christmas tsunami a few years ago, there was concern afterwards about the export of the American version of post traumatic stress disorder and some of our responders ignoring local cultural ways of dealing with disaster and using our model. Ethan Watters has just published “Crazy Like Us” which documents the spread of the American version of mental illness around the world.  He points out at least two factors. First, the notion of persons with mental disease and brain disorders actually has the effect of increasing stigma rather than reducing it. (For an in-depth discussion of the history of how mental illness came to be defined in Western culture, I recommend “Models of Madness: Psychological, Social, and Biological Approaches to Schizophrenia”.) Historically, persons in the third world have had better recovery rates from mental illness than those in the West. In the West, we treat with medicine and institutions. Cultures in the third world keep the individual in the community and the family.  The second point is how Big Pharmacy has helped with the export of our concept of mental illness to spread markets and increase revenues. Indeed there is documentation of research being ghost written by pharmaceutical companies with a physician on payroll to submit the work for publication. There is also the problem of research that shows certain drugs or approaches as not efficacious or even damaging not being published.  Ioannidis (2005) published an article called “Why Most Published Research Findings Are False.”  Leavitt (2003) discussed as to whether addiction research can be trusted. (http://www.atforum.com/SiteRoot/pages/addiction_resources/EBAM_6_Pager.pdf)

In addictions, there are numerous efforts to try to increase the use of evidence based practice.  The Addiction Technology Transfer Center Network says that “Transforming the lives of individuals impacted by the disease of addiction requires a workforce prepared to use the most effective, state-of-the-art tools and techniques. The ATTC Network is committed to helping the addictions treatment and recovery services field stay abreast of what works in order to enhance their skills and change their practice.”  The University of Washington Alcohol and Drug Abuse Institute and the Northwest Frontier ATTC have a website dedicated to evidence based practice in substance abuse. PubMed has listing of 106 EVPs for substance use disorders here and has 320 practice guidelines here. A search of the Mental Health and Substance Abuse Services Administration site for evidence based practice returned 2310 results. SAMHSA has a National Registry of evidence based practices at http://www.nrepp.samhsa.gov/.  A search on the National Institute on Alcohol Abuse and Alcoholism returned 563 results.  Clearly there are many prescribed ways to treat mental health issues in general and substance use disorders in particular. It is not clear to me how changing diagnoses in the DSM V will affect these prescribed treatments for prescribed disorders.

There is an alternative – practice based evidence. David J. Hellerstein, MD discusses this at http://www.medscape.com/viewarticle/575578. Rather than take evidence coming from academic work (with which there may be inherent problems and also problems applying it in the “real world”) we need to look at what works in actual practice.

Project MATCH was a rigorous study conducted by the federal government comparing Cognitive Behavioral Therapy, Motivational Enhancement Therapy, and Twelve Step Facilitation.  Information about the manuals can be found at http://pubs.niaaa.nih.gov/publications/match.htm.  What was found was that all three worked equally well.  The Cannabis Youth Treatment Study compared several methods of treatment (all of which included a combination of MET and CBT) and found similar results across methods. As Scott Miller, Barry Duncan, and others have pointed out, what matters most within the therapy itself for potential change is the therapeutic relationship. Duncan says that, “The notion, however, that any approach is better than another is indefensible in light of the evidence covered extensively throughout ‘The Heart and Soul of Change’ that support the outcome equivalence of the different models (the “dodo verdict”) as well as the relative influence of other factors than model and technique.” You can read all of his comments at http://heartandsoulofchange.com/uncategorized/evidence-based-practice-and-tf-cbt/.  You can also view the handout from a workshop by Scott on “What Works In Drug and Alcohol Treatment” at http://www.scottdmiller.com/uploadedFiles/What%20Works%20in%20D&A%20(steps%20in%20question%20format)%206pp%20ho%20short.pdf

The definition of evidence based practice includes measurement of progress.  Outcomes are very important to all involved in therapy from the therapist (to see how the work is going and to improve one’s work) to payers (such as insurance companies who may mandate evidence based practice) and most especially to those receiving therapy. One method of tracking progress that has been thoroughly researched are the Client Directed Outcome Informed measures – the Outcome Rating Scale and the Session Rating Scale. The former has the person rate how life is going in four categories. The latter has the individual rate the efficacy of the therapeutic relationship with the counselor in four areas. Both are quick and easy to administer and give extremely useful data on progress in counseling. They can be used with any theoretical approach to counseling. To me, these are essential tools in maintaining practice based evidence work.

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