Last week I attended the semiannual member meeting of the Software and Technology Vendor Association (SATVA), the trade association I have mentioned in the past. At lunch, I sat at a table with Don Hevey, the President/CEO of MHCA, described as “an alliance of select organizations that provide behavioral health services.” Their members are some of the largest community mental health centers in the country. We were talking about accountability and evidence based practices and Don mentioned a statistic from the American Medical Informatics Association and quoted in the American Psychological Association’s Monitor on Psychology
that it takes as long as 17 years for research findings to enter medical or mental health practice, and even then, only a fraction makes it in.
One of the others at the table (MHCA chair Tony Kopera, Ph.D.) indicated that part of the problem in mental health is that treatment protocols are often designed for and tested on those with a unitary diagnosis and relatively stable lives. This does not match the real world, community behavioral health center situation where many of the seriously mentally ill carry multiple diagnoses and may bounce from group home to the street to jail to hospital and back again.
The American Psychological Association has begun a science/practice collaboration for the purpose of creating treatment guidelines. Since the U.S. healthcare system has begun a significant focus on accountability, “providers need to show insurers and policymakers that their treatments provide good outcomes for patients” according to Katherine Nordal, Ph.D., executive director of APA’s Practice Directorate.
A treatment guideline won’t be a one-size-fits-all cookbook approach, she emphasized. Instead, a guideline will serve as a decision-making aid to help a practitioner decide the best possible course of care for a particular patient, combining clinical judgment, the best available research, and the patient’s individual characteristics and preferences. Longterm, clinical treatment guidelines can help improve patient care by identifying gaps in research and treatment where more work is needed to develop effective interventions.
I was interested to see that only one of the members of the APA treatment guidelines committee is a private practitioner; another member is with the VA. All others are academician/researchers. While this composition favors quality science, it runs the risk of overlooking real-world needs.
There are researchers who focus their attention on dissemination as well as implementation of the science that already exists. The APA has recently run multiple articles on this new field.
Until we figure out effective strategies to get evidence-based practices integrated so they can help people, they’re not much better than a nice publication,” says the National Institute of Mental Health’s David Chambers, DPhil, who directs the institute’s dissemination and implementation research arm.
Getting research into the real world, by Tori Deangelis, is an excellent examination of the resources and the challenges. DeAngelis quotes Dr. Gregory Aarons:
“Our job isn’t just to create new knowledge, it’s to improve the health-care delivery system,” he says. “Sometimes that means proceeding with the best available information and learning from experience, even though we’d prefer to wait for something a lot more definitive.”
While dissemination and implementation science are multidisciplinary by nature, psychologists with strong research backgrounds and an interest in systems change have much to contribute, adds psychologist Gregory Aarons, PhD, an implementation researcher and associate professor at the University of California, San Diego.
And in Evidence-based psychology in action, DeAngelis reports on an implementation of evidence-based practice in a community program utilizing a structured framework for this implementation.
The challenges of incorporating evidence-based practices (EBPs) into clinical practice has resulted in a whole field called implementation science. The National Implementation Research Network has as its goal “to close the gap between science and service by improving the science and practice of implementation in relation to evidence-based programs and practices. I can imagine this discipline becoming a major field as we attempt to control the costs of health care.
Resources abound. The US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) maintains web resources aimed at dissemination of evidence-based practices, including those for mental health. The Substance Abuse & Mental Health Services Administration (SAMHSA) has long provided access to research and protocols for EBPs.
One of my biggest concerns about possible future mandates for the use of evidence-based practices is the challenge of getting treatments from paper to practice. Implementation science may help.
How is your organization proceding in adopting EBPs? Do you see a role for behavioral health specialists in implementation? What do you think about how we will get there? Please enter your comments below.
Ann Aukamp says:
Evidenced based practices are way too simplistic to work with the population I serve. I have been grateful that this movement is not yet gaining a lot of traction, for all the reasons you cite. My main specialty is trauma. Thankfully I do have the back-up of Treatment Guidelines for the Treatment of Trauma & Dissociation issued and reviewed periodically by a peer reviewed committee of the International Society for the Study of Trauma and Dissociation. Bethany Brand, PhD is also carrying out a longterm outcome study of member therapists’ work with selected Dissociative Identity Disorder patients. Her study includes rather extensive questionnaires that are completed and submitted by the patients as well, giving information about the therapist/patient pairing and interactions.
In addition, I notice that the November 2010 issue of Scientific American is carrying an article about the benefits of psychodynamic therapy, which has not generally been one of the ‘evidence-based treatments.’ Psychodynamic therapy, as probably most of us know is really hard to manualize or empirically validate, but its inherent component, the relationship, has been generally agreed to be a seriously significant component to the success or failure of any treatment modality.
I provide this information in hopes that it will help others who are trying to document why they are not using the more narrow empirically validated treatments. I think a better way to measure treatment success is to look at functional gains that patients make while in treatment. This is not as clean as a controlled study obviously, but if you take a broad enough sample, and enough of them make gains in Activities of Daily Living, one certainly could conclude that the therapy had something to do with the outcomes.
Kathy says:
Thanks for your comment, Ann. I wonder how one might measure the relationship? Operationalizing something that is so ephemeral yet crucial is a challenge. I practiced for years using Cognitive Behavioral Therapy as the basis of the practice, but using the manualized methods was very difficult and strongly resisted by some clients. My Feminist Therapy underpinnings always pushed me to use what the client needed at the moment . . . and that was not always what the protocol might have indicated. Thank you for sharing your experience.