TIPS & TOPICS
Volume 5, No.4
In this issue
— SHAMELESS SELLING
— Until Next Time
Welcome to a combined July-August edition of TIPS and TOPICS (TNT). In August I am leaving the warmth of summer in California to enjoy family and friends in wintry Australia.
Glossary of abbreviations used:
APA: American Psychological Association
ASI: Addiction Severity Index
EBP: Evidence-Based Practice
EBT: Evidence-Based Treatment
FDA: Food and Drug Administration
MI: Motivational Interviewing
NREPP: National Registry of Evidence-based Programs and Practices
SAMSHA: Substance Abuse and Mental Health Services Administration
TNT: Tips & Topics ezine
TTM: Transtheoretical Model of Change
I hesitated about devoting this TNT to a focus on EBP as there are so many mixed feelings about EBPs or EBTs. With current pressures in some states to pay only for EBTs, there is even more documentation required to verify a clinicians’ fidelity to these practices. It makes sense to serve clients with therapies, medications and services that have demonstrated efficacy, but as has been observed by William Miller and associates, “perhaps the proper attitude toward EBTs is one of respect not reverence.” (Miller, Zweben & Johnson, 2005).
About two years ago when the NREPP, a service of SAMHSA, sought comments from the field, I responded in part: “The assumption is that if you train everyone, for example, in Motivational Interviewing, Cognitive Behavioral Treatment, Twelve Step Facilitation, Integrated Dual Disorders Treatment etc, that this translates directly into improved outcomes. Without direct, formal client feedback with proximal outcomes that can modify treatment in real time, EBPs are in danger of just creating “new religions” and ideologies in treatment programs.”
Part of my hesitation to focus on EBPs was that I don’t feel expert to provide all the nuanced research arguments for and against EBPs. Also, I don’t want to be misunderstood to sound like I am saying EBPs should be ignored, and have no validity or use. Actually in SKILLS below, I suggest how to use EBPs in your clinical work. However the more I understand about EBPs, especially in behavioral health versus medical settings, the more I am concerned that we place more time, energy and resources on models of treatment to the detriment of focusing on what contributes much more to improved treatment outcomes.
Some may know the electronic discussion listserv, Co-Occurring Dialogues, which specifically focuses on issues related to dual diagnosis. Recently there was a discussion on EBPs and the relative importance of the therapeutic relationship in treatment outcome. I am sharing excerpts from the posts of two people who know much more about this than me. Underlining is mine.
- “None of the approaches identified as evidence-based have been tested against and proven superior to any approach intended to help.”
Listserv Posting #1
“Our group (www.talkingcure.com) treats all approaches that claim superior results the same way. Specifically, we repeat in print and on the web that there is no evidence that any approach achieves superior results to any other bona fide treatment approach-that is, a model that is intended to be therapeutic. Some readers may not know, but none of the approaches identified as evidence-based have been tested against and proven superior to any approach intended to help. None. It’s staggering when you think about it, especially when you consider the massive amount of money and regulation going into the evidence-based practice movement. Of course, every model claims that fidelity to the approach is required. And, by the way, states like Oregon are in the process of establishing regulations to insure that clinicians not only say they are practicing a particular model but prove via paperwork, etc. that the particular model is being conducted according to the manual.
Admittedly, all of this would make sense if there was any evidence that the various evidence-based models contained specific ingredients that if left out would lead to poor outcomes. But the data say no. Indeed, in his massive review of the literature on the subject (“The Great Psychotherapy Debate”), Bruce Wampold states, “30 years of research has failed to provide a scintilla of evidence that any specific ingredient is necessary—-” (p.204).
Instead of focusing on factors long known to affect treatment outcome-for example, the therapeutic alliance, the therapist, and the formal use of client feedback to guide service planning, delivery, and evaluation-the field continues to devote precious time and scarce resources to promulgating lists of approved treatment models-something which existing evidence shows contributes at most 1-2% to the variability in outcome. For the record, our team has never said that the therapeutic relationship is the only important variable in psychological treatments. It is, however, the most evidence-based finding in the literature, with over 1000 findings published to date. Study after study show that it contributes 4-8 times more to treatment outcome than treatment approach. As such, its absence in most professional discourse and the EBP movement is nothing short of stunning.
The standard applied to giving “evidence-based” status is the same as that used by the Food and Drug Administration (FDA) to approve new drugs; namely, to be identified as an EBP, a new treatment approach had to achieve outcomes equivalent or superior to an established treatment in two studies. Two studies. The problems associated with drawing conclusions from studies meeting this standard have been discussed in detail elsewhere and are too numerous to review here. Anyone interested, can click on the link (http://www.talkingcure.com/reference.asp? id=66) and download any of the articles we’ve written on the subject from our website (for starters, read Losing Faith, and then read the EBP talking points).
The APA has just officially changed the definition of EBP in response to critiques offered by our group and many others. The report, which appeared in the May- June 2006 issue of the American Psychologist, represents a major move forward and away from the overly simplistic and medicalized idea of “specific treatments for specific disorders” popular among proponents of EBP.
Instead, clinicians are encouraged to consider all the evidence in the context of client culture, preferences, and perceived benefit from services. To this, we say, “Bravo!” and “It’s about time!” Indeed, for the last decade, we’ve been advocating that clinicians use the best evidence tempered by the preferences and response of the client. As clients and practitioners know, the real challenge in treatment is not figuring out what works for drug addicts or the borderline-diagnosed clients in general, but rather what will work for THIS person seated in this office on this day at this stage in their recovery. You know, we wrote an article about working this way called, “Making Treatment Count’ which can be downloaded from the website.
Scott D. Miller, Ph.D.
Co-director, Institute for the Study of Therapeutic Change. Chicago, IL
- “Mandating use of a given treatment manual is not likely to produce the desired goal of improving treatment in real life settings.”
Listserv Posting #2
“Having looked at the “evidence” supporting some of the programs being pushed by the feds, the evidence is less than impressive. Some of the findings do not seem to be that superior to those we found during the 1980s and 1990s – the difference is that the proponents of the “practices” got federal funding to document results under controlled situations rather than routine monitoring of outcomes in standard practice.
As Scott pointed out, the “method” of the treatment is only one component – and often not the major one – in accounting for the observed treatment outcomes. The failure to find consistent superior outcomes for any given approach was well publicized by Project MATCH and as Scott pointed out by many other impartial studies.
That states would mandate following a given treatment manual seems similar to the mandates for using the Addiction Severity Index (ASI) as an intake instrument – a function for which the ASI is not suited and was not designed for. Those mandates resulted in a lot of wasted time and related costs on the part of the treatment programs and probably frustrations on the part of clients without contributing much to either the clinical assessment or treatment process. Mandating use of a given treatment manual is not likely to produce the desired goal of improving treatment in real life settings.
If federal and state agencies are really interested in the effectiveness of treatment, they should fund routine monitoring of outcomes as Minnesota (MN) did years ago. In the MN evaluations, providers collected baseline data and an independent contractor paid by the state did the outcome monitoring. The state agency then did the analyses of matching baseline to outcomes, which allowed them to consider differential case-mix prognostic indications.
Another alternative is one Florida explored with Abt Associates of Cambridge, Massachusetts where public databases with unique identifiers (e.g., arrest records, Medicaid utilization, etc.) were merged with the treatment records to get indications of whether different treatment programs were able to demonstrate changes on tangible indications of treatment impacts (e.g., reductions in arrests and medical care utilization). Given appropriately designed reporting data from treatment programs, case-mix could also be considered in this type of analyses.
There is a big difference between outcomes-based treatment strategies and evidence-based ones. The former requires using outcomes in real life and real time to help refine treatment and improve results. The latter just means that someone did a study to document good results and then expects the same results given fidelity to the protocol.
“Treatment is more than following a manual.”
And in a follow-up message here’s the bottom line:
I think the key points regarding EBP are the following:
1. Even if it works with skilled clinicians or clinicians under tight supervision, it might not work as well in uncontrolled settings.
2. When mandating only a few EBPs, such mandates limit innovation and what might be developed that could even be better.
3. The better approach is an outcomes-based one with routine monitoring of results regardless of the model. If it works – OK; if it doesn’t, then changes are required.
On this last point, who would want to invest in a company where there was no accounting system to keep track of results – profit or loss?
Norman G. Hoffmann, Ph.D.
Evince Clinical Assessments
References and Resources:
· Co-Occurring Dialogues is an Electronic Discussion List that specifically focuses on issues related to dual diagnosis. A subscription to the Co-Occurring Dialogues Discussion List is free and unrestricted and can be done simply by sending an e- mail to email@example.com.
· Evidenced Based Practice (EBP): Talking Points. Excerpted from: Duncan, B., & Miller, S. (2006) Treatment Manuals Do Not Improve Outcomes. In Norcorss, J., Levant, R., & Beutlre, L. (Eds) Evidence-based practices in mental health. Washington, D.C.: APA Press
· Miller, W.R., Zweben, J., Johnson, W.R. (2005): Evidence-based Treatment: Why what, where, when, and how? Journal of Substance Abuse Treatment. 29:267-276.
· Miller, S.D., Mee-Lee, D., Plum, B. & Hubble, M (2005): “Making Treatment Count: Client-Directed, Outcome Informed Clinical Work with Problem Drinkers.” In J. Lebow (ed.). Handbook of Clinical Family Therapy. New York: Wiley.
· National Registry of Evidence-based Programs and Practices (NREPP), Substance Abuse and Mental Health Services Administration (SAMHSA).
· Wampold, B.E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, New Jersey: Lawrence Erlbaum.
So what are we to do about EBPs?
Do we just forget them and focus only on therapeutic alliance and engagement of the client? No.
If you only have one tool in your toolkit, it is hard to be flexible to meet a variety of needs and situations. EBPs give you more tools in your clinical repertoire. This allows you to move nimbly onto another approach if outcomes in real time are poor.
- “Figure out what will work for THIS person seated in this office on this day at this stage in their recovery.”
–> In a client-directed approach, the clinician is committed to collaborating with the client about goals and strategies. That’s what a therpaeutic alliance encompasses. The fact is that clients self-manage and do what they want to do anyway . Unless you plan to live with the client and guide their every decision, at best we can just be consultants to their self-change process.
Carlo DiClemente reminds us that the Transtheoretical Model of Change (TTM) illuminates the process of natural recovery and the process of change involved in treatment-assisted change. But “treatment is an adjunct to self-change rather than the other way around.” “The perspective that takes natural change seriously—shifts the focus from an overemphasis on interventions and treatments and gives increased emphasis to the individual substance abuser, his and her developmental status, his and her values and experiences, the nature of the substance abuse and its connection with associated problems, and his or her stage of change.” (DiClemente, 2006)
(DiClemente CC (2006): “Natural Change and the Troublesome Use of Substances – A Life-Course Perspective” in “Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It” Ed. William R Miller and Kathleen M. Carroll. Guildford Press, New York, NY. pp 91; 95.)
–> By all means learn about EBPs and become proficient to use them confidently. Then you will have a greater variety of methods and techniques in your clinical toolkit. But don’t become too self-conscious over fidelity to a model. If you already have a natural and effective style which engages people in a good working alliance, don’t let an EBP mess that up. What you do need to be self-conscious about is whether the client is showing up and engaged with you; and whether he or she is getting better—-not whether you are doing a technique perfectly.
–> Figure out with the client what is working and what will work to reach the client’s goals. If the outcomes are good, keep doing what works. If the outcomes are poor, be ready and able to change quickly what you are doing. That’s where EBPs come in handy. They allow you to have a variety of tools on which to draw.
- Use Evidence Based Practices and Models and Techniques to Enhance Alliance, Engagement and Outcomes.
Take for example, Prochaska and DiClemente’s Stages of Change. Some have used this model to allocate tight resources to treat only those clients who are in the Preparation or Action stages of change (Ready to Change). They would label others as mere Precontemplators (in denial) eligible only for a few education sessions. Such “reverence” of a model allocates resources in a categorical manner for which the model was never designed.
–> Use EBPs like Motivational Interviewing and models like Stages of Change to help you stay person- focused, empathic and close to the client’s goals. You and your client create a mutually agreed-upon treatment plan. This will hold them accountable to get positive results, or examine how & why they are not.
–> Many clients are doing things like neglecting their children, using substances, and behaving impulsively and destructively. The urge to want to force a client to change is almost irresistible! It is so clear to us how the client is “driving towards the cliff”. You develop a recovery plan in which the client has no investment, and then marvel at their non-compliance.
–> As I have said before, if your client is non-compliant, don’t look at the pathology of the client; look at the lousiness of your treatment plan, because it is probably your plan, not the client’s. That’s when you use your EBP training on Motivational Interviewing and Stages of Change, to catch yourself hopefully.
–> Now we can accurately tune in empathically and observe ourselves: “Silly me, I’m at Action for anger management, parenting skills training and abstinence.” My client, however, is at Action for staying out of jail, or getting her children back, or keeping her job. She is at Precontemplation for anger management, parenting skills training and abstinence. I need to get where she is at, not have them struggle to be where I am at.
We “respect” the model to help us shift course whenever the outcomes are poor.
In the July 2 issue of TIME Magazine, there was a profile on Michael Chertoff, Department of Homeland Security Secretary. Apparently he is nearly alone among Bush Cabinet members in attending the Washington cocktail parties, and socializing with his opponents. He said it allows him “to make sure we’re not living in a tunnel”. That’s good – to be open to a variety of opinions and to gain a sense of perspective.
But I was even more interested in another benefit of mixing with his opponents where you can look them in the eye. “It’s harder to demonize somebody if you’ve gotten to know them as a person,” he said.
I have always been curious about the way people of good will, working hard to help others; can also act so dismissively and disrespectfully towards others who believe differently. Recovering counselors are suspicious of doctors who prescribe medications. Mental health clinicians think 12 Step-oriented counselors are religious zealots more interested in a Higher Power than higher education. Abstinence- oriented counselors reject harm reduction advocates and methadone treatment providers as dangerous enablers—and on and on. You pick your pet peeve about the other disciplines or program models you don’t like.
I suppose it is naïve and idealistic to think we could solve a lot of wars and conflicts if we could just look our opponents in the eye; and get to know them as a person. But it would go a long way towards tuning in empathically to the other person—Express Empathy. And that’s the first principle of the EBP of Motivational Interviewing.
Maybe there are good reasons for evidence-based practices after all!
It’s finally here!
Rush to buy the latest offering from Hazelden in their Clinical Innovators Series.
“Applying ASAM Placement Criteria” DVD and 104 page Manual with more detail based on the DVD with Continuing Education test (10 CE hrs), 75 minute DVD
David Mee-Lee (DVD) and Kathyleen M. Tomlin (DVD manual)
Don’t miss out—just like the iPhone—rush to get yours.
Click here for the Hazelden DVD
Until Next Time
I’m glad you could join us. See you in September.