Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care - summary of an article in American psychologist

Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care
American Psychologist, 63, 146-159.

Introduction  

A central issue is the extent to which findings from research can be applied to clinical practice.

Empirically support or evidence-based treatment (EBT) refers to the interventions or techniques that have produced therapeutic change in controlled trials. Evidence-based practice (EBP) is a broader tem and refers to clinical practice that is informed by evidence about interventions, clinical expertise, and patient needs, values, and preferences and their integration in decision making about individual care.

Evidence-based treatments and clinical practice: illustrative concerns

Concerns about evidence-based treatments

An concern about EBTs is that key conditions and characteristics of treatment research depart markedly from those in clinical practice and bring into question how and whether to generalize the results to practice.

Another concern about research in psychotherapy pertains to the focus on symptoms and disorders as the primary way of identifying participants and evaluation treatment outcomes. In clinical practice, much of psychotherapy is not about reaching a destination (eliminating symptoms), but it is about the ride (the process of coping with life). Psychotherapy research rarely addresses the broader focus of coping with multiple stressors and negotiating the difficult shoals of life, both of which are aided by speaking with a trained professional.

There are concerns about the methods of analysis or the results among several studies. They question whether these are satisfactory bases for concluding that treatment is effective or efficacious. These concerns are: 1) Conclusions about treatment that are based on studies showing statistical differences are difficult to translate into effects on the lives of participants in the study, let alone generalize to patients seen in practice. 2) The outcome measures in most psychotherapy studies raise fundamental concerns. Changes on rating scales are difficult to translate into changes in everyday life. Many valid and reliable measures of psychotherapy are ‘arbitrary metrics’, we do not know how changes on standardized measures translate to functioning in everyday life. 3) Typically, in a single study, multiple measures are used to evaluate outcome, and only some of these show that the treatment and control conditions are statistically different. An EBT may have support for its effects, but within individual studies and among multiple studies, the results are often mixed.

There are inherent limitations in the ways EBTs are discussed. Large segments of the literature usually are grouped together.

A central concern about EMBTs involves the generalization of the results form controlled research to clinical practice.

Concerns about clinical practice

There is a concern about clinical decision making, judgment, and expertise as a guide to individual treatment. EBP consists of integrating evidence, clinical expertise, and patient considerations and then making a judgment of what to do. Clinical judgment as a way of integrating information has not fared well over decades of evaluation. Many critical clinical issues and concerns are not heavily researched.

The results form a controlled trial may not generalize to patients because of differences in recruitment and patient characteristics. It is not clear on what basis the therapist can generalize form a prior client to several prior clients. If we assume that every patient is different, in ways that influence treatment decisions,, then there is a problem in knowing how to make a decision that is well based and defensible. Moderators, whether identified from research or clinical experience, are a set of variables related to an outcome but not invariably related to outcome in any individual case.

The way cases are evaluated in clinical work raises an important assessment issue. Patient progress is often evaluated on the basis of clinician impressions, as opposed to systematic observations using validated measures. Without systematic measures, the reliability, validity, and replicability of results in clinical work are easily challenged. The absence of systematic assessment raises many obstacles to making claims about what happens in therapy and the accumulation of knowledge.

An additional concern is the proliferation of new treatments. The majority of treatments have never been studied, nor are they based on a theory.

General comments

Concerns about the research-practice split often can be reduced to empirical questions about treatment.

Rapprochement: refocusing research and practice on patient care

Three shifts in emphasis are: 1) Optimally develop the knowledge base. 2) Provide the best information to improve patient care. 3) Materially reduce the divide between research and practice

Psychotherapy research

The shifts include giving greater priority to the study of mechanisms of therapeutic change, the study of moderators of change in ways that can be better translated to clinical practice and qualitative research.

Study of mechanisms of change

Understanding mechanisms may well be the best long-term investment for improving clinical practice and patient care. These are the processes that explain why therapy works or how it produces change.

Two constraints have limited the identification of mechanisms in psychotherapy research are: 1) Studies rarely establish the timeline. 2) Studies do not explain how the process unfolds to alter patient functioning, how the process moves along a pathway that directly affects a particular outcome or set of outcomes.

Knowing critical factors of treatment and the processes through which they operate can optimize therapeutic change.

Study of moderators and translation to clinical care

Moderators are those characteristics that influence the intervention-outcome relation.

Two problems that make the translation of research to practice difficult are: 1) the ways in which moderators are studied and reported. 2) not knowing how the moderator works across multiple conditions or treatments.

It isn’t clear what should be done with the finding.

Three changes would improve the research on moderators, improve patient care, and help bridge research and practice are: 1) it would be useful to report findings in a way that makes them applicable to clinical work 2) It would be helpful to know if a variable predicts (moderates) responsiveness to a particular treatment or to multiple treatments. 3) it would be helpful to understand what facet of the moderator is relevant or how the moderator works.

Qualitative research

Qualitative methods meets the desiderate of science, the methods are systematic, replicable and cumulative. The methods look at phenomena in ways that reveal many facets of human experience that the quantitative tradition has been partially designed to circumvent.

Qualitative research methods and their many variations are well suited to providing and understanding of the individual experience of patients, to codifying treatment changes, and doing so in replicable ways. It can also both test and generate conceptual models and specific hypothesis.

Clinical practice

Use of systematic measures to evaluate patient progress

Systematic evaluation is the use of psychological or other measures that have or in principle could have reliability and validity and provide replicable information about the status of patient functioning. Three reasons if this are: 1) To provide high-quality care, we do not have a guarantee of the result, not matter what the research or experimental base of the treatment(s) we use. 2) To monitor treatment effects in an ongoing way to make decisions about continuing, altering, or terminating treatment on the basis of how well the patient is doing 3) To complement clinical judgment.

Clinical practice can contribute uniquely to our knowledge base

Clinical work can contribute directly to the scientific knowledge base.

Direct collaborations

We need collaborations between colleagues who identify themselves as primarily form research and those who identify themselves as primarily form practice to evaluate clinical practice. A researcher-clinician collaboration that helped identify the circumstances in which judgement, expertise, and context are important would be helpful in patient care.

A line of direct bridging work would underscore the distinction between the technique and its methods of delivery.

Three ways to improve the outcomes of treatment are: 1) Identifying effective and the most effective interventions. 2) Understanding how and why an effective treatment works 3) Identify moderators of treatment