what is best practice – is evidence based practice the answer? tor-johan ekeland professor, volda...
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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
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
Akureyri May 7-8 2009 TJE
Evidence based excitement:
Government Politicians Managers and payers Researchers Clinicians ?
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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
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The Logic of Evidence Based Practice
Research literature
Selection -filtering
Management
Clinical practice
Gold standard
Manuals
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Hanne Foss Hansen
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What is new and what is old? What is good and what is the problems?
Is ”evidence based” synonymous with scientific?
Evidence based practice
Akureyri May 7-8 2009 TJE
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
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Archibald Leman Cochrane (1909 - 1988)
Can it work? Does it work in
practice? Is it worth it?
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……but:
Why does it work?
EBP is a kind of empirical pragmatism…..
May foster pseudoscience…………
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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?
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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
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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)
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“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).
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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”
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
Thank you!
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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
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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:
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
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
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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)
Akureyri May 7-8 2009 TJE
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)
Akureyri May 7-8 2009 TJE
«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)
Akureyri May 7-8 2009 TJE
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)
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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)
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
Konklusjon på behandlingsforskinga
Frå behandling
Til
Samhandling
Frå
Det andre (sjukdomen)
Til
Den andre (den sjuke personen)
Akureyri May 7-8 2009 TJE
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)
Akureyri May 7-8 2009 TJE
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)
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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
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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.
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
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....)
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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
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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)
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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).
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
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
Akureyri May 7-8 2009 TJE
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.
Akureyri May 7-8 2009 TJE
How to Improve by 65%:Pop QuizHow to Improve by 65%:Pop Quiz
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
Akureyri May 7-8 2009 TJE
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.
Akureyri May 7-8 2009 TJE
Old and new heroes
Emil Kraepelin (1856-1926)
Sigmund Freud
(1856-1939)
That other• Objectification• Explain• causality• Treatment
The other• Subjectification• Understand• Intentionality• Cooperation
Akureyri May 7-8 2009 TJE
• 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.
Akureyri May 7-8 2009 TJE
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) ,