Life-Line Annual Community Luncheon

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Life-Line Annual Community Luncheon The New
Evidenced-Based Practice
Ellen Behrens, Ph.D. Ellen_at_canyonrc.com
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Outline

• the new evidence-based practice (EBP)
• 2. NEW EBPs for intensive adolescent care

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Proponents of EBP

• Promoted by federal policy authorities
• -National Advisory Mental Health Council
  Workgroup on Child and Adolescent Mental Health,
  2001
• -Presidents New Freedom Commission on Mental
  Health 2003
• -Department of Health and Human Services, 1999
• Implemented at
• -National Institute of Mental Health,
• -Substance Abuse and Mental Health Service
  Administration,
• -Medicare and Medicaid,
• -most state mental health authorities
• (Panzano Herman, 2005).

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Goal of EBP RECOVERY

• What is the way to the goal?
• Originally narrow focus research supported
  interventions. Empirical position.
• Now broader focus interventions AND broad
  factors that are research supported, clinically
  informed, and matched to client. Contextual
  Position.

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Old EBP in Mental Health Care

• Paid relatively little attention to the role of
  the client and therapist
• Focused on evidence

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Hierarchy of Evidence
Effective Solid research
Level 1
Assumption was that only Level 1s (or 2s) were
legitimately EBP.
Level 2 Probably Effective good preliminary
research

• Level 3
• Possibly Effective
• Isolated research studies, anecdote, standard
  practice, individual opinion .

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Lists of Level 1 interventions were the primary
focus
SAMHSA http//www.modelprograms.samhsa.gov/templa
te_cf.cfm?pagemodel_list Office of Juvenile
Justice and Delinquency Prevention (OJJDP) and
Center for Substance Abuse Prevention http//www.s
trengtheningfamilies.org/html/programs_1999/progra
ms_list_1999.html
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Lists of Level 1 interventions werethe primary
focus

• Cochrane Library http//www.update-software.com/
  cochrane/
• British Medical Association http//www.clinicalevi
  dence.com/ceweb/conditions/index jsp.
• APA http//www.apa.org/divisions/div12/rev_est/ind
  ex.html

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Level 1s worksort of

• Meta-analytic reviews show EBPs outperformed
  usual care.
• However, the magnitude of the differences are in
  the small to medium range.
• What does that mean?

Weisz, J.R. et al., 2006, Evidence-Based Youth
Psychotherapies Versus Usual Clinical Care A
Meta-Analysis of Direct Comparisons. American
Psychologist, 61, 671689.
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New evidence-based practice?

• 1. 3-legged stool
• EBP is a process of blending 3 factors
• Research
• Care Provider
• Client
• Research evidence for interventions is necessary,
  but not sufficient.
• The integration of the best available research
  evidence with clinical expertise in the context
  of patient characteristics, culture, and
  preferences. (APA Task Force on Evidence-Based
  Practice, 2006).

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3 Legged Stool

• Client factors expectations, readiness for
  change, active effort, and problem severity (25
  of the variation in outcomes)
• Therapist factors Personal attributes (e.g.,
  flexibility, honesty, respectfulness,
  trustworthiness, confidence, warmth),
  professional judgment and expertise (10 of the
  variation in outcomes)
• Therapeutic relationship
• (10 of the variation in outcomes)

Emerging Level 1

• Norcross, J.C., Lambert, M.J. (2006). In
  Norcross, J.C., Beutler, L.E., Levant, R.F.
  (Eds.), Evidence-based practice in mental health
  Debate and dialogue on the fundamental questions.
  

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Therapeutic Relationship

• Critical factors appear to be
• Instilling hope
• Sense of mastery/success
• Feeling understood
• Empathy
• Rapport with therapist
• Confronting the problem
• Support

Bergin Lambert, 1994 Weinberger, 1995
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New EBP

• 2. Common factors
• Looks beyond research supported interventions and
  manualized treatment programs,
• common factors can predict positive outcomes
  and can be Level 1

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Common Factors

• Vast bodies of research show that adolescent
  mental health substance abuse care is optimal
  when treatment is individualized and when
• community,
• education, and
• family resources are integrated.
• These are common factors in programs like
  Multi-systemic therapy, case management, and
  wrap-around.

• Confer SAMHSA, NIMH, Presidents New Freedom
  Commission, OJJDP, etc.

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Common Factors

• Community-based
• Family-based
• Individualized treatment
• Research supported interventions

Henggeler, S.W. (2006). Juvenile Drug Court
Enhancing Outcomes by Integrating Evidence-Based
Treatments. Journal of Consulting and Clinical
Psychology,74, 4254 Transforming Mental Health
Care for Children and Their Families, Huang, L,
et al., 2005, American Psychologist, 60, 615627
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Why do common factors work?

• Youth do not necessarily generalize learning
  from intensive treatment to more normalized
  settings unless they have ample opportunity to
  practice new skills in their day-to-day contexts
  (i.e., school, work, peer groups, church,
  family), especially because those contexts are
  often the determinants of clinical problems.

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Common Factors

• Outcomes with Family- Community-Focused mental
  health treatment
• Juvenile Justice Reduced re-arrest rates
  long-term
• Family Improved functioning, Reduced
  out-of-home placements
• Education Improved performance
• Therapy High retention rates
• Youth Decreased externalizing, oppositional
  behaviors, substance use

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Community-Based Treatment
Improve outcomes? Comprehensively address the
known determinants of clinical problems
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Spiritual Community

• Research
• New (1990s) and growing
• Reviews conclude that spirituality is associated
  with improved sobriety and mental health and
  physical health (Level 2?) (Larimore, Parker,
  Crowther, 2002)

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Educational Community

• school connectedness belief by students that
  adults in the school care,
• is positively related to academic, behavioral,
  and social success in school (Blum Libbey,
  2004 McNeely, Nonnemaker, Blum, 2002).

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Peer Community
Longitudinal studies on the development of
adolescent problem behavior provide compelling
evidence that such behavior is embedded within
the peer group Deviancy Training (Dishion et
al., 1999) deviant talk is a tool high-risk youth
use to formulate and establish friendship
networks, during adolescence
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Juvenile Justice Community

• adult drug courts research found close
  collaboration of criminal justice professionals
  and treatment providers has positive outcomes
  (i.e., retention in treatment, closer and
  comprehensive supervision, reduces substance use,
  produces cost savings).
• treatment promoted by some juvenile drug courts
  are intended to address an array of the
  correlates of adolescent substance abuse
• (Belenko, 2001 Parnham Wright, 1998)

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Mental Health Community

• Outcomes are maximized when youth are not
  required to navigate numerous mental health
  systems -- when they experience a seamless
  continuum of care.
• All providers, past, present, future, are
  integrated.
• Progress from more to less restrictive care
  matched for readiness.
• Levels of care are part of a larger treatment
  program that operates in an integrated manner.

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Common Factors only work.

• when they work together.
• Integrated services are EBP.

Drake et al.,2001
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Family-Based Treatment
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• Paradigm shift

Remove from family
Restore the family
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Family involvement is a strong predictor of
outcomes

• Parent-focused interventions
• more effective than child-focused programs
• are the most extensively tested and supported
  form of treatment for conduct problems, substance
  abuse, and mental health problems such as ADHD,
  anxiety, and depression.
• quality?
• parents as partners
• collaborate in entire process

(Huan et al., 2005 Kumpher, 1999 Sunseri, 2004).
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Level 1 Family therapies
Common Therapeutic Mechanisms Alliance
Negativity reduction Reattribution
(reframing) Competency development (parenting,
communication etc) Common Programmatic
Aspects Articulate the therapeutic
process Structured yet clinically responsive
relationally sensitive Integrated into overall
program Sexton, Hollimon, Mease, 2002
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• Families, in their many forms and structures,
  are openly, actively and respectfully included in
  all aspects of their childs treatment
  experience. They are assumed to have strengths,
  to be capable of growing and responding to their
  challenges in a positive manner, and to be
  involved in their childs treatment plan.

Self-Study Guide, Treatment Improvement (2004)
Reclaiming Futures National Program Office
Graduate School of Social Work.
www.reclaimingfutures.org/documents/treatment_guid
e.pdf Based on U.S. Department of Justice,
Office of Justice Programs (OJP), Promising
Strategies to Reduce Substance Abuse. National
Council for Juvenile and Family Court Judges
Curriculum, Effective and Innovative Approaches
to Adolescent Substance Abuse Treatment.
National Institute of Drug Abuse (NIDA),
Principles of Effective Treatment A Research
Based Guide.
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Take Home Message

• In the new EBP, research supported
  interventions are necessary, but not sufficient,
• For EBP to be sufficient it must
• be a 3 legged stool (client, therapist,
  relationship),
• be Family-focused and Community-focused

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Recommended Reading

• Psychiatric Clinics of North America 13 (2) 2004,
  13 (4) 2004, 14 (2) 2005. http//www.psych.theclin
  ics.com/
• Special Issues devoted to Evidence-Based
  Practices Residential Treatment Excellent
  primers. Each 41
• What Works for Whom? A Critical Review of
  Treatments for Children and Adolescents. Fonagy
  et. al., (2002). 30
• Evidence-Based Psychotherapies for Children and
  Adolescents. Kazdin Weisz, Eds. (2003).
• order at http//www.guilford.com/cgibin/cartsc
  ript.cgi?pagepr/fonagy.htmdirpp/cpapcart_id57
  9565.22624