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Evidence-based Practice is a Verb not a Noun

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Evidence-based practice (EBP).  What is it?  Take a look at the graphic above.  According to American Psychological Association and the Institute of Medicine, there are three components: (1) the best evidence; in combination with (2) individual clinical expertise; and consistent with (3) patient values and expectations.  Said another way, EBP is a verb.  Why then do so many treat it as a noun, continually linking the expression to the use of specific treatment approaches?  As just one example, check out guidelines published for the treatment of people with PTSD by the National Institute for Clinical Excellence (NICE)–the U.K.’s equivalent to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).  Despite the above noted definition, and the lack of evidence favoring one treatment over another, the NICE equates EBP with the use of specific treatment approaches and boldly recommends certain methods over others.

Not long ago, ICCE Senior Associate, and U.K.-based researcher and clinician, Bill Andrews, addressed the problems with the guidelines in a presentation to an audience of British practitioners.  He not only addresses the inconsistent use of the term, evidence-based practice, in the development of guidelines by governing bodies but also the actual research on PTSD.  After watching the clip, take some time to review the articles assembled below, which Bill cites during his presentation.  The main point here is that clinicians need not be afraid of EBP.  Instead, they need to insist that leaders and officials stick to the stated definition–a definition I’m perfectly content to live with mas are most practitioners I meet.  To wit, know what the evidence says “works,” use my expertise to translate such findings into practices that fit with the values, preferences, and expectations of the individual consumers I treat.

Click here to read the meta-analysis that started it all.  Don’t stop there, however, make sure and read the response to that study written by proponents of the NICE guideliness.  You’ll be completely up-to-date if you finish with our response to that critique.

Whoa Nellie! A 25 Million Dollar Study of Treatments for PTSD

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I have in my hand a frayed and yellowed copy of observations once made by a well known trainer of horses. The trainer’s simple message for leading a productive and successful professional life was, “If the horse you’re riding dies, get off.”

You would think the advice straightforward enough for all to understand and benefit.  And yet, the trainer pointed out, “many professionals don’t always follow it.”  Instead, they choose from an array of alternatives, including:

  1. Buying a strong whip
  2. Switching riders
  3. Moving the dead horse to a new location
  4. Riding the dead horse for longer periods of time
  5. Saying things like, “This is the way we’ve always ridden the horse.”
  6. Appointing a committee to study the horse
  7. Arranging to visit other sites where they ride dead horses more efficiently
  8. Increasing the standards for riding dead horses
  9. Creating a test for measuring our riding ability
  10. Complaining about how the state of the horse the days
  11. Coming up with new styles of riding
  12. Blaming the horse’s parents as the problem is often in the breeding.
When it comes to the treatment of post traumatic stress disorder, it appears the Department of Defense is applying all of the above.  Recently, the DoD awarded the largest grant ever awarded to “discover the best treatments for combat-related post-traumatic stress disorder” (APA Monitor).  Beneficiaries of the award were naturally ecstatic, stating “The DoD has never put this amount of money to this before.”
Missing from the announcements was any mention of research which clearly shows no difference in outcome between approaches intended to be therapeutic—including, the two approaches chosen for comparison in the DoD study!  In June 2008, researchers Benish, Imel, and Wampold, conducted a meta-analysis of all studies in which two or more treatment approaches were directly compared.  The authors conclude, “Given the lack of differential efficacy between treatments, it seems scientifically questionable to recommend one particular treatment over others that appear to be of comparable effectiveness. . . .keeping patients in treatment would appear to be more important in achieving desired outcomes than would prescribing a particular type of psychotherapy” (p. 755).
Ah yes, the horse is dead, but proponents of “specific treatments for specific disorders” ride on.  You can hear their rallying cry, “we will find a more efficient and effective way to ride this dead horse!” My advice? Simple: let’s get off this dead horse. There are any number of effective treatments for PTSD.  The challenge is decidedly not figuring out which one is best for all but rather “what works” for the individual. In these recessionary times, I can think of far better ways to spend 25 million than on another “horse race” between competing therapeutic approaches.  Evidence based methods exist for assessing and adjusting both the “fit and effect” of clinical services—the methods described, for instance, in the scholarly publications sections of my website.  Such methods have been found to improve both outcome and retention by as much as 65%.  What will happen? Though I’m hopeful, I must say that the temptation to stay on the horse you chose at the outset of the race is a strong one.