As I have often discuss in this blog, modality-or type of therapy-adds little to clinical outcomes with clients. For example, Orlinsky's ground breaking research demonstrated that type of therapy only accounts for 0.3 per cent of outcomes. The common factors of therapy are much more important. This includes the ability to form a working alliance, inure hope and develop optimism in the capacity for change. This is not to say we do not need therapeutic models. We need ways to establish rapport, set goals and participate in tasks to achieve them. When the model matches the clients world view results follow, regardless of which modality is being deployed. So, sometimes a narrow focus on modality means we invest in areas of practice the contribute the least outcome gains for the client. A recent study of evidence based practice-where practitioners must deliver treatment in accordance to established protocols-explored the impact of providing high fidelity evidence based modalities. What was the result?
A new study from Penn Medicine and Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) shows that, unfortunately, evidence-based therapies to treat youth with mental health problems are slow to catch on. Specifically, researchers found that over a five-year period in Philadelphia, use of evidence-based therapies -- practices backed by scientific data showing that symptoms improve in response to treatment, such as cognitive behavioral therapy (CBT) -- increased only modestly, despite the city and researchers' substantial efforts to showcase the value of these approaches and to provide training to community clinicians. The results were published this month in Implementation Science.
This finding is of critical importance because clinicians who use evidence-based practices (EBPs) as part of their routine care obtain much better outcomes for children with depression, anxiety, trauma, and disruptive behavior disorders compared with clinicians who do not.
"Evidenced-based therapies are effective for treating a wide range of psychiatric conditions, but there is still a gap in widespread use," said the study's lead author Rinad S. Beidas, PhD, an associate professor of Psychiatry and Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania, and founding director of the Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI). "While findings showed a modest increase in use, the data point to a clear need for finding better ways to support clinicians and organizations in using EBP therapies. This research-to-practice gap is a historically intractable problem, which exists not only in behavioral health but all across health care specialties."
Researchers identified two factors driving the observed increases of EBP implementation in publicly funded clinics that could inform future strategies to increase EBP use. First, the more city-sponsored EBP trainings clinicians attended, the more likely they were to apply evidence-based techniques in their practices. Second, use of EBP was more likely among clinicians who worked in a practice with a "proficient culture," meaning the organization expects clinicians to place the well-being of their clients first, to be competent, and have up-to-date knowledge.
Over the last decade, cities from Philadelphia to Los Angeles have placed an increased emphasis on implementing EBP into care, from building EBPs into contracts to initiating new policies that support their use in an effort to help improve outcomes for vulnerable youth. In 2007, Philadelphia's DBHIDS began large-scale efforts to increase EBP use. The department created the Evidence-based Practice and Innovation Center (EPIC) in 2013, a city-wide entity intended to provide a centralized infrastructure to support EBP administration. Despite a national focus on EBP use, very few EBP implementation efforts around the country have been systematically and rigorously evaluated, which ultimately limits the ability to understand the effects of said efforts.
The researchers surveyed clinicians from 20 different publicly funded Philadelphia clinics that treat youth at three different points from 2013 to 2017. Sixty percent of the 340 clinicians contacted completed the survey. All of the clinics had the opportunity to receive system-level support provided by EPIC, but only half of the clinicians participated in city-funded, EBP training initiatives. On average, use of CBT techniques increased by six percent from the first data collection to the last, compared to no change in psychodynamic techniques, a frequently used type of "talk therapy" that has less evidence of effectiveness in children. The researchers also found that each EBP training initiative predicted a three percent increase in CBT use, but no change in use of psychodynamic techniques. In organizations described as having a more "proficient" culture at the beginning of the survey, clinicians exhibited an eight percent increase in CBT use, compared with a two percent decrease in organizations with less proficient cultures.
"Philadelphia is a leader in making EBP available to its most vulnerable citizens with mental health and substance abuse problems. This study represents an opportunity to learn from an exemplar system encouraging EBP implementation," Beidas said. "To build upon Philadelphia's and other cities' deep commitment to increasing this implementation, we need further studies to test and evaluate strategies that increase use of EBP to guide our understanding of the best ways to use and how to implement them."
Materials provided by University of Pennsylvania School of Medicine.
Rinad S. Beidas, Nathaniel J. Williams, Emily M. Becker-Haimes, Gregory A. Aarons, Frances K. Barg, Arthur C. Evans, Kamilah Jackson, David Jones, Trevor Hadley, Kimberly Hoagwood, Steven C. Marcus, Geoffrey Neimark, Ronnie M. Rubin, Sonja K. Schoenwald, Danielle R. Adams, Lucia M. Walsh, Kelly Zentgraf, David S. Mandell. A repeated cross-sectional study of clinicians’ use of psychotherapy techniques during 5 years of a system-wide effort to implement evidence-based practices in Philadelphia. Implementation Science, 2019; 14 (1) DOI: 10.1186/s13012-019-0912-4