Currently, one of the most important areas in healthcare is accountability. As part of this movement toward accountability, the mental healthcare industry and their stakeholders tend to talk about Evidence Based Practices (EBP) as a way to link programs to desirable outcomes.
Evidence based practices can be found in multiple areas: from Education to Mental Health. And within mental health you can find them from medication (Kentucky Medication Algorithm; and Texas Medication Algorithm where the main goal is to use the medication that will create the best outcomes), to specific interventions or programs like Assertive Community Treatment (ACT) in adult individuals and Multi-systemic Therapy (MST) for youngsters; to specific illnesses like Schizophrenia and Bipolar disorder. Furthermore, the Substance Agency (SAMHSA) which supports most substance abuse and mental health funding at the Federal level, maintains and supports through funding multiple studies to determine and encourage the use of EBP throughout the country (go here to see what SAMHSA endorses) Professional organizations like the American Psychological Association, the American Psychiatric Association, as well as organizations for Occupational Therapy, Psychiatric Rehabilitation, Nursing , etcetera, endorse the use of EBP with their members. Insurance providers, Federal funded entities like the National Institute of Health and Consumer advocacy groups like NAMI fund or endorse Evidence Based Practices. In fact, Tanenbaum 2008 states that “EBP is a matter of mental health policy in USA” (page 699).
So what is the big deal about EBP? Why would we want to use EBP rather than other practices that are not considered EBP’s? The main reason has to do with the definition of EBP, and the rationale for the creation of EBP. There are multiple definitions for Evidence Based Practices (this is one); but most of them speak about interventions that are backed by empirical or scientific research. What that means for the individual on the receiving end is the certainty that what is being used is scientifically sound, and not just some unproven therapy, or, even worse, some form of quackery that will not deliver the expected outcomes on a regular basis.
If EBPs are the best thing since sliced bread, then why is there resistance to implement them? There are several issues associated with the implementation of EBP. One is related to the level of information regarding EBPs (who knows about them and how much). Evidence about consumers knowing or participating in decisions regarding services (in this case, EBP services) is usually limited. Tanenbaum, for example, found out that though consumers may be willing to use EBP, they are rarely consulted about the services they received (the decision is not up to them).
Another area is the science to service gap associated with research. There are multiple numbers being tossed around, but Druss 2005 speaks about a twenty year gap between scientific research and implementation in an applied setting. In that regard entities like SAMHSA are doing the best to help move research to practice. For example, SAMHSA instituted an award for centers that do their best to bridge that gap (MHCD received this award in 2009 for its Growth and Recovery Opportunities for Women (GROW) program).
Finally, there is also resistance from providers to implement EBP for multiple reasons: From need for new training, to expense, to the importance of fidelity to the model.
• Regarding training, most EBP require that clinical people learn new techniques, or ways to do things that seem to be counterintuitive to what is known or has been practiced for many years. As an example, of new implementations for trauma-oriented for women survivors of trauma, the Trauma Recovery and Empowerment Model TREM; uses an approach where abuse is not seen as “the primary problem”.
• Regarding expense, many of these interventions require very extensive training, or require special certifications to be used. This not only means expense in terms of training and materials, but also certifications; not many centers can afford such implementations.
• Finally, most of these models have been created in research settings, under very controlled situations, and they have been proven to work –mostly-- under those circumstances. Therefore, the model creators will require that you “follow the model” with fidelity. For example, clinicians may have to be on call on a 24 hours/7 days a week schedule; or the ratio of clinician to individuals receiving services is 1-10. And if you do not follow the model within some specific bounds (determined by instruments created by the model designers), then the center or clinicians doing the implementation are formally not using the model, or will not be endorsed by the model developer.
Why then try to use Evidence based practices? The short answer is because they have been proven to work in most situations. That is, the expected outcomes are met as described by the model. For example, youth receiving Multi-Systemic Therapy (MST) will stay at home (rather than at out-of-home-placements), stay in school, reduce the number of arrests, and reduce psychiatric symptoms and substance/alcohol use. Therefore, most people figure that the cost, extra training, continuing certification is worth the hassle. But the field is new, and sometimes it is not clear whether all the program components work as intended, or whether the model really works as intended outside the –most times-- very restrictive conditions imposed by the program developers. This is a new field, and new evidence is mounting every day that speaks in favor or against what we know about EBP. We’ll have more to say about this area in future blogs.