Evidence based practices

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.

Mindfulness and Psychotherapy

The practice of mindfulness is a practice that is finding increased attention in the application of psychotherapy. What exactly is mindfulness as it relates to psychotherapy? The term mindfulness comes from the word sati, taken from the Buddhist tradition of meditation and psychology. This word suggests awareness, attention and remembering. According to Dr. Ronald Siegel, Psy.D, Assistant Clinical Professor of Psychology at the Harvard Medical School, mindfulness as it relates to psychotherapy is assisting a person to learn to cultivate a practice of awareness of a present emotional experience. In the book co-edited by Dr. Siegel (2005), Mindfulness and Psychotherapy, New York: Guilford Press, Dr. Siegel suggests that it is also very important that the person is able to practice acceptance of that emotional state as it arises. As used in psychotherapy, mindfulness is a practice that systematically teaches the patient how to accept their emotional experience. This is similar to the use of mindfulness in Marsha Linehan’s Zen-inspired dialectical behavior therapy (DBT). Linehan, M. (1993). Cognitive-behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. As emphasized in DBT, emotions can become overwhelming, and this may impact one’s behaviors and thoughts in a negative or destructive manner. Mindfulness as utilized in dialectical behavioral therapy attempts to break this pattern by helping the patient better manage these emotions.
  While mindfulness has most often been related to Buddhist or religious/contemplative practices, mindfulness is now also being integrated into what we might call the more traditional forms of psychotherapy as what is now being called the third wave in behavior therapy. The first wave was Operant and Classical Conditioning and the second one is Cognitive Behavioral Therapy. The third wave now incorporates mindfulness into the well know evidence based practice of Cognitive Behavioral Therapy as Mindfulness-Based Cognitive Therapy, (MBCT).
 Mindfulness-based cognitive therapy was developed by Zindel Segal, Mark Williams and John Teasdale (2001), Mindfulness-Based Cognitive Therapy for Depression: a New Approach to Preventing Relapse, New York: Guilford Press. Their work was largely influenced by the work of Jon Kabat-Zin whose work was discussed in a previous article found on this blog site regarding the work of Kabat-Zin and the development of the Mindfulness-Based Stress Reduction Program at the University of Massachusetts Stress Reduction Center.
Mindfulness-based cognitive therapy is a blend of cognitive behavioral therapy (CBT) which focuses on changing our thoughts in order to change our behaviors, and the meditative practice of mindfulness, a process of identifying our thoughts on a moment-to-moment basis while trying not to pass judgment on them and experience them with acceptance as suggested by Dr. Ronald Siegel. While cognitive behavioral therapy has always emphasized the end result of change of one’s thoughts, mindfulness really looks at how a person thinks — the process of thinking — to help one be more effective in changing negative thoughts. What does some current research suggest about the effectiveness of this newer form of psychotherapy?
Coelho et. al. looked at research about mindfulness-based cognitive therapy and found four relevant studies that examined the effectiveness of this approach. Coelho, H.F. (2007). Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. J Consult Clin Psychol., 75(6):1000-5.
The current evidence from the randomized trials suggests that, for patients with 3 or more previous depressive episodes, MBCT has an additive benefit to usual care. It is important to note here that MBCT is designed to help people who suffer from repeated bouts of depression. Coelho found however, because of the nature of the control groups, these findings cannot be attributed to MBCT-specific effects. The researchers did suggest that MBCT has found some positive results for those with a more chronic depression but they could not say that this was as a result of specifically MBCT alone.
It is clear that there is an ever increasing mindfulness oriented model of psychotherapy. Treatment strategies can be derived from the basic elements of mindfulness – awareness of present experience, with acceptance. A review of the empirical literature by Baer (2003); Baer,R. , Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125-142, suggests that mindfulness based treatments are “probably efficacious” and en route to becoming “well established”.
The possible emerging model of mindfulness as integrated into psychotherapy can be seen to have promise in many areas of psychology and psychotherapy and has indeed become well established. Similarly empirical research in this area has seen a significant increase. In 2003 at the time of the review by Baer, there were several hundred empirical research articles on mindfulness and psychotherapy and now, 2010, one can find several thousand. Mindfulness is beginning to move into other areas such as brain science, health/medical psychology and positive psychology. It seems that the clinical literature is promising and psychologists and mental health clinicians have the opportunity to integrate a form of mental practice that is based on a 2,000 year old contemplative practice of bringing the mind to the present state, experiencing this state and accepting this state.
Additional Resources
University of Massachusetts Medical School, Center for Mindfulness and Medicine

Dr. Ronald Siegel, (2010), The Mindfulness Solution: Everyday Practices for Everyday Problems, New York: Guilford Press

By Marcia Middel, Ph.D.
Dr. Middel is the chief psychologist at the Mental Health Center of Denver. She is also the Director of the Center for Integrated Psychological Services (CIPS) and team associate with MHCD Evaluation and Research team

Our Role in Preventing Suicide…

With the recent untimely death of Broncos WR Kenny McKinley and tragic loss of several college youth across the nation this question has been thrust into our community’s collective conscious. Sadly, suicide has become an all too common occurrence within our society, while at the same time remaining a rather taboo subject for our own interpersonal relationships. Despite our frequent reluctance to discuss this issue with those that we care about, there are vey few of us who have not had our lives directly touched by suicide, whether through a child, parent, sibling, relative, neighbor, coworker, or acquaintance. We’re often left with lingering existential questions that challenge our own sense of meaning in life... Why? How could someone with seemingly so much going for them take their own life? What could lead a person to believe that suicide was an option in their situation? What could I have done differently or how could I have known this was going to happen? Perhaps the most important question we can ask ourselves, as we seek to move forward and create meaning from such a seemingly senseless act, is what can we do to reach out to those still suffering in silence to help prevent suicide from taking another life? Through this brief post I hope to review current research to provide some context to the national suicide epidemic, dispel some myths about suicide, and empower you with some tools and resources to make a positive impact on the struggle against suicide.Colorado consistently has one of the highest suicide rates in the nation, with suicide representing the 7th leading cause of death across all age groups and the 2nd leading cause of death for young people ages 10-34. Just last year Colorado had its most deaths by suicide on record at 940. Nationally, death by suicide claimed the lives of 34,598 people in 2007. It is estimated that another 11 suicide attempts occur for every 1 death by suicide. These are staggering and heartbreaking statistics that highlight the all too prevalent nature of suicide within our nation and immediate community. For more information on some of the national suicide statistics you can visit the National Institute of Mental Health (NIMH) or see the Suicide in Colorado report for information specific to this State.
             Given the widespread nature of suicide within our communities, one might think that this issue would be a more frequent topic of conversation and routine preventative effort by nearly all people. Unfortunately, some of the myths and stigma surrounding suicide has prevented this from becoming the case and we all too rarely openly discuss or ask about suicide until the topic has been thrust before us by the loss of someone we love or a prominent public figure. By then it’s already too late. Our own fears, assumptions, and false beliefs about suicide often get in the way of reaching out to those in need around us.
  • How can I possibly say anything that might be helpful to someone considering suicide? People contemplating suicide are just like you and me. We have all been through some difficulty in our own lives and share a common humanity which gives us the capacity to help someone who is depressed or thinking of taking their own life.
  • If I say anything it might make the person upset or give them an idea that makes them more likely to hurt themselves. This is actually the opposite of what research has found to be true. Being direct with someone about suicide generally lowers their anxiety and sense of isolation that has been created by the stigma surrounding suicide. By opening a line of communication we can cue in to any warning signs and decrease the risk of an impulsive act. Additionally, if you’re worried that someone you know might be considering suicide, it’s nearly a guarantee that they’ve already at least thought about this themselves.
  • People who consider suicide keep their plans to themselves. This is another common misperception that has been debunked by the literature. Psychological autopsies on those who have completed suicide found that approximately 95% of these individuals had in some way communicated their suicidal intent.
  • People who talk or joke about suicide don’t actually do it. As previously highlighted, nearly all people who attempt suicide convey their intentions in some way. Increased talking about death or suicide is a frequently evident precursor in individuals who try to take their own life.
  • Once people make up their mind to complete suicide there’s no way to stop them. Most people have conflicting feelings about suicide and are generally ambivalent about their decision to complete the act. Interviews with Golden Gate Bridge survivors indicated that one of the most common thoughts that entered their minds after jumping from the bridge was “I wish I hadn’t done it.” This is also why the vast majority of people convey their intentions in some form or another before performing a suicidal act. People generally want help but don’t know how to ask. Suicide is the most preventable cause of death and any positive action you take may save a life.
            I know how incredibly difficult it can be to break the circle of silence surrounding suicide. I live with my own painful reminder of how I was unable to do just that with an acquaintance during my sophomore year of college. However, as I’ve learned to break that silence and reach out to those in both my personal and professional lives (as both a crisis helpline worker and therapist) I’ve come to appreciate the incredible power of a simple question or gesture of support to someone contemplating suicide. Whether a person is actually considering suicide or not, the mere act of asking a question offers a tremendous opportunity to create a profoundly meaningful connection with another person that you may find not only has a significant impact on that person’s life but on yours as well.
            So what can we do to help? Everyone can play an important role in suicide prevention by being mindful of several simple things and being willing to reach out to others whenever warning signs arise. Moreover, we can all work together to help break the silence and lower the social stigma surrounding suicide.
  • Be attuned to any suicide cues or warning signs in those around you. Listen for direct verbal cues (e.g. I wish I were dead, I’m going to kill myself, I’m going to end it all) and indirect verbal cues (e.g. I’m tired of life, You won’t have to worry about me much longer, You’d be better off without me anyway, I just want out of it all).
  • Be on the lookout for behavioral cues (e.g. previous suicide attempts, giving away possessions, sudden disengagement, making arrangements for an absence, acquiring a weapon, storing large quantities of pills). Symptoms of depression and drug/alcohol abuse are present in approximately 90% of instances of suicide.
  • Also, be mindful of times in which previously depressed individuals seem to be getting better or have an increased level of energy as they may now feel as though they have the resources to carry out the act they have been thinking about for so long. Moreover, as counterintuitive as it may sound, the hours preceding an attempt may involve an air of happiness or calm as the person has resigned themselves to death.
  • Check-in with people following any major life changes that may represent a situational cue for suicide (e.g. loss of job, end of a significant relationship, death of a family member or friend, difficulties at school, serious medical condition).
            Whenever you have any concerns the most important thing you can do is simply ask if someone is considering suicide, or if you’re unable to then find someone who can. Ask the question and then listen. Listen without judging and then ask if you can help them get connected with resources to help. For additional information on suicide and how you can help people struggling with this issue checkout the National Suicide Prevention Lifeline and the Suicide Prevention Resource Center.

By Scott Nebel, Psy.D.
  • Scott is a Psychologist on MHCD’s Intensive In-Home Treatment Team and collaborates with the MHCD Research Institute.

Books on Suicide and Depression:
Darkness Visible by William Styron
Night Falls Fast by Kay Redfield Jamison