Therapeutic Relationships

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Journal of Evidence-Based Psychotherapies, Vol. 14, No. 2, September 2014, 259-270.

EVIDENCE-BASED RESEARCH: THE IMPORTANCE FOR THE PRESENT AND FUTURE OF EVIDENCE-BASED PRACTICE

Demetris KATSIKIS*

Hellenic Institute for Rational Emotive and Cognitive Behavior Therapy,

Athens, Greece

Abstract The purpose of this article is to offer further support to the concepts of Evidence-Based Research (EBR) and Evidence-Based Practice (EBP). Definitions, characteristics, connections and important clarifications between the two concepts and their impact in science, health and society are made throughout the text. Indicative important EBP protocols are proposed while David and Montgomery’s unique Psychotherapies Classification Framework is highlighted because it stresses the importance of taking into consideration the combination between theory and therapeutic package as a basis for efficacy classification. We also propose that treatment packages could be tested across different types of theories given that practice should be accompanied by a general theory of concepts, a classificatory schema of problems/issues, a theory of problems/issues and a theory of change. Finally, we discuss the current status of EBR and EBP in psychology and psychotherapy while we comment on the critical importance of the integration of EBP protocols in contemporary health care systems and societies.

Keywords: evidence-based research, evidence-based practice, evidence-based protocol, theory and therapeutic package, general theory of concepts, classificatory schema of problems, theory of problems, theory of change.

Introduction

Evidence Based Research (EBR) is a multidisciplinary approach to practice that signifies a scientific base not only for effectiveness but also for efficacy of treatment programs. Not all mental health professionals know and/or receive training in EBR and consequently many people do not receive accountable services. Yet, it is widely accepted that professionals must be well-

* Correspondence concerning this article should be addressed to: E-mail: [email protected]

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informed about the newest knowledge in order to best serve their clients and remain professionally relevant and responsible (Patterson-Silver Wolf, Dulmus, & Maguin, 2012) because a vast amount of studies have demonstrated improved health outcomes and a general attitude that treatments should be based in scientific evidence (Institute of Medicine, 2001).

EBR was fully unfolded back in the 90’s as the cornerstone of contemporary medicine for the improvement of physical health and as a means of protection from the dangers of non-scientific views. The contemporary scientific seeds of EBR had already been planted by Cochrane (1972), who suggested that because resources would always be limited, they should be used wisely to provide forms of health care which had been shown in properly designed evaluations to be effective, while he maintained that the most reliable evidence was that which came from Randomized Controlled Trials (RCT’s). Generally, EBR is spread into a variety of fields such as psychology (and psychotherapy), medicine, education, finance, nursing, social work. For the last ten years, it has also been extended in coaching practice as a golden standard (David, 2014; Cavanagh, Grant, & Kemp, 2005) promoting accountable and valid data about what works best on a continuum of efficacy. EBR (that leads to Evidence-Based Practice, EBP) was recommended by various scientific organizations and managed care systems as the rule of thumb for more cost-effective services (e.g. see Canadian Psychological Association, 2012; National Institute for Clinical Excellence, 2009; The Australian Psychological Society, 2010). The lack of valid scientific evidence for a more efficacious practice had already “tormented” the field of psychotherapy for more than a century. Conversely, in the same field, EBP promotes the idea that efficacy is not a matter of psychotherapeutic approach, but a matter of what works, for whom, under which circumstances, and with which tools (Miller, Zweben, & Johnson, 2005).

EBP involves comprehensive processes of decision making and problem solving according to the setting, the characteristics of clients and the available evidence. It is in opposition with biased folklore, traditional and lore-based approaches unless they are rigorously tested. From an EBP perspective, human care is conceptualized as ever-changing, full of uncertainties and probabilities but with a potentially effective corpus of knowledge that is dynamically transformed according to multiple health needs. For example, EBP does not only test directly the efficacy of different approaches, but also tests the best possible matching of individual characteristics to different treatment modalities.

The main concept of EBR and EBP is based on the importance of interpretation of research results into meaningful practice. EBR provides the platform for the essential transfer of research data into practice. Contrary to the frequent view that “evidence-based means something quantitative only” or that “EBR doesn’t consider personal judgment”, EBR embraces the movement of high-quality research with the mixed-method design approaches being one of the newest advancements in the EBR world for the last ten years at least (see

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Creswell, 2009). Also, appropriate EBR promotes the idea of personal judgment (see practice-based evidence: Peile, 2004), although research has shown that personal judgment is inferior to actuarial (e.g. empirical) judgment (e.g. Dawes, Faust & Meehl, 1989). Most importantly, EBR promotes rigorous methodological considerations, guidelines, methods, techniques and a mindset that widens the validity of research data. EBR and EBP: Clarifications and indicative protocols of classification in (mental) health

It is important for the reader not to confuse similar terms that may suggest

the idea of EBR. For example, sometimes research based practice means evidence-oriented or evidence-supported (and not evidence-based) practice; promising and upcoming practice that may work in some level, while there is still room for further research (Berke, Rozell, Hogan, Norcross, & Karpiak, 2011). The same is true for the term Empirically Supported Treatments (EST’s) which refer to evidence-supported/oriented practice and not to the term Empirically- Based Treatments (EBT’s); several scientists use the EBT term through the EST label though. We believe that this is not a matter of linguistic terminology only, but an illumination of the difference between effectiveness and efficacy research, plus the matter of a more crucial difference between what works and what might work. Furthermore, in a review of outcome studies, 70% were found to have stated conclusions unjustified by their research designs (Rubin & Parrish, 2007). Therefore, the pure term of EBT means that the recommended treatments are efficacious and evidence-based and that they have been clearly specified under diverse conditions within a delineated population.

To this point, the APA Presidential Task Force on Evidence-Based Practice (2006) defines Evidence-Based Practice in Psychology (EBPP) as the integration of the best available research with clinical expertise for the promotion of efficacious psychological interventions (APA Presidential Task Force on Evidence-Based Practice, 2006; Beautler, Norcross, & Beutler, 2005). Subsequently, it highlights the differentiation between EBPP and EST where EBPP is a comprehensive concept that encompasses a wider range of clinical activities (e.g. assessment, case conceptualization, therapeutic alliance) integrating multiple data of research evidence, while EST includes more specific psychological/psychotherapeutic treatments that have been shown to be efficacious in controlled situations.

Additionally, there are different protocols used as frameworks which include criteria for the establishment of what is considered “best practice” in EBP terms. Typically those protocols include some routine core activities such as questioning approaches to practice leading to scientific experimentations, meticulous observation, enumeration, analyses replacing anecdotal case description, rigorous metaanalyses of data, Systematic Research Syntheses (SRS; Cooper, 2003; Pignotti & Mercer, 2007), cumulative evidence scores (e.g. Miller,

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Wilbourne, & Hettema, 2003) and recording evidence for systematic retrieval (Peile, 2004). Below, we briefly cite seven indicative protocols and/or frameworks as examples.

Chambless and Hollon (1998) proposed that an intervention is considered efficacious if there is evidence from at least two settings that it is superior to a control group or another bona fide treatment. Yet, if there is support from one or more studies than from just a single setting, the intervention is considered possibly efficacious pending replication.

The Kauffman Best Practices Project (2004) highlighted that a treatment would need to have a sound theoretical base, general acceptance in clinical practice, and considerable anecdotal or clinical literature. This protocol also requires absence of evidence of harm, at least one randomized controlled study, descriptive publications, a reasonable amount of necessary training and the possibility of being used in common settings.

Saunders, Berliner, and Hanson (2004) proposed research to be classified under six categories according to the strength of evidence of possible harm, the general acceptance of the research study, the theoretical background and the general quality of the research design. Category 1 includes efficacious treatments (two or more randomized controlled outcome studies with the target treatment showing a significant advantage to an appropriate alternative treatment); category 2 includes probably efficacious treatments (positive outcomes of nonrandomized designs with some form of control which may involve a non-treatment group); category 3 includes acceptable treatments (interventions supported by one controlled or uncontrolled study, or by a series of single-subject studies, or by work with a different population than the one of interest); category 4 includes promising treatment (treatments that have no support except general acceptance and clinical anecdotal literature); category 5 includes novel treatment (interventions that are not thought to be harmful but are not widely discussed in the literature); category 6 includes treatments that have the possibility of doing harm, as well as having unknown or inappropriate theoretical foundations.

Khan, ter Riet, Glanville, Sowden and Kleijnen (2001; see also Khan, Kunz, Kleijnen and Antes, 2003) proposed a general method for assessing psychosocial and medical interventions. They noted that RCTs add true incremental validity if there are true randomization, “double-blindness” research procedures, attrition prevention, adequate theoretical descriptions of groups, treatments at every stage of the research process and “blindness” processes.

The National Registry of Evidence-Based Programs and Practices (2007) assigns quality ratings from 0 to 4 to certain criteria and examines reliability and validity of outcome measures used in the research, evidence for predictive validity of the interventions, levels of missing data and attrition, potential confounding variables, and appropriateness of statistical handling, including sample size. Also, peer-reviewed journal publications, evaluation in reports and documentation via training materials are important criteria for eligibility.

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Mercer and Pignotti (2007) used a taxonomy of classification stressing the differentiation between five terms. Evidence-based practice includes randomized designs employing comparisons to established treatments, independent replications of results, blind evaluation of outcomes and the existence of a manual. Evidence-supported practice includes interventions that are supported by non-randomized designs including within-subjects designs. Evidence-informed practice includes case studies or interventions tested on populations other than the targeted group, without independent replications. Belief-based practice includes no published research reports or reports based on composite cases; it may be based on religious or ideological principles or may claim a basis in accepted theory without any acceptable rationale. Potentially harmful practice includes interventions for which harmful mental or physical effects have been documented.

In the field of psychotherapy, David and Montgomery (2011) proposed a framework for the whole clinical science. This classification integrates all the actions proposed by the aforementioned protocols and promotes the premise that EBR in psychotherapy needs to test the effectiveness and the efficacy of the therapeutic package in conjunction with the theory where this practice is based according to nine different categories and three specific levels of efficacy, respectively. For example, the first cognitive behavioral therapy, Rational Emotive Behavior Theory (Ellis, 1958, 1962), one of the most researched approaches nowadays (David, 2014; David, Lynn, & Ellis, 2010), lies in Category II. The Table below presents the nine categories and the three levels of classification. Table 1. Psychotherapies Classification Framework: Categories I-IX (David & Montgomery, 2011).

Theory

Therapeutic package Well supported Equivocal - No preliminary, or MD SCE

Well supported Category I Category II (REBT) Category V

Equivocal - No preliminary, or MD (Mixed Data)

Category III Category IV Category VII

SCE Category XI Category VIII Category IX

The novelty in David and Montgomery’s model is the simultaneous consideration of theory and treatment package during the EBR process. To reinforce this point, we would like to propose that treatment packages could be tested across different types of theories given the fact that therapeutic practice is usually accomplished within a context of a) a general theory (explanations of

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normal and abnormal processes), b) a classificatory schema of problems/issues (identification and descriptions of signs, symptoms, severity, intensity, frequency and duration of problems), c) a theory of problems/issues (how and why the problem function as it does) and, d) a theory of change (what accounts for how problems are maintained and/or changed) (Rounds & Tracey, 1990). For example, REBT should test therapeutic packages across a) the general REBT theory, b) the different REBT problem classifications and conceptualizations, c) the REBT theory of problems and d) the REBT theory of change.

Evidence-based research and practice in psychology and psychotherapy

In 1992 the APA Board of Professional Affairs and the APA Committee for the Advancement of Professional Practice created the Template for Developing Guidelines: Interventions for Mental Disorders and Psychosocial Aspects of Physical Disorders (American Psychological Association, 1995). It strongly recommended that panels should take into serious consideration the available evidence according to accepted standards of scientific merit acknowledging that the conclusions differ widely for different bodies of data. A significant problem was the great diversity in the quality of different guidelines and protocols in terms of specificity and generalizability of their treatment recommendations.

Therefore, three major components in psychology and psychotherapy were set as the cornerstones of EBPP, that are, a) the best available research, b) the expertise and, c) the client characteristics (Spring, 2007). Then, APA Division 12 (Clinical Psychology) Task Force on Promotion and Dissemination published criteria identifying 18 empirically validated treatments for particular psychological disorders based on RCT’s with a specific population and implemented by using a treatment manual (Chambless, Baker, Baucom, Beutler, Calhoun, Crits-Cristoph et al.., 1996; Chambless, Sanderson, Shoham, Bennett Johnson, Pope, Crits-Cristoph et al., 1998); those components were further refined in 2005 by the APA Presidential Task Force on Evidence-Based Practice (Levant, 2005).

Standard EBP procedures consider client’s values, religious beliefs, worldviews, goals and preferences for treatment in combination with the psychologists’ experience and understanding of available research (American Psychological Association, 1995; Levant, 2005). Firstly, patient characteristics, such as personality traits, comorbidities and/or polysymptomatic manifestations, different demographic characteristics (e.g. gender, gender identity, ethnicity, race, social class, disability status, and sexual orientation) and stages of change (Freeman & Dolan, 2001; Prochasca & DiClemente, 1983) should be tested further as possible moderators of the impact of empirically tested interventions. Secondly, research should answer the question of which social factors and

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cultural differences necessitate different forms of treatment or, conversely, the extent to which interventions can be readily adapted for people from different ethnic or socio-cultural backgrounds. Thirdly, interventions should adequately attend to developmental considerations in different populations (e.g. APA Task Force on Evidence-Based Practice with Children and Adolescents, 2008; Chorpita, Daleiden, Ebesutani, Young, Becker, Nakamura, et al., 2011) through longitudinal research designs with a measurement burst approach (intensive longitudinal study designs where multiple assessments are obtained over a relatively short time span; see Sliwinski, 2011), as a basis.

Opponents of the EBR (and EBP) claim that “what works” rationale in medicine doesn’t fit in social sciences. We believe that this critique partially echoes some traditional views which consider psychology as a non-scientific method. We also believe that psychology is not the same in terms of content with medicine (in psychology there is not a strictly specific corpus of knowledge), but since 1879 when the first psychological laboratory founded by Wilhelm Wundt in Leipzig, Germany, the science of psychology embraced the empirical methods of testing differences via empirical methods providing a common base of validation for social sciences. Further, Ellis (1973, 1979a) stressed the importance of critical empiricism (critical reflection of reality accepting objectivity and subjectivity at the same time) which runs at the intersection between classical empiricism (accepts objective reality only) and constructivism (accepts subjective reality only). We believe that psychology (and psychotherapy) should place themselves in this dialectic intersection for a more objective stance towards diverse people’s needs. Therefore, appropriate EBR should stand at the level of critical empiricism, accept constructivism, promote the idea of an objective investigation of the whole human experience and keep in touch with personal and cultural characteristics plus with the fundamental importance of therapeutic alliance (Norcross, 2010; Norcross & Wampold, 2011; Wampold, 2001, 2007).

There is evidence which already shows that psychological practices work for a wide variety of people across a wide range of psychological problems (e.g. Barlow, 1996; Beutler, 1998; Smith & Glass, 1977; Smith, Glass, & Miller, 1980). Yet, major limitations are the relative weight in different methodologies; representativeness of samples; transferability of results into practice settings; generalizability of results in non-YAVIS (Young-Attractive-Verbal-Intelligent- Successful) populations; whether research results should guide practice at the levels of principles of change, intervention strategies or specific protocols; the way in which other design limitations (e.g. limited number and duration of treatments) are troubleshot (Norcross, Beutler, & Levant, 2005). The future of EBR and EBP

The use and misuse of evidence-based principles in the practice of health care has affected the dissemination of health care funds but not always to the benefit of people. For example, several educative systems (e.g., in Greece) still

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organize socially acceptable treatment school programs (e.g. rudimentary drug prevention programs) that are not up-to-date and are neither effective, nor efficacious in a long-term basis. For example, in the Greek educational system drug prevention programs are implemented by external organizations (Prevention Centers) in the schools since 17 years. Most of these programs repeat the same basic concepts annually and have not widely integrated in the public school policies yet. Therefore, psychologists, whose training is grounded in empirical methods, have an important role to play in the continuing development of EBP and its focus on improving mental health care. The same is true for all contemporary scientists-practitioners that are involved in social and humanistic sciences. At the same time, the EBP movement has become a key feature of health care systems and health care policy. At the state or federal level, a number of initiatives encourage or mandate the use of a specific list of mental health treatments in different countries throughout the world with their reference here being outside the scope of this text. All these initiatives focus on promoting, implementing and evaluating EBP within state mental health systems. The goals of EBP initiatives are to improve quality and cost-effectiveness and to enhance (mental) health accountability although empirical evidence of system-wide improvements following their implementation is still limited. Nevertheless, scientists-practitioners should boost EBP initiatives as the best possible means for direct and appropriate access to care and choice of treatments. For example, the goal of the English organization called “We need to talk coalition” is to offer a full range of evidence-based psychological therapies to all who need them within 28 days of requesting a referral (We need to talk coalition, 2014)

There are increasing challenges for a wide range of social policy makers and other stakeholders who run various programs through governments and other types of agencies to be based on sound evidence as to their effectiveness and efficacy (Gaudiano & Miller, 2013). Increased emphasis on the use of a wide range of evaluation approaches directed at obtaining evidence about social programs of all types is a prerequisite for effective and efficacious service delivery. More EBP movements and related summits for the promotion of EBP attitude in diverse social policy arenas are still to be set up for more responsible decision-making. This collaboration echoes the pioneering appeals of Cochrane for the integration of an EBP approach to all social policy actions because it has the potential to extend the EBP treasure to diverse people serving the most fundamental purpose of psychology and psychotherapy, that is helping people to develop and flourish in an individual and socio-cultural basis. Conclusion

The purpose of this article was to highlight the constantly upcoming and evolving EBR (and EBP) concept for contemporary societies. This article also

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promotes three ideas. First, that APA’s criteria proposed by Chambless and colleagues (1996, 1998) and more recently from the APA Presidential Task Force on Evidence-Based Practice (2006) need to be diffused in more countries for the advancement of human health care.

Second, these criteria are recommended to be promoted under David and Montgomery’s psychotherapy classifications framework (2011). This framework is unique in terms of its proposal to combine theory and treatment package in a simultaneous basis for a more cutting-edge classification of efficacy not only in a statistical-terms level or in a treatment-package level, but also in a theory-level via a composite model combining three differing levels of theory and practice.

Third, this article promotes the idea that the aforementioned framework could work at its best should the theory-level part of this classification be conceptualized according to the Rounds and Tracey (1990) scheme of categorization for theoretical models (general theory, classificatory schema of problems, theory of problems and theory of change). Concluding, we believe that EBR and its counterpart, EBP, will gradually become more important and, hopefully, main players in the future of human health programs if their integration into policy is meaningful, accountable and rigorous. This integration should continue following scientifically designed and implemented larger trials, institutional trials, online applications, multidisciplinary applications, people tolerance studies, group scale studies, longitudinal studies, studies in real situations, studies in experimental and semi- experimental situations, studies in analogue and simulated conditions, pervasive symptom focus studies, biomarkers for psychological change, psychological markers for biological/physical change, multi-scale life expectancy studies and healthcare cost reduction studies. Bona fide research has already shown that a wide variety of psychological practices are safe, effective, efficacious, cost- effective, cost-utile and lead to increased productivity and life satisfaction; most importantly, they are particularly enduring in time (Levant, 2005). REFERENCES

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