Robbie Busch and Sharon McCarthy at the Palgrave Encyclopedia of Critical Perspectives on Mental Health wrote that evidence-based practice (EBP) is a framework that assumes the incorporation of clinical expertise and patient characteristics with established evidence to enable beneficial health decisions. However, evidence-based practice is not only a set of guidelines; it is a discourse, serving to universally moralize, standardize, and govern research, training, and practice. The discourse of evidence-based practice (EBP) was developed through the establishment of empirically validated treatments (EVTs) and then empirically supported treatments (ESTs). During the establishment of EVTs and ESTs, various American Psychological Association (APA) divisions developed their own conceptualizations of evidence-based research and practice that reproduced and resisted their dominance. Consequently, various research approaches, both within and external to the APA proposed alternative conceptualizations of evidence-based practice.
According to McGill, Best Practices in Psychology, evidence-based practice (EBP) aims to maximize the effectiveness of psychological interventions through adherence to principles informed by empirical findings, clinical expertise, and client/patient characteristics.
The National Library of Medicine stated that the evidence-based practice movement has become an important feature of healthcare systems and healthcare policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an integration of science and practice, the Task Force’s report describes psychology’s fundamental commitment to sophisticated EBPP and considers the full range of evidence psychologists and policymakers must consider. Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationships, and intervention.
More specifically, EBPP entails:
- Efforts to provide the best possible services (which minimize the risk of harm and maximize the chance of benefit) for those seeking psychological treatment.
- A reliance on peer-reviewed, scientific research evidence as the basis for treatment selection, with preferential attention given to studies based on research methodologies that control threats to both the internal and external validity of the research findings.
- Respect for the dignity lived experience, and preferences of individuals seeking psychological treatment, as manifested by consistent communication and collaboration between the clinician and the client/patient.
- The monitoring and evaluation of services provided to clients and patients. Practitioners should regularly and systematically monitor clients’ and patients’ reactions as well as changes in their symptoms and functioning throughout treatment. This can be done through progress tracking and outcome monitoring.
- A willingness on the behalf of practitioners to alter the treatment plan based on ongoing treatment monitoring, discussions with the client or patient, and a reconsideration of the relevant research evidence.
According to the Association of Behavioral and Cognitive Therapies (ACBT), evidence-based practice (EBP) can be best described as the application of research-based treatments, that are tailored by an experienced therapist to meet the individual needs, preferences, and cultural expectations of those receiving them. If you are like many people, you may have heard the phrase “evidence-based practice” at some point when searching for or receiving healthcare services, including mental health services, but not be sure what this means. Evidence-based practice (EBP) is commonly likened to a three-legged stool (Sackett, 2000). You can think of the first leg of the stool as representing the best available clinical scientific evidence. This leg is commonly described as the most important leg of the three-legged stool; thus, this article includes more information about this leg than the other two legs. The second leg consists of your values and preferences as a patient. The final leg consists of your provider’s (such as a psychiatrist, psychologist, psychiatric nurse, or mental health counselor) own clinical experience. The rationale behind EBP is that your healthcare outcomes will be optimized if all three legs of the stool are considered in making decisions about your care. On the surface, EBP makes a lot of sense and is straightforward. However, there are some things you will want to consider in deciding whether a given therapist is, in fact, engaging in EBP.
The First Leg: Best Available Clinical Research Evidence
When people look for mental health treatment for themselves or a loved one, they often search for a psychotherapy provider who may have availability in their schedule, be located nearby, have desired fees, or be covered by a specific insurance plan. However, when you search for treatment, it is essential to also get specific information about the type of treatment or treatments that a mental health care provider will offer. It is important to understand that not all mental health treatments are equally effective, and it helps to be educated when searching for a therapist. Simply put, some therapies may work better for some psychological problems than others. Mental health care providers (i.e., psychotherapists, such as psychologists, social workers, and psychiatrists) may subscribe to different ‘schools of thought,’ or approaches on how to effectively reduce psychological symptoms. Some therapists rely on approaches that are based directly on scientific evidence that indicates the best routes to symptom relief. However, other mental health care providers offer treatment that is not based on strong scientific evidence, or for which no evidence is available. Keep in mind that “scientific evidence” means much more than psychotherapists’ subjective experiences or informal clinical impressions (such as “I’ve repeatedly found that this treatment works for my patients”). Decades of psychological and medical research have shown that these kinds of experiences and impressions are imperfect and, at times, deeply flawed. Thus, you cannot rely on them to determine whether a treatment works. Instead, by “scientific evidence,” we mean rigorous, controlled research conducted by multiple teams of investigators (see next paragraph). Therapists are human and have their biases, and careful research is the best means of reducing these biases.
For therapists to truly engage in evidence-based practice, they must anchor your treatment in the best scientific evidence available and use the techniques and psychological approaches that have scientific support. Unfortunately, many members of the public assume that all psychological treatments have been adequately tested in scientific research- this is not the case. Many other people are unaware that psychological treatments with significant scientific support exist. These treatments are often called “empirically supported” or “evidence-based” treatments. Empirically supported treatments are treatments that are based directly on scientific evidence suggesting the most likely contributors and risk factors for psychological symptoms. Empirically supported treatments and their associated techniques typically have been studied in several large-scale clinical trials, involving thousands of patients and careful comparison of the effects of these versus other types of psychological treatments. Dozens of multi-year studies have shown that empirically supported treatments can reduce symptoms significantly for many years following the end of psychological treatment – similar evidence for other types of therapies is not available to date. Although there are several empirically supported treatments, the most commonly used empirically supported approaches for the treatment of psychological symptoms involve cognitive-behavioral therapy (CBT). The efficacy of CBT has been demonstrated for a wide range of symptoms in adults, adolescents, and children.
The Second Leg: Patient Values and Preferences
You have a right to have a voice in the treatment you receive. Psychological treatment should be a collaborative process that respects your own experiences, needs, and values. Thus, you should expect your therapist to take your values and preferences into consideration when making treatment recommendations. You may find that you have preferences regarding the type of person who you would optimally want to be your therapist. For instance, you may prefer a therapist of a particular gender or ethnicity or a therapist who has a specific background (e.g., substantial experience in the military). In an optimal world, you would be able to receive empirically supported treatment (the first leg of the evidence-based practice stool) delivered by a therapist who fits your preferences. Unfortunately, because many therapists do not follow evidence-based practice and are not experienced in providing empirically supported treatments, it may come down to luck or availability as to whether you can find a therapist who both meets your preferences and can provide you treatment according to evidence-based practice (EBP). In this situation, consider first identifying the therapists who will deliver empirically supported treatment and then see which therapist seems to be the best fit. Also, feel free to share any concerns you have with that therapist so that you can work together to address them to the degree possible.
It is important to bear in mind that research consistently demonstrates that even when therapists are of a different gender, ethnicity, cultural background, and so on, from you, they can still be extremely helpful. Also, differences between therapists and patients might even be helpful in some cases. For example, when dealing with a male patient who is anxious around assertive women, a female therapist may be especially effective in giving him practice with confronting his anxieties. Although your preferences and values are a critical component in evidence-based practice, it also is essential to realize that many of the most effective treatments for mental health problems require people to do things that they do not want to do. For instance, many treatments with solid scientific support ask patients to attempt activities that they find to be anxiety-producing or to engage in social activities when they feel depressed. Thus, there is a good chance that your therapist will encourage you to step outside your comfort zone even if your initial preference is to not do this. For this reason, it is essential to feel comfortable with your therapist so you can honestly discuss concerns and ensure that you truly understand why it makes sense to proceed with the proposed treatment. As part of this process, you should expect your therapist to provide a clear rationale for the treatment being proposed, review the research evidence for the treatment, and explain any proposed deviations from the standard delivery of the treatment so you can make an informed decision to proceed or not. If your therapist does not supply this information, be sure to ask.
Evidence-based practice (EBP), The Third Leg: Clinical Expertise
Ultimately, it is your therapist’s job to interpret the best evidence from systematic clinical research (the first leg) considering your preferences, values, culture, and daily life realities. Therapists rely on their own clinical expertise in figuring out how to integrate these different pieces of information to formulate your individual treatment plan. They also rely on clinical expertise whenever the existing research base does not provide sufficient information to address your situation. A therapist serious about engaging in evidence-based practice (EBP) should give the scientific evidence extra weight in designing your care so that you have the best chance to improve. However, sometimes the scientific evidence is lacking or incomplete. For instance, if you present with two mental health problems for which there are two different treatments, the existing scientific literature may not clearly spell out whether you would be better off starting with Treatment A or Treatment B. In this situation, your therapist will use his or her clinical experience to create an individualized treatment plan for you. In this case, you should expect your therapist to clearly explain to you how the scientific evidence applies to your situation/problem, where the gap in information lies, and what your options are. Then you can collaboratively pick the best path forward. Clinical expertise also includes the degree of experience that a therapist may have with a particular problem or group of people. For instance, many therapists who engage in evidence-based practice (EBP) have areas of specialty (e.g., anxiety, eating disorders, depression etc.). In many cases, you may find that there is an added benefit in finding a therapist who has substantial clinical expertise in addressing the problems you are facing. This expertise, however, does not outweigh the first leg of the evidence-based practice stool. A therapist may have substantial clinical expertise in treating a particular problem but may ignore the existing scientific evidence. In this case, you will want to find a different therapist because clinical expertise does not outweigh the scientific evidence. Finally, research indicates that even relatively inexperienced therapists, such as those who recently received their doctoral degrees, can be extremely helpful in alleviating psychological distress. If new therapists (a) are well trained, (b) caring and empathic, and (c) rely on scientific evidence to guide their interventions, they can often be just as effective as more experienced therapists.
This article is provided by Dr. Ralph Kueche (Child Psychologist). Dr. Kuechle is a Child and Adolescent Clinical Psychologist who specializes in treating children and their families who may be struggling with mood and behavioral issues. Learn more about Dr. Kuechle.
