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What is best practice – is evidence based practice the answer?

What is best practice – is evidence based practice the answer?. Nordic Conference New perspectives – best mental health practice Akureyri May 7-8, 2009. Tor-Johan Ekeland Professor, Volda University College Professor II, Molde University College. Evidence based…….. Comes from medicine

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What is best practice – is evidence based practice the answer?

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  1. What is best practice – is evidence based practice the answer? Nordic Conference New perspectives – best mental health practice Akureyri May 7-8, 2009 Tor-Johan Ekeland Professor, Volda University College Professor II, Molde University College

  2. Evidence based…….. • Comes from medicine • A world wide trend not specific to mental health • Driven by: • Accountability • What works Akureyri May 7-8 2009 TJE

  3. Evidence based excitement: • Government • Politicians • Managers and payers • Researchers • Clinicians ? Akureyri May 7-8 2009 TJE

  4. What does it mean that a treatment are evidence based? Evidence based knowledge: • That a diagnosed group of patient getting a specific treatment, in average get better results compared to the average effect in a comparable group not getting the treatment (or another) Evidence based practice: • Implementing this knowledge through diagnose based procedures Akureyri May 7-8 2009 TJE

  5. The Logic of Evidence Based Practice Research literature Gold standard Selection -filtering Management Manuals Clinical practice Akureyri May 7-8 2009 TJE

  6. Hanne Foss Hansen Akureyri May 7-8 2009 TJE

  7. Evidence based practice • What is new and what is old? • What is good and what is the problems? • Is ”evidence based” synonymous with scientific? Akureyri May 7-8 2009 TJE

  8. This is old: Evidence based knowledge • The idealization of context-independent and universal knowledge • The aspiration to transform knowledge into ”technology” This is new: Evidence based practice • Narrowed and authorized criteria of what counts as knowledge (gold standard) • The use of evidence based knowledge are not a matter of professional autonomy alone, but come with manuals implemented in new strategies for governing Akureyri May 7-8 2009 TJE

  9. Archibald Leman Cochrane (1909 - 1988) • Can it work? • Does it work in practice? • Is it worth it? Akureyri May 7-8 2009 TJE

  10. ……but: Why does it work? EBP is a kind of empirical pragmatism….. May foster pseudoscience………… Akureyri May 7-8 2009 TJE

  11. From science to ”technology”: • Science: If A, then B (i.e. with p=x) • Technology: If you want B, do A Implicit premises: • Stable relation between A and B • Can be replicated • That the action (A) is independent of the acting person • That the response (B) is independent of the person who is the target for the action When is this premises valid? Akureyri May 7-8 2009 TJE

  12. Intervention and prediction in different “worlds” physical biology humane • Responses are: • Distributed • System dependent • Functional • Adaptive • Responses are: • Language dependent • Based on reason • Relational • Historical/Contextual • Responses are: • Stable • Universal • Causal • Unhistorical • Prediction is: • Precise • Prediction is: • Statistical • known variance • Prediction is: • Statistical • Unstable variance Do we have a map (epistemology) which fit the territory (ontology)? Confusion create epistemological errors Akureyri May 7-8 2009 TJE

  13. Experts showed strong agreement that research did support following assertions: • Therapy is helpful to the majority of clients • Most people achieve some change relatively quickly in therapy • People change more due to “common factors” than to specific factors associated with therapies • In general, therapies achieve similar outcome • The relationship between the therapist and client is the best predictor of treatment outcome • Most therapists learn more about effective therapy techniques from their experience than from the research (Charles Boisvert & David Faust, 2003) Akureyri May 7-8 2009 TJE

  14. “Despite volumes devoted to the theoretical differences among different schools of psychotherapy, the result of research demonstrate negligible differences in the effects produced by different therapy types”.(Smith og Glass, 1977, s.760) ”..., there is massive evidence that psychotherapeutic techniques do not have specific effects, yet there is tremendous resistance to accepting this finding as a legitimate one” (Bergin & Garfield, 1994, ”Handbook of Psychotherapy and Behavioral Change”, s. 822). Akureyri May 7-8 2009 TJE

  15. What works? Implication from research outside the evidence paradigm • Difficult to predict good outcome • Equal efforts for the equal problems gives different experiences • Formal treatment variables not so important • Timing: small causes may give great effects (turning points) • A sense of life – functional daily life • A home, work – meaningful activities • A sense of being – identity, respect and acceptance • Involved, trustworthy and dedicated helpers • Regaining responsibility – “a speaking I” Akureyri May 7-8 2009 TJE

  16. Summing up…. • EBP are therapies which are relatively independent of context and therefore can be standardized (= technology): • In medicine ”evidence based” can function well when the diagnostic validity is high and the working theories are adequate • Empirical evidence on psychotherapy and social methods show that this is contextual methods and therefore should not be standardized (= praxis) • The effects of such methods are dependent on individual and contextual conditions • The practice should therefore be “tailor-made” rather than standardized Akureyri May 7-8 2009 TJE

  17. Best practice as I see it…… The main perspective should be the mental suffering person, not the mental illness Implications: • Contextual Model instead of Medical Model: perspective on life world and restoring life-functions rather than focus on pathology and cure. Organizational level • An integrated local service, low thresholds • User oriented and user cooperated services and resources • Ambulant specialists Escalation of: • Common human language, cooperation and ”Care” Reductionof: • Expert language, medicalisation/psychologization and ”Cure” This will move us towards a better practice Akureyri May 7-8 2009 TJE

  18. Thank you! Akureyri May 7-8 2009 TJE

  19. Challenges in practice • Get access with the patients subjectivity • Create hope and belief in coping • Create experience of coping • Create trust in ability to cope • Create trust and recovery of ”a speaking I” The medical model restrain this because: • It focus on pathology/problems instead of resources • Ignore context (local and cultural) • Objectify the service users • Ignore the patient agency Akureyri May 7-8 2009 TJE

  20. Diagnosis-driven, “illness model” Prescriptive Treatments Emphasis on quality and competence Cure of “illness” Client-directed (Fit) Outcome-informed (Effect) Emphasis on benefit over need Restore real-life functioning The Contextual Model: The Medical Model: Akureyri May 7-8 2009 TJE

  21. Summing up…. • In medicine ”evidence based” can function well when the diagnostic validity is high and the working theories are adequate • In mental health and addiction therapy ”evidence based” gives wrong focus Implication • Reduce complexity • Foster medical and mechanical methods • Exaggerate the technical on behalf of the relational and communicative in treatment Akureyri May 7-8 2009 TJE

  22. Some problems • Standardization not efficient if ”best treatment” is individualization • Many health problems without evidence based treatment • The average patient does not exist in practice • ”Absence of evidence is not evidence of absence” • Weak relation between diagnose and therapy method • Marginalization of other kinds of knowledge • Increase the danger to objectify the patient • Less creative practice • Disguise the contextual difference between practice and research • Research informed practice a better strategy than research governed practice Akureyri May 7-8 2009 TJE

  23. Forty years with empirical research on psychotherapy • Therapy works (80% compared to no therapy) • Enduring effects for most patients • No difference between different methods (Dodo-verdict) • Diagnose alone doesn't predict ”best treatment” • The method explain little variance (3-15 %) • Therapists and patients belief in the method explain 2-3 ganger more variance than the method alone • No stable relation between specific technique and outcome • Best predictors are relation and early improvement Akureyri May 7-8 2009 TJE

  24. I medisinen er EBM eit heitt debattema: ”The initially refreshing educational approach of clinical epidemiology has been horribly transformed into the bureaucratic monster of evidence based medicine” (Fowler,1997) Akureyri May 7-8 2009 TJE

  25. Bergin og Garfield (1994) held det som eit viktig funn at «...it is the client more than the therapist who implements the change process» (s.824) Akureyri May 7-8 2009 TJE

  26. «Despite volumes devoted to the theoretical differences among different schools of psychotherapy, the result of research demonstrate negligible differences in the effects produced by different therapy types». (Smith og Glass, 1977, s.760) Akureyri May 7-8 2009 TJE

  27. Systematic use of a human relationship «What appears to matter most in psychotherapy is the interaction of patient`s interpersonal style with the therapist`s skill in managing the interpersonal climate. (....) In this view, psychotherapy is defined as the systematic use of a human relationship for the therapeutic purpose». (Butler og Strupp, 1986, s.36) Akureyri May 7-8 2009 TJE

  28. A new deal? Instead, greater scientific promise lies in the recognition that psychotherapy cannot be meaningfully reduced to «factors» independent of a particular interpersonal context. (......) What is needed is a new approach or paradigm through which to conceptualize and investigate psychotherapy (Butler og Strupp, 1986, s.31 og s. 37) Akureyri May 7-8 2009 TJE

  29. Min konklusjon • Dette er kunnskap basert på ein ”objektivert” brukar • Der er ingen evidens for evidensbasert behandling når det gjeld kommunikativ praksis • Slik praksis må vere skreddarsaum • Vi treng kunnskap som styrker den relasjonelle og kommunikative kompetansen Akureyri May 7-8 2009 TJE

  30. Konklusjon på behandlingsforskinga Frå Det andre (sjukdomen) Til Den andre (den sjuke personen) Frå behandling Til Samhandling Akureyri May 7-8 2009 TJE

  31. Noen implikasjoner av den empiriske forskningen: • Den terapeutiske teorien (modellen) fungerer terapeutisk først og fremst for terapeuten • En terapeutisk metode kan være virksom uavhengig av dens empiriske eller vitenskaplige grunnlag • Psykoterapi er kontekstuell medisin (metamodell) Akureyri May 7-8 2009 TJE

  32. Jerome Frank (1961): • An emotional and trusting relationship • A healing setting in which the client or clients meet a professional whom they believ can help them • A rational group of concepts or the creation of a myth that is able tyo provide a plausible explanation • A belief in the treatment itself (Persuasion and healing) Akureyri May 7-8 2009 TJE

  33. To eksistensielle grunnvilkår • Vi er relasjonelle vesen – avhengigheit er føresetnaden for identitet og sjølvoppleving • Vi er ”meaning makers” – sjølvfortolkande vesen – og meining er føresetnad for ontologisk tryggleik • All meiningsdanning er relasjonell Akureyri May 7-8 2009 TJE

  34. Davidson et al 2007 Bedringsprosessen dreier seg om å gjenskape en opplevelse av tilhørighet i sitt lokalmiljø samt en positiv følelse av identitet utenfor ens problemer, i arbeidet med å skape seg et liv på tross av eller innenfor begrensningene ved situasjonen man er i. Akureyri May 7-8 2009 TJE

  35. Etiologiske mønster ved psykiske lidelser • Ekvifinalitet: ulike årsaker, samme virkning • Multifinalitet: samme årsaker, ulike virkninger • Store årsaker gir små virkninger • Små årsaker gir store virkninger Akureyri May 7-8 2009 TJE

  36. Bakgrunn • Høgt tempo i kunnskapsproduksjonen • Informasjonsoverload og motseiande bodskap frå kunnskapsverda • Behov for oversikter, sortering, syntetisering og formidling av kunnskapsstatus om gitte forhold, t.d. effekten av ulike tiltak (medisinske, sosialpolitiske osv....) Akureyri May 7-8 2009 TJE

  37. GullstandardHierarki av evidens (Geddes & Harrison, 1997) • Metaanalyse av RCT-studiar • Minst eit RCT-studie • Minst ein kontrollert studie utan randomisiering • Minst ein annan type kvasieksperimentell studie • Ikkje-eksperimentelle deskriptive studiar • Ekspertrapportar/eksperterfaringar Akureyri May 7-8 2009 TJE

  38. Empirisk pragmatisme ”Kunnskapssenterets rolle vil særlig være knyttet til det å evaluere og måle og ikke det å forstå mer grunnleggende mekanismer eller fortolke opplevelser og sammenhenger.” (Nasjonalt kunnskapssenter for helsetjenesten, 2005) Akureyri May 7-8 2009 TJE

  39. Metodemetafysikk ”Når det gjelder spørsmål om effekt av tiltak, er det Kunnskapssenterets syn at det finnes et hierarki hvor kunnskap fremskaffet med gode randomiserte kontrollerte studier (RCT) er bedre og mer gyldig enn annen kunnskap”. (Nasjonalt kunnskapssenter for helsetjenesten, 2005, s. 7). Akureyri May 7-8 2009 TJE

  40. Dessutan: • Kvar er evidensen for at implementering av EBP gir betre praksis enn ”vanleg” praksis? • Dette er ein empirisk påstand som ikkje er godt dokumentert Akureyri May 7-8 2009 TJE

  41. Litt presisering: Det uproblematiske: • Bruk av vitenskap - ”evidensbasert” og annen • At forskning etterprøver og evaluerer praksis • At forholdet mellom forskning og praksis er basert på dialog Det problematiske: • Misbruk av vitenskap - pseudovitenskap • At skillet mellom vitenskap og praksis blir tilslørt • At vitenskapen opptrer monologisk (styring) • Evidensbasert praksis Akureyri May 7-8 2009 TJE

  42. How to Improve by 65%:Pop Quiz True Question #6: The bulk of change in successful treatment occurs earlier rather than later. If a particular approach, delivered in a given setting, by a specific provider is going to work, there should measurable improvement in the first six weeks of care. Akureyri May 7-8 2009 TJE

  43. How to Improve by 65%:Pop Quiz • Last Question! • The best way to insure effective, efficient, ethical and accountable treatment practice is for the field to adopt and enforce: • Evidence-based practice; • Quality assurance; • External management; • Continuing education requirements; • Legal protection of trade and terminology. False Akureyri May 7-8 2009 TJE

  44. How to Improve by 65%:Pop Quiz True Question #6: The bulk of change in successful treatment occurs earlier rather than later. If a particular approach, delivered in a given setting, by a specific provider is going to work, there should measurable improvement in the first six weeks of care. Akureyri May 7-8 2009 TJE

  45. Old and new heroes Sigmund Freud (1856-1939) Emil Kraepelin (1856-1926) • That other • Objectification • Explain • causality • Treatment • The other • Subjectification • Understand • Intentionality • Cooperation Akureyri May 7-8 2009 TJE

  46. Part of a world wide trend not specific to mental health and independent of any particular type of reimbursement system. • “Accountability,” “Stewardship,” & “Return on Investment” the buzzwords of the day. Akureyri May 7-8 2009 TJE

  47. Evidens........ • Eit pluss-ord: Evidensbasert praksis, evidensbasert politik, evidensbasert medisin, sjukepleie, sosialt arbeide, pedagogik, leiing, fangebehandling...….. • Evidens i tydinga systematiske kunnskapsoversikter • Nye internatsjonale og nasjonale organisasjonar som spesialiserer seg på å produsere og formidle systematiske kunnskapsoversikter, f. eks. Cochrane, Campbell, EPPI, SCIE... • Ofte semistatlege med rådgivingsoppgåver (f.eks. Nasjonalt kunnskapssenter for helsetjenesten) , Akureyri May 7-8 2009 TJE

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