L6: CBT Flashcards
define evidence-based psychological practice (EBPP)
integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences
what is the phenomenon of “therapist drift”?
the tendency for psychologists to move away from the delivery of the evidence based practices (EBPP) in which they are trained, even when resourced to implement them (which may be ineffective/harmful for client)
what are 9 therapist characteristics that correlate with therapist drift?
- lack of therapist knowledge on how to integrate research w practice
- negative attitutdes toward research, innovation, and evidence
- therapist anxiety
- lack of clinical experience
- therapist age (not sure how)
- theoretical orientation away from EST
- lack of critical thinking
- personality traits (needs more research)
- cultural competency (ethnic similarity between therapists & patients associated w greater adherence to ESTs)
what are some ways to address therapist drift?
- screening prospective psych students based on personality correlates
- increased monitoring of therapist adherence to EBT (evidence based treatments)
- enhancing therapist learning throughout their careers
- didactic training complemented by competence training (especially trhough clinical supervision)
- supervisors & supervisees should develop atttitudes & skills that support ethical practice & fidelity to ESTs
- Continuing professional development (CPD° programs for psychologists should be regulated to discourage therapist drift
where does therapist’ lack of knowledge on empirically valid practices come from?
- have difficulty differentiating between ESTs and non ESTs
- ignore recent treatment developments in favor of treatments in which they may have been trained
- are skeptical about use of therapy manuals, believing that they inhibit the therapeutic relationship
what treatment do we know work best?
- therapy generally more effective than no treatment/placebo
- majority of patients show (long term) improvement w therapy
- guides for effective treatments for specific disorders, but also some concerns about potentially harmful therapies sill in use
- Efforts to incorporate evidence-based practice into clinical guidelines or individualized case formulations (but issues w validity & reliability)
- mix of therapies often used but may pose risk if not guided by evidence (aka empirically supported treatment ESTs)
- clinicians modd & perpection often affect treatment decisions
is evidence based practice being conducted in routine settings?
- Transition from efficacy in controlled settings to effectiveness in real-world settings comes at the cost of reduced internal validity
- Clinical guidelines are popular for bridging science and practice in routine care
- Initiatives like STAR*D program and IAPT in the US and UK respectively have shown effectiveness in implementing guidelines in primary care
- other efforts to enhance evidence based practice include comprehensive cohort studies & assessment of therapist effects
- challenges remain in measuring clinician performance & identifying effective therapists
what are some challenges in implementing an evidence based practice?
Randomized controlled trial (RCT) findings may not be directly applicable to clinical practice due to:
- Non-representative samples in RCTs compared to wider clinical populations
- Inflexibility and lack of adaptability of treatments in RCTs compared to real-world settings
- Reluctance of clinicians to use evidence-based techniques, sometimes due to discomfort or safety concerns
- Discrepancies in focus between clinical care (life functioning, coping, quality of life) and research design
what could be a solution to some of the challenges in implementing an evidence based practice?
Multifaceted programs combining organizational change, education, and feedback
why is monitoring outcomes in therapy essential?
for addressing individual patient concerns & improving treatment effectiveness
how are some ppl trying to bridge the gap between evidence-based practice and practice-based evidence?
proposals for incorporating practice and service systems research into treatment research to enhance the relevance and rigor of the evidence base.
what do we know about measuring effectiveness?
- Psych research relies on stat significance to demonstrate change, while practice relies on efficacy studies to justify treatment
- stat significance alone may not indicate magnitude of change or within group variabilitiy
- Within-group variability often increases as a result of therapy, meaning not all individuals improve following treatment.
- recommend citing effect size
- also need clinically meaningful change aka significance in symptoms and functioning. can show this through providing insights into treatment effectiveness and identifying patients who do not respond positively to treatment.
- Clinical significance is an essential step in bridging the gap between research and practice in psychology, but its impact on clinical care remains a question.
are appropriate definitions of change being used to determine treatment effectiveness?
- def have changed
- “clinical significance” gained attention since 1989
- CS often assessed retrospectively in outcome studies, providing valuable insights into treatment effectiveness.
- but variations in reporting CS so challenges exist due to differering methodologies etc
- simplifying outcomes into recovered and non-recovered categories using the number need to treat (NNT) statistic can help
what is meant by clinical significance?
proportion of patients achieving meaningful recovery, improvmenent, no change, or deterioration during therapy
what are some remanining challenges in the measurement of outcome?
- approximately 35-40% of patients experience no significant benefit, while 5-10% may deteriorate during therapy
- so merely assessing outcomes at admission & discharge is insufficient to address cases of non-improvmeent, real-time action during treatment is necessary
what is patient focused research?
aims to respond to indications that patients are not improving during therapy, and address those concerns in real time for the benefit of that individual (instead of looking at the average patient)
how good/bad is clinical judgment in identifying when treatment isnt working?
- tend to be overly positive, compared to patients reported
- difficulty identifying patients who arent making progress/deteriorating
- can accurately identify which patients were worse off during a specific session but struggled to integrate this info into overall patient progress
- ## clinicans are poor judges of patient progress & outcome
what purpose do errors in clinical judgment serve?
protective function, allowing clinicians to maintain hope and experiment with new techniques in case the treatment plan fails.
what can be done about clinical judgment errors?
develop an effective system for assessing patient progress (ex through progress monitoring & feedback)
how good/bad is patients judgment in identifying when treatment is/isnt working?
- not very accruate
- discrepancies between self reported symptom improvement and patient satisfaction
- retrospective patient satisfaction may not accurately reflect therapy outcomes -> need objective measures
