EVIDENCE-BASED PRACTICE IN THERAPY
Sri Kothur, M.S., Therapist
When clients decide to start therapy, they are faced with many choices. It is critical for clients to consider and understand the type of treatment offered. Evidence-based practice is the use of scientifically supported treatments studied in large scale clinical trials that show symptom reduction, which can often last well after the end of therapy. Unfortunately, many clients (and some practitioners) are not aware of this, and clients do not receive the most safe, effective, and appropriate types of treatment. Other therapies exist; however, they have not been evaluated with requisite scientific rigor. There is much debate about what evidence is sufficient to constitute an evidence-based treatment. Currently, for a treatment to be designated as having strong support there must be at least two well-designed clinical studies that exhibit significant results in comparison to controls or other established treatments.
However, making the list of evidence-based treatments does not always mean they are sound. There are some evidence-based treatments that are controversial due to an unsubstantiated mechanism of action. For example, Eye Movement Desensitization Reprocessing (EMDR) is a posttraumatic stress disorder (PTSD) psychotherapy that combines eye movements with cognitive processing. EMDR shows significant symptom reduction; however, the same treatment without the eye movements accomplishes equivalent results. The eye movements appear to be an unnecessary component unrelated to the active ingredient – exposure.
It is important to remember that the specific disorder and client preferences are significant in selecting the therapy options with the greatest chance to benefit the client. There is no one treatment that is optimal for all clients with a given disorder. Clients should have the opportunity to collaborate with their therapist in order to determine the course of therapy. Though evidence-based practice is important, the therapeutic relationship between client and therapist is also critical. Nonspecific factors play a significant role. These are factors evident in most psychotherapies, and are unrelated to the specific modality. Examples include therapeutic alliance, empathy, genuineness, positive regard, and therapist’s competence.
The following is a small sample of evidence-based treatments that have strong supportive evidence.
Depression: Given the prevalence of major depressive episodes (6.7% of US adults in the past year), research on depression has yielded several effective types of therapy.
Behavioral Activation is based on the idea that individuals withdraw from their environment when depressed. Withdrawal perpetuates the depression since individuals are then unable to be rewarded by engagement in pleasant activities. Behavioral activation seeks to change this by increasing opportunity and contact with activities that are likely rewarding.
Cognitive Behavioral Analysis System of Psychotherapy (CBASP) incorporates features of cognitive, behavioral, interpersonal, and psychodynamic therapies. This highly structured treatment focuses on the role of interpersonal connectedness. The primary tool is the Situational Analysis, a problem-solving technique that helps clients identify and modify behaviors and interpretations in order to achieve desired outcomes. Additional techniques include differentiation between traumatic and healthy relationships, and assertiveness training.
Panic Disorder: Panic attacks are characterized by unexpected spikes in anxiety and fear that last about 10 minutes. They are accompanied by a host of physical symptoms. Furthermore, there is fear of future panic attacks and panic-related consequences.
Cognitive Behavioral Therapy is the only therapy with strong support for Panic Disorder. Like CBT for other disorders, the treatment’s theoretical foundation is the relationship between thoughts, feelings, and behaviors. CBT for panic educates the client about symptoms and modifies dysfunctional beliefs related to panic attacks. Exposure interventions include in vivo (e.g. going to a place where panic is expected), and interoceptive (e.g. intentionally inducing and habituating to panic-related physical sensations). Relaxation techniques such as diaphragmatic deep breathing and progressive muscle relaxation are also utilized.
Bipolar Disorder: This disorder has a 12 month prevalence of 2.6%. It is characterized by periods of mania and depression. Per the DSM-5, a manic episode is a “distinct period of abnormally and persistently euphoric or irritable mood that lasts at least 1 week.” Hypomanic episodes are less severe in that symptoms must last at least 4 consecutive days. Treatments of mania and depression are evaluated separately.
Psychoeducation (for mania) involves educating clients about bipolar disorder, especially the biological basis. The purpose is to increase medication compliance. Additionally, clients learn warning signs for an impending episode.
Systemic Care has strong support for treatment of mania. It consists of a system-level treatment and group therapy. One system is an outpatient team (psychiatrist, nurse care coordinator) capable of providing regular appointments and telephone consultations. In addition, group psychoeducation focuses on targets similar to the aforementioned psychoeducation. Self-management plans with coping strategies are also utilized.
Posttraumatic Stress Disorder: PTSD may develop after a person experiences, directly or indirectly, an “actual or threatened death, serious injury, or sexual abuse.” Furthermore, individuals experience numerous symptoms from several categories related to intrusive memories, avoidance, negative affective changes, and increased arousal.
Prolonged Exposure Therapy is based on the idea that repeated exposures to trauma thoughts, feelings, and situations lead to less distress. The first technique is imaginal exposure, which consists of repeated recounting and processing of the traumatic event. The second technique is in vivo exposure, which requires the client to confront avoided stimuli (e.g. places, people) that were considered benign and safe prior to the trauma.
Person-centered Therapy does not focus on trauma. Rather, the targets are maladaptive relationship patterns and behaviors, psychoeducation about the impact of trauma, and problem solving skills.
References:
http://www.div12.org/psychological-treatments/
http://www.minneapolis.va.gov/services/MentalHealth/MHebt.asp
http://www.nimh.nih.gov/health/statistics/index.shtml
http://www.psychology.org.au/publications/inpsych/treatments/
http://ct.counseling.org/2012/12/a-new-view-of-evidence-based-practice/
