Pierre Desjardins, psychologist Director of quality and development of practice [email protected] 1

EVALUATING THE EFFICACY OF

PSYCHOLOGICAL SERVICES

SYMPOSIUM PRESENTATION FOR THE CANADIAN SOCIETY FOR PSYCHOTHERAPY

RESEARCHMONTRÉAL, OCTOBER 2009

Pierre Desjardins, psychologistDirector of quality and development of

[email protected]

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OPQ POLICY STATEMENT

The purpose of evidence-based practice in psychology (EBPP) is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention.

Excerpt from the OPQ policy statement on evidence-based practice

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MENTAL HEALTH

Context:

Individuals suffering from significant mental illnesses

Identification of specific problems that have been thoroughly researched (e.g., anxiety disorders and depressive disorders)

Limited supply of services given a financial and human resources

Importance of protecting the public and assuring adequate services (in the wake of Bill 21)

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FACTORS TO CONSIDER

Clinical decisions should be made in collaboration with the patient, based on the best clinically relevant evidence, and with consideration for the probable costs, benefits, and available resources and options.


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THE IMPORTANCE OF PROFESSIONAL JUDGMENT

Treatment decisions should never be made by untrained persons unfamiliar with the specifics of the case.


The Trudeau report indicates that the initial assessment constitutes one of the key elements of psychotherapy. This applies equally to all services offered to clients.

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EVIDENCE-BASED PRACTICE:THE ONE AND ONLY REFERENCE?

It is important not to assume that interventions that have not yet been studied in controlled trials are ineffective.


Significant Risks:Reducing the amount of services offered and the limiting the diversity of treatment modalities.Affecting the quality of the services to clients who have comorbid diagnoses or clients who have an Axis II diagnosis.

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THEORETICAL MODELSOPQ:

Cognitive Behavioural Existential-humanist Psychodynamic-analytical Systemic-interactional Social-community

Trudeau Report: Cognitive Behavioural Humanistic Psychodynamic Systemic and communication theories

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PLEASE, BE RIGOROUS!

However, widely used psychological practices as well as innovations developed in the field or laboratory should be rigorously evaluated…


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CLIENT CHARACTERISTICS

Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.


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FOR MAXIMUM EFFICACY

The involvement of an active, informed patient is generally crucial to the success of psychological services.


Adapting services to the client’s personality, specific problems and strengths, as well as to his or her socio-cultural context and personal preferences fosters the development of a stronger therapeutic alliance and the achievement of treatment goals.

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CLINICIAN CHARACTERISTICS

Integral to clinical expertise is an awareness of the limits of one’s knowledge and skills and attention to the heuristics and biases—both cognitive and affective—that can affect clinical judgment. Moreover, psychologists understand how their own characteristics, values, and context interact with those of the patient.


Thereby reducing the relevance of third-party treatment decisions

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THE KEY: EVALUATION

The treating psychologist determines the applicability of research conclusions to a particular patient. Individual patients may require decisions and interventions not directly addressed by the available research. The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential to EBPP.

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THE KEY: EVALUATION

Importance of evaluating available research data

In order to ensure the relevance and validity of research and evidence based practice

Note: The competence research is one out of 7 that psychologists acquired during their curriculum (initial training) and it refers notably to the ability to read, understand and interpret research results and to be an informed consumer

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THE KEY: EVALUATION

Importance of assessing the impact of various interventions

To go beyond probabilistic inferences To counter any biased positions or personal

prejudices To adjust the services offered to clients, taking into

account their progress, their reaction to services and their understanding of their treatment

As a measure of accountability vis-à-vis those requesting the services (e.g., the CSSS who expects that his psychologists provide services both effective and efficient)

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ETHICAL COMMITMENTS

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DIGNITY AND PERSONAL FREEDOM

3- In their practice, psychologists must show respect for the dignity and freedom of persons.

Importance of recognizing that each client is a unique individual

Importance of providing the client with choice, and being sure not to ignore who the client is and what he wishes or requests

Importance of not imposing anything in the name of science, personal beliefs or convictions

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IN SUPPORT OF SCIENCE

5- In keeping with good practice in psychology, psychologists must practice according to generally recognized scientific and professional principles.

Professional practice depends both on scientific grounds as well as a professional foundation

The scientific mind should prevail in practice as it does in research

The scientific mind should be distinguished from the scientific method

Some approaches are more amenable to classical and current scientific measurement

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THE INFLUENCE OF RESEARCH: IS THERE A DOWNSIDE?

6- The psychologist takes into account all foreseeable consequences on society, research and practice

What is the impact of such extensive research focused on CBT, and widely spreaded, on the future of psychological practice?

On membership On the diversity of services offered On the development of innovative approaches On insurance coverage

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HOW TO MINIMIZE THE EFFECTS OF SUBJECTIVITY

7- Psychologists must discharge their professional obligations with competence, integrity, objectivity and moderation.

Psychologists must avoid any misrepresentation with respect to their competence or the efficiency of their own services or those generally provided by the members of their profession.

Only working with approaches in which one is trained and competent

Having the necessary knowledge to take things into account

Being able to judge the relative effectiveness of services Maintain up-to-date skills based on current findings

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THE FRAMEWORK, THE CLIENT, & THE PSYCHOLOGIST

10- Before agreeing with a client to provide professional services, psychologists must consider the client's request and expectations and the extent of their skills and means at their disposal.

Considerations: Standards of practice and treatment methods that fit

the mandate (referring to evidence based practice) Scientific expertise, if required The nature and extent of services that employer has

to offer or that the client could afford

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EVALUATING THE RESEARCH

Free and informed consent:

11,1- the objective, nature, relevance and main terms of the professional services, the advantages and disadvantages of the services and alternatives, the limits and mutual responsibilities of the parties, including any agreement on fees and terms of payment;

Clearly present what services can be offered based on the framework, knowledge and research, in terms of the initial assessment and proposed treatment plan

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FREEDOM OF CHOICE VS ALLIANCE RUPTURES(Free and informed consent)11,2- the possibility of refusing the professional

services offered or ceasing to receive professional services at any time;

42- Psychologists must acknowledge the client's right to consult another psychologist or any other competent person. Psychologists may not, by any means whatsoever, interfere with the client's freedom of choice.

Given the client’s right to leave therapy, involve the client in ongoing evaluations of the services, thereby reducing the client’s likelihood of prematurely ceasing therapy

True freedom of choice requires that the client be fully informed about the treatment, including its potential effectiveness

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THE CLIENT, A HOSTAGE?23- Psychologists must subordinate their personal

interests or, where applicable, the interests of their employer or colleagues to those of their clients.

30- Psychologists must not use the professional relationship established with a client for personal, political or commercial purposes.

66- In their practice, psychologists must preserve their professional autonomy and recognize that they are not required to perform any task contrary to their conscience or to the principles governing their practice…

Because the employer’s (the province, CSST…) priority is the client base and the psychologist works with individual clients, there may be conflicts between these parites Avoid fruitless confrontations (recommended approaches,

other available methods) psychologist/employer, psychologist contract worker/organisms giving mandates

Provide the best possible services23

THE RELEVANCE OF MEASURING TREATMENT EFFICACY

28- Psychologists must not, for the same client, intervene in a manner that is likely to affect the quality of their professional services.

Given the type of services provided, is a program evaluation of a service’s effectiveness appropriate?

Rather, positive effects on treatment outcomes result when the effectiveness of treatment is assessed with the client.

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38- Psychologists must establish a psychological diagnosis in respect of their client and give advice to the client only if they have sufficient professional and scientific information to be able to do so.

39- Psychologists must develop, perfect and maintain their knowledge and skills in the field in which they carry on their professional activities.

Necessity of knowing and properly evaluating research that affects your clients and the specific problems that are often encountered in your practice

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NOT JUST A BUNCH OF HOT AIR!

EMPOWERMENT OF CLIENTS

41- Psychologists must seek to establish or maintain a relationship of mutual trust and respect with their clients.

A good way to do this: empowerment. Giving voice to the client and proceed with him or her to assess the effectiveness of services.

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DOING WHAT WE HAVE TO: NOT MORE, OR LESS44- Psychologists may not persistently or

unwarrantedly urge a person to have recourse to their professional services.

45- Psychologists may not perform unwarranted professional acts or unnecessarily increase the number of such professional acts, and must refrain from performing acts that are inappropriate or disproportionate to the client's needs.

Could misunderstanding of research findings result in a psychologist inappropriately initiating treatment?

Is psychoanalytic treatment appropriate first-line treatment? Or should first-line treatment for depression be limited to 6 sessions of CBT?

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MEASURES OF EFFICACY:USING THE RIGHT TOOLS47- Psychologists must comply with the scientific and

professional principles generally accepted in psychology when using, administering, correcting and interpreting psychological tests, and when publishing tests and information that must be provided with the related manuals and documents.

48- Psychologists must recognize the inherent limits of the measurement instruments they use and exercise caution in interpreting the psychometric material…

Avoid improvising and resorting to rough guess Rely on the use of valid instruments

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A CRITICAL VIEW59- Psychologists who give information to the public

on psychological procedures and techniques must indicate the restrictions, limits and contraindications that apply to their use.

61- Psychologists acting as professional consultants informing the public must stress the relative value of the information or advice being given.

How can a psychologist do this if he has not learned to critically analyse research?

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CREDIBILITY OF THE PROFESSION AND OF THE DISCIPLINE60- Psychologists must avoid publicly discrediting,

without substantiation, any traditional or new psychological techniques that differ from those they use in their practice if the techniques are consistent with the professional and scientific principles generally accepted in psychology.

62- To the extent of their resources, qualifications and experience, psychologists must seek to promote the development and credibility of the profession.

The risks of discrediting a colleague or a specific approach leads to discrediting the discipline of psychology, undermining public confidence and creating a barrier to consultations

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ASSESSING PROGRESS: A NECESSITY76- Psychologists who are involved in the commercial

distribution of instruments, books or other products related to psychology must base any statement concerning the operation, advantages and performance of such products on proof scientifically and professionally recognized in psychology.

77- Psychologists must be able to substantiate the special skills or qualities they claim to possess in their advertising, in particular as to the effectiveness or scope of their professional services and to those generally provided by other members of their profession, or as to their level of competence.

How can we comply with these provisions without either sacrificing scientific inquiry or the services we offer?

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TO THINK ABOUT!

How do we define scientific and professional? Am I a scientist/professional or a believer? Does objectivity exist? Is the client held hostage to my beliefs and

convictions? Can the client decide which services he should

receive? Does professional autonomy mean that I can make

all my own decisions? Can a boss, a physician or another colleague decide

what treatment I should use? Are there limits to my creativity?

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A FEW REFERENCES Les données probantes: science et

dogmatisme, Psychologie Québec, novembre 2005

Les données probantes en psychothérapie: pour qui, pourquoi?, Psychologie Québec, janvier 2007

Psychologie Québec, septembre 2007 (numéro thématique intitulé: Évaluer ses interventions)

La psychothérapie: recherche et pratique, Psychologie Québec, mars 2008

La recherche en psychothérapie: des échos du congrès, Psychologie Québec, janvier 2009

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CONTACT INFORMATION

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Documents

Pierre Desjardins, psychologist Director of quality and development of practice [email protected] 1