TIPS & TOPICS
Volume 6, No.10
In this issue
— STUMP THE SHRINK
— SUCCESS STORY
— Until Next Time
Welcome to all the new readers who joined us this month and to our long-term readers as well. I understand we all receive a lot of information in our inbox each day; I appreciate your taking the time to look this edition over.
When visiting Australia in January, I heard great debate about stimulus bills and ways to revive the economy. Here in the USA, the same thing. On February 16, the New York Times reported that: “The $787 billion economic stimulus bill approved by Congress will, for the first time, provide substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness.” It makes sense to be sure that healthcare dollars are spent wisely and effectively; and there is a constant drumbeat for evidence-based practice at work, conferences and in funding decisions.
From time to time, I have respected friends and colleagues contribute his/her ideas to Tips and Topics. The following cautions came a few weeks ago from Norman G. Hoffmann, Ph.D., Adjunct Professor of Psychology, Western Carolina University and President, Evince Clinical Assessments.
- Routine Outcomes are the Best Evidence.
The “evidence-based” craze sweeping the country is likely to impede progress in promoting the overall effectiveness of treatment services for substance use disorders. A more logical, practical, and effective approach is to implement outcomes-based treatment services. Outcomes-based treatment relies on routine, real-time and real-world monitoring of key outcome indicators observable during the treatment continuum-especially during maintenance services often referred to as aftercare. Simply implementing an “evidence-based” program does not necessarily result in effective treatment.
Care should be taken in dealing with so-called “evidence-based” treatment models.
- This usually means that there has been some study documenting that under certain conditions (usually rigorous randomized clinical trials) the model shows positive outcomes or outcomes superior to other models.
- This does not guarantee that the model will necessarily yield similar results when applied in real-world situations or with populations that differ from those covered in the research. Most randomized studies require inclusion and exclusion criteria, a luxury not afforded to programs serving a broad range of clients.
- Additionally it is important that the “evidence” utilize measures that are relevant to the real world. Many studies rely, at least in part, on arbitrary metrics – measures that are reliable, scientifically valid, and yet irrelevant to the real world.
What relevant real-world measures?
One such measure is days of use during a given time frame – usually 30 days. Unless there is substance use which results in negative consequences or even qualifies for a diagnosis of substance use disorder, measuring “days of use” is arbitrary. One has to determine whether the client’s substance use interfered with functioning or if there are negative consequences of the use. Otherwise, days of use may be irrelevant. This is true when the metric, “days of use”, is used as a baseline measure or an outcome criterion.
A person who has only one glass of wine with dinner each evening would score a maximum score of 30/30 on this metric. On the other hand, a person who binges only on weekends, drives drunk and has all manner of consequences to meet dependence criteria would score only 8/30. Days of use is relevant only in context – where use is considered along with a diagnosis and other severity indices.
Consider the following hypothetical outcome results:
- Programs A and B each treat 100 individuals meeting criteria for substance dependence and who have an average of 25 days of use in the previous 30 prior to treatment.
- One year after treatment the average days of use for Program A is 11, and for Program B it is 8.
Which has the better results- A or B?
Now let’s look beneath the “days of use” metric.
- Program B has succeeded in getting the clients to restrict use to weekends, but all 100 still meet current criteria for substance dependence and continue to experience a range of negative consequences related to their use.
- For Program A, 52 individuals achieved stable recovery with abstinence, serenity, excellent social relationships and good vocational functioning. The other 48 still use substances at pre-treatment levels, but to some extent have minimized the consequences of their use.
To which program would you refer a client or family member- A or B?
Thus, days of use in whatever period of time is irrelevant unless one knows whether or not the individual is substance dependent in the first instance and whether there are continuing consequences of use or other indications of current abuse or dependence in terms of outcomes. As the only criteria, the measure, days of use, is an arbitrary metric – reliable, valid, and irrelevant. Only in the context of other measures does it contribute any valid information in terms of either severity or outcomes.
The Bottom Line
Don’t rely on “days of use” to tell you how well a program performs – even though this is often the primary measure of federally-funded clinical trials.
Assessment Instruments and “Evidence-Based”
An egregious misuse of the term “evidence-based” is in referring to assessment instruments. Diagnostic and treatment placement instruments either provide clinicians with useful, consistent, and defensible information or they do not. There is no “evidence-base” other than that. Diagnostic tools need to cover the diagnostic criteria in question (e.g., DSM-IV-TR or ICD-10) in a way to inform and support the clinician’s determinations.
Clinicians make diagnoses; instruments do not.
Treatment planning and placement instruments must provide information that clinicians can use to make clinical decisions. The “evidence” is whether the instrument covers placement criteria, such as the American Society of Addiction Medicine’s Patient Placement Criteria, Second Edition Revised (ASAM PPC-2R), or whether it provides information relevant to treatment planning.
Diagnostic and treatment planning/placement instruments are not psychometric instruments that have norms and psychometric characteristics such as standard deviations from the norm.
The utility of such instruments is whether they provide clinicians with the evidence to inform and support clinical decisions.
Clinicians make treatment decisions; instruments do not.
In the case of psychometric instruments that measure psychological constructs, such as self-esteem, intelligence, personality characteristics, etc., the developer of the instrument should have normative data and other empirical data to support the utility of the tool. These requirements have been standards of the American Psychological Association for decades and are by no means new to the evidence-based craze.
In short, employing “evidence-based” treatment models does not guarantee anything.
A recent meta-analysis of a large number of rigorous outcome studies determined that the overall differences among a range of treatment models were not statistically significant. Of the differences found, researcher allegiance to a given model was associated with the minimal differences observed.
(Imel, Z.E., Wampold, B.E., & Miller, S.D. (2008) Distinctions without a Difference: Direct Comparisons of Psychotherapies for Alcohol Use Disorders. Psychology of Addictive Behaviors Vol. 22, No. 4, 533-543.)
The Bottom Line
Only routine outcomes-based monitoring will identify whether programs are performing up to expectations. Without this, we will not know which programs or clinicians are producing excellent results and which are not. Additionally, only routine outcomes-based monitoring will able us to determine why the results are good or not.
References and Resources:
1. Hoffmann, N.G. (2009) Routine Outcomes Are the Best Evidence.Waynesville, NC: Author
Norman G. Hoffmann, Ph.D. Adjunct Professor of Psychology, Western Carolina University; President, Evince Clinical Assessments, 29 Peregrine Pl., Waynesville, NC 28786
2. Imel, Z.E., Wampold, B.E., & Miller, S.D. (2008) Distinctions without a Difference: Direct Comparisons of Psychotherapies for Alcohol Use Disorders. Psychology of Addictive Behaviors Vol. 22, No. 4, 533-543
For more on Evidence-Based Practices, refer to previous editions:
Having many tools in your clinical toolkit is important so you can quickly shift strategies if the outcomes are not going well. Evidence-based practices give you a wide range of guidelines and techniques to draw from when engaging and treating clients. But if you focus only on the particular model as if strict adherence to the model will automatically produce positive outcomes, expect to be disappointed.
- Even if you do not use formal measures of outcome and the therapeutic alliance, you can still be curious about these and check them out clinically.
–> Is your client missing appointments? Is she inconsistent in her attendance at sessions? Clients may be voting with their feet that treatment is not helping. You best listen to them to discover what is in your services that’s not working for them.
–> Is the client passively sitting in individual or group sessions? Do you feel like you are doing all the work? When a client is “doing time” not “doing treatment”, the clinical work may be focussed on something clearly not of interest to them. They are not pursuing changing in that area of focus. For example, if you’re zeroing in on abstinence when your client just wants to cut back their use, don’t be surprised if there is poor participation. Perhaps you are working on medication compliance for someone who thinks they are being poisoned; you will usually experience resistance and passivity.
–> Is the client relapsing with substance use or mental health signs and symptoms? The focus should not be on discharge or sanctions, but to revisit assessment. Recurrence of substance and mental health problems may be a a crisis, and can worsen. A client might not even agree there is an addiction or mental health problem to work on, therefore the strategies you’ve put in a treatment plan mean nothing to them. Engagement and motivational enhancement then becomes the clinical focus of attention. There’s many possible explanations for relapse. Maybe the person wants help, however what you worked out with them to do is too hard; maybe new obstacles have arisen; or they are demoralized and defeated that anything will work. Providing hope and collaboration on a realistic plan is then the next step.
–> How long since you revamped the service plan with the client- weeks, months? Does your client even know what their treatment plan says, what they want to do in group treatment or an individual session to advance their treatment plan? The treatment plan may either be so generic that it has no meaning as a “living document.” It might be out-of-date so neither you nor the client can remember it.
–> What is the quality of the therapeutic alliance you have with your client? Remember that a therapeutic alliance is not some nebulous, touchy-feely relationship. It is agreement on goals and strategies in the context of an emotional bond. This has the best chance of producing a positive outcome. If you work on things the client is not interested in; if you use methods and interventions that don’t make sense to them and their family members; if you raise issues in an atmosphere coercive of change rather than conducive of change, don’t be surprised if the outcomes are poor. And don’t blame the client for being non-compliant, resistant and unmotivated.
–> What variety of methods and models have you been drawing from to create a mix of clinical strategies? Ask this question especially if the client has been unengaged and passive with poor adherence. If something is not working, it’s time to quickly shift to a different method/model in collaboration with the client. Figure out what might work better to help the client get what they want. And they do want something from you or they wouldn’t be there. It’s just that what you want for them, and think they should do, might not be what they want and think should be done. But that is your problem, not their problem! That’s where evidence-based practices come in to play – to have enough tools in your clinical tool-kit to shift quickly when the outcomes are not going well.
On January 20, newly inaugurated President Obama said: “The question we ask today is not whether our government is too big or too small, but whether it works, whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end.”
I might re-phrase this: “The question we ask today is not whether treatment should be with this evidence-based practice or that model or this ideology, but whether it works, whether the treatment helps clients and families find hope and wellness, care they can understand, a life that is dignified and full. Where the answer is yes, we intend to move that treatment forward. Where the answer is no, that treatment will end and new strategies will take its place.”
Just as strongly-held beliefs can strangle any chance for bipartisan collaboration and effective consensus-building, witness the difficulties we have in the healthcare field. People of goodwill still struggle to integrate mental health and addiction services. Still, too many people with co-occurring disorders fall through the cracks. Too many emergency rooms still have the unwritten sign above their door that says: “Alcoholics need not apply.” Addiction treatment professionals send a relapsing person away, telling him to come back sober, when we would never tell someone depressed, psychotic, manic or panicky to go away and come back when they are stable.
I recognize the dangers of “the end justifies the means.” So I am not suggesting all that counts is the result, and that it’s ok to use abusive or unethical means. Nor am I saying that the “destination” is more important than the “journey.” There are rewards, joys and benefits in the process of getting there. There are elements of truth in all these pithy sayings. But too often – in the name of program purity, fidelity to a model or practice guideline or rigid compliance with a policy – we lose our focus on what works for clients and families.
It’s time for a change.
STUMP THE SHRINK
Dear Dr. Mee-Lee,
I have heard recently that the Stages of Change may be losing favor. If this is so, how will this impact ASAM Patient Placement Criteria assessment Dimension 4, Readiness to Change, which my agency uses weekly in our treatment team meeting to rate where our clients are in treatment?
Lynn A. Garcia, CSAC.
There are some researchers who question whether you can really categorize people into neat stages of Precontemplation, Contemplation, Preparation and Action and whether those stages are valid as to how people move through stages. And it is true that stages of change should not, in my opinion, be used as a strict categorization of clients, therefore developing programs as if people are in these fixed stages.
What I usually say is that if the client is there talking to you in treatment, then they are in the Action stage for something e.g., staying out of jail; getting their kids back; keeping their job. They may be in Contemplation or Precontemplation as regards to what WE think they should work on – e.g., abstinence, recovery etc. But of course we should start with where THEY are at, not where WE think they should be at.
Also, a client may be at Action for a mental health problem, at Action for stopping alcohol but at Precontemplation for stopping marijuana. If Stages of Change is used in this way to identify what a client is ready to work on, then it is a very helpful model to help clinicians stay close to what is important to the client. If you use it as a labeling method to put a client in a program based on a Stage of Change level, then it is this way of understanding Stages of Change that I believe is losing favor; and it should lose favor.
ASAM Dimension 4 is not married to a particular model alone. It is just saying that we should assess a person’s interests and readiness to change whatever model or method you use to assess that. It is a generic assessment concern that should be addressed for any client.
Sent: Saturday, January 31, 2009 6:51 AM
I just wanted to let you know that this month’s Soul (January 2009) re-awakened something from my “past life” that I will use when clients come to me and voluntarily start telling me about their past. Today I let them talk and occasionally ask questions. I need to go the next step and ask what “worked” in their life. That way they should leave our conversation with not just saying “Thanks for listening”, but also a positive feeling that their life wasn’t all bad and that they can control their future.
At one time in my “past life” I was the manager of a small software integration and test group for a large computer company. After each software release we used to meet with other groups to discuss what needed to improve for the next release. We always went around the table with each person saying something, capturing it on a flip chart, and then voting on the five top things to focus on fixing for the next release. It always became a finger pointing exercise over every small detail that “didn’t work”.
One year the manager running the session started out by saying that this time we must first identify one thing that went right before identifying one thing that went wrong. When it was your turn, if you didn’t have one good thing to identify, then you had to pass. No repeats. There were many pluses that came from this:
1) The meeting was less than an hour instead of the 2+ hours of the past.
2) Only the important issues were presented, not the nitpicky items that weren’t really problems.
3) But most important was the focus on what went right. The meeting didn’t turn into a finger-pointing exercise. People felt good about being told what they did right that made it easier for other people. So when they walked out of the meeting they were upbeat and ready to start planning for the next release.
If we (I) can allow clients time to not just relate stories and feel good about that, but also to focus on what was/is good about their life, maybe they will take more control of their own recovery.
I read your newsletter each month. Please continue with the current format.
Until Next Time
Thanks for reading. See you in late March.
Copyright 2009 | DML Training & Consulting |