Apply the principle of evidence-based practice to actual and simulated case studies;
This assessment task covers learning outcomes 2 and 3:
• Apply the principle of evidence-based practice to actual and simulated case studies;
• Plan brief interventions that take account of the physical, psychological, social, cultural and spiritual needs of people with mental health issues and their carers;
• Describe the theoretical underpinnings and practice of psycho-education, motivational interviewing, Cognitive Behaviour Therapy(CBT), relaxation strategies, interpersonal therapy and narrative therapy
1. Interpersonal Psychotherapy, Motivational Interviewing, Narrative Therapy and Crisis Intervention describe four approaches to working with people suffering from mental health issues. Summarise these approaches in terms of:
(a) The underlying theories and important concepts related to the approach
(b) The therapeutic aims
(c) The role of the practitioner and the consumer in the therapeutic process.
(600 words, 30 marks)
2. Paul is a 22 year old, unemployed man from a Jewish background. He did well at school but has not been employed since. He lives with his mother, father and young sister in the suburbs. He studied IT at TAFE for one year but dropped out. He has recently been diagnosed with depression by his GP. He has difficulty sleeping, has lost five kilograms in the last ten weeks, feels tired all the time, and doesn’t leave his bedroom much. He doesn’t drink but he is a regular marijuana user. He has become isolated and spends a lot of his time playing computer games. He had a relationship with a girlfriend at school but has not been in a serious relationship for the last three years. He wants to become a creative writer, but finds it too hard to sit and write. He has a poor relationship with his mother who complains that he doesn’t do enough to help at home. His father is a professional musician and is disappointed that his son can’t find work. He is happy to attend counselling as he wants to feel better and doesn’t want to take anti-depressant medication. Choose two of these approaches and, for each approach, describe briefly how you would work with this consumer to create positive change for the consumer. Compare the effectiveness of each approach for working with depression, referring to the evidence-based literature to support your argument. Attach a research-based article (that you refer to in your answer) that demonstrates the efficacy of one approach for this mental health issue. Support your discussion with research-based articles wherever possible.
(1000 words, 50 marks)
3. Provide two brief examples of psycho-educational resources (no more than two pages each) that you would use with this consumer (or their carer) to educate them about two of the following in relation to their depression: their physical, psychological, social, cultural or spiritual wellbeing. Attach these examples to your assignment (and reference their source). Explain your rationale for choosing each resource and critically analyse their effectiveness, using references.
(400 words; 20 marks)
This is an academic essay and you are expected to use references throughout. You may use the first person when answering parts 2 and 3, but you still need to use references correctly in this part.
Note that students in the School of Health are required to follow the APA referencing style when presenting written work.
NOTE: The graed for this assignment is out of 100 and will be adjusted to relkect the 40% in Moodle once the assignment has been
2a. what is evidence-based practice?
READ: Chapter 8 “Does therapy work” in your text: Layard, R., & Clark, D. (2014). Thrive: The Power of Evidence-Based Psychological Therapies. Leicester, UK: Penguin. This chapter goes beyond just accepting success as evidence to understanding how we can really trust the evidence.
Within the mental health field, increasing emphasis has been placed upon the need to adopt evidence-based treatment approaches when working with consumers and their carers. One need only glance at the latest mental health journals or guidelines set down by the various governing professional bodies to discover which treatment approach has become the most recently ‘endorsed’. As Charman and Barkham (2005:8) have noted, “the most consistent message has been that best practice is determined by research evidence derived from comparing contrasting treatments.”
Interestingly, however, despite the push for the adoption of an evidence-based approach to mental health care, little consensus exists on what exactly constitutes ‘evidence’ (Eliason 2007). In an effort to rectify the current confusion, a variety of hierarchical models have been offered to help practitioners ‘sift and sort’ through the ‘evidence’ to determine its scientific rigor, validity and ultimate merit.
Your Meadows et al (2009:139) textbook discusses two ways in which evidence may be categorised: a ‘five levels of evidence’ approach and the GRADE system. Levitt (2003) (cited in Eliason 2007) offers another method of categorisation, the ‘hierarchy of scientific evidence’ pyramid, in which research studies and their findings are ranked from the most to least useful, with the most rigorous (and therefore the most useful) studies situated at the top of the pyramid.
Figure: The Hierarchy of Scientific Evidence Pyramid (cited in Eliason 2007:28)
Eliason (2007:27–30) provides the following explanations of the different hierarchies contained within the pyramid:
Systematic Reviews and Meta-Analysis of Randomised Clinical Trials (RCTs)
• Systematic reviews collate all the research literature relating to a specific practice and examine it for the ‘big picture.’
• In meta-analysis, data is pooled from a number of RCTs, and a sophisticated analysis is performed to ascertain the degree of effect that the practice under investigation has on outcome measures. However, meta-analysis uses the individual studies as the unit of analysis rather than pooling all the subjects.
Warning: Both systematic reviews and meta-analysis sometimes fail to obtain relevant literature across multiple sources (thereby biasing the study) and may ‘muddy’ their results by ‘pooling’ information from studies with different client populations, treatment settings and different outcomes measures.
For an example of Reviews and Meta-Analysis of Randomised Clinical Trials (RCTs):
Murphy, Kylie and Mathews, Rebecca. Evidence-Based Psychological Interventions: What Measures Up? . InPsych: The Bulletin of the Australian Psychological Society Ltd, 32 (3), 28-29.
(Available in e-reserve)
Randomised Clinical Trials
• In this type of research, clinical treatment agencies (rather than controlled laboratory settings) are used and study participants are selected according to clearly defined inclusion and/or exclusion criteria.
• Participants are randomly assigned to treatment conditions(s) or ‘treatment as usual’ groups.
• Participants’ progress is charted for a minimum of six months after the conclusion of treatment.
Cohort Studies (also called prospective, incidence or follow-up studies)
• The most common type of research studies undertaken.
• Involves an experimental group and a control (or comparison) group.
• Participants’ progress is followed before, during and after treatment.
Warning: Participants might not be randomly assigned and may be drawn from convenience samples (such as individuals already in treatment rather than recruited specifically for the research).
• Participants are selected on the basis of an already achieved outcome (for example: remained in or dropped out of a 12-step programme) and the researcher engages in retrospective analysis (for example, looking at the participants’ intake records, therapy case notes etc to discover what factors may have contributed to this outcome).
Warning: The quality of past record keeping and recall of information can contribute to biased results.
Cross-Sectional Surveys (also called prevalence or epidemiological studies)
• This type of research examines a specific group of participants at one point in time to give a ‘snapshot’ of the area under investigation (for example, household studies of pain-killer consumption).
Warning: These studies can demonstrate associations but cannot examine cause and effect relationships.
• These are published studies of new approaches, unusual or unexpected events or specific agency changes (for example, reports about the adverse effects of a new anti-depressant medication).
Warning: Whilst these reports provide interesting new information they do not constitute solid ‘evidence’.
Perspective or Theoretical Reports
• The focus of these reports is upon personal opinion or commentary, clinical experiences and the proposition of new theoretical frameworks to be examined.
• They may be useful in identifying prevailing attitudes and viewpoints in the profession.
Warning: No scientific evidence is offered to back up the claims being made.
A cautionary note
While taking an evidence-based approach to practice is something to be encouraged within the mental health field, it is important not to become too blinkered or tunnel-visioned in our quest to provide only the ‘most clinically proven’ treatment available. As practitioners we must not lose sight of the psychosocial factors that also come into play in any therapeutic relationship and intervention we engage in, as well as the past clinical experience and wisdom of the practitioner. As Williams and Garner (2002:8) observe, “too great an emphasis on evidence-based medicine oversimplifies the complex and interpersonal nature of clinical care.”
In the following reading, these authors provide a different perspective, a counter-balance if you like, to the evidence-based argument. In doing so, they highlight the need for the ‘heart’ of therapy to remain firmly within every approach to client treatment and care.
Williams and Gardner (2002) “The Case Against ‘the evidence’: A different perspective on evidence-based medicine.”
• Write 3 points in favour of a strict evidence-based approach to clinical practice.
• Write 3 points against.
• Look at the limitations (warnings) listed under the different sorts of evidence in the hierarchy above. Which (if any) of these had you not considered before?
• Post your thoughts on the discussion board for us all to discuss.
Last modified: Thursday, 26 February 2015, 1:03 PM
2b. Principles of evidence-based practice
Translating evidence-based practice into practice
It seems logical to assume that once a practice has been demonstrated to be more effective than ‘treatment as usual’, that it will be adopted quickly and successfully within the field. This, however, is not always the case.
As Eliason (2007:30) notes, in some instances, despite having an excellent research track record (for example, thorough and extensive randomised clinical trials, applicability across a wide range of client groups in controlled research studies, a comprehensive treatment manual), it may not have practical translatability within the field.
Staff training costs, competing agendas, time constraints, resistance within the organisation to change, complicated or excessively priced treatment manuals, prohibitive treatment fees and lack of access to relevant client populations, for example, may prove the death knell for even the most rigorously investigated, scientifically-based, practice.
In the following reading, Deane et al (2006) explore some of the challenges in implementing evidence-based practice into mental health services:
Deane et al (2006) ‘Challenges in Implementing Evidence-based Practice into Mental Health Services’ originally published Australian Health Review, vol. 30, no. 3, pp. 305 – 309.
• Think about an organisation in which you have worked where an initiative was implemented, unsuccessfully, in an effort to change workplace practice.
• What barriers were present during this process?
• How were they addressed?
• On reflection, what might you, or management, have needed to do differently to increase the chances of a more successful outcome?
Readiness for change and co-morbidity
Readiness to change and the Stages of Change model
In the previous sections, we examined the importance of adopting an evidence-based practice approach when working with consumers experiencing mental health issues. It is vital to remember, however, that the success of an intervention is not based solely upon how much evidence exists to substantiate its effectiveness. Rather, success is determined by a number of inter-related factors, including the consumer’s readiness to change.
Prochaska and DiClemente (1982), as part of their ‘Transtheoretical Model of Behaviour Change’, developed the ‘Stages of Change Model’ to describe the five stages that an individual goes through as part of his/her change process. In its day, this model was theoretically ‘revolutionary’, since rather than regarding change as an ‘event’ (for example, ‘quitting smoking’), it conceptualised it as a ‘process’, thereby adding a temporal dimension.
While the tasks within each stage must be accomplished by every individual before they can to move on to the next phase of the change process, the timeframe for completion of these tasks remains flexible and open to individual difference.
Initially the Stages of Change Model was developed during a smoking cessation study; however, it has since been successfully applied to addictive behaviours, weight loss and biosocial issues such as domestic violence and child abuse. The table below provides an overview of the different stages of the model as well as the mental health practitioner’s role in the change process.
You will notice that the final category ‘relapse’ is not considered to be an actual ‘stage’ in the model. However, as relapse is a common change process experience, its inclusion within the table both acknowledges and normalises its existence. As mental health practitioners, it is important to provide consumers with the ‘warts and all’ reality of the change process they are engaging in, as this will reduce the risk of any unrealistically high expectations leading to a sense of demoralisation at having ‘failed’ if relapse occurs.
While the Stages of Change model provides a useful framework for assessing an individual’s level of motivation to change, it is also critical for mental health practitioners to identify any co-morbid mental health issues that the individual is dealing with as these can have a significant impact on the change process. For example, whilst an individual may be highly motivated to quit smoking marijuana, he/she may be less keen to either experience the PTSD symptoms that the marijuana has been ‘masking’ or to explore the traumatic event that initially evoked these symptoms.
Using the Transtheoretical Model, including the Stages of Change Model, this article explores African American women’s readiness to change in relation to abusive relationships:
Bliss et al 2008, ‘African American Women’s Readiness to Change Abusive Relationships’, Journal of Family Violence, vol. 23, pp. 161-171.
(also available in e-reserve)
Other useful resources
Prochaska, J.O. & DiClemente, C.C. 1982, ‘Transtheoretical therapy: Toward a more integrative model of change’, Psychotherapy Research and Practice, 20, pp. 161 – 173.
• Motivational interviewing
• Narrative therapy
• Interpersonal psychotherapy
• Crisis intervention
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