Mom, Apple Pie and Evidence Based Practice

This is reworking of an assignment for my Grad Dip of AOD Studies at Turning Point. I’m posting partly as a material to work with while I cut my teeth blogging and getting to know WordPress but I also think there are some interesting things to say about the role of Evidence Based Practise and associated concepts as they relate to addiction treatment and recovery.

“At first blush, there is universal agreement that we should use evidence as a guide in determining what works. It’s like publically praising Mother and apple pie. Can anyone seriously advocate the reverse: non-evidence based practice?” (Messer, 2004 in Norcross, Beutler & Levant, 2007)

Non-evidence based practice?

Could anyone seriously advocate non-evidence based practice?

The promoters of evidence based practice (EBP) often accuse practitioners of not based their practice in evidence. Is it not self-evident that the incorporation of scientific evidence will improve practise and policy in the addiction treatment field?  The real controversy is not whether practise ought to be founded on evidence but on the question – what is acceptable evidence?

This important question does not just hinge on differing philosophies of science but also professional rivalries, political and economic interests as well as intellectual fashions and trends. There is often a blindness in the science and research community to the humanness of their enterprise which can allow unexamined intellectual and personal assumptions to generate unfortunate real world implications for the lives of treatment seekers.

The purpose of research in addiction treatment is to further knowledge and improve practice. Rigid insistence of fixed rules of evidence and uncritical adoption of research designs from other fields of health does not advance this goal.

This article discusses what kind of evidence is relevant to clinical practice and how that relates to the movement known as evidence based practise.

In particular I critique the commonly used hierarchy of evidence and the uncritical promotion of randomised controlled trials (RCT) to evaluate the effectiveness of psychosocial treatments in general and mutual aid programs in particular.

What is Evidence Based Practice?

Evidence based practice (EBP) is an international reform movement that started in the UK when people noticed that many medical practices were not based on scientific evidence but on convention and tradition. The resulting movement, often promoted by non-clinicians such as researchers and policy makers, spread from medicine to other health professions and has resulted in a lot of debate, as well as resistance and confusion amongst clinicians who often resent being told by outsiders what to do.

A medical definition of EBP is “the contentious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”.

Because many equate evidence solely with research evidence such definitions have added to the confusion that EBP is about valuing research evidence over clinical expertise and patient preferences.

The American Psychological Association has warned that misuse and misunderstanding of evidence based principles has led to simplistic decisions – especially with regard to evaluation of treatments and enforcement of clinical guidelines over clinical expertise – that has not always led to better patient outcomes.

What is Evidence?

The definition of Evidence Based Practise in Psychology from the American Psychological Association is “the integration of best available research evidence with clinical expertise in the context of patient characteristics, culture and preferences.”

This comes with warning that the application of guidelines must be systematically weighed against clinical expertise, especially with regard to patient acceptability, and to carefully investigate the quality of evidence and the political and funding agendas behind pressure to adopt many clinical guidelines.

Before we ask “What is best evidence? We have to step back and ask “What is evidence?” In the APA definition we see an explicit acknowledgement of three different kinds of evidence – research evidence, clinical expertise and patient factors.

This hard won awareness came out the challenge to clinical psychology from the rise and rapid spread of pharmacological treatments starting in the 1980’s.  The APA rushed to publish criteria for Empirically Supported Treatments (EST) – treatments considered to be well established if supported by randomised controlled trials with specific populations using manualised treatments. The goal was to head off the threat of pharmacological treatments by establishing an evidence base for the efficacy of psychological treatments by using the same research designs favoured by medicine.



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