Psych 361 week 15

-        APA Presidential Task Force on Evidence-Based Practice in Psychology, 2005

o   At its August 2005 meeting, the council of representatives unanimously adopted an APA policy based on the report from a Presidential Task Force on Evidence-Based practice in psychology (EBPP)

§  Very important achievement for the APA from a year’s intensive work by a large and heterogeneous committee

§  T

o   The task force report on EBPP is not perfect

o   But to Davison, it is as good a statement as can be expected, given the sometimes highly different views of clinical psychology

o   The report is particularly relevant to our psyc 361 course and can serve to tie the whole semester together

o   What is “evidence” in evidence-based practice?

§  The report defines evidence-based practice in psychology as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences”

§  Thus, 3 key elements:

·        The best research evidence

·        Clinical expertise

·        Patient characteristics

§  This is based on a definition from the Institute of Medicine (now called the National Academy of Medicine) in 2000

§  How does one define “evidence”, equivalent to “research”?

·        Merriam Webster: empirical – “originating in or based on observation or experience”

§  Some restrict acceptable research to such methodologies as randomized clinical trials or Skinnerian-type single-subject designs

§  Viable, but the core meaning of the word “empirical”, a term that has always been part of the discourse of what we are now calling “evidence-based”, is “based on experience”. What kind of experience? Whose experience are we talking about? Which research methods? Is there room for clinical experience?

§  In collaboration with Arnold Lazarus, Davison has argued for over 50 years that it is a serious mistake to discount the experiences (empirically based observations) of practitioners

§  What kinds of information should we pay attention to? Davison doesn’t believe that the EBPP report addresses this issue fully

§  Serious mistake to discount the importance of clinical experience

§  Repeated exposure to any given set of conditions makes the recipient aware of subtle cues and contingencies

§  Clinical experience enables a therapist to recognize problems and identify trends that are usually beyond the perceptions of novices

§  Different kinds of data and differing levels of information are obtained in the laboratory and the clinic. Each is necessary, useful, and desirable

o   The importance of theories and paradigms

§  People don’t simply observe what is out there

§  Even at the basic perceptual level, we encounter the world with conceptual filters or what Thomas Kuhn called “paradigms”

§  Our perceptions of even simple inanimate phenomena are not simply experiential summaries of what stimulates the sensorium. Eye is not a camera.

§  Things get more nuanced when we enter the domain of complex interpersonal phenomena, such as in the arena of applied psychology

§  In the section entitled “Multiple Types of Research Evidence” the APA report suggests that clinicians must create “optimal combinations” of different kinds of research, their own individual personality and values, the treatment relationship, and the particularities of the patient to devise the best intervention; and that when empirical data are sparse, “clinicians use their best clinical judgment and knowledge of the best available research evidence to develop coherent treatment strategies”.

§  “it is important to know the person who has the disorder in addition to knowing the disorder the person has.”

·        Any knowing of a patient is possible only within a general perspective of what makes people tick

·        The very definition of a datum and the means by which one garners that datum are not theory-free or paradigm-free

o   The report does not deal with this core epistemological issue

o   Education

§  Education is the kindling of a flame, not the filling of a vessel – Socrates

§  Education, not training

·        Suggestion: do away with the title “director of clinical training” and other similar designations that emphasize training rather than education

·        Training refers to teaching people specific skills, obviously important for our students – and for independent practitioners and teachers – to acquire these skills

·        Doctoral programs in clinical should concentrate much more on education

·        Meaning, the encouragement of critical and independent thinking in the process of mastering relevant bodies of knowledge

·        Goal is to reflect carefully and critically on what one reads, hears, and says, and to evaluate sometimes widely touted innovations in assessment and intervention with a modesty and skepticism that befit a true scholar

·        Intellectual humility

o   The liberal arts

§  Definition:

·        (from Merriam webster) college or university studies intended to provide chiefly general knowledge and to develop general intellectual capacities (such as reason and judgment) as opposed to professional or vocational skills

·        The liberal in liberal arts, a cornerstone of the education of so many, has very little to do with political leanings; its roots can be traced to the latin word liber, meaning “free, unrestricted”. Our language took the term fro the latin liberals artes, which described the education given to freemen and members of the upper classes, and involved teaching the mind in subjects like grammar, logic, geometry, etc. the lower classes were trained in servile arts, which were mechanical or occupational in nature. The phrase liberal arts has been part of our language for a very long time, with use dating back to the 14^th century

§  The liberal arts provide breadth of knowledge and perspectives

§  “liberal education teaches the importance of tempering profound convictions with a measure of tolerance and a judicious sense of humility”

§  Such study requires students to engage in areas of inquiry they might not have elected voluntarily

§  It encourages students to become generally well educated people who can think across a spectrum of disciplines, who question what is known, how it was learned, and why it might change over time

§  These acquired abilities, these habits of careful, analytical critical thinking are the keys to all kinds of intellectual and professional success, particularly at the higher levels of professional achievement

§  These habits of thought can also facilitate creativity and wisdom. Also intellectual humility

§  Can the liberal arts influence values?

§  A report from Harvard on general education emphasizes the sometimes overlooked importance of the liberal arts to the nourishment of the human spirit, to the meaning that each of us forges over time a life worth living

o   Doctoral education and breadth

§  Problems Davison sees in how we select and educate graduate students:

·        The primary focus of admissions committees is research methods, psychology content courses, and especially involvement in psychological research

·        Exclusion of non-psychology work and intellectual interests that can provide broader context

·        De-emphasis on non-psychology topics becomes even stronger in graduate school

·        Students not being encouraged or required to appreciate the macro factors that influence their subject matter, in my opinion

§  A solid liberal arts education is the foundation for all fields of graduate postgraduate specialization. Especially important for clinical psychologists

§  Both researchers and clinicians have to be menschenkenner, people who know and understand people, including themselves

§  A broad education can contribute to the ability to figure out the vagaries of human conduct

§  Increasing and earlier specialization in such domains as cognitive (neuro)science and behavioral neuroscience makes it difficult for them to avail themselves of graduate-level coursework in areas such as social, clinical, and developmental psychology

§  Who can say that the graduate-level study of psychopathology, for example, could not play a heuristic role in the research of a nonclinical graduate student?

o   Where do our theories come from?

§  The generation of a theory is perhaps the most challenging part of the scientific enterprise—and one of the least understood

§  Bold directions, paradigmatic shifts, go beyond what extent data and theorizing tell us

§  Creativity and the excitement of finding a novel way to conceptualize things

§  New ideas suddenly occur, and connections previously overlooked are suddenly grasped

§  Fertility of imagination is not nurtured by a narrow study of a specialized domain of inquiry and application

§  As Kurt Lewin said many years ago, “there is nothing more practical than a good theory”

§  One characteristic of a good theory is that it is testable and open to disproof, and one characteristic of a good scientist is that he or she does not become so invested in a given theory or paradigm that the search for disconfirming information ceases

o   Patient characteristics, culture, preferences, and values

§  The APA EBPP report discusses the need for clinical psychologists to understand and respect the range of social and cultural factors that affect patients

§  An awareness of and sensitivity to cultural and ethnic differences are of critical importance

§  Developmental factors also need to be considered, e.g., different problems at different stages of life

§  Macro variables also must be incorporated into the clinician’s understanding of the patient, e.g., political and economic factors

§  Implications of the EBPP report on the questions of ethical decision-making by therapists, the choice of goals in treatment, questions of meaning and values

·        The report asserts that patients’ values are of paramount importance and should be the primary guide in the design and content of therapeutic intervention

o   Not so straightforward as that…

o   Values and goals

§  Previously discussed:

·        The nature of research and evidence

·        The sometimes unacknowledged role of theories and paradigms in clinical practice and research

·        The implications that I believe the EBPP document has for education and training in clinical psychology

·        Now goals and values

§  The EBPP report and other APA policies on setting therapy goals

·        The EBPP report asserts that the patient’s values and preferences are of overriding importance, including:

o   Personal preferences

o   Values

o   Preferences related to treatment

o   Cultural values and beliefs and social factors

o   Desired outcomes (cf. Davison’s lecture on ethics of sexual reorientation)

o   Social and environmental context

o   EBPP seeks to maximize patient choice among effective alternative interventions

·        The EBPP report and 1977 APA policy on setting therapy goals for gays

o   Report doesn’t confront fully some political and ethical issues that set the parameters for deciding upon therapy goals

o   Cf. 1974 presidential address to the annual meeting of the Association for Advancement of Behavior Therapy

o   The APA later (1997) adopted guidelines that are similar to my earlier position but that do not, I believe, go far enough

o   The 1997 council resolution asserted the importance of basing treatment decisions on scientific evidence and that intervention decisions aim at reducing prejudice about homosexuality

o   Concluding comment on Davison’s critique of APA’s empirically based practices in psychology report

§  Davison believes therapists are, to use Perry London’s term, “secular priests”. The EBBP report does not deal with these non-empirical issues

§  Must place issues in a broad societal context that considers questions of a qualitatively different nature from what we define as empirical evidence

§  Whatever one’s stance on sexual reorientation or most other biopsychosocial human phenomena, the political and ethical issues need to be faced squarely

-        Concluding comments on the course

o   Intellectually and emotionally demanding

o   Strong mind and tender heart

o   Paradigms a leitmotif, a constant theme and preoccupation

o   Bias impossible to escape

o   Broad education and perspectives important. Clinical psychology cuts across the liberal arts – humanities, social sciences, natural sciences