Evidence Based Practices

From its earliest beginnings, psychiatric rehabilitation has sought, usually by trial and error, to develop effective services for persons with severe mental illness. This process has led to the existence of a large number of essentially idiosyncratic services, some of which are effective and some not. The adoption of an evidence-based practice approach is addressing this problem. The EBP process employs controlled clinical trials to identify effective services and define the critical elements that produce positive outcomes.

The Implementing Evidence-Based Practice Project

As the PsyR research and knowledge base grew, it became clear that some practices and strategies were superior to others at producing desired outcomes for persons. This situation was clearly demonstrated by the recommendations of the Schizophrenia Patient Outcome Research Team (PORT) project (Lehman & Steinwachs, 1998). The PORT study, which made recommendations for the treatment of schizophrenia, also found that in many cases individuals with schizophrenia were not provided with proper treatment and services. Additionally, there was increasing recognition by researchers and administrators that service providers and programs were slow to adopt new research findings to usual practice, indicating a large lag between research findings and implementing those findings in the field.

To address this issue, in 1998 the Robert Wood Johnson Foundation sponsored a meeting of researchers, clinicians, administrators, consumers, and family members to begin the process of identifying evidence-based practices for PsyR. This group, dubbed the Implementing Evidence-Based Practices Project, was charged with identifying interventions that were backed up by reliable research results. Through an extensive review of the research literature this group was able to identify six potential evidence-based practices.

Identifying an Evidence-Based Practice

A number of important steps must be carried out to establish an EBP. Most EBPs started from a service innovation. Such innovations (e.g., assertive community treatment [Chapter 7], supported employment [Chapter 9]) typically come about through the trial-and-error efforts of dedicated professionals trying to improve services. After an innovation shows promise, the next step is to carefully and objectively define the service including carefully explaining just how the service is performed, who performs it, for how long, and so forth. The definition of the service becomes the service model that will subsequently be field tested.

The service model of a potential EBP must be studied using multiple controlled clinical trials. This type of research, which typically involves random assignment of participants

BOX 1.3 Robert E. Drake

Robert E. Drake, M.D., Ph.D., is the Andrew Thomson Professor of Psychiatry and Community and Family Medicine at Dartmouth Medical School. He is also the director of the New Hampshire-Dartmouth Psychiatric Research Center. Dr. Drake has been a long-term contributor to the psychiatric rehabilitation knowledge base through his work developing and evaluating innovative community programs for persons with severe mental disorders. He is one of the recognized leaders in the development of evidence-based practices for PsyR. He is well known for his work in integrated dual disorders treatment (substance use disorder and severe mental illness), supported employment services, and assertive community treatment, among other work. Dr. Drake's many books and more than 300 papers cover diverse aspects of adjustment and quality of life among persons with severe mental disorders and those in their support systems. Educated at Princeton, Duke, and Harvard universities, he has worked for many years as a clinician in community mental health centers. Dr. Drake is a sought-after speaker in the United States and internationally regarding his work on improving services for people with severe mental illness.

to experimental and control groups, has the advantage of allowing researchers to make causal inferences between the variables under study. For example, a researcher may determine that a specific educational strategy helps consumers learn about their illness, or that a specific medication reduces a specific category of symptoms. In addition, controlled clinical trials greatly reduce the possible effects of bias on the results. A good example of bias reduction in research is the use of "blind" evaluators. In an experiment comparing, let us say, consumer quality of life in different housing situations, the "blind" evaluator would not know which experimental condition (e.g., experimental group or control group), in this case which housing type, was represented by the consumers she was evaluating. In this way, the evaluator is protected from unconsciously biasing the evaluations and hence the research results. Evaluators might also be blind to the hypothesis being studied or the exact form of the research design.

The evidence to support an EBP must be in the form of reliable, objective evidence. Of course, we have just stressed that controlled clinical trials are designed to produce reliable, objective evidence if it is present. Still, the reliability of data and the objectivity of data can and should be independently assessed. In addition, such research needs to be repeated in different settings, by different researchers, and produce similar corroborating results. This replicability is one of the hallmarks of science.

If the model for the EBP, refined by the research results, proves to effectively produce specific desirable outcomes for persons with severe mental illness its elements are converted into a fidelity scale. Think of this fidelity scale as a blueprint for how the service should be provided as well as a rating scale that determines how close a service comes to replicating the model. The fidelity scale of an EBP is used to determine how well other programs are providing the same service. In short, how much fidelity to the EBP model do they demonstrate? Research findings suggest that services with higher fidelity to the EBP model produce better outcomes (e.g., Bond, 2004).

Current Evidence-Based Practices

To date six EBPs, each of which will be described in some detail in this textbook, have been identified:

1. Medication management

2. Assertive community treatment (ACT)

3. Supported employment (SE)

4. Illness management and recovery education

5. Family education

6. Integrated treatment for dual disorders (Dixon et al., 2001; Drake et al., 2001;

Mueser, Torrey, Lynde, Singer, & Drake, 2003; Torrey et al., 2001).

Each of these EBPs has been shown to have a positive impact on one or more aspects of these disorders. Specifically, multiple controlled clinical trials of the six EBPs just listed have been shown, among other things, to produce:

• Symptom improvement (especially for positive symptoms)

• Less hospital utilization

• Fewer and less severe relapses

• Higher rates of competitive employment

• Improved quality of life

• Increased community involvement

• Better control of substance abuse problems (Dixon et al., 2001; Drake et al., 2001;

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