Staying “up-to-date” isn’t easy in today’s practice environment. In these lean economic times, training budgets are often the first to be cut. On the other hand, trying to separate the “important” from “irrelevant” in our information-rich age can be, as Mitchell Kapor once observed, “a bit like trying to get a drink from a fire hydrant.”
Clinician Beware: Ignoring Research Can be Hazardous to Your Professional (and Economic) Health
So what do the data actually say? S adly, the answer is often, “it depends on who you ask.” If you read the latest summary and treatment recommendations for post-traumatic stress disorder (PTSD) posted by the Cochrane Collaboration, you are told that TFCBT and EMDR are the most effective, “state of the art” treatments on offer. Other summaries, as I recently blogged about, arrive at very—even opposite—conclusions; namely, all psychotherapies (trauma-focused and otherwise) work equally well in the treatment of PTSD. For the practicing clinician (as well as other consumers of research), the end result is confusion and, dare I say, despair.
Unable to resolve the discrepant findings, the research is either rejected out of hand (“it’s all crap anyway”) or cherry-picked (“your research is crap, mine is good”). In a world where experts disagree–and vehemently–what is the average Joe or Jane therapist to do?
Fortunately, there is another way, beyond agnosticism and instead of fundamentalism. In a word, it is engagement. This last week, I spent 5 days teaching an intensive workshop with ICCE Senior Associate Susanne Bargmann to a group of Danish psychologists on “Statistics and Research Design.” That’s right. Five days, 6 hours a day spent away from work and clients learning how to understand, read, and conduct research.
The goal of the training was simple and straight-forward: help practitioners learn to evaluate the methods and meanings, strengths and weaknesses, and political and paradigmatic influences associated with research and evidentiary claims. At the conclusion of the five days, none of those assembled had difficulty engaging with and understanding the reasons for the seemingly discrepant findings noted above. As a result, they could state with confidence “what works” with PTSD, helping clarify this not only to colleagues, payers, and policy members but also to consumers of behavioral health services.
The “Statistics and Research Design” course will be held again in Denmark in 2011. If the experience of this year’s participants proves anything, it is that, “The only thing therapists have to fear about statistics and research design, is fear itself.” Please contact Vinther and Mosgaard directly for more information.
Finally, as part of the International Center for Clinical Excellence (ICCE) efforts to improve the quality and outcome of behavioral health services worldwide, two additional intensive trainings will be offered in Chicago, Illinois (USA). First, the “Advanced Training in Feedback-Informed Treatment (FIT).” And second, the annual “Training of Trainers.” In the Advanced Training, participants learn:
What Works in the Treatment of Post Traumatic Stress Disorder? The Definitive Study
What works in the treatment of people with post-traumatic stress? The influential Cochrane Collaboration–an “independent network of people” whose self-professed mission is to help “healthcare providers, policy makers, patients, their advocates and carers, make well-informed decisions, concludes that, “non trauma-focused psychological treatments [do] not reduce PTSD symptoms as significantly…as individual trauma focused cognitive-behavioral therapy (TFCBT), eye movement desensitization and reprocessing, stress mamangement and group TFCBT.” The same conclusion was reached by the National Institute for Health and Clinical Excellence (or NICE) in the United Kingdom which has developed and disseminated practice guidelines that unequivocally state that , “all people with PTSD should be offered a course of trauma focused psychological treatment (TFCBT) or eye movement desensitization and reprocessing (EMDR).” And they mean all: adults and kids, young and old. Little room for left for interpretation here. No thinking is required. Like the old Nike ad, you should: “Just do it.”
Wait a minute though…what do the data say? Apparently, the NICE and Cochrane recommendations are not based on, well…the evidence–at least, that is, the latest meta-analytic research! Meta-analysis, you will recall, is a procedure for aggregating results from similar studies in order to test a hypothesis, such as, “are certain approaches for the treatment of post traumatic stress more effective than others?” A year ago, I blogged about the publication of a meta-analysis by Benish, Imel, & Wampold which clearly showed that there was no difference in outcome between treatments for PTSD and that the designation of some therapies as “trauma-focused” was devoid of empirical support, a fiction.
So, how to account for the differences? In a word, allegiance. Although written by scientists, so-called “scholarly” reviews of the literature and “consensus panel” opinions inevitably reflect the values, beliefs, and theoretical predilections of the authors. NICE guidelines, for example, read like a well planned advertising campaign for single psychotherapeutic modality: CBT. Indeed, the organization is quite explicit in it’s objective: “provide support for the local implementation of…appropriate levels of cognitive beheavioral therapy.” Astonishingly, no other approach is accorded the same level of support or endorsement despite robust evidence of the equivalence of outcomes among treatment approaches. Meanwhile, the review of the PTSD literature and treatment recommendations published by the Cochrane Collaboration has not been updated since 2007–a full two years following the publication of the Benish et al. (2008) meta-analysis–and that was penned by a prominent advocate of…CBT…Trauma-focused CBT.
As I blogged about back in January, researchers and prominent CBT proponents, published a critique of the Benish et al. (2008) meta-analysis in the March 2010 issue of Clinical Psychology Review (Vol. 30, No. 2, pages 269-76). Curiously, the authors chose not to replicate the Benish et al. study, but rather claim that bias, arbitrariness, lack of transparency, and poor judgement accounted for the findings. As I promised at the time, I’m making the response we wrote–which appeared in the most recent issue of Clinical Psychology Review—available here.
Of course, the most important finding of the Benish et al. (2008) and our later response (Wampold et al. 2010) is that mental health treatments work for people with post traumatic stress. Such a conclusion is unequivocal. At the same time, as we state in our response to the critique of Benish et al. (2008), “there is little evidence to support the conclusion…that one particular treatment for PTSD is superior to others or that some well defined ingredient is crucial to successful treatments of PTSD.” Saying otherwise, belies the evidence and diverts attention and scarce resources away from efforts likely to improve the quality and outcome of behavioral health services.
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