It just makes a lot of sense for mental health and substance abuse professionals, as Bob Bohanske, Project Leader, asserts in the new edition of the Heart and Soul of Change, to formally partner with consumers and the recovery movement in total. According to SAMSHA:

Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

Client based outcome feedback (click here for more information or here for free client based outcome and alliance measures) or consumer driven outcomes management gives recipients of our services a real voice in their own care, not just lip service. Therapists and clients could be allies in ensuring that services are recovery oriented (National Consensus Conference on Mental Health Recovery and Mental Health Systems Transformation, 2004)—a shift from professional interventions based on diagnostic labels and prescriptive treatments to individually tailored, consumer-directed services that at their core require clients’ active participation:

The 10 Fundamental Components of Recovery
Self-Direction: Consumers lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.
Individualized and Person-Centered: There are multiple pathways to recovery based on an individual’s unique strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.
Empowerment: Consumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources—that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and aspirations. Through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in his or her life.
Holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and healthcare treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.
Non-Linear: Recovery is not a step-bystep process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery.
Strengths-Based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, consumers leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). The process of recovery moves forward through interaction with others in supportive, trust-based relationships.
Peer Support: Mutual support—including the sharing of experiential knowledge and skills and social learning—plays an invaluable role in recovery. Consumers encourage and engage other consumers in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.
Respect: Community, systems, and societal acceptance and appreciation of consumers —including protecting their rights and eliminating discrimination and stigma—are crucial in achieving recovery. Self-acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.
Responsibility: Consumers have a personal responsibility for their own self-care and journeys of recovery. Taking steps towards their goals may require great courage. Consumers must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.
Hope: Recovery provides the essential and motivating message of a better future— that people can and do overcome the barriers and obstacles that confront them. Hope is internalized; but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process. Mental health recovery not only benefi ts individuals with mental health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, but also enriches the texture of American community life. America reaps the benefits of the contributions individuals with mental disabilities can make, ultimately becoming a stronger and healthier Nation.

Resources
www.samhsa.gov

Also check out a great video about recovery at
http://promoteacceptance.samhsa.gov/action/partnersInRecovery.aspx

And speaking of recovery, check out the next webinar:

From Illness to Recovery: Consumer Voice and Choice
A sharp departure from customary discourse on mental illness, recovery-driven services shift away from professional-directed treatment based on diagnostic labels and prescriptive practices to individually tailored, consumer-authored plans. After telling her personal story of recovery, Dr. Ashcraft asserts that moving from illness toward recovery means that counseling professionals must be both responsible and responsive to their customer base and directly involve clients in decision making. This webinar calls for recovery-focused services based on the heart and soul of change—services that recognize clients as the primary movers of change, that require the unique tailoring of intervention to their preferences, and that call for relationships that are collaborative and respectful. Dr. Ashcraft also discusses how to successfully integrate peers into your workforce: peer training and preparation, worksite preparations for a smooth integration of peers, performance improvement approaches for peer work, and evaluation of peer services.

Lori Ashcraft, Ph.D., CPRP is the Executive Director of Recovery Opportunities Center based in Phoenix, Arizona with Peer Support training, consulting and system development operating in 30 states and three countries. Dr. Ashcraft recently served as a professor for the University of Arizona teaching psycho-social rehabilitation and managing one of eight SAMHSA funded employment demonstration programs. Her latest book, Offering Wellness, provides insight to the “whole person” wellness and Recovery approach.

Title: Dr. Lori Ashcraft–From Illness to Recovery: Consumer Voice and Choice

Date: Wednesday, March 10, 2010

Time: 12:00 PM – 1:00 PM CST

Join the members site to enjoy this upcoming webinar here

All approaches have valid explanations and solutions for the problems that clients bring to us. It makes sense to expand our theoretical horizons and learn multiple ways to serve client goals. Similarly, it also makes good clinical sense to be “evidence based” in our work. In truth, no one says, “Evidence, smevidence! It means nothing to my work—I fly by the seat of my pants, meander Willy Nilly through sessions, and rely totally on the wisdom of the stars to show the way.” Saying you don’t believe in the almighty evidence in tantamount to not believing in Mom or apple pie, or whatever your sacrosanct cultural icons happen to be. So what is the controversy about?

On the heels of the American Psychiatric Association’s development of practice guidelines in 1993, to ensure their continued viability in the market, psychologists rushed to offer magic bullets to counter psychiatry’s magic pills—to establish empirically supported treatments (EST). With all good intentions, the task force of Division 12 (Task Force on Promotion and Dissemination of Psychological Procedures, 1995) reviewed available research and catalogued treatments of choice for specific diagnoses based on their demonstrated efficacy in two RCTs. On one hand, the Division 12 Task Force effectively increased recognition of the efficacy of psychological intervention among the public, policymakers, and training programs; on the other hand, it simultaneously promulgated gross misinterpretations—that ESTs have proven superiority over other approaches, and therefore, should be mandated and exclusively reimbursed. Unfortunately, many now believe, to paraphrase Orwell, that some therapies are more equal than others.

The notion, however, that any approach is better than another is indefensible in light of the evidence covered extensively throughout The Heart and Soul of Change that support the outcome equivalence of the different models (the “dodo verdict”) as well as the relative influence of other factors than model and technique. I encourage you to dig a little deeper and bolster your ability to respectfully counter statements that suggest mandates for practice. Littell’s (2010) scathing commentary of ESTs in The Heart and Soul of Change is a good place to start. Littell provides a useful template for understanding the varied ways that findings can be distorted and evidence constructed from underwhelming results.

Like understanding anything else, there is a language involved here and it takes a bit of wading through tedious material. But it is worth it if you desire to counter mandates for specific approaches and promote the freedom for therapists to practice as they see fit according to client preferences and benefit. Our necessary pluralism, the theoretical breadth so important to resonating with clients and accentuating our development, is at stake, as well as our identity—ESTs suggest a therapist identity based on technical acumen in administering manualized, cookie cutter interventions (Duncan & Miller, 2006).

Efficacy over placebo, sham, or no treatment is not efficacy over other approaches, or what is called differential efficacy. In the minority of studies that claim superiority over treatment as usual (TAU) or another approach, you need only to ask one question of the investigation (see Duncan et al., 2004 and Sparks & Duncan, 2010 for a full discussion and examples): Is it a fair contest? Is the study a comparison of two valid approaches intended to be therapeutic administered in equal amounts by therapists who equally believe in what they are doing and who are equally supported to do it—are the therapists from the same pool with equal caseloads or is the experimental group specially selected, trained, and supervised by the researcher/founder of the approach, and have reduced caseloads?

I have never seen an advantage of any approach over another (or TAU) that wasn’t a lopsided contest that had its winner predetermined. Consider Trauma Focused (TF)-CBT, an approach to child sexual abuse that is getting a lot of press as the preferred approach that should be implemented across the board. Let’s look at their “definitive study:” Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.

SSDD all the way! It is always the same when you scratch below the surface of superiority claims—they just don’t hold up to critical scrutiny. First let me say that there is nothing wrong with TF-CBT. It has good ideas and good possibilities, and is surely helpful for some kids and parents. I just wish they would present it that way; i.e., if you work with kids and families where abuse and trauma are involved, you might consider adding these ideas and interventions to your repertoire—they probably will make some sense to some of your clients. But, of course, that is not what they say and instead they claim superiority and folks get the crazy idea that it should be mandated or practiced exclusively.

As always, you gotta consider whether or not it is a fair contest or one in which the winner is pre-determined by the design (imagine the porpoise and the cow in a swimming contest), the pet approach of the researcher pitted against a less than equal opponent. Child Centered Treatment (CCT), the comparison treatment in this study, is not a fair comparison—it is a sham treatment. Therapists did not see the kids and parents together at all, whereas the TF-CBT therapists saw kids and parents together 3 times out of the 12 possible sessions. It just is not reasonable care of a kid who has been sexually abused without meeting with both the child and parent (or caring adult) together to make sense of what has happened. That’s one thing, and then there is the real kicker: Therapists in the CCT condition did not provide advice or suggestions to kids or parents. This is not a real treatment. In the face of such serious concerns, even the most died in the wool “client centered” therapist would address client requests for suggestions and guidance.

Given this mock therapy, one might also suspect that the therapists likely believed that the TF-CBT offered some advantages over CCT given there was at least some structure and ideas offered to these struggling families. Enter allegiance factors. Therapists served as their own controls (performed both TF-CBT and CCT) and were monitored for fidelity, or other words to ensure they didn’t offer guidance (beyond processing feelings and finding client solutions) in the CCT condition. It doesn’t say who provided the “intensive supervision” but that probably means it was the researchers.

So given that it was an unfair comparison of an active treatment model to one unlikely to ever happen in the real world, and given the therapists in the study could hardly help but like to offer some guidance to clients when asked and therefore likely were more committed to TF-CBT, the results are particularly underwhelming. First off, there was a main effect for both conditions. Both treatments worked, which is a real testament to client factors given the CCT didn’t provide any structure or practical intervention. There were 16 measures for the kids and 4 for the caregivers. 3 of the 16 were clinician rated measures (diagnostic interview by folks trained by the researchers). Of the 16, 8 found a significant advantage for TF-CBT. But 3 of those were the from the clinician’s point of view. Only 5 of 13 client rated measures found an advantage for TF-CBT. All 4 of the adult measures found an advantage for TF-CBT. An inspection of the results table reveals that many of the “significant” findings arise from pretty small differences in the means at post-treatment, challenging at least some of the clinical significance of the findings. Finally, it seems that the measures chosen were reactive, or selected to reflect the very things that TF-CBT directly address while the comparison treatment does not address these aspects at all.

In summary, as always you have to ask yourself when superiority is claimed, “as compared to what?” This is study does not provide compelling evidence that TF-CBT is superior to anything else but rather that TF-CBT has demonstrated that it is a viable way to approach children and families who have suffered the trauma of sexual abuse. Regarding superiority claims, the TF in TF-CBT means totally false!

A summary of the problems often found in such claims can be found at http://heartandsoulofchange.com/resources/handouts/

Thankfully, there is a sanctioned argument to help efforts to rescind mandates for particular approaches. In the face of growing criticism, 2005 APA President Ronald Levant appointed the Presidential Task Force on Evidence-Based Practice (hereafter Task Force). The Task Force defined evidenced based practice (EBP) as “the integration of the best available research with clinical expertise in the context of patient (sic) characteristics, culture, and preferences (Task Force 2006, p. 273). This definition transcends the “demonstrated efficacy in two RCTs” mentality of ESTs and finally makes common clinical sense.

The Task Force also said:
The application of research evidence to a given patient always involves probabilistic inferences. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed are essential (Task Force, 2006, p. 280).

Proponents from both sides of the common v. specific factors aisle recognized that outcome is not guaranteed regardless of evidentiary support of a given technique or the expertise of the therapist (Anker et al., 2009). Practice based evidence must become routine. The new definition supports an identity of plurality, essential attention to client preferences, a focus on therapist expertise, and the importance of feedback.

Bottom Line: There is nothing wrong with ESTs or evidence based practice. Challenge statements, however, that use evidence based practice to justify mandates, exclusive reimbursement, or dictates about “the” way to address client problems. Know about the dodo verdict and unfair contests in research. Educate others about APA’s definition and the importance of measuring the client’s response to any delivered treatment—advocate for practice based evidence as an evidence based practice.

Next Blog: The Recovery Revolution

Two recent articles highlight the amazing fact that good marketing overcomes bad data every single day of the week. As Jacqueline Sparks (Project Leader) and I and our colleagues say in the new Heart and Soul of Change:

The fact that a for-profit industry plays a role in fashioning what counts as evidence may no longer surprise many. The former editor of the New England Journal of Medicine called attention to the problem of “ubiquitous and manifold . . . financial associations” authors of drug trials had to the companies whose drugs were being studied (Angell, 2000, p. 1516). The result is a direct correlation between who funds the study and its outcome. For example, Heres et al. (2006) looked at published comparisons of five antipsychotic medications. In 9 out of 10 studies, the drug made by the company that sponsored the study was found to be superior…Antonuccio, Danton, and McClanahan, (2003) detail the vast reach of the pharmaceutical industry—from Internet, print, and broadcast media, direct-to consumer-advertising, “grassroots” consumer-advocacy organizations, and professional guilds to medical schools, prescribing physicians, and research—even into the board rooms of the FDA. They conclude, “It is difficult to think of any arena involving information about medications that does not have significant industry financial or marketing influences” (p. 1030). Given the infiltration of industry influence, reliance on press reports, web pages, and even the academic literature as a basis for sound decision-making is unwise. Discerning good science from good marketing requires a willingness to engage primary source material.

Think this is overkill? Think twice. Check out the embedded article “From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents” written by Glen Spielmans & Peter Parry. Here is the abstract:

While much excitement has been generated surrounding evidence-based medicine, internal documents from the pharmaceutical industry suggest that the publicly available evidence base may not accurately represent the underlying data regarding its products. The industry and its associated medical communication firms state that publications in the medical literature primarily serve marketing interests. Suppression and spinning of negative data and ghostwriting have emerged as tools to help manage medical journal publications to best suit product sales, while disease mongering and market segmentation of physicians are also used to efficiently maximize profits. We propose that while evidence-based medicine is a noble ideal, marketing-based medicine is the current reality.

Here is the article:

And, as a case in point, consider this is true nowhere more than with antidepressants. The slightly better than placebo efficacy of antidepressants has been know for many years. Roger Greenberg and Seymour Fisher exposed antidepressants in their classic 1997 book, From Placebo to Panacea and we reviewed the subsequent literature and reported it (along with several others) as far back as 2000 and 2004 in The Heroic Client as well as the 2000 article, “Exposing the Mythmakers,” which received the All Time Top Ten Award for one of the most influential articles in the Psychotherapy Networker’s history. But yet millions are still prescribed and millions still take them as a first line of defense (nothing against folks who do and surely some benefit). Irving Kirsch, the person who meta-analyzed FDA trials and reported that the antidepressant emperor wore no clothes, has a new book. Check out this article in Newsweek about it: http://www.newsweek.com/id/232781  

Here is a brief summary of Kirsch’s research that we (Sparks, Duncan, Cohen, & Antonuccio) summarize in the new Heart and Soul of Change:

Kirsch and Sapirstein (1998), in a meta-analytic review of nineteen studies involving 2,318 people, showed that 75 percent of the response to antidepressants was duplicated by placebo. They speculated that the remaining 25 percent of the positive antidepressant effect may be attributable to the un-blinding power of side effects. Adding to the critique, Kirsch, Moore, Scoboria, and Nichols (2002) analyzed the efficacy data submitted to the US Food and Drug Administration (FDA) for the six most widely prescribed antidepressants approved between 1987 and 1999. Approximately 82% of the response to medication was duplicated by placebo control groups—57% of the studies failed to show a drug-placebo difference. When a difference was found, the drug/placebo difference was only, on average, 1.8 points on the clinician-rated Hamilton Depression Rating Scale (HDRS). FDA memoranda intimated that the clinical significance of such a small difference was questionable (Laughren, 1998).

In a review of antidepressant trials involving 12,564 persons (Turner, Matthews, Eftihia Linardatos, Tell, & Rosenthal, 2008), 94% of published trials had favorable results whereas the percentage of positive results for published and unpublished trials together drops to 51%. The authors warn that publication bias of this magnitude dramatically distorts reported effect sizes and has serious implications for researchers, health care professionals, and clients. Kirsch et al. (2008) provide further evidence that the belief in antidepressant efficacy is scientifically unfounded. Meta-analytically examining all trials submitted to the FDA for the licensing of four popular SSRIs, the authors found no clinically significant differences between placebo and the drugs, with the exception of the most distressed in the severely depressed group. Even this negligible difference was found to be due not to the drug, but to a decreased response to placebo.

Regarding taking a critical stance about psychiatric drugs, check out the new webiste of the International Critical Psychiatry Network: http://www.criticalpsychiatry.net/  The Heart and Soul Project’s own Certifed Trainer and psychiatrist, Sami Timimi, is a key member. 

On another note, a new webinar by our own John Murphy has been scheduled for February 17:
Respect, Resources, and Recovery: Putting the 3 Rs into Action with Children, Adolescents, and Schools
Wednesday, February 17, 2010, 1:30 to 2:30 Central
Based on the persistent belief that young people and their caregivers are capable of remarkable changes when invited to actively participate in services and to apply their “natural resources” toward solutions, this webinar describes practical ways to put the principles of CDOI and recovery into action in schools, counseling agencies, and other child/youth settings. Real-world examples are used to illustrate the power of partnership and the benefits of client-driven/strength-based practice.

John Murphy, Ph.D., professor of psychology at the University of Central Arkansas, has extensive experience implementing collaborative approaches with young people and school problems (www.drjohnmurphy.com). He recently authored (with Barry Duncan) the book, Brief Intervention for School Problems (2nd ed.) (Guilford, 2007) and Solution-Focused Counseling in Schools (2nd ed.) (2008, American Counseling Association.

John is also a Project Leader of the Heart and Soul of Change Project and a featured speaker at the Heart and Soul of Change Conference in New Orleans. Join John and Barry for this timely discussion of kids and school at: http://www.cdoimembers.com/Default.aspx?pageId=199866