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This presentation addresses the controversies of the day that impact our identity as therapists: managed care, EBT v. EBP, psychiatric medication, and the medical model. Encourages you to dig deeper ...

This presentation addresses the controversies of the day that impact our identity as therapists: managed care, EBT v. EBP, psychiatric medication, and the medical model. Encourages you to dig deeper and draw your own conclusions.



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Controversies Controversies Document Transcript

  • 4/3/2011 Controversies of the Day Threats to Our Identity Barry Duncan, Psy.D. Psy.D. 954.721.2981 1
  • 4/3/2011 Take Clients at Face Value But Nothing Else  Several issues threaten our identity  Bottom Line: Look at it yourself and draw your own conclusions Controversial Issues and Threats Gotta Dig Deeper  ThirdParty Reimbursement Trends  Evidence Based Practice  Psychotropic Medications  Psychotherapy and the Medical Model 2
  • 4/3/2011 Therapists and Mangled Care Whine, Whine, Whine  Things are relative…When CHAMPUS started, such outrage.  Paid less than others & had the audacity to require a tx plan at session 24! Many could not work for such measly pay or with such unreasonable demands.  To any therapist today, what CHAMPUS paid then with such limited oversight, would be to die for. All Downhill From There  We didn’t work w/ 3rd party payers to address costs, we demonized them.  They deserve their Darth Vader status. But we didn’t offer alternatives. Mainly responded with righteous indignation.  But not going away…  Instead of fighting, join them at the table; data can help us be “players” 3
  • 4/3/2011 Stepping Up Return on Investment  Conversant in the language (proof of value, return on investment); responsibility for cost & effectiveness.  Managed care has reason for concern: dropout, therapist and treatment variability.  Collecting data & using feedback solves concerns.  These advantages can be bargaining chips. Efficiency should increase the value of our services. Darth Vader Is Still Darth Vader How Will They Use the Data  Some will employ the data to improve outcomes, i.e., provide immediate feedback so you can adjust to benefit your clients.  Giving you feedback to improve your services speaks to an interest in the quality of the services delivered. 4
  • 4/3/2011 Other Purposes  Clinician profiling, removing therapists from provider panels or limiting referrals.  Or, to steer referrals or pay higher rates—or “P4P”  Client welfare often invoked as an explanation—clients steered have best chance for success. But even the best don’t benefit up to a third of their clients. P4P does not address clients receiving services now. P4P Doesn’t Work Wet Blanket  P4P Threatens Our Identity; Puts Us In Competition w/Each Other—Advantage Gained at Someone’s expense  Kills the Spirit…Everybody Can Get Better  We are motivated by getting better at what we do… 5
  • 4/3/2011 Bottom Line Become a Player  Become a player.  Collect data, take responsibility, learn the language of business, & negotiate higher rates.  Oppose collection of data w/o feedback. Voice concerns that P4P will kill the spirit of outcome management. Take Clients at Face Value But Nothing Else  Two approaches: ESTs or EBTs and EBP  One establishes criteria based on RCTs and creates lists  Other describes process of applying evid. & incl. participants 6
  • 4/3/2011 Evidence Based Practice What’s the Hubbub?  All approaches have valid ways to help clients. Makes sense to learn multiple ways.  Also makes sense to be “evidence based”  In truth, no one says, “Evidence, smevidence!”  Like not believing in Mom or apple pie. So what is the controversy about? Evidence Based Practice A Little History: EST to EBP  1993 apa guidelines  Magic bullets to counteract magic pills: ESTs & Div 12; increased rec. therapy efficacy, but  Promulgated gross misinterpretations and now often wielded as a mandate for competent and ethical practice.  That’s the controversy. Intent is not to demonize 7
  • 4/3/2011 Be Skeptical Like My Little Friend  Can be tedious  Worth it to counter mandates & practice according to client preferences and benefit.  ESTs suggest a therapist identity based on technical acumen in administering manualized, cookie cutter interventions No Data Supports Such Edicts The Question: Is It a Fair Contest  Dodo: most replicated; no specific effects; efficacy over placebo, sham, or no tx is not differential efficacy.  In few claiming superiority: Is it a fair contest?  Comparing 2 approaches intended to be therapeutic administered in = amts by those who believe in what they are doing & equally supported—from same pool? 8
  • 4/3/2011 Whose Evidence Is It? Allegiance Effects  At least 40% of any observed effect is attributable to the belief in (allegiance to) the approach by the researchers…TDCRP  Even meager differences disappear when researcher allegiance is controlled… PMTO (Ogden & Hagan, 2008)  PMTO effective in reducing parent-rep. child externalizing problems, improving teacher- rep. social competence, & enhancing parental discipline over TAU.  “The findings thus indicate that PMTO is an effective treatment program…and moreover that an evidence-based treatment program can be transported Ogden, T., & Hagen, K.A. (2008). Treatment effectiveness of Parent Management Training in Norway: A randomized controlled trial of successfully…” (p. 617). children with conduct problems. Journal of Consulting and Clinical Psychology, 76(4), 607-621. 9
  • 4/3/2011 The Data PMTO v TAU  16 measures—only 4 found a difference  On 1 of 4 (CBCL Total), the difference was 1.92 points.  On CBCL Ext., difference was 1.53 points. Clinical significance questionable at best.  Differences by age. Superior finding for PMTO on 4/16 measures for 7 & younger only. None on 15/16 measures for 8 & older; 1 favored TAU. In Addition to These Underwhelming Results…Unfair Contest  PMTO therapists: 18 months training & ongoing sup. during study: TAU therapists received no training, support, or sup.  Dose favored PMTO 40 v. 21 hrs.  No findings on 12/16 measures, no effects children 8 & over, combined with differential training & support of the 2 therapist groups & unequal doses of tx cast doubt on this study’s conclusions. 10
  • 4/3/2011 Trauma Focused CBT Unfair Contests  Child Centered Treatment (CCT), the comparison tx is not a fair comparison—therapists did not see the kids & parents together, TF-CBT therapists saw kids and parents together 3 x out of the 12 sessions. Not reasonable care…  CCT condition did not provide advice or suggestions to kids or parents. Not a real tx.  Reactive measures; 5 of 13 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. APA Definition of EBP Evidence-based practice is the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences (American Psychologist, May 2006). 11
  • 4/3/2011 APA Recommendations  Decisions should be made in collaboration with the client, based on the best evidence  Most effective when responsive to the client’s strengths, cultural context, and preferences.  Responses are variable. Therefore, ongoing monitoring of client progress and adjusting as needed is essential No Silver Bullet Cures  EST/EBTs offers choices for clients—but are merely lenses that may or may not fit the client’s frame and prescription. Methods and models are neither deity nor demon, but are useful metaphorical accounts of how people can change.  But any mandates… 12
  • 4/3/2011 A Mountain of Manure Lopsided Contest Look for Yourself I have never seen an advantage of any approach over another (or TAU) that wasn’t a lopsided contest that had its winner predetermined. 13
  • 4/3/2011 DBT Should It Be Prosecutable? Using vague, unstandardized methods to assist troubled clients ‘should be prosecutable’ in some cases, said Dr. Marsha Linehan (Carey, 2005, p. 2). DBT: What do the data say? •DBT therapists: •Received 45 hours of specialized training; •NIMH•Pre- and during-studyof DBT: funded study supervision. • Compared(38 x 2½) more hours of •Gave 95 DBT to services offered of the hospital to keeping people contact dedicated by “community- out nominated” treatment experts; • Community experts: •Received no training, supervision, or consultation; •No control of type, amount, or quality of services . •Provided significantly less direct service than DBT therapists. Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow up of DBT. Archives of General Psychiatry, 63, 757-766. 14
  • 4/3/2011 The Truth Is in the Tables Smoke and Mirrors Real World Applications DBT for “BPD”  In a large CMHC serving SPMI clients: Of 382 eligible by dx, only 25 (6.5%) thought it was for them; 25% of those dropped out before program started; another 25% dropped out…is it worth the cost? Haynes, M. (2006). Real world applications of evidence based practice. Heart and Soul of Change 3. Bar Harbor, ME. 15
  • 4/3/2011 APA Conclusions and the Bottom Line…  Outcome not guaranteed Mandates regardless of evidence  Challenge statements that don’t use EBTs to mandate or make reimburse.  Know about dodo verdict & empirical unfair contests in research. sense  Educate others about APA definition & importance of measuring client response. NOT ANTI-EBT or EST  Calling for a more sophisticated clinician who chooses from a variety of orientations and methods to best fit client preferences and cultural values. Although there has not been convincing evidence for differential efficacy among approaches, there is indeed differential efficacy for the client in the room now— therapists need expertise in a broad range of intervention options, including ESTs. 16
  • 4/3/2011 Reminds Me of Animal Farm Some therapies are more equal than others The Medical Model Equation Is It Your Identity? Diagnosis + Prescriptive Treatment = Cure or Symptom Amelioration 17
  • 4/3/2011 The Medical Model Fighting the Borg?  MM is not the Borg, nor am I Captain Picard.  Psychotherapy, however, is not a medical, it is relational.  Never challenged on that.  Yet, MM rules as a description of what we do. Ironically, its assumptions and practices are not supported by the data. Diagnostic Dys- Order Dys- Poor Reliability Unknown Validity Does not predict LOS or outcome Little help in treatment selection Surveys consistently find that MHPs do not like it or find it useful… Kirk, S.A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass. 18
  • 4/3/2011 Quotable Quotes about Diagnosis “Psychotherapy is the only form of treatment which, at least to some extent, appears to create the illness it treats” Jerome Frank (Frank, 1961, p. 7). Reliability: “To say that weve solved the reliability problem is just not true…Its been improved. But if youre in a situation with a general clinician its certainly not very good. Theres still a real problem, and its not clear how to solve the problem" Robert Spitzer, lead •Creates the Illness editor of DSM III (Spiegel, 2005, p. 63). •Reliability not good •It’s bullshit Validity: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it… these concepts are virtually impossible to define precisely with bright lines at the boundaries.” Allen Francis, lead editor of DSM IV (Greenberg, 2010, p. 1). Diagnosis Final Comment  Remains a fixed part of graduate training programs, a prominent feature of ESTs, and a prerequisite for funding in most mental health and substance abuse delivery systems—all engendering an illusion of scientific aura & clinical utility that far overreaches the DSM’s deeply flawed infrastructure. 19
  • 4/3/2011 The Beat Goes On: MH Parity Good But  Just like FOC leg. enslaved us to reimbursement by dx & the medical way we talk, parity promises further bondage.  Payers still set fees. Have to cover the costs of equal access somehow: reducing profit?  Negotiating based on benefit, or a fixed no. of sessions in return for better rates & autonomy would be moot. Parity does not address outcome. Medical Model: Doesn’t Fit Me, My Experience, or the Data  Not pts with illnesses requiring tx from experts w/powerful interventions. Not best described by Killer Ds. Therapy is not model & technique.  Identity lies outside dx, prescriptive tx, cure, & reflects the interpersonal nature of the work & the consumer’s perspective of the benefit & fit of services. 20
  • 4/3/2011 Data Could Help Here Too  National data base could reevaluate funding models & MM assumptions.  As evidence emerges re dx, ESTs, LOS, & outcome, the real predictors may come to light (alliance & early change).  Reimbursement based on benefit Bottom Line Collect Data  Nothing wrong with MM. But not empirically supported nor an apt description. Collect data & use it to introduce new conventions for understanding our services. Parity is fine but client benefit should be in the mix. 21
  • 4/3/2011 Raving Lunatic Psychotropics  Same as EBTs—whether any approach should be privileged above others, predictors, client preferences. None earned that empirical respect.  Evidence: Meds should never be considered more than 1 option among many—never automatic.  Identity threat compelling: Just like I am not a technician administering one size fits all interventions, I am not a lower tiered way to help clients. Medication, Like All Treatments, Work Sometimes  Very studies purporting to support major classes of drugs reveal: limited efficacy of antidep. over placebo, the underwhelming results of antipsy. and their pervasive intolerability, and a lack of meaningful benefit of combing therapy and meds.  Regarding children, the data is even less compelling 22
  • 4/3/2011 The APA Working Group on Psychoactive Medications for Children and Adolescents For most of the disorders reviewed herein, there are psychosocial treatments that are solidly grounded in empirical support as stand- alone treatments. Moreover, the preponderance of available evidence indicates that psychosocial treatments are safer than psychoactive medications. Thus, it is our recommendation that in most cases, psychosocial interventions be considered first. (p. 16.) Sparks, Duncan, Cohen, & Antonnucio, Fatal Flaws  Given the infiltration of industry influence, discerning good science from good marketing requires a willingness to engage primary sources  Flaws cast doubt on claims that medication should be a first line, a priori solution to any client problem. 23
  • 4/3/2011 Five Fatal Flaws of Drug Studies •Compromised blind •Client versus clinician measures •Time of measurement •Conflicts of interest •Minimization of risks #1 Compromised Blind  DB foundation of RCT  Inactive placebos make it possible to know tx status (side effects)  Many experienced with medications, and many actively seek to determine their status  Double blind integrity not monitored 24
  • 4/3/2011 #2 Client versus Clinician Ratings Doctor knows best!  Clients & clinicians differ on impressions of improvement  Outcome measures are most often clinician-rated  When client ratings are used, no difference results  If clients don’t know they’re better, how much better are they? #3 Time of Measurement  Medications are never prescribed for short periods of time  8-12 week trials inadequately determine effect; differences start to dissolve by 16 weeks  Drug trial time frames: logistics or strategy? 25
  • 4/3/2011 #4 Conflicts of Interest When money speaks, the truth keeps silent. Russian Proverb #5 Minimization of Risks  Lack of standardized measures for adverse events; mostly from spontaneous report  Lack of clarity of AE This won’t hurt a bit terminology  Failure to publish unfavorable studies  Rhetoric obscures data  Conclusions for tolerability and safety do not reflect findings 26
  • 4/3/2011 Flaws in Action: TADS (Treatment of Adolescent Depression Study)  Multicenter, randomized, masked, effectiveness trial funded by NIMH. N = 432  Short term (12-weeks) and long-term (36-weeks) of 4 tx for adols. dx MDD  Prozac, placebo, CBT, Prozac + CBT  Primary measures: CDRS and dichotomized CGI-I . . . a landmark government-financed study has found that Prozac helps teenagers government- overcome depression far better than talk therapy. But a combination of the two treatments, the study found, produced the best result. NY Times, June 2, 2004 "The medication is addressing "This study will help the chemical imbalances in the brain while the psychotherapy is put the argument to addressing the behavior and the rest," Emslie said. thoughts," said Dr. Timothy Wilens, a child psychiatrist at Massachusetts General Hospital, who reviewed some of the Prozac effective preliminary results for ABC News. The studys findings so far indicate that patients became less suicidal as the study advanced, "The take-home message is that take- Emslie said in an interview. Nevertheless, the medication works, that suicide risk of suicide attempts was greater among those risk is minimal and that the taking Prozac than those on placebo or talk positive effects of the medicine therapy: Five people on Prozac and one on outweigh the risk," said placebo made a suicide attempt, he said. He Koplewicz. ABC News, June 2 added that the number of patients in the study was too small to establish whether an increased risk actually exists. Newsday, June 3, 2004 27
  • 4/3/2011 TADS A Tad Short on Evidence  Flaw #1: No active placebo; No placebo comparison for Comb.; CBT and Comb. knew tx status (no difference with placebo).  Flaw #2: Primary measures clinician- rated. Secondary measures have limited psychometric credibility. 1 of 2 clinician- rated scales (CGI-I) at 12-weeks shows difference. Primary measure shows no difference. No effects client measures  Flaw #3: 12-week trial with limited masking; beyond 12 weeks, all participants knew treatment status. No difference at 30 weeks TADS A Tad Short on Evidence  Flaw # 4: Lead investigator, John March: support from Eli Lilly– extensive ties; Emslie and other researcher: consultants, speakers bureau, and research support from Eli Lilly.  Flaw # 5: 6 suicide attempts out of 200 Prozac takers compared with 1 out of 200 non-Prozac takers. 28
  • 4/3/2011 This Doesn’t Mean That Meds Are Not Helpful  Justmeans that med. is no more viable than anything else, client preference is paramount, not any empirical mandate. Penn, Schoen, & Berland Associates (2004). Survey for the APA. unpublished paper. Prescription Privileges Well Intentioned but Dangerous  Psychiatristswere trained as therapists. Despite lack of data & under the influence of massive marketing & increased income, most have become pill pushers. Are psychologists different? 29
  • 4/3/2011 Consider a Monitor Feature The Ability Not To Prescribe  Thinking about how being able to prescribe has improved patient care, he mentions a patient diagnosed with bipolar disorder. Fain put him on a combination of medications no one had tried with him before. The medications brought relief from his manic symptoms for the first time, Fain says.  "He tells me every time, he pats me on the shoulder and says, You saved me." The Ability NOT to Prescribe  Such medication cocktails, SOP for psychiatry, are neither empirically supported nor FDA approved. Success of this client will likely lead to continue unsupported and unapproved poly- pharmaceutical solutions just like psychiatrists—paving the way for the diminishment of psychotherapy as a first line of action and further marginalization. 30
  • 4/3/2011 Conclusions and Discussion Sparks et al  When clinical trials are critically examined…psychiatric drug treatments should not be privileged. And when effects to tx are noted, who Therapy provides the tx, the quality of the alliance, and the clinician and recipient’s expectations for success should provide a better explanation than any  specific effects due to the medication. Knowing that there is no irresistible be first justification to medicate, therapists are free to put other options on the table & draw in the voices of their option clients—to engage in an informed risk/benefit analysis to choose txs in concert with client values, preferences, & cultural contexts 31