Community-Based Psychotherapy with Young People: Evidence and Innovation in Practice

Community-based Psychotherapy with Young People: Evidence and Innovation in Practice. Front Cover. Geoff Baruch. Psychology Press, - Psychology.
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• Evidence-Based Psychotherapy: Advantages and Challenges

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Related articles in Google Scholar. Citing articles via Google Scholar. Seeking Solitude and Distance from Others: Similarly, rigidly adhering to a uniform procrustean bed of psychotherapy for all patients ineffectively binds the individual to ineffective treatment [ 44 ]. Efforts to promulgate evidence-based psychotherapy must include a focus on the therapeutic relationship. There are several recommendations to ensure the therapeutic relationship makes evidence-based psychotherapy as effective as possible. First, a comprehensive understanding of effective and ineffective psychotherapy must consider how the therapeutic relationship acts in concert with other determinants and their optimal combinations.

Practice and treatment guidelines should explicitly address therapy behaviors and qualities that promote a facilitative therapeutic relationship.

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This involves viewing psychotherapy as a process of change through structured curiosity and deep engagement in pattern identification and narrative reconstruction. Psychotherapists must be caring, understanding, and accepting, which allows patients to internalize positive messages and enter the change process of developing self-awareness [ 47 ].

In addition, they must recognize that professional structures create credibility and clarity, but cast suspicion on care within the relationship. Psychotherapists who forge productive relationships with their patients appreciate that psychotherapy progresses as a collaborative effort with discussion of differences between both parties. In addition to attention to the therapeutic relationship, evidence-based psychotherapies that yield good outcomes are those that are practiced with a high level of fidelity such that the core components of the psychotherapy are implemented [ 43 ].

The core components refer to the basic elements of the evidence-based psychotherapy that are required for applicability and validity of the intervention [ 48 ]. Core components are often defined by the evidence-based psychotherapy developers or in policy guidelines and help describe population characteristics, content of the psychotherapy, context or setting of the intervention, and sequence of the treatment. For example, population characteristics could include adult women with post-traumatic stress disorder; the content is described as 5 lessons on 5 themes of emotion regulation; the context is in a clinic group therapy room on a weekly basis; and the sequence is described as first, emotional identification, then promotion of positive emotions.

Fidelity to an evidence-based psychotherapy is important because when elements of the treatment are changed, the practice is no longer the same as the researched practice. In other words, psychotherapists are no longer implementing an EBP when it no longer resembles the practice in the evidence.

Consistency, achieved through fidelity, allows for stronger statements about the efficacy of a practice. Evidence-based psychotherapies implemented with fidelity are more likely to achieve the desired outcomes as described in the evidence. Many tools for maintaining fidelity are available and include toolkits and training manuals, ongoing training and supervision, and fidelity monitoring and fidelity scales.

Fidelity adherence when using evidence-based psychotherapies faces some challenges. Unfortunately, other than in efficacy research, it is not generally feasible to closely monitor fidelity in real-world implementation. Rigid application of fidelity reduces the usability of a particular psychotherapy. For example, labeling a treatment as only for depression without anxiety eliminates application to many patients with depression. Maintaining fidelity often requires time and resources for training and ongoing monitoring.

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In fact, programs with high staff turnover requiring repeated trainings of new-hires, leadership or government requirements, and extensive training for the psychotherapy can influence fidelity over time, particularly for larger-scale implementation of evidence-based psychotherapies [ 49 ]. Some evidence-based psychotherapies are simply more challenging to implement with fidelity than others.

Fidelity requires conscientious application of the principles of the evidence-based psychotherapy to practice, which is subject to problems in translation or competence, particularly in the context of dissemination efforts.

While fidelity is a crucial component of successful evidence-based psychotherapy practice, implementation with flexibility is also necessary. Flexibility refers to areas where the application of the psychotherapy differs from the specific EBP, such as deviations from manual-based protocol or individualized applications based on patient characteristics. Flexible implementation should still retain core components of the evidence-based psychotherapy.

Flexibility may be desirable in a number of different situations. For example, therapists may use flexibility to build rapport, select treatment modality, or alter the pacing of the intervention in order to assist a patient who has difficulty learning multiple skills rapidly or integrating particular aspects of the treatment.

Moreover, flexibility may be necessary in situations in which individuals present with comorbid conditions, as these must be taken into account in treatment selection and implementation. For example, patients struggling with obsessive thoughts in addition to post-traumatic stress disorder will likely need an alternative therapy prior to starting evidence-based trauma exposure treatment.

Modality changes may also be needed for unique patient situations, such as telephone or internet sessions if the patient travels frequently. In addition, some patients prefer the use of technology e. Finally, many patients benefit from booster sessions or skills refreshers that are not necessarily built into evidence-based protocols and therapists must be open to accommodating such needs. Incorporating flexibility into an evidence-based psychotherapy treatment is not without challenges. Flexibility can be difficult to include in research on evidence-based psychotherapy as the variation from the protocol becomes challenging to monitor and introduces confounding factors.

Overuse of flexibility reduces fidelity, which as discussed earlier, is critical to maintaining an effective evidence-based psychotherapy. The challenge psychotherapists face is walking the fine line between flexible implementation of an evidence-based psychotherapy and the maintenance of the core components of the intervention. It is for this reason therefore that evidence-based psychotherapies are increasingly being developed that provide guidance with regard to both flexibility and fidelity. For example, the Skills Training in Affective and Interpersonal Regulation—Narrative Therapy STAIR-NT protocol includes a wide range of sessions per topic, allows for nonprotocol sessions to address individual patient crises, and encourages optional booster sessions [ 50 ].

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Effective implementation must also take context into account. In terms of context, evidence-based psychotherapies are implemented across a multitude of settings, including private practices, Veterans Health Administration facilities, counseling centers, medical centers, and educational systems to name a few. While some evidence-based psychotherapies are designed for specific contexts, others are formulated for implementation across multiple contexts.

As with other components of evidence-based psychotherapies, the context of development should be considered when selecting a treatment. Although the intent is generally to implement evidence-based psychotherapies across multiple settings, therapists should consider the extent of applicability to their patient population. For example, the Veterans Health Administration VHA often uses guidelines for various disorders and postdeployment health, and evidence-based psychotherapies are often a major cornerstone of treatment.

Indeed, the VHA has been a leader in training staff in the delivery of evidence-based interventions and in disseminating and implementing these psychotherapies [ 51 ]. Data from program evaluations reveal that such training has resulted in positive outcomes for psychotherapies, such as greater clinical competence and self-efficacy [ 51 ]. In addition, patient outcomes have been encouraging in response to these evidence-based psychotherapies as well, in terms of both symptom reduction and improvements in quality of life.

Unfortunately, this has led to concern that treatment at the VA is based on modules and algorithms with limited flexibility or individualized care and may not be suited to all settings. For example, medical settings face challenges with the stepped care or algorithm-based care rather than treatment tailored to the individual needs of the patient.

In the medical context, motivational interviewing is an effective modality for addressing behavioral health issues, such as substance use disorders, obesity, chronic pain, and diabetes, and is a valuable evidence-based psychotherapeutic intervention for depression that is flexible in its delivery and easily integrated into primary care settings [ 52 , 53 ].

The education system is a very different type of site that provides evidence-based psychotherapies to people diagnosed with autism spectrum disorders, depression, and anxiety. In addition, the education system provides suicide prevention screening for all students.

Those in educational settings face numerous challenges to the implementation of EBP, including the cost of manuals for evidence-based interventions, selection of a specific EBP intervention, provider reluctance to use EPB, and stigma regarding the interventions from students, parents, and teachers [ 54 ]. Although evidence-based psychotherapies are typically thought of as primarily oriented toward cognitive-based therapies CBT , there are evidence-based psychotherapies associated with a multitude of therapeutic orientations.

When selecting evidence-based psychotherapies, it is important to consider the therapeutic orientation in terms of what is most applicable to the patient and what is most authentic to the provider. Examples of first- and second-wave CBTs include applied behavioral analysis, behavioral therapy for various disorders, behavioral parenting training, CBT for various disorders depression, anxiety, psychosis, etc. Third-wave CBT is a modality that is sensitive to context and functions of psychological phenomena and focuses on metacognition, cognitive fusion, emotions, acceptance, mindfulness, dialectics, spirituality, and the therapeutic relationship.

Examples of third-wave CBT include behavioral activation, schema therapy, acceptance and commitment therapy, cognitive behavioral analysis system of psychotherapy, dialectical behavior therapy, metacognitive therapy, mindfulness-based cognitive therapy, and mindfulness-based stress reduction. Other orientations of evidence-based psychotherapies include interpersonal, emotion focused, systemic e. As may be evident from these listings, there are evidence-based therapies for young people [ 55 ], adults, older adults, and couples and families [ 12 , 55 — 57 ].

Most evidence-based psychotherapies are designed for single-diagnosis conditions, while the reality is that many patients have multiple comorbid conditions that all require treatment [ 58 ]. Fortunately, some evidence-based psychotherapies are specifically designed for comorbid conditions or have research available for comorbid conditions.

For example, the Seeking Safety protocol addresses post-traumatic stress disorder and comorbid substance use disorder [ 59 ]. Adolescent Coping with Depression [ 60 ] treats young people with both depression and conduct disorder. Recently there has been movement toward a transdiagnostic approach for addressing comorbid disorders effectively with evidence-based psychotherapies. A crucial component of evidence-based psychotherapy is the provider. Many evidence-based psychotherapies imply that psychologists are the primary providers.

However, given the multitude of contexts and settings using evidence-based psychotherapies, there is an equally wide variety of providers, including physicians, nurses, social workers, professional counselors, and graduate students. Therapist variables must be considered, including individual attributes such as training, clinical experience, theoretical orientation, and therapist attitudes towards EBP [ 61 , 62 ].

An essential part of most evidence-based psychotherapies is training, including both initial training and ongoing training and supervision. Complex interventions may require additional provider training and skill. Therapist knowledge improves and attitudinal change occurs following training, and the method for training particularly ongoing influences ease of implementation, accessibility, and desirability.

Organizational variables and culture influence training and consequent therapist uptake and adoption of evidence-based psychotherapy [ 63 ]. Training can occur during a specific period or be part of life-long learning, and typically includes didactics, manual review, practice, and supervised experience, often in groups and with review of actual case materials, as well as training to become a trainer. The training method is an important vehicle and active learning, an interactive process that uses action and reflection has been an effective teaching strategy [ 28 , 31 ].

Clinical experience is an additional important provider variable and the therapists in EBP will vary with some being more skilled. Research settings often rely on trainees in various disciplines and specialties; however, therapists in clinical trials are selected for their expertise and may be removed from the study if they cannot deliver the treatment skillfully [ 61 ].

In clinical settings, there often is a combination of providers with different specialties and levels of training that can create challenges, as there are no clear replicable procedures for how to tailor EBP to an individual patient, and different providers may not reliably select a similar individualized plan when presented the same case [ 34 ].

Provider theoretical orientation and attitudes towards EBP are key factors. Provider training and level of professional development should be considered as those who trained using evidence-based assessment protocols are more likely utilize these methods. Moreover, therapists who have an allegiance to other treatments may bias the outcomes and also have issues with adherence to the treatment fidelity concerns as above.

In addition, provider attitudes are influential in the willingness to adopt and implement EBP and educational attainment is positively associated with endorsement of EBP and attitudes toward its adoption [ 61 , 62 ]. The EBP and associated evidence-based psychotherapy movements have countless advantages. The dissemination and implementation of evidence-based psychotherapies can promote recovery of individuals who present with a myriad of psychiatric disorders [ 51 ]. Despite the availability of effective evidence-based interventions for a range of common mental health disorders [ 10 ], consistent provision of such interventions is not widespread [ 64 ].

For efforts to be more successful in ensuring that evidence-based psychotherapies are practiced more consistently by practitioners in multiple settings, the efficacy and effectiveness treatment research literature must be bolstered, the mechanisms of change associated with intervention effectiveness must be articulated, clinical guidelines that integrate information on mechanisms of change must be developed and disseminated, measures of intervention quality must be developed and utilized, and systematic methods for evidence-based intervention implementation and ongoing utilization that include training practitioners in these approaches must be created [ 12 ].

Systems that have been effective in their dissemination and implementation activities, such as the VHA, can serve as models for other service delivery settings [ 51 ]. More wide-scale efforts will be optimized if they are guided by the research on dissemination science. In addition, for the EBP movement in general and the evidence-based psychotherapy movement more specifically to advance and become truly integrated into practice [ 65 ], many of the unintended consequences of this movement need to be acknowledged and addressed [ 30 ].

More specifically, there needs to be greater appreciation of the value of individual practitioners being flexible in their implementation of protocols based on the unique needs and preferences of their individual patients [ 30 ], along with their own clinical expertise [ 49 ]. In a related vein, the approach must be practiced in a manner that places greater value on patient-centered care and the relationship between the patient and the healthcare provider [ 30 ].

To this end, there may need to be greater prioritization given to the evidence-based relationships movement [ 44 ]. There also needs to be greater attention paid to the factors common across psychotherapeutic approaches and the guiding principles of therapeutic change and processes, rather than to specific empirically supported treatments or even treatment guidelines [ 61 , 66 ]. Training in evidence-based psychotherapy must move beyond teaching people specific manualized treatments and emphasizing a high level of fidelity to such intervention practices toward an emphasis on applying such practices to real-world situations [ 30 ].

For example, this would require more attention to ensuring the cultural relevance of the delivery of evidence-based interventions [ 35 , 67 ]. For the evidence-based psychotherapy movement to continue to advance and to inform clinical practice, a number of steps must be taken with regard to the research efforts [ 8 , 14 , 68 ]. The relevance of various sociodemographic factors e. The conditions under which various psychotherapies are effective versus ineffective must be determined.

More attention needs to be paid to the mechanisms of change that account for intervention outcomes. Moreover, there needs to be more attention paid to developing and evaluating interventions that combine psychotherapeutic and pharmacological interventions, given the value of each for various psychiatric disorders. Providers must be given opportunities for continuing education in evidence-based psychotherapies to help ameliorate the inverse relationship of experience and EBP use. The known cost-effectiveness of using EBP would more than offset the cost of provider training.

Interventions found to have good empirical support under controlled conditions need to be evaluated more thoroughly in real-world settings. Implementation issues also need to be attended to earlier in the research process. Finally, the research agenda needs to be creative and imaginative [ 30 ]. This can be accomplished by greater incorporation of interprofessional cadres of researchers, inclusion of qualitative, as well as quantitative, methods, and involvement of participants who can potentially benefit from the psychotherapies being created and tested.

Clinicians and researchers must collaborate to achieve shared goals of achieving measurable outcomes and improving patient well-being. Disclosure forms provided by the authors are available with the online version of this article. National Center for Biotechnology Information , U. Journal List Neurotherapeutics v. Published online Jun Cook , Ann C. Schwartz , and Nadine J.

Abstract Evidence-based psychotherapies have been shown to be efficacious and cost-effective for a wide range of psychiatric conditions. Electronic supplementary material The online version of this article doi: Evidence-based psychotherapy, Evidence-based treatment, Evidence-based treatment strengths, Evidence-based treatment challenges, Evidence-based treatment misperceptions, Evidence-based therapy.

Background Psychiatric disorders are prevalent worldwide [ 1 ] and are associated with high rates of disease burden, including elevated rates of morbidity and mortality [ 2 , 3 ]. History of Evidence-Based Practice The roots of evidence-based medicine go back centuries [ 13 ].

Strengths of Evidence-Based Psychotherapy There are advantages of evidence-based psychotherapies for practitioners, clinical teams, and patients [ 18 ]. Challenges of Evidence-Based Psychotherapy Despite the many strengths of using evidence-based psychotherapy, there are challenges that must be considered [ 30 , 34 ]. Misperceptions of Evidence-Based Psychotherapy Resistance to using evidence-based psychotherapies results from clinicians and patients, often due to misunderstandings or misperceptions of the role of evidence-based psychotherapies [ 23 ].

Implementation and Application of Evidence-Based Psychotherapy In this section, attention is paid to various factors association with the optimal implementation of evidence-based psychotherapies. Relationships While much attention has been paid to the value of evidence-based psychotherapies, there is considerable evidence that the therapeutic relationship makes substantial and consistent contributions to psychotherapy outcomes independent of the type of treatment [ 44 — 46 ].

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Fidelity In addition to attention to the therapeutic relationship, evidence-based psychotherapies that yield good outcomes are those that are practiced with a high level of fidelity such that the core components of the psychotherapy are implemented [ 43 ]. Flexibility While fidelity is a crucial component of successful evidence-based psychotherapy practice, implementation with flexibility is also necessary.

Context Effective implementation must also take context into account. Provider A crucial component of evidence-based psychotherapy is the provider. Future Directions The EBP and associated evidence-based psychotherapy movements have countless advantages. Electronic supplementary material Below is the link to the electronic supplementary material.

Required Author Forms Disclosure forms provided by the authors are available with the online version of this article. Footnotes Electronic supplementary material The online version of this article doi: A systematic review and meta-analysis Int J Epidemiol Mortality in mental disorders and global disease burden implications: Walker, Mental disorders and medical comorbidity Policy Brief No.

The Robert Wood Johnson Foundation: J Clin Psychol Med Set The evidence-based practice of psychotherapy: Int J Methods Psychiatric Res J Clin Psychiatry, Institute of Medicine, ed.

Evidence-Based Psychotherapy: Advantages and Challenges

Psychosocial interventions for mental and substance use disorders: History and development of evidence-based medicine. Smith RD, Rennie D. Evidence-based medicine—an oral history.