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It Is More about the Person Than about the Practice

By Victor Martini, Community Rehabilitation and Emergency Services Director

The great debate about what works in behavioral healthcare has been gaining speed. On the one hand some practitioners advocate for the use of methods that have been shown to work repeatedly, so called Evidence Based Practice, or EBP.

Evidence Based Practice is determined through the collection of client data over time. With enough data from different clients, it’s possible to assess different mental healthcare therapies to see which ones work best. Once a model has been identified as an EBP it is broken down into several parts so that it can be followed faithfully.

Other practitioners line up behind an approach that focuses on the relationship between a client and his/her counselor and relies on feedback from the client about how things are going. This method seeks to define how to maintain positive alignment between client and counselor to facilitate a good outcome. “I can only help you if you are able to influence the type and manner of help that I provide to you. Your information to me about how it is going is more important than the type of practice that I provide.”

Among the EBP camp are those who emphatically uphold their particular therapeutic model, such as Dialectical Behavior Therapy, Illness Management and Recovery, Cognitive Behavioral Therapy, Integrated Dual Disorders Treatment, or Eye Movement Desensitization and Reprocessing  just to name a few. These therapeutic models are followed faithfully to assure positive predictable results.

On the other hand, advocates of immediate feedback seek immediate positive results. They argue that EBP methods alone are simply a mechanized “cookbook,” but superior results depend on good, reliable and rapid feedback, which creates good alignment between the client and counselor. The client needs to convey to the counselor how well he/she is functioning and how the counselor is doing at making a connection with the client and helping him/her progress.

So, where does this great debate stand today?

As a member of the Clinical Practices Advisory Panel (CPAP), I have worked for several years with the Department of Mental Health in partnership with the Vermont Council of Developmental and Mental Health Services to review Evidence Based Practices in adult mental health and to make recommendations to the mental healthcare system.

After extensive research, the panel made recommendations common to all Evidence Based Practices. Here is a link to the recommendations:

First and foremost the panel found that good outcomes are linked to the manner in which practices are delivered. In other words, Evidence Based Practices are excellent therapeutic tools. But to be fully effective, they depend on good alignment between the client and counselor. Here’s an example of this relationship between the two approaches:

A highly recognized expert in Dialectical Behavior Therapy (DBT) was discussing a particularly difficult client who was not progressing in treatment despite the best work of skilled and dedicated people. The client had successfully completed a DBT skills training group. She had worked with a therapist who was highly skilled in DBT. The client consistently used after-hours telephone coaching.

Despite the impressive array of services, the client was steadily regressing. Colleagues provided many helpful suggestions: “Perhaps a refresher on affect regulation skills.” “Maybe the therapist should review the client’s diary cards to look for recent trends.” “Cognitive restructuring might be helpful.”

After reviewing these options, inspiration struck and the DBT expert realized what to do with exciting clarity that brought a smile to her face: “I’ll take her out for a cup of cappuccino,” she thought. “There is no limit to the exhausting number of service techniques we might offer. There is no limit to fine-tuning the treatment plan. There is, however, a limit on the quality of the relationship that we build with the client. When nothing is working, that is the time to re-establish the relationship.”

Whenever a client is not doing well in treatment I always have to look at the therapeutic relationship I have with the client. How is that alignment working? Is it producing a good outcome?

In the end EBPs are the limitless techniques that we might and should have in our clinical bag of tools. I believe that the successful use of those tools depends more upon the quality of the relationship with the client than the skills with which we follow fidelity to the practices.

It is more about the person than about the practice.

Where do we go from here? In Vermont, we are developing an Evidence Based Practice Cooperative. It will serve as a clearing house for resources and information on best practices. Additionally it is hoped that the cooperative will support the use of data collection, outcomes-monitoring and community-based research to evaluate the effectiveness of Vermont’s mental health system. In essence the cooperative will bring both EBP and alignment-focused approaches to community mental health agencies.

I am pleased and grateful to be a member of the development committee that is working hard to establish a practice cooperative. It is my hope that a successful cooperative will serve to improve not just the quality of services available but more importantly the quality of the lives of people.

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