——— UNIT 3.

EBP ———

1. Empirically Supported Treatments (EST):

Starts with a treatment and asks whether it works for a certain disorder or problem under specified
circumstances. ESTs are specific psychological treatments that have been shown to be efficacious in controlled
clinical trials.

2. EBP in psychology:
- EBPP is the more comprehensive concept. Starts with the patient and asks what research evidence
(including relevant results from RCTs) will assist the psychologist in achieving the best outcome.
- Encompasses a broader range of clinical activities (e.g., psychological assessment, case formulation,
therapy relationships).
- Articulates a decision-making process for integrating multiple streams of research evidence (including
but not limited to randomized controlled trials) into the intervention process.
- The purpose of EBPs lies in promoting effective mental health and addiction practices, having
profound implications for practice, training, and policy.
- Increasingly requires professionals to base their practice, to whatever extent possible, on research
evidence. Clinical expertise and judgement is critical but must be coupled with the best research
evidence and good patient communication.
- In mental health, the EBP movement has become most visible (and controversial) in identifying certain
“evidence-based” treatments in the form of compilations, lists, and guidelines and then publicizing.
- “Evidence-based practice in psychology is the integration of the best available research with clinical
expertise in the context of patient characteristics, culture, and preferences”

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- Which research design belongs to the first level of evidence?

- Which research design is best?

● For efficacy of treatments, randomized control trials may provide the best evidence.
● To learn about the evolution of a certain condition, longitudinal studies may offer the best evidence
● Systematic reviews may offer a general view about the effectiveness of an intervention across different
settings and research groups.

● When making clinical decisions, the evidence taken from systematic reviews and meta-analysis
(compendium of results from many studies, with clear selection criteria) is more important.
● In case of individual studies, randomized controlled trials (one group receives treatment while another
group receives another, or does not receive one, with the groups being homogeneous and randomly
assigned participants) constitute the golden rule of designs.
● A last resort appreciated by professionals are evidence-based guidelines, which collect systematic
reviews, meta-analysis and randomized controlled trials (best studies) in relation to the effectiveness of
treatments.

3. Términos importantes:
● EFFICIENCY: No estamos gastando recursos. no estamos gastando los recursos necesarios. no se
están utilizando mal los recursos.
● EFFICACY: Significa que este tratamiento soluciona un problema para el cual fue diseñado.
● EFECTIVENESS: Significa que la intervención es buena en general para el cliente, no solo para lo
que está diseñada sino tb para otras áreas.

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 4. Clinical expertise:
Psychologists trained as scientists as well as practitioners: clinical expertise informed by scientific expertise
allowing the psychologist to understand and integrate scientific literature as well as to frame and test hypotheses
and interventions in practice as a “local clinical scientist”. Para ganar experiencia clínica necesitas adquirir
herramientas. Clinical expertise is essential for identifying and integrating the best research evidence with
clinical observation.

- Components of clinical expertise:

➔ Assessment, diagnostic judgment, systematic case formulation, and treatment planning and setting
goals;
➔ Clinical decision making (selecting interventions), skilful treatment implementation, and monitoring of
patient progress (adjusting practices accordingly); Justificación de por que han decidido eso
➔ Interpersonal expertise;
➔ Continual self-reflection and acquisition of skills;
➔ Appropriate evaluation and use of research evidence in both basic and applied psychological science;
➔ Understanding the influence of individual, social, and cultural differences and contexts on treatment;
➔ Seeking available resources (e.g., consultation, adjunctive or alternative services) as needed;
➔ Having a cogent rationale for clinical strategies. Ser coherentes, usan teorías, principios, una estructura
coherente…
No solo con la parte empírica es suficiente, necesitamos ayuda o feedback de un profesional. entrenarse
constantemente. evoluciona
➔ Experts:
➔ recognize meaningful patterns
➔ disregard irrelevant information
➔ acquire extensive knowledge and organize it in ways that reflect a deep understanding of their
domain. Organize it using functional rather than descriptive features
➔ retrieve knowledge relevant to the task at hand fluidly and automatically (que es importante y
que no, darle sentido de forma rápida)
➔ adapt to new situations
➔ self-monitor their knowledge and performance (SUPERVISOR)
➔ know when their knowledge is inadequate
➔ continue to learn
➔ and generally attain outcomes in line with their expertise.

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- Patient’s characteristics, culture, and preferences:

➔ Personal values y hay que adaptarlas. Normative data on “what works for whom” provide essential
guides to effective practice.
➔ Psychological services are most likely to be effective when they are responsive to the patient’s specific
problems, strengths, personality, sociocultural context, unique concerns and preferences.
➔ Assess the meaning of the different values or words ask about the expectations of the patients.
➔ EBPP involves consideration of the patient’s values, religious beliefs, worldviews, goals, and
preferences for treatment with the psychologist’s experience and understanding of the available
research.
➔ Clinical decisions should evolve in collaboration with the patient and in consideration of the probable
costs, benefits, and available resources.

- Questions about the role of patient characteristics in EBPP

➔ Many presenting symptoms (e.g., depression, anxiety, school failure) are similar across patients.
➔ However, symptoms or disorders that are phenotypically similar are often heterogeneous with respect
to etiology, prognosis, and the psychological processes that create or maintain them.
➔ Personality variables underlie many psychiatric syndromes and account for a substantial part of the
comorbidity among syndromes widely documented in research.
➔ Psychologists must attend to the individual person to make the complex choices necessary to
conceptualize, prioritize, and treat multiple symptoms. MUY IMPORTANTE

- Patient-related variables and characteristics to consider

➔ Cross-diagnostic characteristics (e.g., functional status, readiness to change, level of social support).
➔ Variations in presenting problems or disorders, etiology, concurrent symptoms or syndromes, and
behavior;
➔ Chronological age, developmental status, developmental history, and life stage;
➔ Sociocultural and familial factors (e.g., gender, gender identity, ethnicity, race, social class…);
➔ Current environmental context, stressors (recent life event), and social factors (institutional racism)
➔ Personal preferences, values, and preferences related to treatment (e.g., goals, beliefs, worldviews,
treatment expectations).
➔ It is important to know the person who has the disorder in addition to knowing the disorder the person
has.

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 - The role of patient culture in EBPP

➔ Culture influences not only the nature and expression of psychopathology, but also the patient’s
understanding of psychological and physical health and illness.
➔ Cultural values, beliefs and social factors (e.g., implicit racial biases) also influence patterns of seeking.
➔ Clinicians must carefully consider the impact of race, ethnicity, and culture on the treatment process,
relationship and outcome.
➔ Racial power differentials between clinicians and their patients, along with systemic biases and implicit
stereotypes based on race or ethnicity, contribute to the inequitable care of non-white patients receive
across health care services.

- Evidence-based practice (EBP) in mental health: controversies

There is near universal agreement that evidence works as a reference guide in determining the practice.
Some controversial topics related with EBPs:

➔ What qualifies as evidence of effective practice?

Tener en cuenta la experiencia personal, más importancia al empirical movement include experiencia y valores y
añadir cosas que va a decir en clase.
➔ What qualifies as research for effective practice?
➔ What treatment outcomes should establish EBPs?
Medicine often has physical, measurable indices of treatment outcome (e.g., laboratory measurements,
pathology reports).
En nuestra ciencia no tenemos una, necesitamos construir un standard for replicar the measures.
➔ Does manualization improve treatment outcomes?
Treatmen integrity: medir si estás siguiendo los pasos que deberías seguir. si los sigues tendrás una buena
intervención. In mental health research, this standardization has frequently involved the use of treatment
manuals and observation checks to insure fidelity. Manualization has been deemed a prerequisite for inclusion in
most compilations of EBPs. While treatment manuals indisputably prove helpful for training and research, the
research on their value in improving treatment outcomes shows mixed results.
➔ Do research patients and clinical trials accurately represent real-world practice?
Evidence-based practices seek to identify the most effective treatments in research studies so that we can widely
implement those same treatments in practice. However, research findings do not automatically or inevitably
generalize.
➔ What should we seek to validate?
In mental health and addictions research, however, we often find diverse perspectives and conflicting results.
Some argue that the treatment method forms the natural and inclusive target for research validation, while others
argue that the psychotherapist, the therapy relationship, and the patient actually account for more of the success
and, thus, should be targets for research validation and EBPs.

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 ➔ What influences what is published as evidence?
Research results fall under the inevitable influence of the researcher’s theoretical allegiance, funding sources,
and conventional wisdom.
➔ Do treatments designated as EBPs produce outcomes superior to non-EBPs?
By definition, treatments designated as evidence-based outperform no treatment and placebo treatment.
We can confidently state that EBPs are superior to no treatment and sham treatments; however, we cannot state
that EBPs are necessarily “best practices” or “treatments of choice” unless they outperform bona fi de,
structurally equivalent therapies.
It remains unclear and controversial whether EBPs perform reliably better than practices not designated as
evidence-based.
➔ How well do EBPs address patient diversity?
The ensuing contention is to what degree EBPs, validated primarily on studies with majority populations,
qualify as “evidence-based” for marginalized or minority clients.
➔ Do efficacious, laboratory-validated treatments readily transport to clinical practice?
Despite these controversies, there is an impressive consensus in the definition and purpose of EBP.

5. Empirically Supported Treatment: Recommendations for a New Model

"Many authors, including those broadly in agreement with the EST concept in theory, have raised significant
concerns about how ESTs are currently defined."

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"We propose that symptom reduction no longer be considered the sine qua non of treatment outcome."
- Does the world need another list of ESTS?
Añadir más calidad, estudiar factores comunes, mejorar los que hay ahora…
- “To what extent should we focus on established treatments, versus principles of change?
Over time, the field would likely benefit from a shift away from “named” or “packaged” treatments. The current
EST list includes more recent multicomponent treatments that contain many different interventions within one
treatment “package.”
"While the assessment of such treatment packages is a necessary step in identifying what works, such research
does not allow for a determination of which aspects of the treatment are responsible for change. That is, within a
given treatment package, there is no way to determine which components of that treatment are therapeutically
active or inert."
"An emphasis on identifying the active ingredients of change need not exclude factors associated with the
therapeutic relationship. Indeed, many have suggested that the therapeutic relationship accounts for greater
variance in clinical outcomes than do those aspects of the therapy that are described as “techniques”.
"The proposed system takes into account the recommendations of APA work groups, suggesting that treatment
guidelines should:
(a) be based on broad and careful consideration of the relevant empirical literature,
(b) take into consideration the level of methodological rigor and clinical sophistication of the research,
(c) take comparison conditions into account,
(d) consider available evidence regarding patient-treatment matching,
(e) specify the outcomes the intervention is intended to produce,
(f) identify known patient variables that influence the utility of the intervention,
(g) take the setting of the treatment into account,
(h) note possible adverse effects, and
(i) take treatment cost into account."

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- Common factors:

6. Single-case experimental designs EXAMEN

➔ They are research designs whose purpose is to allow the evaluation of functional relationships between
one or more independent variables (IV, interventions) and one or more dependent variables (DV,
behaviors).
➔ Continuous assessment based on observations on multiple occasions over time; before and during the
period in which the intervention is administered .
➔ Vamos a evaluar el proceso que está ocurriendo en esa persona
➔ It is the alternative al random control trial
➔ Una caracterítica no definitoria es el número de participantes que interviene
➔ Se llama de caso único porque el control está dentro del individuo, no se necesita grupo control

- Basic dimensions:
- Time (SE NECESITA MÁS TIEMPO)
- Repeated observations
- Case (idiographic investigation). ALGO QUE ESTUDIAR
- Independent variables
- Dependent Variables
- Basic characteristics:
- Each case is its own control.
- The dependent variable is repeated over time, under different conditions.
- The evidence is confirmed by replication. (en esa misma persona, no en otro grupo)
- Single-case experimental designs are dynamic by nature.

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 - Baseline:
Baseline assessment: The baseline assessment is
implemented over a period of time before the
intervention. To describe current performance and
predict what performance is likely to be in the
immediate future if the intervention were not
implemented“
• the descriptive function (propósitos)
• the predictive function.
Necesitamos una baseline para medir el cambio en
nuestros participantes

- AB* design (non-experimental)

No es un experimento, sólo un estudio. No hay

grupo control. Tratar de medir, si no medimos no
sabemos si esa persona mejora o empeora.

- Withdrawal or reversal designs (ABAB) Añadir más partes, diferentes estructuras y diferentes partes

- Multi-treatment designs (ABCBC): Tenemos replicabilidad

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- Multiple baseline designs (One subject, several behaviors). Si añadimos control, es un experimento

- Alternating designs

- Variable criteria designs (no pregunta en el examen)

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