Paper
Evidence based practice: the new idol?
- issue: Issue 1 / 2009
- authors: Hubert M. Pijnenburg, Jan Willem Veerman
- keywords: The Netherlands, treatment
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- downloaded: 0
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abstract
Background. Our business as a field-oriented research centre is to provide empirical answers to research and development questions concerning innovative or regular care/education practice. These questions are asked by various governmental and institutional parties in Dutch youth and family care and (special) education. As such, in many of our counterparts (and fellow researchers alike) we observe a growing interest in, ánd belief in, a future of youth and family care where settings rely mainly on evidence based interventions to optimize their outcome. Generally speaking, in our view this belief is as premature as it is one-sided. Therefore this orientation needs to be challenged and broadened.
Eusarf is to be commended for its efforts to assess and broaden the empirical foundation of present day youth and family care. The conference title however suggests a rather one-sided perspective on the issue of how to increase the effectiveness of youth care services: all eyes seem to be on evidence-based interventions. But just how much of a valid empirical foundation do we currently have, when it comes to championing the cause of evidence-based child and youth care intervention and, by consequence, to favoring the implementation of specific interventions as key outcome-enhancing factors? Shouldn't we also look elsewhere, when it comes to achieving and boosting results? And if so: where? The aim of our paper is to explore this question.
Purpose. Presently, youth care policy makers and research funding bodies alike are strongly arguing that in order to boost the outcomes of youth and family care, we must bank on the impact of intervention-specific outcome variables - and therefore focus on maximizing the use of manualized, evidence based interventions. The purpose of our paper is to challenge this new mantra.
We are aware that by taking this position, we introduce a risk of breeding complacency on the part of practitioners who may ask themselves: why bother then about effectiveness/efficacy research in the first place? In our mind this position is equally inappropriate. Rather, we argue in favour of a dual approach, to be adopted jointly by researchers, practitioners and policy makers. In order for the outcome improvement train to move forward, two research rails are required: alongside the specific factors rail (intervention) involving ecologically valid clinical trails, we need to lay down a second, non-specific or common factors rail. In our paper we specifically develop ideas on how to lay down the latter rail.
Findings. In his 2000 review, Kazdin tallied in excess of 500 child and youth care interventions, while others claim we have meanwhile easily passed the mark of 1000 interventions. When looking at the number of interventions that have meanwhile been empirically validated, estimates by various authors run anywhere between 2% and 5%: 95% or more of all interventions by youth and family care workers are as yet empirically unsubstantiated. Moreover, more often than not the interventions under scrutiny are essentially 'research therapies', carried out under such favorable conditions as can hardly be met in everyday youth care practice (Veerman & Van Yperen, 2007). This places these studies, with their typical, non-discriminative, mid-size effect sizes into a less favorable light: not only is our youth care evidence base to date exceptionally narrow, its validity for everyday youth practice must also be called into question. To complicate matters further, a robust and consistent finding from a wealth of therapy studies is that specific treatment approaches fail to show specific effects or relative efficacy, thus validating Rosenzweig's (1936) iconic Dodo bird verdict: all have won and all must have prizes (cfr. Wampold et al., 1997).
When looking at factors that bring about significant change in the lives of families and children who call upon assistance by youth care professionals, the work of authors such as Duncan and Miller (2000), Lambert (1992) and Wampold (2001) clearly suggests that - in terms of explained variance - non-specific or common factors such as a) personal professional effectiveness, b) quality of professional-client alliance, c) expectancy/placebo effects, d) routine outcome-informed care factors and of course e) extra-therapeutic events account for a larger proportion of outcome variance than do specific, intervention-related factors.
Regrettably however, at present such research is overshadowed by research into specific interventions and techniques. As a result of this one-sided interest, especially on the part of policy makers and researchers, 'evidence based care' is at risk of becoming youth care's new idol.
Implications and recommendations. In view of the available literature, research into the effects of non-specific factors in youth and family care is clearly warranted. Based on our analysis of the available literature, in our presentation we aim to provide an overview of important non-specific factors in effective youth care services. Also we want to present an agenda for future research into such factors. Only a combined research effort into intervention-specific and non-specific factors can guide youth care towards a significantly higher yield for its clients.
The implication for policy makers and practitioners is that they need to be aware of the one-sided current trend of validating youth care (and subsequently providing it) by looking at interventions as the only essential ingredient. If we accept the overriding findings of many treatment studies that relative differences between interventions are minimal, and that non-specific factors explain a significantly larger proportion of outcome variance than do specific 'technical' factors, the focus in care evaluation research and care practice should shift considerably. The now dominant focus on clinical trials should be complemented by an equally strong focus on the key non-specific or common factors which also make youth care work.
Key references
Duncan, B. L., & Miller, S. D. (2000). The heroic client: doing client-informed, outcome-directed therapy. San Francisco: Jossey-Bass.
Kazdin, A. E. (2000). Psychotherapy for children and adolescents: Directions for research and practice. New York: Oxford University Press.
Lambert, M. J. (1992). Psychotherapy outcome research: implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94-129). New York: Basic Books.
Veerman, J. W., & Yperen, T. A. van (2007). Degrees of freedom and degrees of certainty. A developmental model for the establishment of evidence-based youth care. Evaluation and Program Planning, 30, 212-221.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods and findings. Hillsdale NJ: Lawrence Erlbaum Associates.
Contacts: Hubert M. Pijnenburg,, Praktikon, Radboud University/ACSW-Building, PO Box 9104, 6500HE Nijmegen, The Netherlands, E-mail: H.Pijnenburg@acsw.ru.nl, Phone + 31 24 3611155/-50.