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Does evidence based practice trump experience?

December 13th, 2015

cool teen boy glasses“Thank you,” the therapist said, “for letting me work with your son. I’ve learned so much.”  I heard these words, or something like them, quite a few times when my son was a child and then a teen.  He had it all, in varying intensities: he was impulsive, explosive, withdrawn, extremely anxious, had wild moods swings, put himself in harm’s way, often acted bizarrely, was sometimes suicidal and frequently saw things that weren’t there.  Sometimes we saw therapists, psychiatrists and mental health workers early in their career and, because he was so complicated and his behaviors and symptoms so severe, they felt they learned a lot.  But usually they didn’t help that much.  Mental health treatment is relationship-based, they used to say.  When the relationship was with someone inexperienced, it was harder to build trust  and confidence.

We live now in a time when people revere “evidence based practice,” often over relationships.  Families know the buzz words and ask how to get cognitive therapy or a wraparound approach like smart shoppers. I have no problem with the new emphasis on evidence based practice – in fact I am grateful for it – because children, youth and families deserve effective care.  My family certainly went through a lot of hit or miss treatment.  Therapists, psychiatrists and other mental health folks provided treatment and approaches that they were familiar with, even when it had already proved inadequate or ineffective.  Yet, when we found someone who was good, at least part of the reason was because they were a seasoned professional.

SAMHSA has a list of evidence based practices here  which draws from compilations both in the US and other countries.  There are evidence based practices for prevention, treatment, substance use, adults, trauma and more.  Many states have similar lists available for perusal and there are new practices added as the body of research grows.  There are other approaches or interventions, such as wraparound, which have been widely studied and are described as “research-based” care and are expected to move onto the evidence based practice list at some point.  Even the new mental health legislation proposed in Congress emphasizes evidence based care.

Before we congratulate ourselves on designing a new framework and checkpoint for delivering services, let’s not forget the old school thinking that relationships are essential too.  Who delivers care is just as important as the way it’s delivered and the evidence behind it.  Delivering services to children with mental health needs and their families is not like operating an iPhone or a Roomba. With user friendly gadgets all you need is a little training, a few tries on your own and you can rely on the device to take it from there.  Parents will say, however, that training and picking the right approach do not beat out experience most of the time.

Here in Massachusetts, partly due to a class action lawsuit and its remedy, we have community based services across the state delivered through a wraparound approach. Other states have also implemented wraparound and similar services and most work hard to maintain adherence to its fidelity measures.  I am often told with pride that someone, or their agency, is delivering high-fidelity wraparound and they are well informed on its principles and stages.  What families say is somewhat different.  Families talk about the experience and skills of the person delivering care.

A couple of months ago I was talking to a mother whose son was receiving wraparound services.  She was engaged, she was connected to natural resources and on and on.  Her son had been diagnosed with reactive attachment disorder (RAD) and that’s why she wanted care for him in the first place.  The care coordinator was young, right out of college, and had never heard of RAD.  Neither had the very young in home therapist.  Neither had the not-much-older supervisor. The mother was disgusted and frustrated.  “What good is training on wraparound if they don’t get the diagnosis and how it affects the family?” she asked.

Another parent had similar things to say about her daughter’s inexperienced therapist who was using cognitive behavioral therapy.  Her daughter had a number of psychiatric diagnoses plus a medical condition. The therapist had taken an online course and at first, the parent thought she’d hit pay dirt by finding this therapist.  After several months went by, she changed her perspective.  “I think she needs more experience in working with someone as complicated as my daughter,” she said diplomatically.

Experienced mental health professionals adapt and evolve their approaches based on years of observation and clinical know how.  Families often rely on this, recognizing that the individual therapist who says, “I’ve seen children similar to your son before.  I have some ideas that I think might work” inspires the greatest confidence.

Most of us understand this is the way things have always been.  The only way to become an experienced, savvy mental health professional is to gain experience.  It’s similar to a teaching hospital where interns and medical students come in to observe and practice alongside your chosen physician.  There is a workforce shortage in the mental health field. Reports state that in the next decade or so many experienced people will leave the field to retire or go into other professions with fewer numbers replacing them.  The percentage of new, inexperienced mental health professionals is sure to go up.

What’s changed is this idea that training in an evidence or research based practice can offset lack of experience.  It simply cannot; nothing replaces the ability to understand a child and family’s struggles and the expertise to address it while drawing upon years of knowledge.  For a number of evidence based practices, the research was carried on demonstration projects, pilots and small projects that attracted high quality professionals who were, in turn, often determined to hire the best people they could find.  They knew that who delivered care mattered.  Often, they had sufficient funding to attract experienced provders and fellow believers.

Many times we match the children and families who have the most serious needs and complexity with those who are the greenest and most inexperienced.  Parents like me appreciate good intentions but we are most grateful for the combination of expertise and experience.  When we find a mental health professional who has both, we are the ones who say thank you.


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