Does evidence based practice trump experience?

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  He had it all, in varying intensities: he was impulsive, explosive, withdrawn, extremely anxious, had wild moods swings, put himself in harm’s way, often acted bizarrely, was sometimes suicidal and frequently saw things that weren’t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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3 thoughts on “Does evidence based practice trump experience?

  1. I too am very concerned. Perhaps it’s because my son’s therapist was just out of school. We waited about 6 months to get her and my son truly needed a therapist. But at what expense to our family. One day I went to his appointment and asked for suggestions what to do when he was having a psychotic break and thought I was someone else as he approached me. Her response was to yell his name. I thought to myself don’t you think I have tried that?!
    A few weeks later I found two oranges in our freezer. I asked my son why they were there. His response was that his “therapist” suggested he put them there so when he was having night terrors he could manage to remember they were there after having a night terror, often falling out of bed and get one. My concern was they were solid and could be used as a weapon or at least something that would cause damage to whatever it hit, me, the wall or a window.
    I spoke to his psychiatrist who thought I was kidding. We moved several months later and now he has a seasoned therapist. They get along well and at one point she told me she was someone who thought outside the box. She has a skill set of various techniques as well as calming ideas. Then I realized one of the reasons he likes her is because he was brought up by a parent who does the same. After 3 weeks of sessions I have seen a tremendous difference in his ability to use calming strategies.

    As for other areas I am concerned about parents getting mixed messages from some professionals who think they understand say an issue with Special Ed. If someone attends the mtg with a family unless they are 100% sure of the regulations they should be there for support only and not become engrossed in the battle between themselves & the school district. If things blow up, the child will be on the receiving end. If they get into a head to head battle the parent should stop the meeting and ask that they reconvene so that they can reach out and find out what to do. Unfortunately many parents think a professional is correct. But this is not always true.

  2. In the 90’s, I oversaw a research project asking adoptive parents whose children had received home-based mental health crisis intervention services from workers who had received special training in issues of adoption about what they felt was most important in making a good worker. The top two items were a sense of empathy, and a sense of humor, which unfortunately are not items than can be taught or that can be acquired through experience. Knowledge of adoption issues ranked #6. I am also aware of research conducted by Pacificare, a mental health managed care organization, which studied treatment for depression. Patients ranked therapists by their effectiveness. Patients who ranked their therapist highest had the best outcomes, regardless of whether they were taking anti-depressants, receiving psychotherapy or both.. The lowest ranked therapists had the worst outcome even if they both prescribed drugs and provided psychotherapy. To my mind, trusting relationships are still the basis of effective interventions, and trust requires believing that the therapist you are working with knows what he or she is doing, and gets help from someone more experienced if she doesn’t. I am all for EBTs in the hands of a therapist who understands the issues the child and family are dealing with. You need to know what the problem is before you can treat it. I would also like to make a pitch for knowing what doesn’t work. Knowledge of the research showing the kinds of interventions that have no proved helpful is also critical.

  3. I am thankful for evidence based practices and research- along that is the main connection and understanding of families, experiences of siblings and the journey of the child going through mental health in their own eyes.

    Very important blog!! Share it on Facebook and around so we can all remember the importance of both.

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