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The Practitioner Connection
Volume XXIX, 1st Quarter

The right help at the right time!

EVIDENCE BASED TREATMENT PLANNING

Choosing the most effective psychotherapy for a mental health condition to be treated or being treated as well as reassessing the effectiveness over time of the psychotherapy being used is an important part of an initial and ongoing treatment plan. Although not all psychotherapies have been part of research studies, many have been studied. These studies support the efficacy of using evidence based treatment modalities. However, despite having good data to support the effective psychotherapies, many of the evidence based treatments are still underutilized.

There is a long list of evidence-based psychotherapies, including some of the psychosocial adjunctive treatments used for bipolar disorders such as psycho-education, family focused therapy (FFT), cognitive behavioral therapy (CBT) and interpersonal and social rhythm therapy (IPSRT).

For borderline personality disorder (BPD), there is strong data to support dialectal behavioral therapy and some psychoanalytical /psychodynamic therapies. Both should be high on the list of evidence-based psychotherapies to be considered when treating borderline personality disorder. More recently, transference focused psychotherapy (TFP), which is a modified psychodynamic therapy that is highly structured and based on Kernberg’s “object relations” model of borderline personality disorder, has been getting increased exposure in related literature as a very effective psychotherapeutic treatment for BPD.

For panic disorder, there is ample research data on cognitive behavioral therapy (CBT) that has continued to show short and long term efficacy in clinical studies. At the same time, it has been found that this therapy approach has been underutilized despite good evidence to support it as being a highly effective, and to date one of the most effective, psychotherapy approaches for this condition.

For major depressive disorders (MDD), interpersonal therapy (IPT) and cognitive behavioral therapy (CBT) have proven effective. In fact, although there are other effective psychotherapies for MDD. the APA Practice Guidelines for psychosocial treatments for major depressive disorders state that, “CBT and IPT have the best-documented effectiveness in the literature for the specific treatment of Major Depressive Disorder”.

In addition to trauma-focused CBT for PTSD there is evidence for the effectiveness of EMDR as well. In OCD, CBT and Exposure and response prevention are not the only psychotherapies used. But, there is good data that suggests that CBT and Exposure and response prevention are among the most effective psychotherapies for OCD. In fact, some studies show that CBT is as effective as, and in some cases more effective than, medications in the treatment of OCD.

Things are also changing in the treatment of chemical dependency and it is important to be aware of the different types of data-supported psychotherapies for the treatment of chemical dependency. The traditional psychosocial treatment most commonly used for chemical dependency is the 12 –step model used in AA. However, there are many other treatments that have been shown to be effective and include: motivational enhancement therapy (MET), modified Cognitive Behavioral Therapy, and Behavioral Therapies such as contingency management, aversion therapy and community reinforcement, to name a few. These additional psychosocial treatments should also be considered, especially for those who might not do well in groups or are not interested in the traditional 12 step model and the concept of a “higher power” which is central to the 12 –step model. At the same time, there are some psychosocial treatments, such as hypnosis, which have not been well studied for chemical dependency other then as an aid in smoking cessation.

For children, evidence-based psychotherapies have lagged behind those for adults. However, this is changing and we are starting to see more research studies being done to support various forms of psychotherapy in adolescents and children. One example is the growing evidence supporting the use of CBT with children and adolescents for various disorders, with the most data supporting its use for anxiety and depressive disorders.

Along with choosing an evidence-based psychotherapy, it is also important to re-evaluate the effectiveness of an evidence-based psychotherapy over time for the condition being treated. When treating someone with one type of therapy that over time seems to be ineffective or minimally effective, considering another modality would be the appropriate next step. Evidence-based psychotherapies should always be considered as a first-line treatment.

So what should one do when an evidence-based psychotherapy is recommended for treatment of a particular disorder but the practitioner does not have experience or training in such therapy? If a therapist does not have such training or experience then s/he should consider referring people with such disorders to a colleague who is experienced with the recommended evidence-based therapy.

When developing a treatment plan, practitioners should first consider any evidence-based psychotherapies for the psychiatric disorder being treated. Once the treatment has started, practitioners should re-evaluate over time if it that treatment has been effective. If not effective, then the practitioner should re-evaluate the treatment plan, discuss and address barriers (e.g. not doing homework assignments when using CBT) and/or consider changing to another evidence-based therapy. This approach is very similar to what is done when using medications alone or in combination with psychotherapy.

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