4. PBE en salut mental
• Important volum de tractaments eficaços
per a trastorns específics
• Baix ús de TSE a la pràctica clínica - els
clínics llegeixen lliteratura científica?
• Condicionants externs (asseguradores,
divulgació, formació, ...)
llabres.cat - març 2012
5. Potencialitats del moviment TSE
• Via més factible per traslladar a la pràctica clínica les
troballes de la recerca: generalització de tractaments
estandarditzats
• Estratègia útil per a la formació - què s’ha d’ensenyar als
futurs clínics?
• Superació de les limitacions del judici clínic per a la derivació
de tractament
• Encoratja la recerca clínica - estàndards de qualitat
• Aproximació més pragmàtica i eficient a la teràpia
llabres.cat - març 2012
6. Why is EBP important in the practice
of clinical psychology with children
and adolescents?
Psychologists are ethically bound to "do no harm"
L’ús de tractaments sense suport empíric suposa ...
• ... major risc de fracàs terapèutic i això redueix la
probabilitat de cercar tractament en el futur
• ... un curs més llarg de la simptomatologia i per tant un
augment de la seva severitat
• ... no acabar amb els problemes a la vida quotidiana
associats al trastorn (fracàs escolar, rebuig dels iguals, ...)
llabres.cat - març 2012
7. • Eficàcia
El tractament funciona en estudis controlats
• Efectivitat
El tractament funciona en condicions normals
(pràctica clínica quotidiana)
• Eficiència
Anàlisi de cost / benefici
llabres.cat - març 2012
8. Els pilars dels TSEs
• Especificitat específics per a trastorns
Llistat de tractaments
concrets, no orientacions terapèutiques
• Manualització la pràctica clínica - protocols
Estandardització de
• Tecnologia a les tècniques i als procediments
El pes es dóna
específics, no al procés d’intervenció
llabres.cat - març 2012
10. Tractaments amb suport empíric (TSE)
per infants i adolescents
la Div.53 de l’APA revisa la
cap guia per seleccionar
psicoteràpia basada en effectivechildtherapy.com
tractaments / problemes
evidències segons els criteris
de control de qualitat
de la Div.12 SCCAP
1993 1998 2008 2010
la Div.12 de l’APA Society for Clinical la Div.53 de l’APA Society for Clinical Child
Psychology elabora uns criteris per and Adolescent Psychology SCCAP publica
determinar si un tractament té o un número especial a la JCCAP amb un
no suport empíric Ten Year Update
11. Criteris (1) tractaments ben establerts
There must be at least two good group-design experiments, conducted in at least
two independent research settings and by independent investigatory teams,
demonstrating efficacy by showing the treatment to be:
a) statistically significantly superior to pill or psychological placebo or to another treatment
OR
b) equivalent (or not significantly different) to an already established treatment in
experiments with statistical power being sufficient to detect moderate differences
AND
treatment manuals or logical equivalent were used for the treatment
conducted with a population, treated for specified problems, for whom inclusion
criteria have been delineated in a reliable, valid manner
reliable and valid outcome assessment measures, at minimum taping the problems
targeted for change were used
appropriate data analyses
12. (2) tractaments probablement eficaços
There must be at least two good experiments showing the treatment is superior
(statistically significantly so) to a wait-list control group
OR
One or more good experiments meeting the Well-Established Treatment Criteria
with the one exception of having been conducted in at least two independent
research settings and by independent investigatory teams
(3) tractaments possiblement eficaços
At least one "good" study showing the treatment to be efficacious in the absence of
conflicting evidence
13.
14. We have relied on expert opinion precisely because we are asking crucial questions that are not yet
well answered by the literature. One thing that the history of medicine teaches us is that expert
opinion at any given time can be very wrong. Accumulating research will ultimately reveal better and
clearer answers. Clinicians should therefore stay abreast of the literature for developments that would
make at least some of our recommendations obsolete.
32. I si no hi ha TSE ?
Until such empirical evidence is
available, clinicians must provide EBP
that best balances the most current
empirical evidence, clinical expertise,
as well as the preferences of the child
or adolescent client and his/her
guardian. Achieving this balance is
difficult, but essential.
llabres.cat - març 2012
33. I si no hi ha TSE ?
... the provision of services
demonstrated to be efficacious or
effective in any population is very
often sufficient justification for the use
of this approach with an untested
population, and thus is preferable to
the provision of untested services ...
llabres.cat - març 2012
34. I si no hi ha TSE ?
(...) psychologists should recognize the
limitations of clinical decision making (...)
people seek confirmatory evidence, fail to
adequately consider evidence contrary to
expectations, perceive correlations where
there are none (...), and rely on numerous
heuristics that can leave clinicians vulnerable
to errors.
llabres.cat - març 2012
36. Mites, controvèrsies, emperons
La llista de TSEs es basa en estudis controlats i
aleatoritzats (RCTs), els quals poden estar equivocats i
no aporten més informació que altres fonts
d’informació
1. the EST list does not require treatments to be tested
using RCTs (...) a series of rigorous single-case designs
can also suffice
2. RCTs currently represent the "gold standard" of
evidence in that they control for a host of sources of
error, such as placebo effects, spontaneous remission,
regression to the mean, and demand characteristics
llabres.cat - març 2012
37. Mites, controvèrsies, emperons
La llista està esbiaixada contra les teràpies
psicodinàmiques
(...) this is generally due to the fact that most
psychodynamic therapies (i.e., those based largely on
the theories of Sigmund Freud and his followers) have
been inadequately researched and therefore have yet
to accumulate a sufficient research base
llabres.cat - març 2012
38. Mites, controvèrsies, emperons
La llista de TSEs és injusta perquè un tractament pot
ésser eficaç però no comptar encara amb prou recerca
(...) one must distinguish unvalidated treatments (i.e.,
those that have yet to be adequately researched) from
invalidated treatments (i.e., those that have been
researched and shown not to work). The EST list
should not be construed as implying that unvalidated
treatments might not later become empirically
supported with sufficient research; it implies only that
such treatments have yet to prove their efficacy.
llabres.cat - març 2012
39. Mites, controvèrsies, emperons
La llista és innecessària perquè totes les psicoteràpies
funcionen igual de bé
(...) some researchers have invoked the
"Dodo Bird verdict," (...) Recent
research has clearly demonstrated,
however, that this characterization is
false. Numerous studies have shown that
behavioral and cognitive-behavioral
treatments are more effective than
Everybody has won and all must have prizes other treatments for childhood
disorders.
llabres.cat - març 2012
40. Mites, controvèrsies, emperons
Alguns dels estudis sobre els que es basa la llista de
TSEs s’haguessin pogut fer millor, no són perfectes
(...) it should be remembered that virtually all research
studies are flawed in certain respects (...) Without this
list, there would be little or no explicit guidance to
clinicians regarding which treatments should be
administered for whom and with which conditions.
Imperfect but informative scientific evidence is almost
always better than no evidence at all.
llabres.cat - març 2012
41. Mites, controvèrsies, emperons
Els TSEs no es poden aplicar en el món real de la
pràctica clínica quotidiana
(...) many recent efficacy studies have begun to
examine patients with problems that more closely
reflect the complexities of those found in real-world
settings. These studies have typically found that
treatments with high efficacy also display high
effectiveness
llabres.cat - març 2012
42. Mites, controvèrsies, emperons
Els TSEs estan “manualitzats” i per tant no permeten
la “creativitat clínica”
Treatment manuals are not meant to be rigidly
adhered to in every clinical situation nor do they, for
example, prescribe fixed responses to patients'
behaviors in therapy. Instead, most manuals provide
flexible guidelines for how to proceed at different
stages of treatment. Moreover, increasing numbers of
treatment manuals afford therapists considerable
leeway to respond flexibly to differing patient
trajectories within treatment.
llabres.cat - març 2012
43. Mites, controvèrsies, emperons
La llista de TSEs és una llista tancada que no canvia
amb les noves evidències científiques
This criticism could not be further from the truth.
Researchers are constantly evaluating and comparing
the effects of various treatments for a variety of child
and adolescent mental health problems. Thus, the EST
list is always a work in progress, subject to continual
updating as new data become available
llabres.cat - març 2012
44. resumint
PBE > ull clínic
Disposam de llistats de TSEs, guies, manuals, ... de
diferents organitzacions i tipus
Aquests llistats es basen en les tecnologies
“pràctiques” i no en les orientacions “teòriques”
Cal estar actualitzat per ètica i per qualitat
... i en aquesta mateixa línia, un recurs més, el CLP ...
llabres.cat - març 2012
51. What is CBT ?
• The therapist and child or adolescent client develop goals for therapy
together, often in close collaboration with parents, and track progress
toward goals throughout the course of treatment.
• The therapist and client work together with a mutual understanding that
the therapist has theoretical and technical expertise, but the client is the
expert on him- or herself.
• The therapist seeks to help the client discover that he/she is powerful
and capable of choosing positive thoughts and behaviors.
• Treatment is often short-term. Clients actively participate in treatment in
and out of session. Homework assignments often are included in
therapy. The skills that are taught in these therapies require practice.
• Treatment is goal-oriented to resolve present-day problems. Therapy
involves working step-by-step to achieve goals.
llabres.cat - març 2012
52.
53. Why CBT?
Cognitive behavioural therapy (CBT) differs from most other
types of psychotherapies because it is:
• Pragmatic. CBT helps identify specific problems; an attempt
is then made to solve them.
• Highly structured. Rather than talking freely about your life,
you and your therapist will discuss your specific problems
and set goals for you to achieve. As part of this, you may be
given homework in the form of activities you should try to
complete before your next therapy session.
• Focused on current problems. Unlike some other
therapies that attempt to explore and possibly resolve past
issues, CBT is mainly concerned with how you think and act
now.
• Collaborative. Your CBT therapist will not tell you what to
do. They will work with you to help you find solutions to your
current difficulties.
54. La pinzellada caòtica
• El moviment dels TSE estudia els tractaments que funcionen i no perquè
funcionen. Fa més de 40 anys que la teoria del caos, dels sistemes
dinàmics, s’utilitza a altres ciències, però els terapeutes de conducta
estàvem massa ocupats identificant els tractaments que funcionaven
• Considerar al pacient com un sistema dinàmic, format per altres
sistemes dinàmics, suposa una forma radicalment nova de veure la
teràpia
• La condició saludable no és l’equilibri sinó la flexibilitat, la criticalitat,
estar lluny de l’equilibri (the edge of chaos)
• El terapeuta hauria de ser “caotitzador” però sabent que portar al pacient
lluny de l’equilibri implica no poder predir el curs que seguirà, donat que
els sistemes dinàmics són sensibles a les condicions inicials
llabres.cat - març 2012
Notes de l'éditeur
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- Teníem molts estudis d’eficàcia sense cap ordre ni guia\n- La lliteratura científica s’escrivia per altres investigadors, no pels clínics\n- Adopció de pràctiques pròpies de la medicina (sabem l’orientació teórica del nostre metge de família?)\n