3 Steps to a Kinder Environment: Science in Practice (Part 4)

In the past months, I've been studying the significant challenges we face in doing evidence-based practice. It's portrayed as straightforward: find the evidence, discuss it with the client, do the evidence based 'thing' that best fits client values and preferences. But difficulty finding evidence to guide clinical decisions (see blog post 1 & post 2), and the profound fallibility of clinical judgment make doing evidence-based practice difficult (post 2 & post 3).

What to do?

Transform wicked practice settings into kind environments.

Kind environments help you see and learn the relationship between clinical judgment, intervention, and outcome.

Three steps can help transform your environment:

1. Use progress monitoring.
2. Start with a standardized protocol for the client's main problem (if available).
3. As needed, shift to disciplined improvisation. (Apply the scientific method by specifying treatment targets to be treated with modular change procedures).

1. Use Progress Monitoring

Monitor progress. Regularly collect data on the client's functioning, quality of life, and change in problems and symptoms. This is the most important step to take to create a kind environment. Whether called progress monitoring, patient reported outcomes, measurement based care, or practice based evidence, tracking client change prevents dropouts and treatment failures, reduces treatment length, and improves outcomes (2).

In particular, use progress-monitoring data to guide decisions where bias is likely. For example, when a client shows lack of progress, inertia is the typical response. Instead, routinely require yourself to change the treatment plan every 10-12 weeks if the patient has not had at least a 50% improvement on a validated measure (3).

The key is to build standard routines that help you see relationships between clinical judgment, intervention, and client outcome.

2. Start with an Existing EBP for the Client's Top Problem

Whenever possible, begin with a standardized treatment protocol for the most important problem. Treating the most serious main problem may resolve others. A standardized protocol gives you a benchmark against which to evaluate outcomes. Most importantly, following an evidence-based protocol limits one's own inconsistency and my side bias.

It's not that starting with a 'by-the-book protocol' is a recipe guaranteed to produce good outcomes if delivered with high fidelity.  It's that human brains need guidance.

Protocols help simplify complex clinical situations into a series of systematic prompts to think or act. Like a manually operated spotlight, they lead the therapist's attention to the problems to analyze and specify how to combine component treatment strategies based on the nature and severity of clients' problems.

Using a standard protocol as an "If, then" test like, "if we use this protocol, we should see this change", creates a feedback loop to detect whether the expected outcome happens (or not).  This makes a more learnable (kinder) environment.

But what if there is no evidence-based protocol or the protocol doesn't produce the desired change? Then what?

Then it's time for disciplined improvisation. More on that next time.

--Kelly Koerner

1. Heath, C., & Heath, D. (2013). Decisive: How to make better choices in life and work. Random House.
2. Goodman, J. D., McKay, J. R., & DePhilippis, D. (2013). Progress monitoring in mental health and addiction treatment: A means of improving care. Professional Psychology: Research and Practice, 44(4), 231.
3. Unützer, J., & Park, M. (2012). Strategies to improve the management of depression in primary care. Primary Care: Clinics in Office Practice, 39(2), 415-431.