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Evidence-Based
Practice in the Context of Clinical Training: An Interview with Edmund
Neuhaus
George M. Slavich,
Ph.D.
McLean Hospital/Harvard Medical School
The Clinical
Psychologist
The belief that psychosocial interventions
may be improved through research is not new. What is new, however, are
multiple recent advancements in the movement to define and more widely
employ evidence-based treatment. To examine this movement from a clinical
training perspective, I sat down with Dr. Edmund Neuhaus, Co-Director of
Psychology Training and Director of the Behavioral Health Partial Hospital
Program at McLean Hospital. The clinical internship program that Dr.
Neuhaus operates with Dr. Philip Levendusky recently received the
“Excellence in Internship Training” award from the Association of
Psychology Postdoctoral and Internship Centers (APPIC). In the interview
that follows, I asked Dr. Neuhaus to discuss evidence-based practice in
the context of clinical training.
GMS: First, congratulations on
receiving the “Excellence in Internship Training” award from APPIC, along
with Dr. Philip Levendusky, on behalf of the Psychology Training Program
at McLean Hospital.
ECN: Thank you. It is a tribute to the
talented and hard working faculty, staff, and trainees, and especially to
Phil Levendusky, who first brought CBT to McLean over 30 years ago and had
the vision to ensconce internship training into the mainstream of
psychosocial treatment here.
GMS: Last year, there were 640
APPIC-listed internship training sites nationwide. What do you emphasize
in the training program at McLean that makes it standout?
ECN: It’s several things: this hospital
environment, severe psychopathology, the quality of supervision, and of
course, training in the application of evidenced-based treatments. The
structure of the internship program epitomizes McLean’s teaching hospital
mission, as training and clinical service are fully integrated and
informed by research. The primary site for the internship is the
Behavioral Health Partial Hospital Program, whose treatment philosophy is
oriented to translate evidence-based treatments to the real world practice
of hospital psychiatry with complex and severe psychopathology. Our
students typically have strong academic backgrounds in evidence-based CBT,
mostly in outpatient settings. We offer unique opportunities for applying
evidence-based CBT in partial hospital, which in the 21st century has
patients who are virtually at the inpatient level of care. One more thing:
research. There have been career opportunities for interns to work with
PI’s leading to major training grants, and more recently for interns to be
involved in the “live action” treatment outcome research we are doing in
the Behavioral Health Program, which in turn informs the clinical
treatment that interns are providing.
GMS: Evidence-based practice seems to
be a hot topic these days. Why is this the case in general and why now in
particular?
ECN: Evidence-based practice in mental
health and medicine has been gaining momentum in the past decade. I can’t
say for sure why, but accountability is one big reason in my mind. The
field is healthier as more professionals are pausing to consider if what
they are doing is effective; as such, they are seeking out evidence-based
resources to inform their practice. Another reason, I believe, is the
small, core research community of behavioral and cognitive therapies in
the 1970’s and 80’s was graced with the technological advances of society
to proliferate the field.
GMS: You have written that
evidence-based treatments are “not inherently designed to adapt to the
vicissitudes of our current health care environment” (Neuhaus, 2006, p.
1). Say more about this.
ECN: In that paper, I propose that the
clinical and organizational aspects of a program must be inherently
adaptable to maintain consistent effectiveness. Even though something
works today, we must avoid complacency and embrace the changing world. I
also argue that there remains a wide gap between evidence-based treatments
tested under controlled conditions and the real world practice in a
psychiatric hospital. The fact is, the patients we treat would never be
allowed to participate in a typical efficacy study: too many “rule out”
criteria, such as having several diagnoses. From the opposite angle, our
typical patient could use any number of protocols: for depression, for
anxiety, for borderline personality disorder, and for substance abuse.
Which one to choose? I propose a flexible approach to adapt research to
practice. I believe just being flexible is not the goal. We need fixed
values--principles based on the most rigorous theory and research--to
inform our decision-making. Fixed values are guideposts in the storm to
keep us oriented.
GMS: So, you believe that some amount
of adaptation has to occur in order to effectively employ evidence-based
treatment strategies in certain hospital settings. Along these lines, what
do you see as the biggest difference between conducting clinical work in
graduate school and during internship?
ECN: One of my “July speeches” I give to
interns when they arrive is that in graduate school the ethic is to
achieve greater levels of complexity and sophistication. Now during
internship, it’s time to get simple, not simplistic, and really think
about the basic assumptions of what needs to happen to treat that patient
sitting across from you who can’t process information so well because of
depression and anxiety, or that group of patients waiting to learn about
behavioral activation who barely can get out of bed. The point is, many
students know very sophisticated things about evidence-based treatment for
narrow contexts, but there is no natural bridge to treating a
heterogeneous patient population with severe psychopathology. We are
trying to teach, and use in our treatments, the common elements across
protocols that are effective, which I must say creates anxiety for
interns, as it is often uncharted territory for them.
GMS: So, what do graduate students
need to know in order to make them better prepared to use evidence-based
treatments during internship?
ECN: It’s not so much what they need to
know. It about being open to learn and acknowledging the limits of what
they know.
GMS: Looking forward, what does the
future of evidence-based practice look like?
ECN: I worry about technique overriding
good clinical formulation and clinical decision-making. I don’t look
forward to the next treatment manual for a very specific problem. Having
said that, my hope, and there is certainly evidence for this now, is for
more consolidation of evidence-based practice that highlights common
factors. David Barlow’s recent work on unified treatments for emotion
disorders is the best example of this from a basic research standpoint.
And I hope to make a contribution, as I am developing a training manual
for my flexible CBT approach, emphasizing basic principles and a
clinician’s self-evaluation of treatment effectiveness.
GMS: What can graduate students do to
be better prepared for this future?
ECN: Take time to really understand basic
principles, be mindful that one’s theory and research are based on a set
of assumptions and thus are not the whole truth, and be open to learn with
humility.
GMS: On behalf of the student members
of Division 12, thanks for your time!
ECN: It’s been my pleasure.
References
Neuhaus, E. C. (2006). Fixed values and a flexible partial hospital
program model. Harvard Review of Psychiatry, 14, 1-14.
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Citation |
| Slavich, G. M.
(2007). Evidence-based practice in the context of clinical training: An
interview with Edmund Neuhaus. The Clinical Psychologist, 60(2),
12-13. |
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