Читать книгу Practitioner's Guide to Using Research for Evidence-Informed Practice - Allen Rubin - Страница 51

We have noted that some studies have found that one of the most important factors influencing service effectiveness is the quality of the practitioner-client relationship. We also noted that some studies have concluded that the quality of the practitioner's clinical relationship skills has more influence on treatment outcome than the decisions made about what intervention to employ. Some have taken a more extreme position and argued that the choice of intervention is irrelevant because some studies have found that all interventions are equally effective if the practitioner providing them has good relationship skills (Wampold, 2001). Based on the latter studies, some scholars have criticized EIP and depicted it as a waste of time at best, and perhaps even harmful if practitioners just follow an intervention manual and thus ignore their relationship skills. Their argument is known as the dodo bird verdict, based on the dodo bird's declaration after a race in Alice in Wonderland that “Everyone has won, and all must have prizes” (Luborsky et al., 1975).

TABLE 2.3 Internet Sites for Reviews and Practice Guidelines

Organization	Internet site
American Psychological Association (empirically supported treatments)	http://www.apa.org/divisions/div12/rev_est
BMG Clinical Evidence	http://www.clinicalevidence.com/ceweb/conditions/index.jsp
California Evidence-Based Clearinghouse for Child Welfare	http://www.cachildwelfareclearinghouse.org
Campbell Collaboration	http://www.campbellcollaboration.org/index.html
Cochrane Collaboration	http://www.cochrane.org
Center for Substance Abuse Prevention	http://modelprograms.samhsa.gov/templatecfm?page=default
Crisis Intervention, Comorbidity Assessment, Domestic Violence Intervention, and Suicide Prevention Network	http://www.crisisinterventionnetwork.com
Department of Health and Human Services: Agency for Healthcare Research and Quality Evidence-Based Practice	http://www.ahcpr.gov/clinic/epcix.htm
The Evidence-Based Program Database	http://www.alted-mh.org/EIPd
Evidence Network (United Kingdom)	http://www.evidencenetwork.org/home.asp
Expert Consensus Guidelines Series	http://www.psychguides.com
National Center for Posttraumatic Stress Disorder	www.ncptsd.va.gov/publications/cq/v5/n4/keane.html
National Guidelines Clearinghouse (Department of Health and Human Services)	http://www.guidelines.gov
Office of Juvenile Justice and Delinquency Prevention Model Programs Guide	http://www.dsgonline.com/mpg2.5/mpg_index.htm
Oregon Evidence-Based Practice Center	http://www.ohsu.edu/epc
Substance Abuse and Mental Health Services Administration National Registry of Evidence-Based Programs and Practices	http://www.nrepp.samhsa.gov/find.asp

There are, however, a number of counterpoints to be made to their argument. One, of course, is that – as we noted earlier – EIP questions are not just about intervention effectiveness and are not just at the clinical level of practice. Another counterpoint, also noted earlier, is that other studies have not shared the dodo bird conclusions. Some have found the choice of intervention to have a greater impact on outcome than do relationship skills. The same authors have noted methodological flaws in the studies supporting the dodo bird verdict (Beutler, 2002; Craighead et al., 2005; Lilienfeld, 2007). Moreover, some studies that have concluded that relationship factors are more important have nonetheless found that while the choice of intervention might be less important, it is not unimportant. In light of those studies, one can argue that even if relationship factors are important it is a false dichotomy to conclude that relationship factors are all that matter. Why not work to maximize the benefit of both types of factors?

Another counterpoint to the dodo bird verdict argument against EIP is that virtually every treatment manual that accompanies interventions that are generally recognized as having the best scientific research evidence supporting their effectiveness stresses the importance of the therapeutic alliance and relationship skills as a necessary component of the intervention. Thus, if practitioners do not provide the intervention in the context of a strong therapeutic alliance and with good relationship skills, then they are failing to comply with the manual!

As a final counterpoint, let's suppose that the dodo bird argument is correct, that the choice of intervention does not matter, and that all that matters is relationship skills. Although we don't buy that argument, let's further suppose that practitioners choose, based on the research supporting the dodo bird argument, to focus exclusively on maximizing the strength of their relationship skills and of the therapeutic alliance. Would that mean that they are not engaging in the EIP process? The answer – paradoxically – is a resounding no! Why so? Because there is nothing in the definition of the EIP process that requires choosing a particular intervention. Instead, all that it requires is to choose to intervene in light of the best scientific evidence. If practitioners decide that the best evidence indicates that to be most helpful to their clients they must emphasize relationship skills exclusively (and if that emphasis is consistent with their practice knowledge and client characteristics), and they therefore decide to be guided by that evidence in their practice, then they are following the EIP process and being influenced by what they perceive to be the best evidence! That is what EIP is all about!