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Article Excerpt
Over a short period of time, evidence-based practice (EBP) has revolutionized thinking not only in the health care field, but also in education and throughout many other human service fields (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). The fundamental reason for favoring EBPs, which are practices that have rigorous research support for their effectiveness, over practices that lack this evidence, is self-evident. All things being equal, administrators, practitioners consumers, family members, and funders all should prefer practices that have been proven to work over those that have not.
For individuals with severe psychiatric disabilities, a group of six practices have achieved broad acceptance as evidence-based (Drake, Merrens, & Lynde, 2005). While the extensive dissemination of information about these practices has proven to be a catalyst to the psychiatric rehabilitation field, many questions remain. One concerns whether these 6 practices all warrant the status of "evidence-based." A second key issue is whether other practices merit EBP status at this time. A third pressing concern is the existence of important outcome domains not covered by any EBPs. This paper seeks to clarify what is, and is not, addressed by EBPs for individuals with severe psychiatric disabilities. We are not the first to attempt to comprehensively map the evidence base for this field; many textbooks and reviewers (Bellack & Brown, 2001; Bustillo, Lauriello, Horan, & Keith, 2001; Clark & Samnaliev, 2005; Lehman et al., 2003; Lehman et al., 2004; Mueser & McGurk, 2004; Wykes, 2003; Zahniser, 2005b) have repeatedly attempted at least partial answers to this question. The current paper is a "work in progress" of a template that is a sorely needed and sought-after resource by policy-makers, researchers, family members, and consumers.
In the mental health field, the most common term used to identify the population of interest is severe mental illness, which we use synonymously with severe psychiatric disabilities. Severe mental illness (SMI) is defined by a psychiatric diagnosis found in the Diagnostic and Statistical Manual Version IV Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000), disability, as defined by role impairment in one or more life domains (e.g., social relationships, independent living, employment), and duration, defined by an extended period of time receiving intensive mental health services (e.g., hospitalization or supervised group living) (Schinnar, Rothbard, Kanter, & Jung, 1990). Schizophrenia is the most common psychiatric diagnosis in this population. The range of appropriate services differs for children and adults; the focus of the current paper is on adults. For individuals with SMI (sometimes referred to as "consumers"), mental health treatment and rehabilitation services are usually considered together, because integrated services (i.e., services integrating mental health, vocational rehabilitation, housing, and substance abuse services) have been found to be far more effective than when they are provided separately (Rapp & Goscha, 2005). In this paper, the term psychiatric rehabilitation practices will be used to encompass both treatment and rehabilitation services.
A number of formal definitions with explicit criteria have been proposed for identifying EBPs (Mueser & Drake, 2005). We propose the following set of operational criteria:
The practice must be clearly defined. To meet this criterion, the practice should have a list of practice principles and a fidelity scale, which is a method for assessing if a particular program meets the criteria for a program model (Bond, Evans, Salyers, Williams, & Kim, 2000). In addition, the practice should have a practice manual providing concrete instructions for its implementation.
The practice should designate the target group for whom it is intended. The population(s) for which the EBP has been found effective should be specified.
The practice must be shown effective in a set of rigorous research studies with consistent and convincing results. To meet this criterion, several randomized controlled trials (RCTs) should have been completed, and in the aggregate show convincing and substantial evidence favoring the practice. Optimally, the control groups should consist of strong alternative treatments that are in wide use; the analogy can be used to guidelines used by the U.S. Food and Drug Administration (FDA) for approving new medications (Left, 2005). Some authors suggest as few as two studies are sufficient to meet this criterion; for example, the standards used for "empirically validated therapies" proposed by a task force from the American Psychological Association is "at least 2 rigorous experimental studies showing therapy is superior to placebo or another treatment" (Chambless & Ollendick, 2001). Moreover, a sufficient number of studies with less rigorous research designs (e.g., single case design experiments or quasi-experimental studies) may also be deemed sufficient. The weighting of evidence is a complex issue; most experts agree that meta-analysis is the gold standard for documenting effectiveness (Bero & Drummond, 1995; Lipsey & Wilson, 1993).
The research findings must be independently replicated by at least two research groups. The intent of this criterion is to guard against researcher allegiance effects, which is the tendency for a single research group to replicate its own findings, sometimes when other research groups have not (Luborsky et al., 1999).
The practice should have demonstrated effectiveness in improving outcomes addressing important needs in the target population. In agreement with Mueser and Drake (2005), we have added this criterion to highlight the criticality of targeting meaningful outcomes in evaluating the contribution of a practice. Some EBPs lack salience to the needs of the target population (Roth, Crane Ross, & Panzano, 2003). It is not sufficient that an intervention shows a significant impact if the outcomes are trivial or do not generalize to major life domains; for example, psychoeducation has been widely demonstrated to change knowledge and attitudes while seldom affecting behavior (Mueser et al., 2002).
The practice must demonstrate the capacity to be implemented in a wide range of settings. Generalizability of the implementation of a practice is an important criterion. If, because of cost, complexity of the intervention, dependence on the charisma of the model developer for successful implementation, or other factors, the practice cannot be easily transported to usual service settings, then this is a severe limitation (Weisz, Weiss, & Donenberg, 1992). Fortunately, most of the evidence in psychiatric rehabilitation rests on effectiveness studies where the application to at least some real world settings is already established.
Three issues are of interest in this paper. First, within the field of psychiatric rehabilitation, which practices are regarded as evidence-based? Second, how confident are we that these are in fact evidence-based, and on what bases do we assert these claims? Third, are there outcome domains for which there are no current EBPs?
The organization of this paper is as follows: First, we identify a set of important outcome dimensions for individuals with SMI, based on their needs and aspirations. Second, we summarize the efforts within the EBP movement to identify EBPs for this population. Third, we go beyond that listing to suggest practices that address important needs while lacking sufficient evidence to be considered evidence-based.
A variety of objective rating systems have been developed to assess adequacy of the evidence for a specific practice (Left, Conley, & Elmore, 2005). However, this paper depends almost exclusive on conclusions from existing reviews rather than attempt evaluations of primary studies.
Needs of Individuals with SMI
People with SMI generally have the same aspirations as the rest of the population: meaningful work, decent housing, friendships, health, financial security, and a high quality of life (Carling, 1995; Steinwachs, Kasper, & Skinner, 1992). Mueser and Drake (2005) identified the following 9 major domains of meaningful outcomes (pp. 224-225): (1) Reduction of symptoms, (2) Improvements in social and role functioning (including work, school and parenting), (3) Increased self-care skills, (4) Increased independent living skills, (5) Reduced institutionalization, (6) Securing stable and independent housing, (7) Enhanced quality of life, (8) Better control of substance use, and (9) Improvements in general health. The extent to which these are important domains of need is well documented in the literature (Bond, Salyers, Rollins, Rapp, & Zipple, 2004; Crane-Ross, Roth, & Lauber, 2000; Shumway et al., 2003). Amplifying the typology used by Mueser and Drake (2005), we note that reducing institutionalization has often meant not only reduced hospitalization but also reduced incarceration, given the overrepresentation of people with SMI in correctional facilities (Lamberti, Weisman, & Faden, 2004). Cognitive functioning is increasingly recognized as an important outcome as well (Harvey, Green, Keefe, & Velligan, 2004). Two further outcome domains, recovery and spirituality, warrant consideration.
Recovery is by no means an easy concept to define, but it has gained widespread acceptance as an important focus for EBPs (Anthony, Rogers, & Farkas, 2003). Recovery involves "... the need to re-establish a new and valued sense of integrity and purpose within and beyond the limits of the disability; the aspiration to live, work, and love in a community in which one makes a significant contribution" (Deegan, 1988) (p. 12). Recovery includes the achievement of personal goals, while having a sense of purpose and hope. By contrast, the reality for many consumers is a lack of meaning in life. Indeed, their daily routines are often passive, sedentary, solitary, and meaningless (Krupa, McLean, Eastabrook, Bonham, & Baksh, 2003; McCormick, Funderburk, Lee, & Hale-Fought, 2005). One study reported that consumers spent 71% of their time at home, 37% of their time alone, and 10% of...
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