Evidence Based Approach
In the books of Arthur Conan Doyle, the intrepid Sherlock Holmes is faced with a tangled mystery, and using his wits and the clues available to him, he develops a theory, puts it into practice and captures the bad guy. It’s entertaining, to be sure, but it’s also easy for modern readers to fixate on the genius of Sherlock Holmes and overlook the clues left behind. Without those clues, without that evidence, Sherlock Holmes would have no case at all to solve, as he makes clear in The Adventure of the Copper Beeches: “‘Data! Data! Data!’ he cried impatiently. ‘I can’t make bricks without clay.’” To people engaged in scientific matters, whether they are solving crimes or treating diseases, nothing is really true unless it can be proven by evidence.
At an addiction treatment center, professionals rely on science, evidence and experimentation in their work. Through these methods, interventions that are helpful can be separated from those that are not. It’s an important concept to understand and master, especially when family members are choosing an addiction treatment facility for someone they love. After all, addiction is a serious disease and treatment can mean the difference between life and death. Regrettably, there are some facilities that provide treatments with no firm footing in science, and they can do an incredible amount of damage as a result. For example, the Federal Trade Commission reports that a company claimed to “cure” patients of alcoholism via vitamin supplements. This isn’t a method supported by evidence, yet many patients were conned into accepting these treatments. By asking questions, and asking for proof of claims, families can choose a facility that does provide evidence-based treatment.
Defining the Term
Almost any company could claim that the interventions it provides are based on scientific principles. In fact, most companies could even drum up a few patients, write up quick test results and then claim that the procedure has been backed by science. The true definition of “evidence-based treatment” is designed to weed out these sorts of fraudulent behaviors. In fact, an intervention often must go through several steps before it can truly be considered an evidence-based treatment.
The Iowa Consortium for Substance Abuse Research and Evaluation published a set of guidelines in order to help medical staff separate interventions that are evidence-based approaches from those that are not. The language is technical, and the document goes into much more detail than the average family needs to know, but a few rules might be instructive. For example, in order to meet the criteria, the intervention must:
- Be proven effective in more than one study, using more than one type of population in more than one location
- Be more effective than interventions that are now regularly provided for that condition
- Tend to keep people in treatment, so participants don’t drop out before it is complete
- Be based on a clear theory that is well articulated and easy to understand
- Work to correct an outcome that is considered normal for that particular disease
- Be measurable
In other words, the intervention must have a firm footing in some sort of scientific principle, be tested in a variety of places with different patients, be proven effective and isn’t so difficult that people are tempted to drop out before it’s over.
All of this may sound so reasonable, that it might be easy to believe that all people should only use evidence-based treatments in their programs. Unfortunately, this isn’t always the case. As mentioned, there are some companies that intend to lie or defraud their patients, and they may steer clear of evidence-based treatments for this reason. But, there are other barriers that exist, no matter how honest the company might be.
For example, according to an article published by EBP Substance Abuse, some interventions are designed properly and proven effective in clinical trials, but the people who developed the intervention didn’t write any sort of manual for the procedure. A doctor living in a far-flung state may believe in the idea of that intervention and want to use it in practice, but that doctor may have no idea how the intervention actually works. How many staff members should be involved? How often is the treatment given? When does it stop? The answers to these questions can have a big impact on how well the intervention actually works in the real world, and unless those answers are provided in some sort of manual, it can be hard to put that practice into use. If a doctor tries to wing it and uses different rules, the intervention might not be effective at all. Or, it could provide a significant amount of harm, instead of providing any sort of help.
On the flip side of this argument, according to an article published in the Journal of General Internal Medicine, some doctors resist the idea that they must use an intervention exactly the way it is written without any ability to tweak it to meet the needs of their individual patients. If the rulebook is so tight that it can’t be customized, the intervention might do more harm than good. If they’re told, for example, that they must use a specific dose of methadone in addicts of a certain age and that dosage can’t be changed no matter what else is going on with the patient, they may scrap the evidence-based treatment altogether in favor of providing methadone to their individual patients based on their specific needs. In some cases, this actually might be a good thing. Addiction isn’t a simple disease that works in all people in the same way. Instead, addiction involves a complex interplay of chemistry, heredity and life experience. No two people have exactly the same sets of variables, and therefore no two people will respond to treatments in exactly the same way. Sometimes evidence-based treatments don’t account for this idea.
A Word About Placebos
Even people who don’t work in medicine often know about the placebo effect. Here, an intervention that does no good at all seems to have some sort of miraculous ability to transform a person and combat an illness or disease. An article in Psychology Today suggests that the mind is a powerful healer, and sometimes it will chose to believe information that is completely contrary to any sort of rational thought. For example, some people feel better when they’re given pills made of sugar, even when they’re told that the pills are only made of sugar. In other words, the placebo effect can take hold over people who are seemingly well prepared to guard against it.
While it might be tempting to discard all scientific tests, since the placebo effect is real and it is pervasive, a note of caution is important here. Most well-designed studies include people who received a placebo treatment, and most researchers do a series of analytic, mathematical calculations to account for the effects of the placebo. So while it might be true that the placebo can have some sort of pull on results, it certainly does not mean that all of the results of scientific studies must be discounted due to placebo effects. Scientists are adept at correcting for this phenomenon.
Hidden in Plain Sight
While it might be easy to believe that facilities that offer evidence-based treatment will be easily identifiable from those that are not, the truth is a bit murkier. As mentioned, addiction is a complicated disease that impacts many biological and psychological processes, all at the same time. Sometimes, a therapy that might seem superfluous and obviously like a sham turns out to have a firm footing in science and can be classified as an evidence-based treatment.
To provide just one example, some facilities provide animal therapy as part of their treatment models. The people who live in the addiction facility are asked to work on a farm, ride horses or care for some other furry critter. On first glance, this might seem like a frivolous idea that is designed to lure patients in without really providing an addiction benefit; however, there have been several studies that suggest that animal therapy is quite beneficial in helping a wide variety of mental disorders and addiction. For example, a study published in the Journal of Psychosomatic Research found that six neurochemicals associated with an increase in blood pressure were lowered after the humans and animals interacted. In other words, playing with animals lowered blood pressure, and perhaps stress, which might make it a valuable component in addiction therapies for people with stress disorders. Sometimes, separating sham science from evidence-based treatments isn’t as easy as it might seem. Rarely are snap judgments associated with the truth.
Knowledge Is Power
If looks can be deceiving, and some evidence-based treatments are hard to implement properly, what’s a patient to do? The answer lies in asking questions. It’s hard to separate one facility from another based on glossy brochures or mission statements on a website. Since addiction therapy is so important, it pays to ask detailed questions and really get informed about options before enrolling in any program whatsoever.
The Substance Abuse and Mental Health Services Administration (SAMHSA) keeps an online database of evidence-based programs and practices. This database, known as NREPP, provides information about how the intervention is designed, how it has been studied and the results of those studies. In some cases, it might be beneficial to look through this database when researching facilities. If the facility offers eye movement desensitization, for example, families can look up this intervention on NREPP, find out how it works and see how it has been beneficial for patients in the past.
SAMHSA has also published a list of questions providers can ask of new evidence-based treatments before they choose to implement them in their own facilities. Some questions are technical in nature, designed to help health care providers choose the right plan to provide to their patients, but some of these same questions could be used by families seeking treatment for addiction. These might be good questions to ask:
- Have people with my condition been treated with this intervention? How well did it work?
- In the published studies on this intervention, who were the people that commonly received this treatment? How well did they do?
- How is success measured in this model?
- How many sessions are typically needed?
- Was training required before your staff offered this treatment? Can you provide proof that they received this training?
These questions might seem nosey, but it’s important to remember that, as consumers of services, families have a right to ask questions, look for proof and make researched choices based on facts. Facilities that provide evidence-based treatments are happy to comply. Those that do not might become apprehensive or defensive, and they might be best avoided.
While some families know they can and should ask these sorts of questions, it can be intimidating to do this sort of interrogation, and it can be hard for some families to know whether or not they’re getting honest answers in response. There’s no shame in asking for help. Sometimes, the addict’s doctor will have an opinion about which facility provides evidence-based treatments. Other times, the addict’s counselor or case manager will have an opinion that can help the family make a good decision without asking a series of questions.
At The Canyon, we pride ourselves on providing evidence-based treatments for addiction and mental illness. We do our part to stay up-to-date on research, and we look for ways to implement that research and help our patients do the best they possibly can in recovery. We are happy to discuss our methods will all families who want more information. Just call us, and we’ll answer any questions you might have.