Wednesday, August 20, 2014

Best Best Practices

Certain buzzwords appear and fade during the course of a long career in mental health.  Many times such words are reflective of economic trends rather than any scientific breakthrough.  They galvanize groups and can serve as momentum to pursue one avenue or other in the field, on the promise that the folks we serve will have better "outcomes".  The word outcomes itself has spent some time as a buzzword.  While having better blood pressure is a desirable outcome, a host of problematic side effects to blood pressure medicine are also outcomes, though apparently not the outcomes of interest for some.

One of the current buzzword phrases is "best practice", or its cousin "evidence-based practice".  Something may make a best practice list through rigorous research, which is great, or it may happen through a rather casual and cursory literature review.  Some times they are based on the opinion of a single individual, well known though he or she may be.  And there are times when it just so happens the list parallels a new product or the marketing of services.  It can be difficult for a trained practitioner to make sense of such lists, much less the ordinary consumer, which is to say all of us.

I have found that addressing the credibility of a "best practice" claim is a bit like being a party pooper.  This occurs even when the party goers are supposed to be trained professionals who are in theory versed in the scientific method.  In fact, I once heard someone say "well, that was a buzzkill" when a colleague disputed such a claim.  A buzzkill of a buzzword.  If it fits, so be it.

Maybe it's out there somewhere and I have missed it, but I don't recall ever seeing a method of evaluating best practice claims in the mental health field.  So here goes.  When you hear this claim being made, ask yourself the following questions.  Better yet, ask the one making the claim.

  • What disconfirming evidence was sought prior to the claim, and how was it sought?
  • What is the disconfirming evidence?  (Hint: there is always disconfirming evidence.)
  • What sources of evidence were examined, and were they as broadly distributed across disciplines as possible?
  • What other practices achieve comparable or better results?
  • Is the practice accompanied by any risks?
  • Can the claim be clearly separated from economic pressures, such as ties to pharmaceutical development, billing incentives, or lobbying from professional guilds?
  • Even if the claim stands up to scrutiny, is it possible to offer consumers alternatives better suited to their circumstances, and has this been done?
Many mental health professionals are trained in a scientist-practitioner model, so these questions should not be unfamiliar or treated with disdain.  If that happens, there is something horribly wrong.  Insist on the best of best practices.  Caveat emptor, my friends.