The field of mental health is undergoing unprecedented challenges during the COVID-19 pandemic. Professional counselors who worked with children and adolescents before the pandemic have found that some traditional in-person techniques are not appropriate via virtual platforms.
These circumstances are requiring counselors to consider the selection of treatment approaches and interventions that are adaptable to or created for the provision of telemental health. Today, counselors must determine how to select and implement evidence-based practices (EBPs) when working with child and adolescent clients via telemental health during times of crisis.
History of EBPs
In 1996, David L. Sackett and colleagues stated that evidence-based medicine was “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Additionally, Leslie Greenberg and Frederick Newman recognized in 1996 that there were different types of study designs that lead to the evidence base, each suited to answer specific types of research questions. For example, according to a 2005 American Psychological Association task force, one may use any of the following to build evidence: clinical observation, qualitative, systematic case studies, single case design, ethnographic, process-outcome, random control trails or meta-analysis.
EBPs and the terminology associated with them have gained popularity over the past few decades in all health care fields. However, their exact origins are mixed. Parts of the nursing profession, for example, posit that EBP originated with Florence Nightingale, whereas the mental health field argues that Lightner Witmer used a similar approach with his creation of the first psychological clinic in 1896.
Regardless, the concept of EBP marked a paradigm shift among health care professionals to consider data-based research rather than relying on the opinions of authorities to guide clinical practice.
The rigor, or degree, of scientific evidence is often presented in the form of an evidence pyramid analogous to Benjamin Bloom’s taxonomy of educational objectives.
This evidence pyramid traditionally moves from expert opinions at the base to case series/case reports to case control studies to randomized control trials to systematic reviews and, finally, to meta-analyses at the pinnacle.
These sources of evidence range in forms from editorials to book chapters. They are good resources for an early understanding of clinical areas because they discuss definition, assessments and treatments. However, these sources lack statistical inferences to reach scientific conclusions.
An expert opinion might come in the form of a textbook chapter in which a person who is generally very knowledgeable in the field opines on the subject matter without referencing a specific compilations of facts. While expert opinions can be very informative and insightful, they should be regarded only as a minimal form of scientific evidence. Few of these expert opinions speak to our current predominant practice of telemental health.
Case series/case reports
These are descriptive studies that may be from a single clinical case or from a series of clients with similar presentations. While traditionally missing inferential statistics, single-case experimental designs will often be implemented. However, control groups or conditions are clearly lacking. Despite these limitations, case series/case reports are often heralded for illuminating novel concerns that generate additional research.
Classic examples of case studies in the mental health field seemed to begin with Anna O., who received psychoanalysis for what was termed “hysteria.” Sigmund Freud wrote about her case and how the “talking cure” led her symptoms to fade. Biopsychologists often cite the case of Phineas Gage, who demonstrated personality changes after a large iron rod was driven through his head in a railroad accident. Then there is the behaviorist report on Little Albert (by John Watson), in which fear was actually instilled into a baby through conditioning.
Case control studies
Case control studies are generally retrospective in nature and investigate the risk of exposure to an event with an eventual negative outcome — usually a disease or disorder. Comparison or control groups are then utilized with people who did not have the initial experience or the disease/disorder. However, these studies are able to declare only relationships, not cause-and-effect relationships. Despite this limitation, evidence for a cause and an effect begin with a correlation.
A typical case control study in the field of mental health might investigate the relationship between physical activity and depressive traits. To that end, the investigators would harvest information from a previously administered questionnaire to patients receiving services at a mental health facility. Additionally, these investigators would use a matched control group of participants without mental health concerns who also completed the questionnaire. Although a control group or comparison group is part of the study, it lacks the characteristic that makes it a true experiment: randomization.
Randomized controlled trials
It has often been stated that randomization is what brings an investigation from quasi-experimental to truly experimental. Randomized controlled trials assign patients with similar presentations to either the treatment group or the control group based on chance alone. This allows for other mitigating factors to balance themselves between the groups and for the “treatment” itself to cause the scale to tilt. This strategy allows a treatment to be compared with no treatment, an alternative treatment or a waitlist controlled treatment.
A typical randomized controlled trial investigation for a new treatment for depression would involve randomly assigning half of the participants to the new treatment, while the remaining half would be assigned to an existing treatment. Then pretests and post-tests for each group would be compared to evaluate the efficacy of the new protocol.
Although regarded as the gold standard for clinical research trials, randomly assigning patients to treatments may not reflect the best ethical practice without consideration of other mitigating factors.
Systematic reviews evaluate and synthesize the results of similar studies to reach a higher-order conclusion than could be achieved by any one study by itself. Usually, the authors will select a priori factors or themes for which the studies are to be rated. Then, all of the factors or themes are considered and tabulated to reach this conclusion.
Frequently, systematic reviews will limit themselves to only studies that used randomized controlled trials. This way, the results from the group of similar randomized controlled trials can be integrated for a truly convergent conclusion.
In building upon our previous examples of possible depression studies, a systematic review might be used to identify the best treatment protocol for adolescent depression that involves psychopharmacology, individual therapy or both. Additionally, the investigators might restrict the investigation to include only those studies that utilized random assignment. Then, rubrics might be created to gauge the treatments along themes such as symptom reduction, satisfaction of the approach and time commitments. Generally missing from typical systematic reviews is an objective measure that uniformly assesses the results from the different studies.
Meta-analyses are often referenced as a type of systematic review meriting the gold standard of clinical knowledge. Meta-analyses, like all systematic reviews, evaluate similar studies along factors or themes that are selected a priori. However, these forms of evidence utilize a statistical procedure — effect size — to reduce sources of bias in the conclusions. This is the objective uniform measure that is lacking in systematic reviews.
Basically, effect sizes report the magnitude of progress from a treatment. It has often been stated that effect size actually indicates the importance of the results rather than the likelihood that the results are not due to chance, as is the case with statistical significance.
Increasing the rigor from our previous example of a systematic review to that of a meta-analysis would therefore involve utilizing effect sizes. Rather than building upon the a priori themes for comparison, this meta-analysis would compute the effect sizes from measures reported in each study. Then, from the selected studies, average effect sizes would be computed for each treatment protocol so that meaningful comparisons could be made and so that each protocol could be graded on its efficacy.
Beyond the evidence
While the concept of EBP originally relied on the practitioner to consider only data-based research rather than the opinions of authorities to guide clinical practice, the field of medicine built upon this to include other parameters. Specifically, this newer definition defines EBP as the integration of the best research evidence with clinical expertise and patient values. The expansion of this definition clearly illuminates the additional paradigm shifts that account for cultural sensitivity and patient involvement for treatment decisions, while acknowledging that there are advantages and disadvantages.
EBP has advantages and disadvantages. The 2005 American Psychological Association Presidential Task Force on Evidenced Based Practice described EBP as the integration of science and practice. It acknowledged that much research is needed to determine that a treatment is effective. However, the research demonstrating a treatment protocol effective then needs to become a practice offered by clinicians who are treating patients in the field. So, one must consider both the efficacy and the clinical utility of the treatment.
The APA task force defined efficacy as the way in which we evaluate the protocol and examine how strong the evidence is within that evaluation. The clinical utility of the protocol must then explore if the treatment is generalizable and feasible and the cost benefit of the treatment. The marriage of research and practice leads to better clinical outcomes for clients.
EBPs offer clinicians and their clients information on the efficacy of a treatment. This research can inform the expected time frame and outcomes of a given treatment. It clearly demonstrates what the EBP will treat and the age groups for which evidence is provided. It is then up to the counselor to determine if the EBP is a good fit for the child and family. After all, most children do not present with the exact parameters as the control group in a research study. Nor does the current COVID-19 pandemic offer counselors traditional clinical sittings or historic data mirroring the current situation.
Not all individual differences can be accounted for in each EBP. For example, one should consider how development, gender, gender identity, culture, ethnicity, race, age, family context, religious beliefs and sexual orientation play a role in treatment. Clients should also have input into their treatment protocol and be afforded informed consent. This may lead to their desire or preference for one type of treatment over another.
As counselors, it is our duty to inform clients of the costs and benefits of treatment approaches but, ultimately, clients determine whether they will proceed with the EBP. During our current times, clients may agree with a treatment approach but have difficulty with technology or face other barriers that decrease their comfort with telemental health.
One example of considering fit for EBP is with cognitive behavior therapy (CBT). Pamela Hayes discussed the specific challenges between CBT and multicultural therapy. She acknowledged that CBT is evidence based for many disorders and populations, but it may have limitations when applied to some cultures.
Specifically, she named three major limitations:
1) CBT has strong assertiveness themes, overlooking cultures that favor subtle communication.
2) CBT has present focus, neglecting the past.
3) CBT cognitions are focused on individualism, with less regard for environmental interventions.
The last limitation may be especially problematic for individuals with physical disabilities, for whom the disregard of environmental barriers may be great. In response, Hayes recommended culturally responsive CBT modifications.
However, not all EBPs have recommendations on how to modify them to fit certain clients or populations with which the counselor may be working. Therefore, while a treatment may be proved effective for a particular age or disorder, it may be in contradiction to the client’s values. In addition, there may be other barriers to consider, such as technology, privacy or logistics, as is the case currently for many practitioners.
COVID-19 forced many counselors to examine their “practice as usual.” Many sought to gain certification in telemental health so that they could continue offering services to existing clients. This in many ways followed best practices and guidance from the 2014 ACA Code of Ethics, which prohibits abandonment of clients.
At the same time, this also forced clinicians to consider whether their treatment of choice was still possible via telemental health or whether another practice/protocol made more sense. For example, in the field of child and adolescent counseling, many play therapists examined the feasibility of child-centered play therapy (CCPT), which is an EBP, via telemental health. Dee Ray expressed the opinion that CCPT might not be the best treatment for telemental health but acknowledged that a similar theoretically oriented treatment involving the parents — filial therapy — could be amenable to telemental health.
Jane is a 7-year-old girl who experienced anxiety, reportedly resulting in behavioral outbursts and refusals to comply. Jane was seen by her counselor for approximately six sessions prior to the clinic’s closure due to COVID-19 and a statewide stay-at-home order. Jane’s counselor met state board requirements to provide telemental health services, but she could not conceptualize how to work with Jane using CCPT as she had prior to the stay-at-home order.
Jane’s counselor researched the EBP literature and identified other options for the treatment of childhood anxiety. However, the counselor found herself limited in her training, which restricted her ability to provide EBP services outside of her current scope of practice.
Jane’s counselor discussed the options, including a referral, with Jane’s parents in a scheduled telemental health parent consult. In the consult, the counselor discussed the benefits of filial therapy and the typical populations with which the modality is used in therapy. The counselor also explained that the parents would be more involved in session because filial therapy utilizes parents as change agents.
Jane’s counselor stated that this type of therapy would translate to telemental health in ways that CCPT would not. For example, CCPT relies on the therapist-child relationship to facilitate change. This may be difficult to achieve via telehealth because the therapist is not in the room. Filial therapy, on the other hand, relies more on the parents as change agents and may work well via telemental health because the parents are in the room with the child. In addition, they meet with the therapist via telemental health to learn the techniques to use with their child. Through the weekly telemental health sessions, parents are able to discuss challenges while receiving guidance and supervision, making this method more amenable to telehealth.
EBP databases and clearinghouses
Mental health practitioners can access several EBP databases and clearinghouses online, allowing them to consider different approaches to meet the individual needs of clients and cases. A wide range of techniques and programs is available, and through these clearinghouses, practitioners can make comparisons and learn about the reliability and evidence for the techniques and programs. We will highlight a few examples of databases and clearinghouses that we use within our practice when working with children and adolescents.
The seventh edition of the Collection of Evidence-Based Practices for Children and Adolescents With Mental Health Treatment Needs is an educational tool that specifically highlights available mental health treatments for nonclinicians. The guide breaks down treatments into what works, what seems to work, what does not work, and what has not been adequately tested. It highlights disorders such as adjustment disorder, autism, anxiety, depression and many more.
The Results First Clearinghouse Database is powerful because it combines available EBPs from nine national clearinghouses encompassing the categories of crime and delinquency, child and family well-being, education, employment and job training, mental health, public health, sexual behavior and teen pregnancy, and substance use. The programs can be broken down by category, setting, clearinghouse or rating. The rating scale breaks down programs based on highest rated, second-highest rated, mixed effects, no effects, negative effects and insufficient evidence. The following clearinghouses highlighted in this article are included in the Results First Clearinghouse.
Blueprints provides information on programs to promote healthy youth development and to decrease antisocial behaviors in children and adolescents. The database is geared toward youth, families and their communities, from prevention to intervention programs. The database breaks programs into three categories of research: model plus, model and promising.
The California Evidence-Based Clearinghouse for Child Welfare provides information and resources used by any professional who may work with children and families in the welfare system. The database breaks down treatments based on a scientific rating scale that includes well supported by research evidence, supported by research evidence, promising research evidence, evidence fails to demonstrate effect, concerning practice, and not able to be rated.
Social Programs That Work provides information on social policy programs. The goal is to enable policy officials and other readers to readily distinguish these programs from other available programs that do not have supportive evidence. The guide breaks down programs into top tier, near top tier and suggestive tier. Of particular interest to practitioners, it highlights some early childhood, parenting, substance abuse and suicide prevention programs.
The National Institute of Justice’s CrimeSolutions provides information on criminal justice, juvenile justice, and crime victim services outcomes to inform practitioners and policymakers about what works and what does not. The database breaks down programs and practice outcomes into effective, promising and no effects.
The Substance Abuse and Mental Health Services Administration Evidence-Based Practices Resource Center provides clinicians, community members and policymakers with resources and information on a variety of topics, including mental health services.
The U.S. Department of Health and Human Services Teen Pregnancy Prevention Evidence Review identifies programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted infections and associated sexual risk behaviors. The database breaks down studies based on a quality rating of high, moderate, low or not applicable.
- For practitioners hoping to learn more about the EBP process, Evidence-Based Behavioral Practice is a useful online training resource.
- “Evidence-based practice in social work: A contemporary perspective” by James W. Drisko and Melissa D. Grady, Journal of Clinical Social Work
- “Evidence-based practice in psychology” by the American Psychological Association Presidential Task Force on Evidence-Based Practice, American Psychologist
- “Clinical expertise in the era of evidence-based medicine and patient choice” by R. Brian Haynes, P.J. Devereaux and Gordon H. Guyatt, BMJ Evidence-Based Medicine
- Evidence-based practice for the National Association of Social Workers
- “Evidence-based practice: A common definition matters” by Danielle E. Parrish, Journal of Social Work Education.
Krystal Vaughn is a licensed professional counselor supervisor specializing in children ages 2-12. As an associate professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys both teaching and providing clinical services. Her research interests include autism, supervision, play therapy and parent consultation. Contact her at firstname.lastname@example.org.
Kellie Giorgio Camelford is a licensed professional counselor supervisor specializing in parenting, women’s issues, children and adolescents. She has received specialized training in the fields of play therapy, school counseling, parenting and perinatal mood disorders. As an assistant professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys teaching and supervising students, as well as providing clinical and community services. Her research interests include ethical issues in counseling and supervision. Prior to teaching, she was a professional school counselor at a local parochial high school in New Orleans, and a private practitioner.
George W. Hebert is a faculty member in both the Department of Clinical Rehabilitation and Counseling and in the Master of Physician Assistant Studies Program at the Louisiana State University Health Sciences Center-New Orleans. He is a licensed psychologist and holds certificates as a school psychologist and supervisor of school psychological services. He specializes in the assessment and treatment of learning and behavior problems for school-age children and their families, and supervises interns and practicum students in the university-based Child and Family Counseling Clinic.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.