Evidence-Based Counseling: Implications Counseling Practice, Preparation, Professionalism. ERIC Digest. Hauenstein, E.J. (2008). Building rural mental health system: From de facto system quality care.ID
Review the Sexton article and make a case for the utilization of EBTs in counseling.
According to Thomas L. Sexton's article "Evidence-based counseling: Implications for counseling practice, preparation, and professionalism," the theoretical basis of the counseling profession emerged from the academic disciplines of psychoanalysis and social work, both of which have tended to be characterized by a paucity of empirical research. The emphasis is on anecdotal evidence from the field of practice, rather than statistically validating what techniques or methods work by studying large population groups. However, this must change. Accountability, or proof that a particular type of counseling practice 'works' has become increasingly important given the pressures upon counselors, but the profession has not always kept up with these demands.
Some of the pressures for the use of evidence-based medicine are from exterior market-based sources. Insurance companies demand proof of best practices and will not accord support for treatment unless there is some quantitatively-driven data indicating that the treatment is valid. Empirical research demands an outcome-based focus, and current research in the field, as it is evolving, is heading in this direction. Sexton states that above all, counselors cannot afford to stick their heads in the sand regarding current trends: "It seems clear that evidence-based counseling practice is the future of both the preparation of counselors and the practice of professional counseling" (Sexton 1999). Insurance companies often limit not only the types of counseling their insured clients can receive, but also the number of sessions they are accorded.
However, Sexton does not see evidence-based counseling as a mere necessary evil that individuals must submit to because it is part of the healthcare system. He believes there are some benefits with evidence-based counseling. It allows for a merging of "practice, clinical experience, and reliable treatment protocols" (Sexton 1999). For example, the bulk of the literature suggests that there is no single, unified best approach to counseling but there are instead a host of common factors that unite all forms of effective counseling across a wide variety of counselors, clients, and theoretical orientations (Sexton 1999).
From a client's perspective, evidence-based research provides support when insurance companies contest the value of particular approaches or deny that various approaches can work. It also provides comfort for healthcare consumers who are pressed in terms of time and have limited mental health coverage. Patients want to know they are allocating their personal resources wisely. Research suggests that counselors avoid a dogmatic approach, and instead adhere to 'best practices' and what works well for the individual patient with a specific illness. Clients can thus receive advice from the results of evidence-based studies about what types of counselors to choose and which to avoid, based upon the particular nature of their circumstances
EBT protocols also allow for creating an individualized prescription based upon specific demographic factors. "These protocols are systematic intervention models, usually manual-based, with an extensive collection of efficacy and effectiveness research in multiple settings, with diverse client groups, across various counselors, that produce clinically significant results both in controlled labs and community settings that last for long periods of time" (Sexton 1999). Different protocols may be more or less effective with different clients, and research provides guidance regarding the creation of a perfect prescription for the client. This results in savings of time, money, and also stress for the client.
Just as EBT suggests that clients must be treated in an individuated manner, counselors as a professional category defy easy stereotyping. "From all these efforts we have, however, yet to discover the prototypic effective counselor" (Sexton 1999). Some interesting evidence emerging from research on what constitutes an effective counselor includes how demographic 'matching' of client and counselor seldom produces a better outcome. A female counselor, contrary to conventional wisdom is not a superior counselor for a male patient; a nonwhite counselor is not necessarily a superior counselor for someone of a historically-underrepresented minority group.
Also, counselors who receive therapy themselves do not produce notably better results than counselors who have sought out such therapy to 'work on themselves.' Skillfulness in using counseling techniques and cognitive complexity were found to be far more important attributes. This underlines the need for greater support for counselors' continued education and the value of experience when evaluating the likely efficacy of treatment. Counselors can receive advice from evidence-based medicine regarding their treatment of patients, but also the course of their own professional careers. EBT advocates focusing more upon improving their knowledge of counseling techniques, rather than introspection. Counseling is a skill, current research suggests. It is something that can be learned and taught. It is not something innate and counseling another person should not be confused with self-analysis.
Evidence-based practice may frustrate those who regard it as an imposition upon them by insurance programs, but it can provide beneficial in terms of quality-auditing of a program. Patients seeking assistance likewise want assurance that the counseling they are receiving is 'worth it' and do not have the time for lengthy, undirected psychoanalysis. They can feel confident that there are many paths to wholeness, so long as certain universal best practices are honored. "Evidence-based practices can provide a source of clinical knowledge that can increase a counselor's effectiveness with clients, become a basis of professional education and counselor development, and serve as a unifying force for the profession that will set the agenda for the next evolution of counseling" (Sexton 1999).
Q2. Review the Hauenstein article and identify as many outcome measures as possible and the results used by this researcher to evaluate a rural mental health service delivery system.
According to Emily J. Hauenstein's article "Building the rural mental health system: From de facto system to quality care" substantial discrepancies exist in the quality of care afforded to rural users of the healthcare system, versus residents dwelling in urban areas. Hauenstein provides a plethora of statistical evidence to support her claim and also uses data-driven analysis to provide potential solutions to care deficits. She suggests methods to evaluate current mental health treatment programs and offers ways to address barriers to care.
One of the main problems afflicting rural mental health service delivery is that patients may be less apt to seek treatment and less apt to see their conditions as serious, based upon cultural factors that impact their willingness to receive care. One measure of this cultural concept is descriptive in nature, as manifested "in a large study conducted in the rural South, Fox and her associates" which "found that only 13% of those who had been diagnosed with a mental health condition and received an educational intervention about the condition and how to obtain help actually sought help for that condition" (Hauenstein 2008: 147).
As well as personal, psychological perceptions social institutions can also create barriers to care. In another descriptive study, this time based upon an anecdotal, phenomenological approach, it was found that "African-American churches in the rural South have been shown to provide mental health services but don't always act as a bridge to formal mental health care services" (Hauenstein 2008: 148). Individual and social trust is lacking in the healthcare system, which is further exacerbated by existing structural barriers: "rural treatment networks...have fewer interagency linkages than urban systems" (Hauenstein 2008: 149).
As well as descriptive techniques, Hauenstein also deploys comparative assessment to highlight disparities in rural care systems. One of the most notable is the difference in quality of care received between urban and rural dwellers. "Data from the NCS-R showed that residents residing in a rural area not adjacent to an urban setting were less likely to obtain 'any' treatment for a diagnosed mental health problem or to receive specialty mental health care (Hauenstein 2008: 150). Another comparative study found that "there is some evidence that rural residents are less likely to be prescribed a psychotropic medication for their mental health problems...and that the use of selective serotonin receptor inhibitors, with their more benign side effect profile, has not been completely adopted by rural health care providers" (Hauenstein 2008: 150).
After chronicling in a descriptive and comparative fashion these deficits in care, Hauenstein then addresses the issue of outcome disparities. Rural residents are more likely to commit suicide urban residents, indicating that non-treatment has significant and measurable consequences, as does the fact that "rural residents with mental disorders are more likely than urban residents to be hospitalized for their disorder" (Hauenstein 2008: 150). Higher instances of co-morbidity for abuse of drugs and alcohol also suggests that rural residents are self-medicating in the face of a lack of appropriate medication and treatment for their illnesses. Although a specific causal link cannot be drawn in all instances between poorer treatment and poorer treatment outcomes, there is a strong causal implication, Hauenstein believes, in these disturbing trends amongst residents of rural areas.
Several specific models have been adapted to systematically assess access to care. For example,…
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