On evidence and practise

An opinion piece to restart my blogging after my lovely holiday…

I’ve been reading ABC Therapeutics blog where Chris Alterio writes in response to a long comment by Michele Karnes suggesting that occupational therapists (and by inference all health care providers) ‘should be made aware of treatments that are offered to clients/patients, whether it is traditional or non-traditional, a long existing treatment or new one. This enables our OT profession and professionals to better educate the people they treat and interact with.’

I don’t have any particular concerns about this part of Michele’s comment – but I do have a problem with this part ‘while Evidence Based Practice is on all of our minds, and ultimately the best to utilize with our patients, if we only used treatments for all of these years we would have missed out on the many treatments that OT’s have historically (and still) use.’ (my emphasis)

It raises some concerning things for me – and while I don’t have answers for all of my concerns, I hope to stimulate some debate at least.

Chris writes in his blog ‘Just because people seek out alternative energy healing interventions doesn’t mean that it constitutes appropriate or ethical practice. In an article published in the Journal of the American Medical Association on this topic an author writes: “Given the extensive use of CAM services and the relative paucity of data concerning safety, patients may be putting themselves at risk by their use of these treatments. Only fully competent and licensed practitioners can help patients avoid such inappropriate use... Physicians can also ensure that patients do not abandon effective care and alert them to signs of possible fraud or danger.“‘

I’d add that licensing in itself does not inevitably lead to patients being helped to avoid inappropriate treatments. I also add this:

I think it also takes a critical and educated mind, a systematic approach to reviewing evidence, and considerable determination not to be swayed by forceful opinion. (more…)

Values and goals

I can’t recall exactly where I heard it, but values are like a compass – they provide general guidance as to what is important in life, while goals are the map of how we are going to get there. I’ve been mulling over this as I worked with some people over the past couple of weeks, reviewing how they will measure whether the programme they’re on will have done anything for them.

Each person entering a programme of intervention has dreams of what it will achieve – pain reduction, better sleep, less grumpiness, more flexibility. And while assessment tools such as the Canadian Occupational Performance Measure (COPM) tap into constructs that reflect individual values, I personally find them difficult to use and a bit ‘clunky’. For those who don’t know the COPM, it’s an occupational therapy-only assessment of occupational performance domains (areas of activity in life, for the non-OT’s reading this!) where importance and current satisfaction with performance are rated before and after interventions.

Now the idea of this is quite good – we work to find out what the person wants, see whether they’re happy with how well they’re doing these things, and check to see if change in a positive direction occurs (hopefully as a result of our input!). Problems for me are that with long-term disability, and especially with low mood, at the beginning of a programme, people may not have much idea of the possibility of achieving ‘goals’.

So, I’m toying with the idea of helping people find out what is important to them in a couple of ways – values sort cards are great, and this one with instructions is a great resource (from the Motivational Interviewing website), but requires good reading skills and fairly good concentration. It’s pretty verbal and visual too, so not so terrific for people who are more practical or kinesthetic.
The set developed for people with schizophrenia is somewhat better, but I’d like something more pictorial (yes, I like visual stuff!!).

Another way is to work through the ‘downward arrow’ technique – again this is quite verbal, but not quite as ‘teachy’ as the card sort. Downward arrow technique starts with the person identifying something that has occurred, or that they’ve done in the past, or an activity they would like to do. As they describe the ‘thing’, you can ask them questions like:

‘Why is that important to you?’
‘What’s significant about that to you?’
‘Why do you want that?’
‘What would it mean to you to do that?’

I have scanned a load of pages on the internet looking for other ways to identify values – without an awful lot of success, I’m afraid. Many pages are about career values, or business values, which doesn’t often relate to the kind of people I’m working with.

So here’s an alternative – if the person is visual, use a couple of magazines, and ask them to clip out pictures of things that they like such as people doing activities, things people can buy, headlines and so on. Then ask them to sort them in order of importance. And then go through the process of asking (gently) why it’s important to them (using the downward arrow technique).

Let me know how that works for you – try it out yourself, you may be surprised at what you find out about yourself!

Once values are identified, it can be a lot easier to find out where the current gaps are for the person in terms of actually getting those values expressed in daily life. For example, if a person says that they really value time with their family, but they identify that they spend more time resting than they want to spend with their family, the goal is then to find a way to carry out the valued activities.

And where there is a conflict between current action and things the person values, this provides an opportunity to discuss the priority that is being placed on the actions currently being undertaken. For example, if the person is spending more time resting than being with the family, what is being valued more than family time is relief from pain.

This can be quite a shock to someone who doesn’t recognise that their current actions are really all about what is important in their life. Actions equal intentions equal actions. If they’re not happy with the outcomes at the moment, what are they really making important in their life? This helps with establishing real goals that the person can hold on to because they have clarified the importance for them.

Now I don’t advocate using this as a programme outcome measure – simply because the statistics we can do on 0 – 10 ‘satisfaction’ scales are not as robust as for other measures. But they do reflect patient/client satisfaction with the intervention. So as part of a set of outcome measures, they may supplement measures of other constructs.

Let me know what you think of this approach – and if you’ve enjoyed this post, want to read more, don’t forget you can subscribe using RSS feed (at the top left of the header, just click!), and you can always leave me comments (I love them!).