EXPANDING THE VISION OF IMPLEMENTING EFFECTIVE PRACTICES

Abstract

If we want addiction counselors to improve the effectiveness of the services they provide, we must strive to make explicit the connections between the evidence-based practices that we want them to adopt and the work that they are already conducting. Just as patients often resist change when clinicians do not first understand their perspective and include them in the process [1], addiction treatment providers will not leap to adopt empirically supported treatments just because academic researchers tell them they should [2]. A viable vision of the future must offer a compelling answer to clinicians' predictable and reasonable question: ‘will adopting these new practices really lead to improved outcomes for my patients?’. Any attempt to answer this question based on the current empirical literature requires both ‘informed caution and humility’[3]. Many fundamental assumptions about the role of treatment manuals in evidence-based mental health practice remain untested [4]. Most notably, the critical question of whether empirically supported treatments are more efficacious and cost-effective than standard clinical practice remains unanswered [5]. Although we know remarkably little about the complex phenomena almost derisively labeled ‘treatment as usual’, we do know that it often appears to be helpful [6,7]. Future behavioral therapies research should focus more on understanding standard clinical practice. If we study what providers actually do, we might distinguish inductively derived, empirically supported practices that cut across empirically supported treatments [8]. A detailed understanding of ‘treatment as usual’ could thus provide information about the practices linked to effective processes and outcomes, and also build a foundation for motivating and facilitating changes in practice [9]. As Green and others have noted, inductive research may produce the practice-based evidence that will help us to achieve our goal of evidence-based practice [10] We should also expand our vision to include the larger treatment context in which providers conduct the individual psychotherapy sessions that have served as the primary focus of most treatment manuals. Counselors ply their craft in a complex field of forces that invariably include funding pressures, time constraints, personal relationships among staff members and among patients, and culturally defined norms of behavior [11]. Expanding our vision entails moving beyond the field's current focus on dissemination, with its predominately top-down orientation, to a focus on implementation, which emphasizes how our theories and evidence-based principles function in practice. This shift from dissemination to implementation requires us to move beyond purely educational interventions to include complementary approaches that focus on factors that are external to the individual clinician (e.g. behavioral strategies to reinforce desired behavior changes, social interaction and organizational factors) [12]. Our colleagues working in evidence-based medicine [13,14], implementation science [15,16] and addiction technology transfer [17,18] have developed many excellent, more comprehensive models that can be used to guide these efforts. The stage model of behavioral therapies research was designed originally to expand the focus of scientific efforts beyond large-scale randomized clinical trials (RCTs). Although randomization provides a robust means of controlling for threats to internal validity, and RCTs remain our best means of establishing causal inferences, an over-reliance on this method is not without cost [19]. In order to leverage the critical knowledge that the behavioral therapies field has gained through its RCTs, we now need to devote more attention to external validity and to conducting rigorous effectiveness research, both of which will require critical consideration of specific validity threats and potential confounding variables [20]. Expanding our scientific focus in this way permits the stage model to become a cycle in which the study of ‘real world’ clinical practices may also contribute to studying treatment and implementation interventions that may then be further tested and generalized. Grounding the behavioral therapies vision more firmly in the ongoing real world of clinical practice does not require abandoning rigorous science. Rather, including more inductive methods, placing greater emphasis on external validity and supporting systematic effectiveness research will expand the role of science while ensuring its relevance to practice. Such a vision will permit us to see the world as it is, as well as how we would like it to be.