By Steve Martino
The Addiction Technology Transfer Center (ATTC) Network Transfer Technology Workgroup should be commended for clarifying the multiple overlapping terms that have populated the diffusion of innovations literature and for organizing a model of technology transfer. Specifically, they present 1) “diffusion” as the broad process through which innovations enter practice, 2) “development”, “translation”, “dissemination”, “adoption”, and “implementation” as related stages through which the diffusion process unfolds, and 3) “technology transfer” as the intentional promotion of the use of innovations at each of these stage. Their conceptual model is very helpful in bringing order to this field of study.
One area where the model may add confusion is the inclusion of the Development stage (creating and initially evaluating an innovation) as part of the diffusion process. Diffusion of innovations implies that an innovation already has been developed (e.g., an empirically supported treatment) and is ready for diffusion. A well established and operationalized model for how empirically supported treatments are developed exists - the stage model of psychotherapy development (Onken, Blaine, & Battjes, 1997; Rounsaville, Carroll, & Onken, 2001).
In this model, theory-based ideas about an innovative treatment are first detailed in operational procedures (often in manuals), and methods for training counselors to use the new treatment are established. This is followed by a period of pilot testing of the treatment and methods to measure its effects. In the second stage, the new treatment is tested under tightly controlled research conditions often involving a randomized clinical trial and testing of mechanisms of action. In the third stage, once the treatment has been found to be efficacious, the treatment is further tested to determine if it is effective in the “real world”.
During this stage, treatments typically are examined across several programs and implemented by program-based providers, similar to the manner in which treatments have been studied in the National Institute on Drug Abuse Clinical Trials Network (Tai, Straus, Liu, Sparenborg, Jackson, & McCarty, 2010). If the treatment is found to be effective, then there is a “hand-off” between the treatment development phase and its diffusion into community practice. Translating the treatment into a form that makes it ready to be disseminated, adopted, and implemented is the starting point of a treatment’s diffusion. This approach has been the way in which the NIDA-SAMHSA Blending Initiative has been formulated and conducted for the past decade (Condon, Miner, Balmer, & Pintello, 2008).
Other than this suggested conceptual adjustment, four other points implied by the ATTC Network technology transfer model merit more discussion. They include preparing programs for diffusion, measuring the effectiveness of technology transfer efforts, sustaining innovative practice, and underscoring the bi-directionality of research and practice as part of the diffusion process. Each area is discussed in more detail below.
Simpson and Flynn (2007) have noted the importance of helping programs prepare for treatment implementation by considering the readiness of their service providers and organizations for specific changes in practice. Service readiness refers to the extent to which the providers understand the essential principles and procedures of the new treatment and how it will fit into and enhance the current system of clinical care.
Organizational readiness refers to staff perceptions of service needs, resources available to support treatment implementation, and workgroup infrastructure (e.g., organizational climate). If the providers develop a consensus about the potential value of the new treatment and they perceive the organization as poised to support its implementation, the treatment will be more likely adopted and implemented.
Thus, technology transfer often requires an objective information gathering phase (e.g., leadership discussion, staff surveying) to determine the program’s strengths and weaknesses, opportunities for the providers to discuss bringing a new treatment into their services to establish buy-in, and resolution of program problems that might thwart the successful diffusion of innovative treatments. Applied to the ATTC Network model, an ounce of preparation during the dissemination stage by technology transfer specialists could be worth a pound of implementation later in the process.
Measuring technology transfer
The workgroup has provided several examples about how the ATTC has tried to promote the use of motivational interviewing (MI) as illustrations of each stage of the diffusion process. Absent in the discussion, however, is how the ATTC gathers evidence about the success of their technology transfer efforts. The number of MI-related material website page views or downloads, skill-building workshops, and MIA: STEP supervisor trainings captures some aspects of dissemination, but none of these are indicators of actual MI adoption and implementation.
While some types of treatment are easily verifiable, such as confirming the provision of buprenorphine or contingency management within programs (Roman, Abraham, Rothrauff, & Knudsen , 2010), more complicated psychosocial treatments such as MI may require more objective monitoring to determine if in fact it is being implemented (Martino, Ball, Nich, Frankforter, & Carroll, 2009). Thus, with few exceptions (e.g., Squires, Gumbley, & Storti, 2008), the effectiveness of the specific technology transfer strategies used by the ATTC to promote the use of innovative treatments is unknown to date. More resources, collaboration with researchers, and development of a comprehensive data system are needed for the ATTC to determine how effective it is in transferring treatments to community programs.
Sustaining innovative practice
Just as Simpson and Flynn (2007) have emphasized how preparing a program for treatment implementation is very important, they also note that strategies must be in place to sustain implementation over time. Critical factors that affect the sustainability of implementation efforts include resource allocation and organizational climate. Resource allocations for renewing materials, training, equipment, staffing, and space are often necessary to fully support sustained implementation. Organizational climate factors include issues that impact the providers’ commitments and social interactions that support ongoing high quality use of a treatment, such as the program’s mission, communication, and stress level, which might affect their use of the treatment and how clients response to it (Broome, Flynn, Knight, & Simpson, 2007; Greener, Simpson, Rowan-Szal, & Lehman, 2009). The implication is that technology transfer specialists often need to provide ongoing consultative support to programs to help them sustain implementation. When the consultations are in the service of supporting in-house program advocates, champions or on-site experts (e.g., supervisors with an allegiance to the approach), the diffusion process is likely to be more successful and sustained (Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005; Squires et al., 2008).
Like a chain on the gears of a bicycle’s wheels, The ATTC Network diffusion model contains within it a circular cycle. Innovative treatments developed and empirically validated by clinical researchers become adapted by providers as they use them in the field. These adaptations become new innovations that subsequently require empirical validation in their own right. Thus, a bi-directional process exists in which innovative treatments emerge from research and practice. It is the partnership between these entities that drives the clinical advancement of the field. The diffusion of MI is a prime example of this type of bi-directionality. After the publication of several MI textbooks (Miller and Rollnick, 1991; 2002) and treatment manuals (Miller, 1999; Miller, Zweben, DiClemente, & Rychtarik, 1992), the early recognition of MI as an empirically supported addiction treatment (Dunn, Deroo, & Rivara, 2001), and the establishment of an international network of trainers (Miller & Rollnick, 2002), more providers began to use MI for addictions, apply it to other problem areas, and integrate MI with different treatment approaches (see Arkowitz, Westra, Miller, & Rollnick, 2008; Rollnick, Miller, & Butler, 2008). In turn, these adaptations and new applications of MI have been studied and often have been found to be equally efficacious (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). The development of empirically supported treatments (research) and diffusion into the community (practice) have fed one another.
The ATTC Network has been an important contributor to the process of transferring innovative treatments into community programs. Experiences gained since 1993 has informed the development of a logic model for how diffusion occurs and implies key pressure points at which technology transfer specialists might promote the process. Effective organizational level and provider-based strategies need to be developed to positively impact these points and increase the probability that the best treatments practiced in the best possible manner are made available to clients.
Yale University School of Medicine