Volume 2, Issue 1

The Need for More Attention to the Requirements for Implementation
By Michael Boyle

As Everett Rogers’ classic text identified, innovation is not a random event, but rather a predictable evolution within an organization or professional field that has the infrastructure to adapt over time.  Rogers noted many instances where innovation occurred across diverse settings that shared similar organizational characteristics, such as farmers adopting hybrid corn or primary care doctors adopting tetracycline in standard practice.  In all these settings, practitioners had the skills and infrastructure to adopt as well as thrive through innovation.  Farmers changing from one seed corn to another in their planters or physicians writing a different prescription for a medication were relatively simple behaviors once the decision to change was made.

Adopting and implementing evidence based treatments to address substance use illnesses is a far more complex process.  While dissemination of information is an important and necessary step in the process, implementation is dependent on the existence of an infrastructure within a provider organization that will allow and support the desired change.  This infrastructure is lacking in the majority of the existing treatment programs.

The good news is that we have knowledge of effective treatment approaches based on clinical trials.  These treatment interventions include cognitive-behavioral skills training, motivational enhancements including motivational interviewing and contingency management, Couples Behavioral Therapy and the Community Reinforcement Approach.  All of these interventions include training manuals, fidelity tools, and implementation guidelines.

Thus, organizations and clinicians have access to information on evidence-based practices through activities such as those provided by the ATTC Network.  Nonetheless, simply exposing clinicians to these effective practices through dissemination may not lead to implementation.  Adoption of the techniques is far more challenging and requires both the resources to implement the innovation as well as the removal or bypassing of institutional norms and cultures that sustain outdated practices.

The first cluster of barriers that must be addressed are the existing cultural and belief systems.  Examples include the belief that the 12-step fellowship is the only process to overcoming an addiction or the belief that the therapeutic community approach of changing the character of a person is the only viable approach.  Many persons who have achieved recovery in either model and now serve in counseling roles may have significant difficulty in accepting other treatment approaches.  They have experienced a treatment that was life changing for them and have seen the approach change others.  They may see little need to add new treatments to their long established repertoire.

This first barrier may not be that dissimilar to the farmer who has used the same seed corn for 20 years and has been satisfied with the results.  Exposure to other approaches that are achieving positive outcomes will lead to adoption of evidence-based practices by some treatment organizations that are early adopters but the percentage of late adopters and laggards may be far higher in the addiction treatment field.

A second factor limiting adoption of evidence based practices, despite exposure, is the lack of necessary infra-structure within treatment organizations.  Again, it was a minor change for the farmer to use a different seed corn in their planters or for the physician to write a different medication on the prescription pad.  Changing to new psychosocial treatments and incorporating the use of medications when none had previously been used is a very complex process and requires substantial organizational supports.

The ATTC document utilizes Motivational Interviewing as an example of their technology transfer focus.  Motivational Interviewing is a highly complex clinical practice and it is highly unlikely that a clinician will be able to successfully implement this approach following initial exposure and training.  Ongoing clinical training and supervision by a clinician who is highly skilled in the practice is needed to learn and practice Motivational Interviewing and other evidence based practices.  This should include the taping of clinical sessions, their review and scoring by the supervisor and constant feedback to the supervisee to learn from their successes and omissions.  Many treatment organizations lack highly clinical supervisors who are highly skilled in evidence based practices.  Further, the demands of direct service and limited staffing patterns compete with their ability to devote the time needed to master new clinical approaches.

Many of the evidence based treatments require a substantial amount of the treatment be delivered in individual sessions with the patient and concerned significant others.  Yet, the vast majority of treatment sessions are provided in group formats within existing treatment programs.  Groups can be used to teach people about the stages of change and for skills practice through role playing but the practice of motivational interviewing requires individualized sessions.  Thus, the structure of programs would have to be radically changed if evidence based practices are to be incorporated.  The challenge to such a change is that groups tend to be an efficient way to earn reimbursement.  While reimbursement structures vary among states and insurers, group services with high attendance will usually earn more revenues per input of staff time than providing an individual session in the addiction field.

Use of medication assisted treatment is an evidence based practice.  In fact, the National Quality Forum’s Voluntary Consensus Standards for a Substance Use Illness are that medications be routinely used for detoxification and be offered to all persons with alcohol, opiate or nicotine dependency.  Many programs do not have the medical infrastructure to prescribe, administer and monitor the use of medications to treat these addictions. 

The infra-structure requirements of high quality and time-consuming clinical supervision, ability to provide a substantial amount of individual and family therapy sessions and the lack of medical personal necessary to utilized medications combine to provide barriers to the implementation of evidence based clinical practices.

Imagine a future when the previously discussed issues of clinical supervision and infrastructure barriers have been resolved.  In this future, technology transfer from the ATTCs has resulted in staff learning several evidence based practices. Challenges would still remain in insuring that each patient and family received exactly what services they wanted and needed and exactly when they wanted and needed them.  This will require continuous assessment and clinical algorithms.

In current practice, assessment is an activity that occurs at the initial of treatment and is used to develop a treatment plan.  Ongoing assessment infrequently occurs.  Without ongoing assessment of progress during treatment, there is no feedback mechanism to the clinician regarding the need to change or modify the approaches being used.

Assuming ongoing, continuous assessment, guidance could be provided to clinicians regarding what treatment approaches are most likely to effectively address the problems identified.  These could be structured as clinical algorithms that suggest what evidence-based practices should be delivered.  Responses to the assessment would trigger the algorithms.  Examples of such approaches exist such as medication algorithms for addressing psychiatric disorders.

Efficiently administering ongoing assessment and delivering the treatment recommendations will be achieved through use of new technologies, perhaps in a much faster time frame than many anticipate.  These will include the patient responding to the assessment through web-based applications delivered through a computer or smart-phone.   In addition to algorithms delivered to the clinician, the responses could give “just-in time” recommendations directly to the patient on activities they could engage in to address the difficulties they report.

While the ATTCs’ promotion of Motivational Interviewing may not have yet resulted in a generation of clinicians who are highly skilled practitioners in that treatment approach, they have made a more meaningful contribution to the addiction treatment field.  Exposure to the stages of change model upon which Motivational Interviewing is built has resulted in a cultural sea change in a significant number of treatment organizations and individual practitioners.  The dissemination of this knowledge has resulted in a large number of substance use treatment organizations discontinuing their traditional use of confrontation to break down perceived denial in individuals.  These organizations and their counselors no longer blame the individual for their lack of motivation. They have come to recognize that everyone is pre-contemplating or ambivalent about changes in behavior whether the change is in diet, exercise, or engaging in other potentially beneficial activities.

Addiction Treatment Technology Centers: keep up the great work!

Michael Boyle

The Fayette Companies

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