By Paul Roman, Ph.D., Editor
At some point every field of endeavor defines core problems around inadequacies in communication. Given the surge of activity and interest in technology transfer within treatment of substance use disorders, there is no doubt that we are “talking past each other” a good deal of the time. This is true among both practitioners and researchers, and there is no doubt that researchers are guilty of ignoring the products of their peers as they rush to publish their latest “findings.”
The proposal by the National ATTC Task Force for standardized language, embedded in a standardized model, is timely and offers the potential for improving communication. That is, IF the publishing researchers, practitioners and range of “experts” decide to adopt it. Aha, another technology transfer problem right in front of us…….Can the National ATTC successfully diffuse this set of standardized concepts?
Are we ready for a common language? Well, of course, who wouldn’t be? What possible value can come from using different language to talk about the same thing? But then again, maybe yes, maybe no.
It is exciting to stumble upon an “eternal verity” as a context for considering a new suggestion and perhaps shedding some light on its utility. The ATTC concept paper drew me to the very brief Biblical story of the Tower of Babel. I thought I knew this story, but it turns out to be more complicated than I had remembered. As with most Biblical content, my interpretation may be unique and perhaps wrong, but here goes:
To celebrate their emerging sense of power and understanding, God’s people constructed a huge edifice, the construction being made possible by the fact that the people shared a common language. The core of the story is that this common language was viewed as an incredible empowerment, and with very clear communication amongst themselves, God observed that the people “could do anything.”
Further, a stated motive of the Tower’s construction was for the people to “make a name for themselves.” Interpreters have focused heavily on this phrase, for it obviously has plenty of traction in today’s world. This very tall Tower or complex city, drawings of which have a notably whimsical quality, reached toward or perhaps even into the Heavens.
God’s reaction was to go among the people in the Tower and destroy their common language, such that what one said to another became incomprehensible “babble”. With their new languages, the people became small diverse groups that became widely scattered. The common language disappeared, along with the threat posed to God by the solidarity of common speech and a common location. But we are left to wonder whether the people truly “threatened” God and whether the ultimate effects were greater strength or greater weakness.
The story seems to say that the people were getting too powerful and perhaps too prideful, and God “put them down,” ending the effort to “make a name for themselves.” But perhaps a different interpretation was that the Tower and the common language were a dead end. This story is in the Book of Genesis, and the world was pretty new. Having mankind housed in The Tower speaking a common language suggests the end of exploration, the melding of diversity and perhaps the end of new ideas.
With their new tongues and with their scattering to all corners of the Earth, people unable to understand one another had no choice but to “reinvent themselves” rather than sitting in the glory of having “made a name for themselves.” The interpretation that God became threatened by the people’s unity and did away with it to strengthen His own Hand seems flimsy. More likely He saw that unity and a single magnificent location were premature in the then-newish World.
I likely seem severely out of step, but I suggest that standardization of concepts and ideas at this stage of the development of treatment of substance use disorders might be a harmful curb on invention. I think there are several critical parts of the technology transfer puzzle that we do not understand, and which we may fail to understand if we move too quick toward “closure” on definitions.
First, we have not yet developed a good typology of innovations. Everyone can make the distinction between psychosocial and pharmacological innovations, but that largely misses a number of more important points. Some innovations are intended to replace current practices (motivational interviewing replacing constructive confrontation) while others are intended to supplement current practice (while some may disagree, motivational incentives seems appropriately placed in this category). While there has been much talk about the need to supplement pharmacotherapies with psychosocial treatments, full specification of these models falls considerably short. Finally, some interventions, particularly those associated with the widely-respected NIATx movement, are innovations that can be categorized as treatment management and as organizational management techniques. These do not necessarily address the content of treatment yet can be critically important in guiding the delivery of treatment.
Second, hackneyed as it may sound, we still have no practical working definition of an Evidence-Based Practice. This problem is at least two-fold. The first and most obvious dimension is “how much” evidence is necessary for a new practice to supplant what is currently being done. As should be well known, much of the evidence base involves comparison of new practices against “treatment as usual.” While many graphs and tables have documented statistical significance, the actual variation in impact on treatment outcomes is rarely what one would call a “blockbuster.” In fact, many have observed that we should pay more heed to telling the world how well we really do with “treatment as usual,” a very important point for those not convinced of the value of treatment.
The “how much” question to determine what is and is not a true “EBP” is really the very wrong question. The real question is not “how much,” but “for whom.” It is here that our field seems to be in only the earliest stages of progress. While nearly everyone readily rejects the “one size fits all” approach to selecting treatment, we still have disappointments when “treatment matching” is attempted. This seems out of favor at the moment due to the outcomes of large and expensive projects that aimed to make breakthroughs on the matching issue. However, there can be no doubt that if the treatment of substance use disorders intends to move toward being a part of medicine, we need much more knowledge about the matching of treatment modalities with patients’ clinical and psychosocial characteristics. This seems especially evident with the promising pharmacotherapies, with particular answers needed not only about selection for treatment but duration of treatment.
At the organizational level, we remain in the early stages of learning about implementation, and seem to be stuck at a plateau that suggests implementation is just a lot of adoption. Without this knowledge, standardization of concepts and language seems premature. The implementation issue links with our understanding of the different types of innovations, and how they might be successfully integrated. These patterns of integration may actually produce new models or even new paradigms of treatment. Further, we need to conceptualize implementation as embodying opportunities for change, not as a final product of putting innovations in place so that everyone uses them as routine. Finally, focus is needed on the issue of adapting innovations to fit local circumstances as part of the implementation process, an issue currently treated as the proverbial hot potato, needs to be examined realistically. To be a bit devilish, I’ll just say that it’s far too early to close down our imagination on the implementation front.
Returning to the Tower of Babel story for my last point, it seems to have happened that the ATTC was not placed in a single central location, and while I’ve not been there recently, I have not heard of a sparkling tower reaching into the heavens in Kansas City. The ATTC is dispersed throughout the country, providing opportunities to listen to and attempt to understand the multiple languages spread across each region. The languages to which I refer are those of the State Substance Abuse Authorities as well as those of the (possibly more cryptic) State Medicaid Authorities. We know all too well about the language diversity represented across these quarters. Health care reform will alter these landscapes but it is very unlikely that these alterations will proceed in a uniform fashion. There can be no doubt of the important influence of the States and Territories on the pursuit of technology transfer.
It is indeed a great advantage for the ATTC to have multiple listening posts as the events of the coming months and years unfold. The experiences of the many treatment programs at these dispersed locations are just what we need to advance understanding. In reflecting on the story of the Tower, perhaps the ATTC can use its dispersed locations to “gather these stones (of local evidence) together” as we start to build and use a base of science for using evidence-based practices. We need our dispersion and our many languages (our “babble”) to play our roles in inventing what promises to be a very dynamic future for the treatment of substance use disorders.
Paul M. Roman, Ph.D.
University of Georgia