What are the top 1 or 2 challenges you face in implementing evidence-based practices at your agency? When we started doing work on the Network of Practice we held focus groups with clinical supervisors in several cities and asked that same question. Some of their challenges were:
Keeping a workforce that is constantly turning over properly trained
Financial resources
Some EBPs are too academically-driven
Too rigid in letting an agency modify the practice
Are you facing similar or different challenges?
Bringing Peer Surpport into a Mental Health Facility in the State of MS.
I respect clinical. But there excepting lived experence a just another tool they can use.
Im really newly working at a detox and am trying to bring a new level of clinical significance to the detox experience and am facing cynicism from the mileu counselors and am somewhat flumoxed by the short length of stay. Suggestions?
Hey Jen,
I think the most important thing you can do is work on motivation and getting folks in detox to try treatment. Do you know what your transition rate is? Would your staff be open to doing motivational interviewing or thinking about ways to use motivational incentives to reward people for attending treatment?
Jen,
I worked at a detox for a few years recently and the stays were short 3-4 days for alcohol and up to 7 days for opiates. Part of the problem is that detox is looked at as a medical detoxification treatment, it is for the safety of the withdrawing patient and not necessarily a treatment milieu. Yes they do have groups, case management, clinical staff and facilitation to aftercare, but the priority is safe detoxification, so if they don't want to continue treatment after detox they can still detox in a safe environment. Part of the reason they have shortened detox stays is the aftercare is now done at post-detox step-downs, outpatient treatment, or residential programs. I remember when detox stays were 30 days, now they consider that a CSS.
Mike
Some of the challenges that I have ran into when implementing EBPs are somewhat similar:
keeping a workforce properly trained is probably the most challenging
maintaining fidelity within the program
due to the diverse nature of people, sometimes modifying the program is best but it comprises fidelity; however, people are different
financial resources is always a challenge
My specialty within addiction treatment is tobacco use disorder and the main problem I have is getting the clinicians and administrators to integrate treatment for this drug into the concepts they hold about substance use disorders - they continue to call it smoking cessation and act as if it is a risk behavior for chronic physical illnesses rather than also being an addiction itself. They do seem to be screening for tobacco use but not documenting a DSM-IV TR diagnosis of nicotine dependence and not addressing it on the treatment plan in the same manner they do for all the other substance dependencies. The EBP for treating tobacco use and dependence (per the USPHS Clinical Practice Guideline) is basically simplified CBT and MI strategies so addiction professionals already have more than adequate competence for addressing tobacco use disorder. How can this rationale get through to them so they don't work so hard to help people recover from addiction only to die too soon from the addiction they did not address?
I think there is some literature about how tobacco cessation actually helps improve rates of abstinence for people with alcohol abuse disorders in particular. I will see if we can find the citations for you. Maybe if your staff believe that quitting smoking will help prevent relapse it will provide motivation to try to implement it in treatment and to see what the effect is.
Yes Kim, recovery rates are enhanced by 25% if tobacco is treated concurrent with other addictions, and addicts who smoke have a death rate 4 times higher than those who don't. Alcoholics who quit smoking have longer-term recovery rates than those that don't. Not to mention the effect smoking has on the efficiency of MH medications. Websites such as Mayo Clinic, CDC, Legacy Foundation, Association for Tobacco Treatment Use and Dependence(ATTUD) all have good info. Also the Public Health Services Clinical Practice Guideline for Treating Tobacco Dependence will give you all the EBP and statistics concerning tobacco treatment.
Here is an article that might be useful. It is a review of the literature that was completed in 2010 and also has some suggestions.
Janice,
I'm on board with the tobacco treatment, extremely important! As a CTTS I have worked quite a bit with integrating tobacco into SA/MH treatment. But I face a lot of barriers such as it's not as important on the treatment hierarchy, staff are current smokers, lack of education/training, time management and funding etc. Over the years I have found being persistent and talking tobacco in a general way during the workday has led to acceptance. I am now working at a new job and am starting the process from the beginning at a facility that has very little focus on tobacco, but by having the CTTS has validated that process. When I do a tobacco training for staff, what seems to help with getting the importance of tobacco treatment across is how it effects medication management, and how it relates to enhanced recovery rates, not to mention the health and financial aspects. I have also found that if you fold tobacco treatment into a wellness aspect instead of just the addiction aspect, sometimes it's easier for patients to understand better(since it is legal). What I am trying to work towards now is somehow focusing on nicotine dependence along with smoking cessation because of all the new nicotine products that are exploding onto the marketplace, so in some instances I have changed my language concerning tobacco treatment and to focus more on nicotine treatment. Some staff are still ambivalent, but inevitably they will get on board, but it does take constant planting of seeds.
Michael
Janis,
You might be interested in these resources for administrators and clinicians:
Tobacco Treatment for Persons with Substance Use Disorders: A Toolkit for Substance Abuse Treatment Providers http://smokingcessationleadership.ucsf.edu/Downloads/Steppsudtoolkit.pdf
Tobacco Use Cessation Policies in Substance Abuse Treatment: Administrative Issues
http://store.samhsa.gov/shin/content//SMA11-4636ADMIN/SMA11-4636ADMIN.pdf
Tobacco Use Cessation During Substance Abuse Treatment Counseling http://store.samhsa.gov/shin/content//SMA11-4636CLIN/SMA11-4636CLIN.pdf
A Guide to Quit Smoking Methods http://tobacco-cessation.org/whatworkstoquit/NTCCguide.pdf
I my experience as a senior counselor for a county health department in Illinois the number 1 challenge is staff's commitment to change . Line staff know that EBP should be implemented and taught but reverting to old habits is very common with staff and clients . The prevailing attitude of some counselors is "don't drink and go to meetings". Counselors I have worked get excited after a training in new techniques but then rely on counting the number of 12 step meetings client's have attended. If the client can verify the meetings to satisfy the counselor then he is considered to be active in recovery (no meetings, no recovery). Many clinicians don't listen for "change talk" in individuals. 12 step, which is very non-evidence based continues to be the gold standard of treatment facilities. I have nothing against 12 step, I just don't depend on it. Recovery is an individual process with no right or wrong way to go about it. I'll endorse whatever works for the client.
I my experience as a senior counselor for a county health department in Illinois the number 1 challenge is staff's commitment to change . Line staff know that EBP should be implemented and taught but reverting to old habits is very common with staff and clients . The prevailing attitude of some counselors is "don't drink and go to meetings". Counselors I have worked get excited after a training in new techniques but then rely on counting the number of 12 step meetings client's have attended. If the client can verify the meetings to satisfy the counselor then he is considered to be active in recovery (no meetings, no recovery). Many clinicians don't listen for "change talk" in individuals. 12 step, which is very non-evidence based continues to be the gold standard of treatment facilities. I have nothing against 12 step, I just don't depend on it. Recovery is an individual process with no right or wrong way to go about it. I'll endorse whatever works for the client.
Yes, I do see some of the same issues, it seems it is easier for some to revert back to the old standard of 12 step meetings. The problem with that is, 12 step meetings have a "singleness of purpose" as stated in their traditions. And we know that treatment now has to encompass various support services and modality of treatment resources. What works for one may not work for the other. I feel that 12 step programs are a wonderful tool to put in place along with EBP.
Michael
EBP's are popular right now. That is all you hear in the community. Starting with Probation Office to Residential Treatment to Outpatient treatment...etc. I personally think it's great if an agency wants to use Evidence Based Practices, however the challenge I see is how to implement the program effectively and in a way that is compatible with available resources, current workforce capacity and organizational and community cultures.
I think that a big challenge with the integration of EBPs lack of more technical support and funding for entire agency training. like a 2 or 3 day intensive exercise during transition from the top, down including some CM for staff.
And follow up support as implementation begins. I agree. Lots of funding support for conferences and off site trainings but not enough for organizational level training and implementation support. How have other agencies funded these efforts within their organization? Anyone have suggestions?
I feel that there are organizations that are lacking training on implementing EBP and it may be for different reasons. As you indicated, one can find trainings on EBP outside the facility, but there is cost and timing issues. Our facility has a lot of in-house training and does include trainings on EBP such as MI and Stages of Change. The problem seems to be that implementation after the trainings seems to lose steam. I believe in EBP, but I find it sometimes difficult to practice when working within the population I work with(chronically homeless, dual-diagnosis). We have added a peer support component to our program and this has really helped as a bridge for introducing EBP. We have made strides weaving EBP together with peer support, our experience has been that a facilitator with a shared experience type of background has had success with the components of MI, I won't go as far to say that it helps one way or the other to have that shared experience, but it does seem to have more weight with some clients. I feel that consistent training on EBP within an organization is needed, there is a lot to it, and a lot of techniques to apply. Wonderful concept, using EBP's to train staff in EBP's.
Today's medical management model aims at improvinghealth care quality and costs, in part through mandating the use of "evidence-based" services. What constitutes "evidence," and how it is best obtained, is still under discussion and is collaboratively evolving as treatment providers, researchers, and stakeholders examine and re-examine their needs and avaiable resources.Missing the bases of the program.
Is there anything that the ATTCs could do more of or do differently that would support your implementation of the EBPs that we train on?
It would be great to have a checklist for any EBP that addressed the question of "How will we know we are doing this right?"
Duplicate
Our biggest challenge is integrating EBPs into a staff, like most places, that have a mix of clinical people, some in recovery and others who are not. The challenge is getting recovery clinicians to internalize new ways of practicing that may be different than the methods used to help them achieve sobriety.
Historically, the challenge has several components
1. Getting staff agreement on which evidence based practice(s) will be used
2. Training line staff and supervisors adequately
3. Agreeing on "fidelity" measures
4. Active supervision, feedback, modification loops
I realize that many people in recovery 20 years ago may have been resistant to change, but must staff now have to have education and certification behind their name in order to work. Therefore, I do not see using evidence based practice as a problem here. The project match study showed that people in motivational therapy and cognitive behavioral work had better outcomes and most people were trained to interact with clients following these formats.
My agency no longer pays for us to go to training but will let us take the time off. This means maintaining my licensure and keeping current on new information is on my dime.
A key component for us in implementing EBPs is insuring that the practice is reflected at ALL levels - clerical, administrative, management, clinical supervision, etc. This takes time and intentional actions that are difficult to manage. What would be really great is if the licensure and accreditation standards kept up with what has been proven to work - client-driven and outcome-informed treatment - or perhaps that's just a dream of mine. I'm wondering if anyone else out there can offer some suggestions on reconciling what needs to be done to be "compliant" versus what needs to be done in order to be effective.
Sue, can you talk about how you insure it is reflected at all levels? What have you done that has made sure that happened. Would any of the stuff we have on this website have been helpful?
I think that one of the challenges is our tendency to blame our clients/patients for treatment failures. If we do a little more introspection and are constantly wondering what we could do better to improve treatment outcomes we will also do better at studying and implementing the latest evidence based treatments. We are trying to develop a culture where we take at lest some responsibility or look at what we could be doing better regarding treatment drop out rates, relapses, etc.
Hi Jerry
Good to see you on this forum. Bring some of that wisdom over from the Addict-L Listserve.
Dick, I'm sorry I got behind for awhile, wasn't visiting this forum and just came across your message as I was trying to go over some of my older emails. I very much appreciate everything I learned on Addict-L. It was a tremendous training and start to this part of my career. It is still the bedrock and foundation of most of my philosophy in this work. I look forward to learning more from you in the future!