Implementing Evidence-Based Practices: Strategies in Mental Health and Substance Abuse Child and Adolescent Programs

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Implementing Evidence-Based Practices Strategies
in Mental Health and Substance Abuse Child and
Adolescent Programs
IADDA Conference Oakbrook, IL October 3rd, 2007
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Panel Participants

• Presenters
• Susan Harrington Godley, Rh.D.Chestnut Health
  Systems
• Danielle Kirby, MPH, MSEdDivision of Alcoholism
  and Substance Abuse (DASA)
• Andrea Kuebbeler, LCSWAlternatives, Inc.
• Amy Starin, LCSWDMH Child Adolescent
  NetworkHelen R. Stewart, LCSWPillars
• Discussant
• Stanley G. McCracken, Ph.D., LCSW, RDDP The
  University of Chicago, School of Social Service
  Administration

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Overview of Evidence-Based Practices
Stanley McCracken University of Chicago School of Social Service Administration Susan H. Godley Chestnut Health Systems Bloomington, IL
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Ways of Viewing EBP

• EBP is a process. EBP is a way of doing practice
  that integrates the best evidence with clinical
  expertise and consumer values. (EBP as a verb.)
  (Sackett et al., 2000)

Practitioner Expertise
Best Evidence
EBP
Client Values Preferences
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Ways of Viewing EBP

• EBP is a product. An evidence-based practice is
  any practice that has been established as
  effective through scientific research according
  to some set of explicit criteria. (EBP as a
  noun.) (Drake, 2001)
• EB Interventions. (A-CRA, MET/CBT5)
• EB Skill sets. (CBT, Behavioral Parent Training)

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Definition of Implementation
Specified set of activities designed to put
into practice an activity or program of known
dimensionssuch that independent observers can
detect its presence and strength. (Fixsen et
al, 2004, p. 5)
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Fixsen et al., 2004, p. 29
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Definition of Fidelity

• Strategies used to monitor the faithful delivery
  of a manual-guided behavioral intervention
• Important dimensions include
• adherence (i.e., extent to which intervention
  procedures were delivered as prescribed in the
  treatment manual)
• competence (i.e., qualitative measure of the
  skillfulness in which intervention procedures are
  delivered)

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Different Types of Manuals

• Session Driven
• Procedure Driven
• Principle Driven

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Study of Therapists Reactions to Manual-Guided
Therapy

• Qualitative Interview
• Questions
• Compare contrast doing therapy with without a
  manual.
• Were there times when you deviated why?
• How was manual-based therapy able to address
  individual needs?

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Therapists Interviewed

• At least 3 from each intervention total of 16
  therapists and 3 CM
• 1 to 18 months experience with manual
• Age ranges from 24-55 with a M age of 37
• M of 7 years in drug abuse counseling, services
  to adolescent, and services to family
• 10 had masters degrees, 6 had bachelor degrees,
  and 3 had doctoral degrees
• 5 had previous experience with M-G therapy

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Results
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Structure, Consistency, Focus

• All 19 therapists said that MGT provided
  structure consistency
• 30 noted it helped them prepare for a session
• 6 noted it helped them focus during a session
• 4 out of 6 supervisors talked about quality
  control

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Restrictiveness

• 57 noted some aspect of restrictiveness
• 42 said it limited their ability to respond to
  individual needs
• Cut across all interventions, but highest percent
  (70) were in relation to group

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Exceptions

• 4 therapists discussed how they were able to
  incorporate their personal style and
  individualize the treatment.
• the use of the check-in time at the beginning
• choosing role-play situations related to
  circumstances of the group
• 74 indicated the manual they used was flexible
  enough to address individual needs

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Division of Mental HealthChild Adolescent
ServicesApproach to EBP

• Amy Starin
• Division of Mental Health
• Child Adolescent Network

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Division of MH C A Services Approach to
EBP

• Advisory Committee
• Started in November 2005
• Membership includes
• CMH Agencies
• University Professors
• Parents
• Advocacy Organizations

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DMH C A Provider Survey

• 303 responses
• 75 knew what EBP was
• Agencies not prepared to assist clinicians in
  accessing or applying research
• 44 report having been trained in EBP
• Mostly through a workshop ineffective
• 92 Interested or Very interested in learning in
  EBP

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EBP The Noun or the Verb?

• An extremely diverse client base
• Very narrowly defined EBP interventions
• DMH decision..

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The VERBEvidence Informed Practice

• Process of Infusing concepts of science into our
  C A system
• Individual Assessment
• Define a client specific question
• What does the research say?
• Review evidence with client and make a decision
  based on client values
• Implement the intervention
• Measure the outcomes evaluate

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Evidence Informed Practice Definition

• A collaborative effort by children, families,
  and practitioners to identify and implement
  practices that are appropriate to the needs of
  the child and family, reflective of available
  research, and measured to ensure the selected
  practices lead to improved meaningful outcomes.

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5 Pronged Approach

• 1. Evidence Based Skill Sets
• 2. Agency Leadership Seminars
• 3. University Partnerships
• 4. Consumer Education
• 5. Policy Implications

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EBP Skill Sets - Pilot

• CBT Behavioral Parent Training
• 22 Pilot agencies (FY 07/08)
• 8 Didactic days twice monthly phone supervision
  over the course of 12 months
• University Evaluation

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Provider Agency Leadership Training

• Quarterly seminars at 3 locations in the state.

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University Partnerships

• 3 State University programs have developed C A
  EBP Certification programs for 2nd year masters
  students. Students are being admitted this year.
• Importance of collaboration between Academic and
  Field training.

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Consumer Education

• Consumers are powerful change agents
• Consumer conferences and speaking to advocacy
  groups

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State Policy Barriers Supports

• Development of Action Steps for each level of the
  system.
• Division of Mental Health
• University
• Agency
• Clinician
• Consumer Advocacy Group
• Consumer Family

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Division of Mental HealthChild Adolescent
Services A Providers Perspective

• Helen R. Stewart, LCSW
• Pillars

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Parent Behavior TrainingImplementing in
community-based settings

• Different Perspectives and integration of them
  into one treatment- common language/common
  ground
• Initial skepticism about EBP
• Psychodynamic treatment vs. PBT
• Interpersonal therapy vs. PBT

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Parent Behavior Training, contd

• Engaging parents
• Pre-treatment Phase
• Time Frames
• Constantly revisiting engagement

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Parent Behavior Training, contd

• Adapting PBT
• Trainers adaptations
• Clinicians adaptations
• Home-based services
• Complex, multi-problem families
• Multiple caretakers, multiple siblings
• Crisis
• Family level of functioning

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Parent Behavior Training, contd

• Cultural adaptations
• Language
• Cultural perspectives on parenting in general
• Handouts

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Division of Alcoholism and Substance Abuse
Adolescent Coordination Grant

• Danielle Kirby
• Division of Alcoholism and Substance Abuse
• Chicago, IL

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DASA Why Evidence-Based Practices?

• Outcomes
• NOMs (National Outcome Measures) / State Plan
• Performance-Based Contracting
• Illinois State Adolescent Coordination Grant
  (IL-SAC)

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IL-SAC Illinois Adolescent Substance Abuse
Treatment Coordination Initiative

• Funded by SAMHSA/CSAT
• (Substance Abuse and Mental Health Services
  Administration/Center for Substance Abuse
  Treatment)
• 3 years August 1, 2005 July 31, 2008
• Year 3 August 1, 2007 July 31, 2008
• More Information www.IllinoisTreatmentWorks.org

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IL-SAC 13 Required ActivitiesActivity 4

• 4.Evidence-based treatment Identify barriers
  (fiscal, regulatory, and policy) that impede the
  adoption and provision of accessible
  evidence-based treatment across the full
  continuum of care recommended by the American
  Society of Addiction Medicine (ASAM). Devise and
  implement strategies, in concert with all other
  State-agencies that may fund and/or regulate
  these services, to improve the access to
  treatment, increase capacity and quality, and
  expand the available continuum in communities and
  throughout the State implementing treatment
  interventions with a scientific evidence base for
  the population to be served.

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Considerations in ImplementingEvidence-Based
Practices

• Defining
• SAMHSAs National Registry of Evidence Based
  Programs Practices (NREPP)
• 7 Options
• No MISA EBP
• Manual-Based Treatment
• Noun vs. Verb
• Practice-Based Evidence
• Funding Training and Technology Transfer
• IL-SAC Pilot Program
• DMHs Approach

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Division of Alcoholism and Substance Abuse
Adolescent Coordination GrantEBT Implementation

• Susan H. Godley
• Chestnut Health Systems
• Bloomington, IL

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Overview

• DASA released application for participation in
  GAIN and EBT training in Jan 06
• 8 out of 22 applicant agencies were chosen to
  participate and began the training process in
  April 06

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Treatment Manual and Knowledge Test
EBT Technical Assistance
After certification monthly fidelity checks
Certification Requirements are clearly delineated
monitored
Coaching calls As needed
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A-CRA Clinician CertificationRequirements

• Take a knowledge test
• Attend the 3.5 day training
• Attend coaching calls
• Participate in local supervision sessions
• Demonstrate competency on 9 core
• A-CRA procedures through DSR reviews

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Sample Procedure Rating
1 2 3
4 5



poor needs satisfactory
very excellent

improvement good
Caregiver Overview, Rapport Building, and
Motivation 48. ____ ____ Provided an overview
of ACRA 49. ____ ____ Set positive
expectations 50. ____ ____
Reviewed research regarding parenting
practices 51. ____ ____ Identified CG
reinforcers for continued work
52. ____ ____ Kept discussion (about adolescent)
positive
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Each column represents a different session
A 3 or better on all components denotes
competency
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Narrative Comments Are Also Provided
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Progress MET/CBT5

• 3 sites sent 10 staff to trainings
• Appears to be implemented well at 2 agencies
• Third agency still working towards implementation

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Progress A-CRA

• Five Sites sent 26 Individuals to trainings
• One agency chose not to implement
• Being Implemented at 4 agencies

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Barriers/Advantages to EBT Implementation

• Barriers
• Lack of understanding/
• commitment to time demands of certification
  process
• Limited clinical supervision time

• Advantages
• Like having an approach that all are trained on
  instead of everyone doing their own thing
• Most felt these approaches worked well with their
  clients

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Division of Alcoholism and Substance Abuse
Adolescent Coordination GrantA Providers
Perspective

• Andrea Kuebbeler
• Alternatives, Inc.
• Chicago, IL

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IL DASA EBT ProjectAlternatives, Inc.

• Why we chose to participate.
• Outcomes for Adolescent substance abusers
• Skill building for Staff
• Ability to generate increased funding
• Participation in a learning community
• Advance adolescent substance abuse treatment
  within Illinois

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Barriers Encountered

• Equipment costs
• Supervision/Management Time
• Staff Turnover
• Staff Resistance
• Data Collection
• Sustainability

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Benefits to Agency

• Staff Training
• Staff Supervision-Audio/Video Taping
• Consistent Assessment/Treatment Model
• Common Language
• Influence Statewide adolescent practice