Many years ago,
I had a bad experience with a consultant. She promulgated an evidence-based
treatment curriculum for a specific condition that my programs treat. The
curriculum was excellent; the consultant was not. She complained bitterly to
others when cases were not improving rapidly, and blamed some therapists even
as she attempted to hire others away from our employ. At no time did she
critically examine her own contribution to these circumstances. Good treatment
with bad implementation does not produce a good outcome for anyone.
Central to our
implementation problems was that our therapists needed time to get their minds
around the specific treatment processes. Unfortunately, she and the funders
were not patient. This was before I became aware of Dean
Fixsen’s research on implementation efforts. He would argue that it takes
two years to implement a treatment program with fidelity. In our case, this
meant a good curriculum, good therapists, but poor consideration of
implementation science.
Fast forward a
few years and I have twice consulted to agencies this week on implementing
treatments such as the good lives model and motivational interviewing. As you
might expect, time is tight and money is short. From an administrator’s
perspective, it always seems like a good idea at the time: “there is a good new
treatment method out there; let’s get someone in to do training.” What often
gets lost in the mix are some of the basics. For example, with every rollout of
a new treatment method there is a minority of people who readily embrace change
and another minority who wants nothing to do with it. One example of this took
the form of “we’ve seen these new models come and go over the years. This one
will probably go away as well.”
Even the
greatest attempts at improving services meet with challenges along the way. An
important consideration lies in how we can prevent implementation problems
before they happen. Professionals sometimes do not want to change their
behavior any more than mandated clients do.
Perhaps one
place to start is in considering how best to get the program’s context right
for change. Are we considering full implementation of a specific approach such
as motivational interviewing or the good lives model? To do so with fidelity
can mean even more effort in curtailing old approaches than in learning new ones.
It can also mean stopping a program in its tracks and changing course, which
can result in as much or more tumult for the clients as the program staff.
On the other
hand, one might try integrating program components piecemeal. For example, one
might try to go in a good-lives-model direction through a series of steps:
1)
Ensuring that the mission of
the program is to build client capacities and wellbeing even as clients manage
risks
2)
Focusing on developing goals
that every client can approach rather than avoid
3)
Developing a deep understanding
of each client’s common life
goals
4)
Collaborative work with clients
to understand their past behavior in accordance with the self-regulation
model
5)
Consider full implementation of
the good lives model
Another possible
approach is to consider “Implegration.” This is a term coined by Swedish prison
psychologist Carl Åke Farbring and refers to an integrated implementation effort (see here for a series of
presentations in English and Swedish). Farbring came to conclude that simple
efforts at motivational interviewing implementation were doomed to be less
effective when they did not take place in the cultural context of the program. From
his notes, he describes Implegration as involving:
- An intentional
process of implementation
- Bottom-up
perspective
- An attitude
of exploring and listening
- Local
ownership of processes (separate from the centrally decided goal
orientation)
- Balance
between guidelines and mindlines
- Adjusting
to local conditions means deliberate integration
- Positive
monitoring and support
When considering
the implementation of a treatment approach, it is often easy to overlook the
potential contribution of local expertise. This can be achieved as simply as
through the appointment of in-house experts who consult to both the model’s
developer and the front-line clinicians. It can also use in-house
relationships, such as having an enthusiastic front-liner organize regular
discussions about how implementation is progressing.
For many years,
it seemed acceptable to view clinicians as widgets in the service of
sophisticated treatment regimens established by experts who were too often in
another region. Recent research has confirmed the importance of improving
treatment services one client at a time through close attention to the alliance.
As our field continues its discussion of best treatment practices, it also seems
vital to consider how we make these practices happen.
David
S. Prescott, LICSW
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