DEVELOPment: Evidence Based Training for Evidence Based Practice Sample Chapter

Chapter One
A DEVELOPment problem

Evidence-based treatments (EBTs) for substance abuse and dependence have demonstrated superiority over treatment as usual when applied with strict fidelity in controlled clinical trials. Effective counselor training is critical if substance abuse programs are to realize these interventions full potential to enhance client outcomes in community practice Steve Martino, 2010

A most surprising finding is the lack of proficiency in treatment adherence, competence, and skill reached by therapists trained in the current gold standard (i.e., workshop, manual, and clinical supervision) Rinad Beidas and Philip Kendall, 2010

In 2011 six sites across the UK piloted a Payment-By-Results (PBR) approach to substance misuse treatment. Many in the field watched with interest, curious to see how services performed under such constraints. Few could ignore the implications of PBR extending nationally. The intense interest (and concern) in PBR is understandable: PBR places a
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financial consequence on outcomes; and, outcomes inherently place a strain on capability. Under PBR, treatment services which are not capable dont get paid! The truth is, PBR is but one (albeit extreme) manifestation of the current zeitgeist within substance misuse treatment. Regardless of ones involvement with PBR, all have felt the shift toward outcome-attainment in recent years. More than ever, practitioners are expected to demonstrate the ability to resolve their clients problems. And, treatment services are increasingly scrutinising their choice of intervention and the quality of its delivery. There is little doubt: these are demanding times work in the substance misuse field. Of course, for those passionate about the work, the strain between outcomes and capability demands attention. It is clear that practitioners and treatment services are actively reviving an interest in effective intervention, innovation, and workforce development. But, there is much work to be done. Take, for example, a study by Best, Day, Morgan, Oza, Copello, and Gossop (2009). These researchers assessed the quality of support provided in a Birmingham Drug Intervention Programme (DIP). After reviewing 344 case files and interviewing thirty-five practitioners, they found that, on average, only ten minutes of each one-to-one session could be classified as evidence-based psychosocial intervention. Unfortunately, the ten minutes finding was later replicated (see Best, Wood, Sweeting, Morgan, & Day, 2010), suggesting the effectiveness of client-practitioner interactions, in many treatment services, could be vastly improved. It is a truism that a competent workforce is an organisations primary resource for achieving outcomes. Much faith is invested in its impact. The National Treatment Agency (2009) recognised this when they recommended, Continuous improvement of the capacity and effectiveness of adult drug treatment depends upon sustained attention to workforce development for commissioners, managers and treatment delivery staff. By all accounts,

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workforce development ought to be high on any treatment services agenda. Yet, it is surprising how perfunctory this task is approached. Research in the USA, for example, found that many services (between 20% and 72% of those surveyed) did not provide practitioners with formal training in Motivational Interviewing, Cognitive Behaviour Therapy, Contingency Management, or Brief Strategic Family Therapy (Olmstead, Abraham, Martino, & Roman, 2012). This was despite the fact that, in these services, practitioners were expected to deliver these interventions. Often, gaps in training like this can be attributed to pressures that organisations face. Alavi and Leidner (2001), for example, have made the observation that, Many organisations are so lean that people do not have time to make knowledge available, share it with others, teach and mentor others, use their knowledge and expertise to innovate and find ways of working smarter. Instead, they are task-focused, shifting existing workloads to fight deadlines. It is unfortunate how common this scenario is in the substance misuse field and other helping professions. In the UK, at least, substance misuse treatment services operate within short three-year contracts. There really is little time to establish ones service before discussions turn to keeping the contract. This means that achieving ones performance targets within tighter and tighter budgets usually renders (true) staff development low as a priority. But, it is worth noting that Alavi and Leidners observation is actually a concern about what prevents organisations from being successful. Their warning is that the services provided by an organisation is not just the sum of its available resources. Sustained competitive advantage is actually gained through the way resources are applied, and how new and innovative solutions are identified. This requires a process of utilizing existing knowledge to create new knowledge. Arguably, the majority of an organisations knowledge sits within the workforce. So, it would be wise to heed the National Treatment Agencys call for sustained attention to workforce development.

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Would additional investment in training resolve the issue? Maybe. But, it is becoming clear that the situation is more complicated that first anticipated. Research is showing that, even when substantial training is provided, the benefits can be small. Training methods such as one or two day didactic workshops are proving ineffective (Beidas & Kendall, 2010). And, within all this, there is growing recognition that changing practitioner behaviour is about as challenging as changing the behaviour of the clients they support. Of course, there are many reasons for this, and none are unique to practitioners per say. For example, Miller, Sorensen, Selzer, and Brighams (2006) have reflected that, There is a certain inertia in clinical practice, a tendency to continue doing what is familiar and comfortable, and perhaps a discomfort in considering that long-practiced methods may not be optimal. Most would agree that this sentiment could apply to us all, and in many areas of life. One encouraging finding is the identification of psychosocial interventions which help people change their behaviour, including difficult to change behaviours such as substance misuse. So, it stands to reason that methods can also be found to support practitioners and organisations to change their behaviour with clients. Identifying these methods, as is often the case, lies in first understanding the problem.

The DEVELOPment Problem

All workplaces require workers to possess skills which enable them to fulfil their role. For practitioners in the substance misuse field, many of these skills relate to therapeutic ability the ability to help a person initiate and maintain changes to their substance use. Invariably, this involves the application of psychosocial interventions, which, in turn, requires good interpersonal, relational, and communication skills. Unlike some other job related tasks, these skills are complex and often difficult to acquire. Moreover, attempts to train these
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complex skills typically falls short (Beidas & Kendall, 2010). This book proposes that this failure is largely attributable to the way training is approached. All too often, training consists of short, isolated events, disconnected from actual client-work. They constitute a day out the office where information and guidance is provided to up-skill the practitioner for when they return to their workplace. When approached this way, training is considered to be like installing new software on a computer: At the training event, practitioners are uploaded with new information and procedures. Once installed, they can return to their workplace and run it with service users. Of course, experience suggests that the installation is not always effective: Sometimes, the installation fails completely. Other times, the program is installed but never gets run with service users. Still other times, the program is run with service users, but the program runs differently; it has somehow been corrupted. The computer metaphor, it seems, does not guide us well. Another way to thinking about training and one this book strongly advocates is that it resembles the self-assembly of large cranes. When cranes self-assemble, they do so by using a jack to lift the entire crane upward, creating a space. This allows the crane itself to winch in a new section of shaft. This section of shaft is then secured, allowing the crane to crank itself up further, creating another space. More sections can be winched in, secured, and so on. Unlike the computer metaphor, the crane metaphor implies that training comprises several distinct tasks: Firstly, it requires the crane be receptive to accommodating new sections. Secondly, it implies that the right sections of crane must be made readily available; they must be a good fit for the crane itself, but also support the weight of the work. Thirdly, it recognises that, although support can be provided, practitioners need to play an active role in winching in new sections. Finally, it emphasises the need to secure new sections firmly into place before the heavy work commences.

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The crane metaphor is useful in that it highlights a number of important challenges. However, metaphor only brings us half-way; we need to be specific. The remainder of this chapter extends this metaphor to describe seven challenges within the training of therapeutic skills. Each challenge is characterised by a Promise and a Pitfall. Collectively, they can be called the DEVELOPment problem.

The D in DEVELOPment: Dissemination

Dissemination refers to the combined process of making psychosocial interventions available and motivating practitioners to adopt them. Dissemination is an important, but neglected, aspect of training. All too often, training is limited to what is locally available, and with little consideration given to practitioners readiness to adopt these approaches. The past few decades have seen a range of effective interventions identified for substance misuse issues. Many of these approaches are within traditions which value ongoing advancement in both theory and practice. Unfortunately, few of these advances have filtered into routine practice. In fact, research shows that the interventions used in practice typically lags a decade or more behind current innovation (Corrigan, Steiner, McCracken, Blaser, & Barr, 2001). Worse still, there are multiple instances where interventions of unknown efficacy disseminate far more readily that those proven to be effective. The sad truth is, exciting innovations within substance misuse treatment remain unknown and underutilized. This means practitioners and treatment services are often limited to using outof-date, convenient, or popular interventions. All this is widely acknowledged, and not limited to the substance misuse field. In her commentary on Evidence Based Practice more generally, Enola Proctor (2004) concluded
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that, ...the gap between the availability and actual use of evidence-based treatments remains wide and persistent. What creates this gap? Unfortunately many factors have been identified, ranging from the attributes of individual practitioners (e.g., attitudes and motivation) to broad systemic factors (e.g., organisational support) (Corrigan et al., 2001). To close this gap means finding ways to overcoming these barriers. Doing so is crucial for getting the right interventions in the hands of the right practitioners. The promise of dissemination is that beneficial innovations will become available and established in practice. The pitfall, however, is that this process can takes an inordinate amount of time to happen naturally. And, considering that some highly effective interventions have never achieved widespread adoption, it is also an unreliable process when left to its own devices.

The E in DEVELOPment: Empirical Support

Empirical Support refers to the use of research-based evidence to selectively advocate psychosocial intervention. This approach is most familiar within the Evidence Based Practice (EBP) movement, commonly defined as, the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Sacket, Rosenberg, Gray, Haynes, & Richardson, 1996). There is one primary advantage for using empirical support in this way: namely, to gain certainty that ones actions will result in positive outcomes for a service user. Dissemination and Empirical Support are two sides of the same coin: Dissemination implies the need for selection, and Empirical Support stands as a logical selection criteria.
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Conversely, the fact that Empirical Support continuously evolves (RycroftMalone, Seers, Titchen, Harvey, Kitson, & McCormack, 2004), highlights the importance of seeking out and disseminating innovation. Traditionally, in the substance misuse field, widespread and popular interventions have not been well supported. In some instances, the evidence has even demonstrated detrimental effects. This disconnect between dissemination and empirical support was evident in Miller, Wilbourne, and Hettemas (2003) review of treatments for alcohol dependence. They famously concluded that, The negative correlation between scientific evidence and treatment-as-usual...could hardly be larger if one intentionally constructed treatment programs from those approaches with the least evidence of efficacy. Since then, some progress has certainly been made. Service monitoring in the UK, for example, currently lists nine empirically supported psychosocial interventions (referred to as sub-interventions in the National Drug Treatment Monitoring System (NDTMS)). Such lists certainly create an expectation as to the type of work one should find in substance misuse treatment services. It also means practitioners must select from these alternatives when describing their work with clients. However, the use of these interventions in practice routinely differs from the protocols found in research trials. And, in its worst form, empirically supported brand name are used to describe interventions which bear little resemblance to the original approach (e.g., when Relapse Prevention is used to refer to any form of aftercare). This highlights that Empirical support always entails a need for fidelity: The less an intervention resembles what was tested in research, the more disconnected it becomes from its empirical support; and, the more disconnected it gets from its empirical support, the more questionable becomes its efficacy. Unfortunately, attempts to increase practitioners fidelity to interventions can be experienced as a violation of personal freedom

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and clinical judgement. As such, empirically supported interventions, and especially the use of manuals, have been resisted (Addis, Wade, & Hatgis, 1999). Whilst Empirical support is undoubtedly of value. The extent of its usefulness has continued to remain a topic of debate (e.g., see Mullen & Steiner, 2004). Some have raised concerns that the outcomes found in efficacy research may not generalize to the real-world environment of substance misuse services (e.g., Rothwell, 2005; Flay, Biglan, Barouch & Castro et al., 2005). Others have highlighted that, while we know what interventions are effective, we know relatively little about why they work (Longabaugh & Morgenstern, 1999). This is an undoubtedly an issue for training. If strongly supported interventions, such as Cognitive Behaviour Therapy, do not work through the mechanisms specified by its theory (see Longabaugh & Morgenstern, 1999; Morgenstern & Longabaugh, 2002; Longmore & Worrell, 2007), how should one teach the approach? Which aspect of the approach should be emphasised? Any confidence gained from training an empirically supported intervention is somewhat undermined by the realisation that one may be teaching inert treatment components. The promise of Empirical Support is that research based findings will inform the work of practitioners. The pitfall is that it rarely does.

The V in DEVELOPment: Vocational Skills Training

Together, Empirical Support and Dissemination address the questions of What is to be disseminated and How practitioners are motivated to adopt them. To disseminate, psychosocial interventions are quite complex. They consists almost entirely of knowledge
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and behaviours. The term Vocational Skills describes the acquisition of this knowledge, made relevant to the setting into which it is to be applied. Whilst the purpose of training is to convey this knowledge, training does not always impart the type of knowledge needed to competently deliver an intervention. Training, it turns out, needs to emphasise both know-what (e.g., knowledge about an intervention) and know-how (e.g., the behavioural ability to implement an intervention). Research is showing that these two types of knowledge do not develop in tandem. In a review of therapist skills training methods, Beidas and Kendall (2010) found that knowledge and attitudes change quite readily from training. The development of skill, competence, and adherence, meanwhile, proved far harder to achieve. Much of this can be attributed to the training methods used. There is a general over-reliance on didactic and educational methods in training, and these are generally poor at developing know-how. It seems that knowing about an intervention is necessary but not sufficient to competently deliver it. This failure is particularly difficult to see because the impact of training is rarely objectively measured (e.g., observation of skills). And, the assumption that self-reported competency resembles observed competency is, unfortunately, untenable (e.g., see Miller & Rollnick, 2009). This creates the illusion that training is actually more effective than it is. As a side note, it is telling that we expect educational strategies to change practitioner behaviour. In parallel, many in the substance misuse field overuse the strategy of educating clients about the risks associated with their drug use. The assumption being that, when a client fully appreciates the harm involved, they will change their behaviour. Unfortunately, despite its widespread use, little empirical support supports its value as a method for changing drink/drug use. In fact, in some cases, such strategies have been shown to exacerbate use (Kinder, Pape & Walfish, 1980). Interestingly, the same trend is proving true for the training of practitioners.
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The promise of vocational skill training is that the training methods used will help practitioners acquire the right types of knowledge to be competent.

The pitfall is that they often develop conceptual knowledge but fail to develop behavioural skill. This severely limits practitioners ability to effectively deliver an intervention.

The E in DEVELOPment: Embedding into Practice

Successful training methods are clearly important. But, what if those skills - competently demonstrated within a training event - are hardly used when back in the workplace? Extensively researched under the heading Transfer of Training, this set of large literature has shown that only a small proportion of what is trained is ultimately used. Worse still, recently trained skills appear to decay after only short periods of time. For example, based on the results of survey data, Saks and Belcourt (2006) estimated that only 62% of training is used in the workplace directly after the training event, dropping to 44% after 6 months, and 34% after one year. A significant implication of this is that the majority of an organisations training budget is wasted. Training, by itself, is certainly not cost effective. Research has identified a variety of factors which improve the likelihood that new skills become embedded in a practitioners work with clients. But, they are rarely considered in training design. The promise of Embedding into Practice is that knowledge and skill acquired within the training event will later be applied in the workplace. The pitfall, however, is that most of these skills will remain unused.

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The L in DEVELOPment: Learning to Integrate

Like many others, Kendall and Beidas (2007) have noted that interventions are used far more flexibly in practice, commenting that, Our experience is that competent and reasonable practicing professionals pick and choose features of ESTs [Empirically Supported Treatments] that they see as holding promise or being of merit. Entire EST programs are not as readily adopted as are the personally selected strategies or ideas that are a part of the larger program. In many ways, this is the reality of practice. Ask a practitioner what psychosocial interventions they use and, more times that not, they say, a bit of everything, or, I dont limit myself to one approach. Indeed, surveys have showing that between onethird and one-half of psychotherapists claim to be eclectic in the sense that they dont associate themselves with any single theoretical position (Beitman, Goldfied, & Norcross, 1989). One the one hand, this seems to add to the fidelity issues described above. But, on the other hand, there is a strong rationale for doing this. The finding that all effective psychosocial interventions are, by-and-large, comparably effective (e.g., Imel, Wampold, Miller, & Fleming, 2008) seems to practitioners with the freedom to legitimately select from a range of empirically supported interventions. Furthermore, it might be argued that providing practitioners with more ways of working with clients, empowers them to respond with greater flexibly to their clients needs. Eclecticism is a reality of practice, and rather that shy away from that fact, it should perhaps be embraced as the normal end-point for most practitioners learning. A question does arise, however, when one considers the best way to integrate multiple interventions? Two difficulties are immediately obvious: Firstly, by combining strategies from multiple interventions, the resulting practice can quickly result in a hodgepodge of techniques, and a
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reduced role for intervention theory. Theory, within psychosocial intervention, is important as it functions as a guide, informing when and how techniques should be applied. Without theory, the selection of technique must be revert to common sense or clinical wisdom (both of which are viewed as biased sources of evidence within evidence based practice). Secondly, not all interventions are compatible. All psychosocial interventions are based upon theoretical assumptions about behaviour, addiction, the interventions mechanism of action, and so on. In some cases, these assumptions are so different that they are essentially irreconcilable. For some, their use together may even be contraindicated. Certainly, attempts to formally integrate interventions have not been completely successful. As Patterson (1989) concludes, The existing proposals for an eclectic psychotherapy are independent of each other. Each incorporates limited combinations of methods, strategies and techniques from existing theories or approaches, with little attention to any philosophy or theory. What appears to be happening is the development of a number of new approaches on the way to becoming schools. Rather than truly integrating interventions, it seems that integration merely adds further variety, feeding into the eclectic range of interventions already available. The promise of Learning to Integrate, then, is that practitioners will be supported to work more creatively, competently, and flexibly. The pitfall is that this greater flexibility can easily extend to haphazard application. Paradoxically, this may reduce competence and flexibility.

The O in DEVELOPment: Orienting toward self-DEVELOPment

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The ultimate responsibility for adopting, learning, practicing, and applying new skills rests with individual practitioners. Unfortunately, practitioners approach training with different levels of enthusiasm. Many factors have been found to influence the utilisation of newly trained skills. Motivation to learn, perceived utility of training, and self-efficacy to engage in learning tasks (Blume, Ford, Baldwin & Huang, 2009; Pham, Segers & Gijselaers, 2010) have been implicated. So have practitioner attitudes toward the intervention itself (Knudsen, Ducharme, Roman & Link, 2005; Varra, Hayes, Roget & Fisher, 2008). And, organisational factors have a considerable influence on both training outcomes (Rouller, Janice, Irwin, & Goldstein, 1993) and utilisation of empirically supported interventions (Nelson, Steele, & Mize, 2006). How optimal are these factors? Alavi and Leidners (2001) comments at the start of this chapter suggest cause for pessimism. Organisations are often so preoccupied with fulfilling their contractual requirements that there may be little slack to support a practitioners training. An example many will be familiar with is the practitioner who returns from attending a workshop only to be briefly asked by their line manager, How was the training? If the answer is, It was good...but it was pretty much what I was doing already the training may never be discussed again. The line manager, perhaps reassured that the practitioner has the necessary skills, turns their attention to the days tasks, and so does the practitioner. The practitioners day is full of opportunities to practice, apply, and integrate new learning. But, distractions, demands, and pressures will all negatively affect the engagement in ongoing learning. Interestingly, some common training methods for example, short workshops - have also been shown to adversely affect practitioner motivation. In one study examining the impact of one workshop on motivational interviewing skills, a significant reduction in motivation was found to engage in further learning about the approach (Miller & Mount, 2001).
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The promise of Orienting toward Self-DEVELOPment is that practitioners will be motivated to engage in the learning tasks required of them to develop adequate competence.

The pitfall is that this motivation is not stable, and practitioners vary in their competence to self-direct their learning tasks.

The P in DEVELOPment: Practice Based Evidence

Margison, Barkham, and Evens at al. (2000) describe Practice Based Evidence as, Good quality data from routine practice. There are many good reasons for gaining quality data from ones practice. One, however, is particularly pertinent to training: Feedback. The importance of feedback in learning is nicely described in the following passage by Miller, Sorensen, Selzer, and Brigham (2006): Learning any new skill does not occur without feedback. One of the most consistent findings in motivational psychology is that feedback improves performance. Trying to learn a counseling method without feedback is like learning to bowl in the dark: One may get a feeling on how to release a ball and subsequent noise will provide some clue about accuracy, but without information about where the ball struck, years of practice may yield little improvement. Feedback, when it does occur as part of training, almost always occurs away from the workplace. This is unfortunate. Although Practitioners rarely think of it this way: current clients are the best sources of feedback for ascertaining the effectiveness of ones interventions. Practice Based Evidence is probably the most relevant source of feedback one could obtain. Yet relatively little is actively sought out. When this information is sought out,
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however, it has been instrumental in improving practitioner effectiveness (Horn & Gassaway, 2007; Duncan, Scott, & Sparks, 2011). Practice Based Evidence, it is worth noting, also seems to complement research-based empirical support in a number of ways (Barkham & MellorClark, 2003). Practitioners who are critical of evidence from research trials may be more open to locally obtained evidence of effectiveness. Likewise, research trials typically report as comparisons between aggregated group overages. These averages provide only a probability of individual client success (Seeman, 2001) and hide the significant variance in outcome created by practitioner variables (Elkin, 1999). Both these factors are important from a training and development point of view. The promise of Practice Based Evidence is that the use of feedback ensures effective interventions are used, that training needs are identified, and that practitioners continue to develop their skills. The pitfall, however, is that routine work is rarely approached as opportunity for improvement.

Insert Figure 1a here

DEVELOPing a way forward

The DEVELOPment problem outlined above describes seven challenges. Each is characterised by a promise and a pitfall (see Figure 1a). However, it is clear that some levels are closely connected. For example, Dissemination and Empirical Support are jointly
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involved in the task of selecting and making available the content of training. Vocational Skills Training and Embedding into Practice jointly address the acquisition and elicitation of training content. Leaning to Integrate and Orienting toward self-DEVELOPment seem concerned with individualism within the DEVELOPment process. While Practice Based Evidence provides a common mechanism whereby the impact of the other six levels can be evaluated. Because of these natural divisions, this book is structured into four sections. Each section corresponds to the groupings outlined above. The chapters are further structured around two primary aims: 1) to review theory and research which provides insights into how the DEVELOPment problem can be resolved, and, 2) to describe practical applications of those insights. Therefore, each section might be thought of as an hourglass. The top half of the hourglass represent the chapters on research and theory. These chapters will always conclude by describing a number of guiding principles. These guiding principles represent the narrow, middle portion of the hourglass. The bottom half of the hourglass describes various practical applications and strategies informed by the identified guiding principles. In the final chapter, a holistic overview of the DEVELOPment model will be provided.

DEVELOPment: Finding our Map and Compass

This chapter has outlined the DEVELOPment problem and specified its inherent promises and pitfalls. The chapters that follow should be thought of as a map and compass. Each level of the DEVELOPment problem is a different territory, each with its own landscape and unique challenges. Guiding principles serve as compass points; they specify directions which, if pursued, offer a good chance of successfully navigating through a given territory.

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For those wishing to reduce the tension between capabilities and outcome, DEVELOPment offers a promising way forward.

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Level
Dissemination

Promise
Beneficial innovations will become available and promptly established in practice.

Pitfall
Dissemination is an unreliable process, taking an inordinate amount of time to occur naturally. Innovation lags considerably behind current practice. Empirical support is underutilised. Interventions are not delivered with fidelity. Training methods tend to develop conceptual knowledge but fail to adequately develop behavioural skill. Most new skills will not be used on return to the workplace.

Empirical Support Vocational Skills Training

Research based findings will inform the work of practitioners. Training methods will help practitioners acquire the right types of knowledge. Knowledge and skills acquired in the training event will subsequently be applied in practice. Practitioners will be supported to use interventions creatively, competently, and flexibly. Practitioners will be motivated to engage in required learning tasks

Embedding into Practice

Learning to Integrate

Orienting toward selfDEVELOPment

Practice Based Evidence

Good quality feedback ensures effective interventions are used, that training needs are identified, and that practitioners continue to development their skills.

Greater flexibility can easily extend to haphazard application, paradoxically reducing competence and flexibility. Distractions, demands, and pressures negatively affect use of new skills. Practitioners vary in their competence to self-direct learning tasks. Routine work is rarely approached as a source of feedback to improve performance.

Figure 1a: Summary of the DEVELOPment Problem Promises and Pitfalls

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