Picture this: I have decided I am going to buy a house. I mean, I think I want a new house; most of my friends and family members have one and they tell me: “It's a buyer's market. Buy now before it's too late.” So I am buying a house.
I decide the best place to start is with some type of directory of houses. The newspaper always has lots of listings, so I'll check there. I like the houses with the pretty pictures and, of course, those that are in my price range. Within 10 minutes, I find a picture and description I like. I call the agent and order myself a house.
A year later, I'm sitting in a house on the far side of town with a cracked foundation, nail pops everywhere, and only one bathroom for five people (they never mentioned that in the description). The house is located in a high-crime area, and my children are attending a school that ranks at the bottom for our region. I am now reflecting on how I made this decision. It had seemed so easy.
I had looked at my choices—given my allowable costs—and bought. Sure, I didn't see the house, get an inspection, or ask if the rest of the family liked it or if it met their needs. I just bought because, well, it was a buyer's market.
A ridiculous scenario, right? Unfortunately, I have just described the process, or rather lack of process, often employed when agencies in our field choose and implement an evidence-based practice. Providers may feel the “heat of the buyer's market” via state mandates, third-party payers, or agency initiatives. The message reads: “Quick! Start using an EBP.” In the rush to demonstrate that an agency is using an EBP, the process of choosing what is most appropriate is often lost.
Don't skip critical questions
Organizations that want to proceed with a sound selection process should engage in these steps preceding the actual identification of an EBP:
Answer key questions internally prior to ever looking at a “list” of EBPs. Identify the clients you serve and the diversity of that population; the practice setting and levels of care; the modalities currently used and what modalities are possible given staffing and funding; and the existing level of staff education and training.
Discuss the importance of using EBPs with staff, and increase awareness by engaging in change planning.
Set eligibility criteria based on your program.
Form a workgroup (not of managers only) to investigate options to review against criteria.
Once the group has arrived at recommendations, present these to the larger stakeholder group, including clients and families.
Develop your readiness, training, implementation, and sustainability plan prior to starting.
Move to readiness plan.
In examining EBP options for adolescent treatment, the number of choices is smaller than that for adults, as the current renaissance in adolescent treatment research is a relatively new phenomenon. Nonetheless, there are choices; some public domain (such as the Cannabis Youth Treatment Series available through the Center for Substance Abuse Treatment) and others proprietary (such as the trademarked Seven Challenges Program, a change readiness approach developed by Robert Schwebel, PhD). But what happens if a provider reads a manualized treatment protocol, likes it, and then starts to implement it? The process of exploration stops, sometimes before it is ever started. Using the analogy of buying the house, I jumped directly into implementation prior to considering what might be the best way to meet my family's needs. When organizations rush to announce they are using an EBP, they are in essence building their EBP foundation on shifting sand.
Take the informed approach
After having multiple opportunities to interview staff and supervisors regarding their process of choosing EBPs, I have found it fairly easy to distinguish sound approaches from hasty ones.
Here is how a clinician at one agency might describe how the organization came to use a certain intervention: “I think my boss heard about it and then decided we should do it. All I know is I went to a staff meeting and my supervisor told us we were going to start using X intervention June 1. The training was scheduled for two days the next month. After the training, we have been using X.” Asked how it is working, the clinician might reply: “The kids hate it; they want us to go back to the old way. About outcomes, I think my supervisor keeps up with those.”
Here is how a clinician at another agency might answer the same question: “It was really a process. We attended a statewide meeting where speakers all seemed to be talking about using EBPs. We reported and discussed what we learned in our team meeting. Our supervisor then talked to administration and they gave us the go-ahead to look into EBPs that we could use. Next, a workgroup was formed and the charge set.”
Staff members start to speak a different language when they understand and are involved in the process, versus being “informed” by management. Using an inclusive selection process generates “bi-directionality” within the organization. The Change Book, a blueprint for technology transfer from the Addiction Technology Transfer Center (ATTC) National Office, identifies bi-directionality as a guiding principle in organizational change.