Assistance in adopting new practices

You've been there: You just finished participating in a great training on a new clinical intervention, and you're enthusiastic and committed to trying it with your clients. Although there wasn't much time for skill-building, you have lots of notes and handouts. You're raring to go.

Then you get back to the agency, to the routine, to the caseload and the paperwork, to the supervisor and co-workers who didn't take the training, to the clients who aren't prepared for you to do something new or different. Your notes now seem incomplete and you scratch your head trying to recall details from the training. All that enthusiasm and new knowledge begin to fade. Adopting new practices in the context of everyday practice is often difficult and frustrating. Given all the challenges associated with implementing something new, most of us fall back to the familiar and the necessary.

In 2003, the Addiction Technology Transfer Center of New England was one of 14 ATTCs nationwide to begin working with the National Institute on Drug Abuse to assist in disseminating research emanating from NIDA's Clinical Trials Network (for more information, go to https://www.nida.nih.gov/CTN/index.htm). Following NIDA's instructions to “prepare the field” for upcoming dissemination and adoption efforts, the ATTC-NE staff reflected on the number of times that we as clinicians had experiences like those noted above. We determined to focus our efforts on looking at the process of adopting evidence-based treatment practices, rather than on teaching the EBPs themselves. This process is actually technology transfer—moving the science from the laboratory to the field.

We began our preparation by holding regional and national discussions with key stakeholders, and conducted an extensive review of the research literature in order to identify barriers to the effective adoption of new practices. In contrast, we also researched characteristics of organizations that had successfully completed change initiatives. Eventually a model for adopting new practices emerged. As a vehicle for agencies to experience this comprehensive technology transfer model, we developed the Science to Service Laboratory in association with the New England School of Best Practices.


Stephen J. Gumbley, MA, LCDP

Test case

Daniel D. Squires, PhD, MPH
In order to become skillful in adopting EBPs, agencies must practice implementing a real intervention. Based on recommendations from state and clinical leaders across the New England region, contingency management was selected as an evidence-based practice to model the Science to Service Laboratory. Contingency management, a treatment approach that uses incentives such as prize vouchers to promote positive behavior change in substance abuse clients (see cover story in September/October 2006 issue) is easy to teach and learn, integrates well into a variety of treatment models, and has generated interest among treatment providers. Nancy Petry, PhD, of the University of Connecticut Health Center, a widely published researcher in contingency management, trained the technology transfer specialists and agency staff.

The comprehensive technology transfer model has several key components. The first is getting organizational commitment for the process. Two concepts related to adopting new treatment practices have long impeded successful implementation. One is the belief that making organizational changes “just happens,” that it doesn't require much thought or preparation. Indeed, many practitioners believe that if an intervention is good enough, it will “sell itself.” Another barrier is the widely held belief that implementation is the counselor's responsibility, since the counselor is the one delivering the intervention. Little thought is given to the context and culture into which the new intervention must fit.

The reality is that successful implementation of a new practice depends greatly upon organizational change that requires significant agency involvement. Given the complexity of successfully implementing new treatment practices, the responsibility for spearheading adoption efforts belongs as much with the agency as it does with the individual practitioner, if not more so.

We address these barriers by requiring a number of up-front commitments from the agency:

• An initial pledge to ensure the availability of the fiscal and human resources necessary to complete the adoption process;

• The identification of internal agency “champions for change” and other interested personnel for participation on the implementation team; and

• Assurances that the organization will develop and maintain the use of a work plan as outlined in The Change Book,1 a “blueprint for technology transfer” developed by the ATTCs.

Support for the adoption process begins with an “exposure meeting” for agency executives, to give them an overview of the key elements of the Science to Service Laboratory model, and of the essential components of the intervention (contingency management) that will be used to model that process.

The next key component of the technology transfer model is using a developmental model for change. Most practitioners in the substance abuse treatment field are familiar with the Transtheoretical Model of Change. Dwayne Simpson, PhD, developed a model for organizational change that parallels the transtheoretical model.2 Simpson's model is tailored toward administrators and practitioners. Like the Transtheoretical Model, Simpson's model is divided into stages of action: exposure, adoption, implementation, and practice (roughly equivalent to the stages of change for individuals in the Transtheoretical Model). Similarly, Simpson's model emphasizes that change is a process that takes time and effort. A progressive model such as Simpson's helps break the work of implementation into an orderly, manageable progression.

Using external consultants or coaches is also important. What if you could have had a coach or trainer assist you when you got back from that really great training? Chances are it would have helped immensely. In our model we call these helpers “technology transfer specialists.” They are trained to deal with various issues that can arise during the adoption process and they are knowledgeable about the particular intervention being implemented. The specialists work with agency implementation teams (at the agency and in larger, multi-agency work groups) to help them learn about implementation dynamics and the particulars of adopting the specific intervention. A specialist doesn't solve problems for the implementation team, but serves as a catalyst to help the team solve problems collaboratively.

Another critical component involves connecting the researcher/expert and the practitioner. Despite having the common goal of helping people overcome addictive behavior, researchers and practitioners usually do not have many opportunities to communicate with each other. When they do, they often may be at odds because of differing agendas. Failure to establish effective working relationships between researchers and practitioners is one of the most frequently cited barriers in promoting the use of evidence-based practices. In fact, NIDA established “bi-directional communication” from the lab to the field and back as an essential element in the successful dissemination of research.

Our model is designed to foster a productive connection between the scientist and the practitioner. Both the technology transfer specialists and the agency implementation teams receive training in the selected clinical intervention directly from a researcher or expert. These trainings are designed to allow plenty of opportunity not only for the flow of knowledge, but also for skill development and discussion of adoption and implementation strategies with the researcher/expert.

Fidelity and adaptation are important elements of any adoption and implementation process. Fidelity refers to implementing the intervention as closely as possible to the way it was designed and delivered during the research stage. Adaptation occurs when practitioners modify the intervention. While intentional adaptation constitutes a normal part of adopting a new practice, accidental adaptation (sometimes called “drift”) can pose significant problems. Most notably, too much adaptation might decrease an intervention's effectiveness. Having an opportunity for in-depth discussions between researchers/experts and implementers is vital to finding the right mix of fidelity and adaptation.

Finally, development of multi-agency work groups is important. Working in groups rather than individually fosters interaction that supports change. This is an area in which the organizational change process parallels the client change process. In the Science to Service Laboratory, we ask multiple agencies to come together to work with the technology transfer specialists (a cost-effective approach to using consultants). Initially, we had concerns about how effectively staff from multiple agencies would come together to work in groups. These concerns quickly were put to rest as individuals were clearly eager to learn from one another's experiences regarding adoption and implementation of the contingency management intervention. Having agencies of different sizes and that used different treatment modalities meant that not all adoption efforts looked the same or had similar timelines. In addition, agencies presented with varying levels of sophistication and change experience with respect to the adoption process.

Overall, team members problem-solved together, shared ideas about internal changes, and collaborated to identify what client profiles work best with the intervention. Participating in multi-agency work groups appears to be an important aspect of promoting successful organizational change.

Looking at results

So does the model work? Since 2003, the ATTC-NE has worked with 54 community-based substance abuse treatment agencies from across New England using the Science to Service Laboratory. Ninety-six percent of agencies that have completed all Science to Service Laboratory components have successfully adopted and implemented contingency management. Through surveys that provided feedback on satisfaction with the quality, organization, and utility of the Science to Service Laboratory as an organizational change model, agencies and their staff members rated these components favorably.

When asked about future training resources, agency directors throughout New England voiced a clear desire for professional conferences, workshops, or seminars outlining practice options; information outlining the relative advantage of evidence-based practice over existing practice; a menu of practice options; and patient outcome data to support change efforts.

Based on this growing demand for organizational change strategies and evidence-based practices in the region, we are working to incorporate a number of new components into the existing Science to Service Laboratory. First, we are beginning to incorporate other evidence-based practice options in addition to contingency management, including cognitive-behavioral therapy and Motivational Interviewing. In order to support these expanded practice offerings, we have been developing a comprehensive clinical supervision and follow-up support component. It will provide both knowledge and skill training for supervisors and will link practitioners with clinical feedback resources following didactic training.

We also are exploring ways to incorporate Web-based technology, including our award-winning ATTC-NE Distance Education program, into this effort in new and innovative ways such as interactive online supervisory and feedback forums. Finally, developing and evaluating outcomes is also an important element that drives the adoption of EBPs. In collaboration with state treatment administrators, we are developing new training modules to help providers enhance the effective use of outcomes in their clinical planning.

The ATTC-NE continues to work with local, state, and regional entities across New England to bring science to the front lines of treatment, and we welcome additional opportunities for collaboration.

Stephen J. Gumbley, MA, LCDP, is Associate Director of the Addiction Technology Transfer Center of New England at Brown University, and has been a counselor, supervisor, administrator, and trainer for 20 years. His e-mail address is Stephen_Gumbley@brown.edu.
Daniel D. Squires, PhD, MPH, is Director of the Addiction Technology Transfer Center of New England at Brown University and is a clinical psychologist.
Susan A. Storti, PhD, RN, CARN-AP, is the former Director of the Addiction Technology Transfer Center of New England, and holds a faculty position as a Research Associate at The Warren Alpert Medical School of Brown University.

References

1. Addiction Technology Transfer Centers. The Change Book: A Blueprint for Technology Transfer (2nd ed.). Kansas City Mo.:ATTC National Office; 2004.
2. Simpson DD. A conceptual framework for transferring research to practice. J Subst Abuse Treatment 2002; 22:171–82.