Understanding the Common Elements of EBP June 18, 2007
Posted by rickbarth in Uncategorized.trackback
Bruce Chorpita and colleagues have a seminal paper out in JAACAP on the common elements of EBP. This paper reviews evidence supported interventions (ESI) and looks at their components and details which components are most common across interventions. Recognizing that many problems do not have a ESI their approach offers some ideas about what elements of child and adolescent interventions might make sense to try–insofar as they are components of ESIs for other, possibly related, problems. As part of this paper they offer a DMM model (distillation and matching model) which identifies the way that a large number of interventions are based on a relatively modest number (n = 24) of component parts. According to Chorpita, there is good reason to believe that if clinicians knew these elements and incorporated elements into their treatment plans they would be likely to generate effective services even if they did not follow a manual. Using DMM preserves the benefits of manualization but the flexibility often called for in clinical judgment. He and his colleagues also address myths of this approach. They have been using this in Hawaii with some success for the last 4 years.
If you take one paper to the beach, this summer, this might be the one–it’s short and very rewarding. Here’s the citation.
Corpita, B. F., Becker, K. D., Daleiden, E. L. (2007). Understanding the common elements of evidence-based practice: Misconceptions and Clinical Examples. Journal of American Academy of Child and Adolescent Psychiatry, 46, 647-652
If you decide to take 2 papers to the beach, the following from the current issue of Research on Social Work Practice might be a good companion..
Bledsoe, S.E., Weissman, M. M., Mullen, E.J. Ponniah, K., Gameroff, M.J., Verdeli, H. Mufson, L. , Fitterling, H., & Wickramaratne, P. (2007). Empirically supported psychotherapy in social work training programs: Does the definition of evidence matter? Research on Social Work Practice, 17, 449-455.
Unfortunately, the results suggest that most social work programs are not providing training on empirically supported psychotherapy (EST).
Rather than totally paraphrase, I’ve cut the abstract below.
Objectives: A national survey finds that 62% of social work programs do not require didactic and clinical supervision in any empirically supported psychotherapy (EST). The authors report the results of analysis of national survey data using two alternative classifications of EST to determine if the results are because of the definition of EST used in the national survey. Method: Psychotherapies in the national survey are classified by three definitions of EST. Data are weighted to provide estimates generalizable to the population of social work programs. Results: The classification of EST does not have a major impact on the findings of the national survey. The national survey definition produce estimates of training in any EST in social work that fall between the two alternate definitions. Conclusions: Regardless of which definition is used, the data clearly show that the majority of social work programs offer little training in EST.
The reputation of JAACAP over other “seminal papers” is under fire from several sources:
See here
Gillberg Affair, Kewller and JAACAP
or
http://scientific-misconduct.blogspot.com/2007/07/gillberg-affair-and-fall-of-scientific.html
Thanks Rick for passing along this article. I finally got a chance to read it and interestingly, a colleague had also forwarded a copy of the earlier Chorpita et al article from March 2005 a while back which provides a more detailed overview of the DMM process which I also finally got to read. Holding concerns about the integrity of the editorial board of JAACAP aside, I do agree with the authors that the DMM is a useful and important framework that may help promote the greater utilization of research in practice. I especially like its flexibility and its recognition and support for clinical judgment. This seems to echo the “evidence-informed programs and practices” approach that we have also been trying to promote through my work at the Children’s Bureau. Both 2007 and 2005 articles did raise several questions/ issues for me:
1. In the 2007 article, the authors write, “The practice elements approach is designed to encourage clinicians to “borrow” strategies and techniques from the best known treatments, using their judgment and clinical theory to “adapt” the strategies to fit new contexts and problems for which there is an insufficient evidence base.” This raises a number of issues related to fidelity and adaptation and the fine line before one enters the “zone of drastic mutation” where the practice element/ program component being implemented may no longer be what was originally intended. I agree with the need to be flexible and allow for adaptation, because in reality, that will happen anyway. The question is how does one evaluate the effectiveness and impact of the new adaptation and even determine what that adaptation was? The key will be understanding whether the adaptation by a particular practitioner for a particular client turns out to be the new element that is more effective….(or not).
2. The 2005 article discussed the importance of defining the elements to include in the DMM. This is the most critical piece for me. I was also wondering how philosophical principles such as cultural competence, strength-based, individualized, family focused, community-based, family engagement, etc. gets considered in this DMM process. The specific components for many child abuse prevention and family support programs are sometimes not as clearly specified or described.
3. This also raises the question of who will actually do these DMMs for various types programs or problems? This is a fairly complicated process and one cannot expect practitioners to do this work which is akin to a meta-analysis or systematic review of the literature for a particular program strategy/ approach. However, it is vital that the practitioners are the ones to identify the topics and the elements for the DMM so that there would be a greater likelihood that it would be used in practice.
4. Finally, we should also be sensitive to the political implications and the potential resistance from developers of well-established/ nationally recognized program models/ treatments. Their livelihood depends on people being interested in replicating their entire program which they believe to be unique and may be more reluctant to support efforts that break down their program into common elements that anyone can use with little or no training from the original developer…..
Anyway- thanks for stimulating my thinking on this topic—I probably could go on but I will stop now as I seem to have a problem with keeping my posts brief!
Melissa
Melissa, this is a great post. No need to keep it short, it’s chuck full of keen observations. ON your 4th point, I would say that those with proprietary interests in ESIs are not as large a group as some think. Many ESIs are not easily obtained, in fact, becasue their developers have moved on and not developed effective methods for dissemination. Joelle Powers at UNC showed this with regard to school-based ESIs. Many were not available. Anyway, even among those with proprietary interests, there may be interest in identifying active ingredients and reconfiguring their work to fit broader populations as Patti Chamberlain has done in San Diego with Project KEEP and, now, KEEP SAFE which use MTFC elements (e.g, parent daily report and foster parent groups) and apply them in the general foster care population. This is an opportunity to widen the scope of the intervention. It’s not exactly the method that Chorpita indicates, but it is a sign that there are reasons to go beyond the tightly held packages and develop additional models.
CDC is also working with developers to identify the most key ingredients in pregnancy and STI prevention programs and to also identify elements that can be adapted. I’ve posted about this, before. Again, this is not quite the same but does suggest that there are ways to identify DMMs that draw on the expertise of developers to help identify what they think to be the DMM. I don’t think that it is vital that the practitioners are the only ones to identify the topics and elements for the DMM (your poitn 3) in order to make it more likely to be used–marketing it for use may be a somewhat separate activity. This certainly needs practitioner input.
Rick
Thanks for your ideas.