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Infidelity: It's not always a sin

April 17, 2013
by Dennis Grantham, Editor-in-Chief
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Practitioners may be "unfaithful" to evidence-based programs in the name of better treatment

Before a packed meeting room at the 2013 National Council for Behavioral Health Conference, longtime psychologist and mental health administrator Tony Salerno took a hard and entertaining look at the question of whether and how providers can maintain “fidelity” to evidence-based practices in behavioral health.  

Comparing practice fidelity to relationship fidelity, Salerno got the session off to a humorous start with a titillating question: “Is being ‘unfaithful’ really a sin?” Perhaps not always, he suggested, noting that the key to effectively moving EBPs from the laboratory to the office often lies in a few well-chosen modifications.  These, he said, may well be the difference between a new approach that offers significant benefits and an EBP that “is too difficult to use in the real world.”

A developer’s perspective

Salerno challenged the audience to look at the development of an EBP through the eyes of its developer. “From the developer’s perspective, when you see a practice that delivers great outcomes in the lab, it feels as though you’ve found a universal truth,” he said, displaying a movie graphic of Moses (Charlton Heston) holding the Ten Commandments. From there, “it is easy for a developer to say, ‘do what we did in the lab, play by the rules.’”

But he warned that an EBP, like a bright eyed baby in the arms of its developer, can come to look downright ugly to a provider organization. “Sometimes, an EBP just won’t align with internal training programs, with organizational capabilities, or with reimbursements. You just can’t get it to fit in.” Sadly, he noted, “the only service that doesn’t fall off the radar for reasons like these is medication.”

“Champion dependent” programs

Often, he said, services are built around EBPs that suffer from the problem of being what Salerno called “champion dependent.” Because many EBPs have demanding preparation and delivery requirements, service providers typically end up relying on two or three key professionals, who act as champions, to launch and sustain new practices in a given organization.  

“So,” he asked, “what’s the problem with that? Your program gets off to a great start, and you know that Ted and Millie are running the program. Participants love it and you’re seeing great outcomes. But then, what happens?” Salerno suggested that often, one or more or the practice’s champions leave the organization and those who step in—short on passion and on training—often drop the ball. “Then you blame the provider. And the developers wonder, ‘What happened to my baby?’ They don’t see that the baby was ugly in the first place and was never going to work out.”   

This, he suggested, is a typical example of an EBP that demands an unsustainably high level of professional involvement and support.

Characteristics of sustainable EBPs

The key to successfully implementing and sustaining new EBPs is what Salerno calls “uptakability.”

“I’m going to name a list of attributes.  I want you (indicating audience) to tell me whether each attribute is a plus or a minus for uptake of a program.” He continued with the following statements, asking the audience for its response.

Attribute

Effect on uptake

The program is sensitive to turnover

Minus

The program provides outcomes in a short period of time

Plus

Practitioners find the time commitment for the program burdensome

Minus

The program uses many forms and requires a lot of documentation

Minus

We aren’t sure that we can get the treatment paid for

Minus

The program addresses a ‘felt need’ of the organization

Plus

After the audience responded, Salerno stated, “Developers ought to see what it is that makes it difficult for organizations like yours to absorb and sustain a practice over time. Sometimes, it’s important to ‘dump’ some characteristics, or perhaps adapt them.  The goal is to keep the good stuff yet adapt the program to its environment.”  But, he warned, “this isn’t an easy task.”

Three rules for effective programs

To gain insight into how programs might be adapted, Salerno suggested these rules, gained through experience in adapting an effective multi-family therapy program:

1) “Engage those who are affected by the program—the practitioner who delivers it and the people who receive it.”

He said that a program that taught families how to deal with members affected by mental health disorders emphasized the point that mental illness is neurobiological in origin—essentially that it is not the “fault” or choice of the individual.  While this explanation was effective for many families, Salerno found that it was inappropriate for an ethnic Chinese family. “To them, having a member with a mental illness of was experienced as a ‘curse’ or a taint on the family.” They saw the cause as more spiritual, rather than biological in nature.  Program content had to be changed.

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