Discuss two common factors that help Bridge the Gap Between…

ElderSardine2610Discuss two common factors that help Bridge the Gap Between…Discuss two common factors that help Bridge the Gap Between Research and Practice in Social Work Efforts to Bridge the Gap Between Research and Practice in Social Work: Precedents and Prospects: Keynote Address at the Bridging the Gap Symposium Allen Rubin1 Abstract This keynote address discusses previous and ongoing efforts to reduce the persistent gap between research and practice in social work and offers recommendations for further bridging that gap. Key among those recommendations is the need to conduct descriptive outcome studies of efforts to adapt research-supported interventions in everyday practice settings to develop a database of case studies that can be analyzed to ferret out the factors associated with variations in client outcomes. These studies would have additional value in bridging the gap by showing agencies whether the intervention they adapted is as effective in their setting and with their clients as they hoped it would be and whether they might need to tweak it or replace it. The keynote address also discusses ways to incentivize academia-based researchers to conduct such studies and the impact of pressure on them to obtain major research funding. Keywords evidence-based practice, methodological article The history of efforts to bridge the gap between research and practice shows that the theme of this conference addresses a long-standing challenge in social work and other professions. Even though Mary Richmond (1917) called for social work practice to be guided by research a century ago, social work practitioners by and large have devalued research studies and rarely utilized them to guide their practice. This problem has persisted despite two national conferences during the late 1970s which—like this one—attempted to bridge the gap between research and practice. The gap has outlived the empirical clinical practice movement, which—in its heyday—spawned so much optimism about bridging the gap. And the gap continues to persist today despite the progress made in the evidence-based practice movement. The gap also has outlived the following developments: federal funding of research development centers in schools of social work; the birth and growth of the Society for Social Work and Research; and an increase in the number of social work faculty grant applications for federally funded research and an increase in the number that got funded (Austin, 1999). The gap continues today, as university administrators pressure deans of schools of social work to bring in more research funding. Indeed, we hear a lot these days about obtaining major research funding as a prerequisite for garnering tenure and promotion among social work faculty—especially in Research I Universities. In one sense, this pressure may be helping to narrow the gap between research and practice in social work. As well-funded social work researchers have helped provide the empirical support for various evidence-based treatments, they have shown practitioners more effective ways to intervene, thus paving the way for more practitioners to be guided by research. And yet, despite the great strides that have been made in the development of empirically supported treatments (ESTs), a variety of studies have found that the degree to which these ESTs are being implemented appropriately and with successful outcomes in the real-world practice of social workers and their colleagues in allied professions has been terribly disappointing (Embry & Biglan, 2008). Implementation Science In response to this disappointment, a rich field of implementation science has blossomed, which is beginning to identify 1 Graduate College of Social Work, University of Houston, Houston, TX, USA Corresponding Author: Allen Rubin, Graduate College of Social Work, University of Houston, 110HA Social Work Building, Houston, TX 77204, USA.  Research on Social Work Practice 2015, Vol. 25(4) 408-414 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049731514535852 rsw.sagepub.com factors at various organizational levels that help to explain why some organizations have been more successful than others in implementing ESTs with adequate fidelity and good outcomes. By identifying these factors, implementation science can offer recommendations for bridging the gap between research and practice (at least with respect to implementing ESTs with fidelity; Damschroder et al., 2009; Embry & Biglan, 2008; Glisson & Schoenwald, 2005; Weisz, Ugueto, Herren, Afienko, & Rutt, 2011). Some of these promising recommendations were presented by speakers at this conference. Despite the value of these recommendations, however, their successful implementation will have to overcome some negative attitudes about research among not only rank-and-file practitioners and administrators, but also among some of our profession’s esteemed leaders. For example, in 1998—as president of Society for Social Work and Research (SSWR)—I attended a National Association of Social Workers (NASW) Summit Meeting that was held with the purpose of uniting the diverse elements of the social work profession and identifying what issues and priorities social work organizations could agree upon. And yet—despite that unification purpose—the Summit’s keynote speaker decried the excess amount and excessive influence of research in social work education. He added that he is ”insulted” by the notion that we need to research the outcome of our efforts to provide care. Hearing that, I left that summit less than sanguine about the prospects of ever bridging the gap between research and practice (Rubin, 1999). However, that summit meeting was 15 years ago. Let’s hope that much has changed since then—especially in light of the growth of the evidence-based practice movement. Common Elements and Common Factors One promising change is the current effort to begin to identify common elements that are shared by various ESTs. The aim of identifying those common elements is to make the implementation of ESTs more acceptable, less complex, and less costly to practitioners and agencies. Instead of expecting practitioners to rigidly adhere to an entire manualized EST, identifying the core essential and indispensible elements of the EST as well as its adaptable elements might give practitioners more flexibility to make the EST fit their organization and clientele and also reduce the costs of practitioner training (Galinsky, Fraser, Day, & Rothman, 2013; Sundell, FwrrerWreder, & Fraser, 2012). However, there is a big difference between adapting a specific EST for a specific setting or population, and trying to identify a broad array of common elements shared by various ESTs. Taking the broader approach to identifying common elements can be risky. For example, consider the difference between the common elements identified by Chorpita, Becker, and Daleiden (2007) and those identified by Bender and Bright (2011). Chorpita et al. (2007) searched for common elements in the ESTs for ”depression in girls between ages 10 and 12” (p. 648). Their search yielded the 23 common elements displayed in Figure 1, in order of the relative frequency with which each appeared in the randomized clinical trial (RTC) literature for that target population (p. 468). In contrast to the approach taken by Chorpita et al. (2007), which limited their search to depressed girls between ages 10 and 12, Bender and Bright (2011) reviewed RCTs for a target population specified in much broader terms: ”disruptive behavior and traumatic stress among adolescent girls.” After reviewing a database of 430 RCTs of mental health interventions for youth (again, notice the broadness of their search boundaries), they recommended that instead of training practitioners in any particular manualized EST for reducing disruptive behavior and traumatic stress among adolescent girls, they be trained in the eight common elements shown in Figure 2. In the eight common elements derived by Bender and Bright, there is no mention of exposure therapy, which is known to be one of the ESTs with the most empirical support 1. Psychoeducation- child 2. Cognitive/coping 3. Problem solving 4. Activity scheduling 5. Skill building/behavioral rehearsal 6. Social skills training 7. Communication skills 8. Maintainence/relapse prevention 9. Psychoeducationparent 10. Relaxation 11. Self-monitoring 12. Self-reward/self-praise 13. Therapist praise/ rewards 14. Modeling 15. Peer modeling/pairing 16. Family engagement 17. Crisis management 18. Guided imagery 19. Interpretation 20. Assertiveness training 21. Relationship/rapport building 22. Stimulus control/ antecedent man 23. Tangible rewards 1 Listed in order of the relative frequency with which each appeared in the RTC literature for depression in girls between ages 10 and 12 Figure 1. Common elements identified by Chorpita et al. (2007) for the treatment of depression in girls between ages 10 and 12. Goal setting Monitoring Communication skills Praise Problem solving Psychoeducation with parents Social skills training Tangible rewards Figure 2. Common elements identified by Bender and Bright (2011) for the treatment of disruptive behavior and traumatic stress among adolescent girls. Rubin 409 for traumatic stress. Also absent from their list is cognitive processing therapy, which also has a strong evidence base in trauma treatment, especially when coupled with exposure therapy (Rubin & Springer, 2009). It should also be noted that the primary techniques or elements from these treatments (e.g., exposure to the traumatic event, changing distressing cognitions) were also not a part of the list. Therefore, I recommend caution when employing the common elements approach, especially if the common elements are derived from casting a very wide net to find a broad and diverse database of interventions for a diverse range of target populations. The striking difference between the list of eight common elements derived by Bender and Bright and the 23 derived by Chorpita et al. speaks both to the promise of the common elements approach and to its risks. Several distinctions are important to note here. One is that the common elements approach can be characterized as falling somewhere within a continuum from very narrow to very broad. As displayed in Figure 3, at the narrowest end of the continuum the approach can be limited to a single EST. In this case, the ”common” elements are those that are core parts of the intervention that need to be kept but that can be adapted to fit different target settings or populations. A less narrow approach might involve identifying common elements across a small set of ESTs that target the same problem. A broader approach would identify common elements that target different problems, but would not cast too wide a net regarding the range of problems being targeted. At the broadest end of the continuum would be approaches like the one taken by Bender and Bright, in which a very wide net is cast to identify common elements across a diverse range of ESTs and target problems. I suggest that the riskiness of the comment elements approach increases as we move from left to right—from the narrower to the broader end of the continuum displayed in Figure 3. In fact, while extolling the promise of the common elements approach, Barth et al. (2013) caution that ”although the common elements approach allows for … flexibility … following a treatment manual as prescribed may still be the best option when appropriate or available” (p. 110). Transferability of RCTs to Real-World Practice Conditions Despite the progress being made in implementation science, there is evidence that even when ESTs are implemented with excellent fidelity in real-world agencies they only modestly outperform treatment as usual (Weisz et al., 2011). When considering possible reasons for the disappointing degree to which ESTs are being implemented successfully in the real world of practice, we may need to consider some of the problems in the research supporting the ESTs—especially the degree to which RCTs are assessing ESTs that have limited transferability to real world practice conditions. One important issue involves differences in clientele, particularly regarding the underrepresentation of comorbid and minority participants in many RCTs. Regarding minorities, for example, despite the strong evidence base for trauma-focused cognitive behavioral therapy (TFCBT) with traumatized children, there is a dearth of evidence regarding whether it is effective with Latino and Latina children. The underrepresentation of comorbid and minority participants in many RCTs is especially problematic for social work practice because so many social work clients are minorities or have multiple comorbid problems. Thus, it is conceivable that even when ESTs are implemented the same way that they were implemented in the RCTs supporting them, they may not be as effective with clients who differ Less Risk More Risk One EST (Identify core elements that must be kept but that can be adapted to fit different target settings or populations) Common elements among several ESTs that target the same problem Common elements among several ESTs that target a narrow set of problems Common elements among a broader range of ESTs that target a narrow set of problems Common elements among a very broad range of ESTs that target a diverse range of problems Figure 3. Level of risk of ineffectiveness or harm using a common elements approach. 410 Research on Social Work Practice 25(4) from the RCT clients. Consequently, one implication for further bridging the gap is the need for outcome studies with the kinds of clients that social workers are most likely to serve. This need is especially applicable to the issue of comorbidity. For example, many clients with PTSD also have a substance use disorder. In addition to knowing whether ESTs like exposure therapy are effective with PTSD, and in addition to finding out if they are effective with clients with such comorbidity, we need to learn about what interventions for substance abuse they need to be combined with, and in what sequence. The need for such studies is particularly serious for the large numbers of military service members now returning from Iraq and Afghanistan, whose PTSD is often comorbid not only with substance use disorders but with other critical problems. Treatment Fidelity These issues also have implications for concerns about treatment fidelity when implementing ESTs. Maybe the need to implement ESTs in exactly the same way that they were implemented in RCTs is being overrated. The evidence-based practice process emphasizes the importance of practitioners integrating the research evidence with their knowledge of idiosyncratic client attributes. Therefore, in addition to worrying about whether practitioners are following treatment manuals meticulously when providing ESTs, we should be equally concerned about the need for them to modify the manualized approach to better fit those clients whose comorbidity or other attributes make them different than most clients who have participated in the research providing the empirical support. Likewise, practitioners should consider the flexibility of existing treatment protocols of ESTs when deciding whether to adopt a specific EST and whether and how to adapt it. For the same reason, another implication for bridging the gap is the need to do more effectiveness studies assessing the outcomes of interventions that are currently empirically supported when they are provided in the context of real-world practice settings where the training and supervision in the intervention may have been less than ideal or where the realities of the practice setting—such as level of practitioner experience or skill, or caseload sizes—might beless desirable than the ideal conditions inthe RCTs that provided the empirical support for the intervention. In addition, these designs should include variables derived from implementation science to try to ferret out the processes and organizational variables thatleadtothe successfulimplementation of the interventions that are found to be effective in these settings. Likewise, as mentioned earlier, they should assess what combinations of common elements are most associated with treatment success in settings in which one or more ESTs have been adapted. Social work should be at the forefront of this kind of research, given our emphasis on applied research in real practice settings. Value of Descriptive Outcome Studies To facilitate this kind of research, we need to recognize how difficult (and rare) it is for social work researchers to use rigorous RCT designs in assessing outcome in real-world social work practice settings. For those researchers who do not opt for the route of seeking major funding for RCT studies, there is a loweSocial SciencePsychology