Each year our government spends approximately:
- $95 billion dollars on research to develop new treatments (medical, behavioral, psychiatric, addiction)
- $1.3 trillion dollars a year on actual services to patients
Yet sadly, less than $1 billion dollars a year is spent on understanding how to take what we learn from science and research – the new interventions – and implement them in practice. The result is that many opportunities are lost to help people who struggle with a host of problems, including addiction.
Implementation science
Fortunately, there is increased momentum to study implementation science and learn how to get the latest treatment discoveries to the front lines – to the clinicians who can make a difference in people’s lives. The movement has been led by Dr. Dean Fixsen who heads The National Implementation Research Network. There is a goldmine of information on this site, including a synthesis of implementation research that can be downloaded for free.
What I find most interesting from this work is:
What doesn’t work
We know from a lot of research what does not work. For example, training alone, no matter how well it is done, does not result in successful implementation of new innovations. Sadly, this finding has significant implications in the academic arena, where teacher lectures account for a large percentage of class time.
Applying Evidence-Based Practices
Having a toolbox of evidence-based practices for addiction, as we do today, is one thing, but getting clinicians to use the various evidence-based tools is an entirely different thing. My dissertation research on use of addiction medications provides evidence for this fact.
Components of implementation
Implementing a new practice or innovation requires a number of specific drivers, diagrammed below from a presentation on the NIRN website. Notice that implementation is a process, not a specific point in time, and it involves individuals at all levels of an organization, dedicated to learning and refining new actions.
This topic also has a lot of relevance for individual treatment. Learning to manage chronic behaviors, resolve underlying core issues, and engage one’s creativity requires implementation of specific actions. This is why therapy is also a process – a collaboration between patient and therapist who work together over time to learn how best to incorporate new behaviors into the patient’s life, and stop or limit unhealthy behaviors.
Writing about implementation science reminds me of an earlier post I wrote about making addiction education stick. To increase the chances that new ideas take hold, whether in an organizational context or in individual therapy, we must make our interventions sticky. To do this we must tell stories, boil down complex issues to their essence, be unexpected in our delivery, and make things concrete so understanding is enhanced.
In the end, there are no short cuts to implementation.
Remember Wexelblatt’s scheduling algorithm. When implementing an innovation you can pick any two out of a possible three choices: cheap, fast, good (i.e., it can be done cheap and fast, but not good; fast and good, but not cheap; or cheap and good, but not fast). Take your pick.
It seems like our current health care system has chosen fast and cheap. Sometimes managed health care plans work to prevent people from accessing services. There is a lot of focus on behavioral therapy, which may be the least personal, or sticky, form of therapy out there. So how do you make a fast and cheap method more good?
I think the CRAFT program does a pretty good job by teaching families to avoid negative behavior patterns. Families can see how their anger leads to reactivity from the person struggling with addiction and can take simple steps to change these patterns. Counseling families can be as affordable as counseling individuals, and the impact it has on the individual’s overall environment is much more personal.
I checked out the NIRN site thinking in the back of my mind, this whole blog resembles the education system in the United States. And poof, there I was in the land of educational reform. Funny, I actually own Bridging the Gap, one of the books showcased on the site. Sadly it was one of those books our school district picked up for a hot second and then dismissed a year later. Being in the educational system I see so many instances of discontinuity between what the research suggests and what is truly being implemented. We hear so much research, so many facts and figures so much information that it’s hard to whittle down what really works and what is just useless fanfare. And quite frankly, leadership that is given the responsibility to carry through with implementation often fails at doing so. I would argue the most important factor in implementation of things that truly work is whether or not the organization is lead by a visionary. Whether it be the educational system, the health care system, or the restaurant down the street, if a leader can’t envision what something different will look like, then it’s never going to happen. There doesn’t have to be an expensive overhaul of the entire system. Billions of dollars don’t need to be spent on useless books with strategies for implementing things that truly work. So often the powers that be think that revamping the entire thing will solve the problems and they throw money at it left and right, when in fact, if they just went piece by piece, organization by organization, office by office, school by school, person by person and began working from within to ensure people capable of envisioning something that works were in the leadership roles, things would be drastically different.
I cannot help but think of President Obama’s famous speech, “One voice can change a room, and if one voice can change a room, it can change a city,” and so on. This sort of momentous, but gradual process could apply to implementation science. The notion of implementation of new innovations is so hugely overwhelming, that we avoid such massive restructuring, no matter how great the reward. The automobile industry is a great example. Fossil fuels are now such a limited resource and are causing cost inflation and corruption. Not to mention the irrevocable and irrefutable damage to our planet. To truly adopt change, we would have to create new technologies and adopt the industries along with them. Not just problem solve or “band aid” the old industries with bail out programs that will only temporarily alleviate troubles. This is sadly a consistent theme with much of our American culture and certainly with health care and addiction. How do we convince the system to replace the colossal machine with a brand new model, at an enormous, devastating expense? Raising awareness and educational standards concerning the results of positive research is key. The more available and accessible the research is to our health care providers and decision makers, the more likely the potential for change. Also, what if we approach this vast mission in the small, independent venues first? The positive, encouraging results may inspire other facilities to espouse such progressive, cutting edge ideals.
The current treatment of most issues in our culture seem to be fast and cheap. Whether it’s the medical system, the education system, the automotive system, or even our own goals, our society wants things done quickly and at little or no cost. As we noted in an earlier blog, we are a speed-driven society and we want our needs met NOW. Anything less is uncomfortable and we certainly don’t want to be uncomfortable for very long – let’s get that over with quickly too.
As a result, there is stagnation in bringing new, proven methods to the forefront. Nobody, including a visionary leader, can implement change alone. As a former president of a large nonprofit organization, I tried to bring new proven methods into the system that would benefit all concerned. However, change brings that element of discomfort to an organization and there will always be factions that are highly resistant to change. Getting from ‘fast and cheap’ to ‘good’ can be an uphill struggle.
Implementation is a long term process as a part of management. Education on the benefits of new methods and time for feedback should be given to all participants involved in the change in order to increase each person’s buy-in to implementing the new practices as well as to avoid resistance. Collaboration between all aspects seems to be the key.
Great post, Deena, I couldn’t agree more! So much of what we’ve talked about it this course has direct connection to the world of education. We desperately need visionary leaders in this realm if we want to see change.
As noted in previous posts, the changes that are needed in education, health care, and addiction treatment, are complicated. We can’t expect quick-fixes and therefore, we need to be ready to work hard and even face discomfort. What I think is most important is that in our efforts to bring change, our goals remain clear, attainable, and incredibly worth it.
As counselors working in the field of addictions, we need to be convinced that our efforts are worthwhile. In the midst of greater contexts in need of reform (health care, education, etc.) our goal of providing holistic, effective therapy to our clients must remain clear and attainable or we will become satisfied with the status quo. We depend on others (and ourselves) to research the best practices in a way that makes them feasible and worthwhile.
Likewise, our clients will be looking to us to provide assurance: that even though managing addictions is incredibly difficult and at times uncomfortable, it is worth it. Reminding myself that we all need this hope in order to create change in our lives, it’s easier to remember that really, we’re all in the same boat.
Unfortunately seems as though our health care system is doomed to continue devaluing”good” in the cheap/fast/good trifecta. With the widespread need for health care and the astronomical costs of our existing health care system, any solution that is good but not fast or cheap (as cheap is often dependent on being fast) will not satisfy the people who budget tax dollars or institutional expenditures, and it will not satisfy the voting public who need to be convinced of the necessity of good care over fiscal conservation. That is a tall order, as the broad societal benefits of good mental health are not as tangible as, say, springing for a medical operation that resolves an easily definable and observable problem.
Of course, Wexelblat’s scheduling algorithm is not a hard and fast law. To varying degrees, solutions may be discovered that are cheap, fast, and good. In those instances, such a satisfying solution is likely to be adopted quickly and without controversy, although as Dr. Fitzgerald notes, translating ideal treatments to consumer benefits is dependent on effective implementation, an area where funding is lacking.
I agree that our socieity has seemed to have continually implemented the “cheap” and the “fast”. From household appliances, to laptop computers, to school programs, to addictive treatment programs, we can find cheap and fast strategies that have continued to fail.
We must shift these implementation strategies to cheap and good, and take the focus off of fast. Things that are done hastily are more likely to fail. The most important focus should be on creating addiction treatment programs that are good, and only then we can worry about the cheap factor. It is interesting that this brings me back to my very first response a couple months ago, in which I responded about our society’s addiction to time. It seems that everyone on all levels of the system is affected by this time addiction, hence, why we create things so quickly. Quality solutions are far more important than quick solutions. I have recently slowed my life down in areas that I have the ability to do so, and have noticed that I am incredibly happier as a result. So, slow down Americans!
I really like what Kelly said about how we need to change addiction treatment to cheap and good, rather than cheap and fast. As we have learned in class through lecture and research articles, fast addictions treatment is rarely effective. It may work for a little while but typically the addiction is either resumed or replaced by a different addiction or behavior. I think this emphasizes the importance in long-term treatment/care for people with addictions. This can be done cheaply (self-help groups, sponsors, etc.) and also moves away from the “get in, get out” view of addiction treatment
There was a program on NPR last Friday and the subject was “Can Science make Psychotherapy more Effective.” This is the link:
http://www.npr.org/templates/story/story.php?storyId=121092295.
The main topic was – if we have empirically proven psychotherapy methods why aren’t they being taught and why aren’t they being practiced. The debate ends without any conclusions, but it’s an interesting exploration of the very issues your blog is commenting on, implementation. I didn’t feel very encouraged by the debate, as it seems to run into the same dead end feeling, like so many debates in this country, i.e., health care reform. We humans tend to see things how we see them, and it’s pretty hard for us to see them any other way, but on the brighter side, it does seem that as people plod along and make small steps towards a goal, larger scale change does eventually happen!
I couldn’t agree more Dina! One of the main frustrations I had when I taught is that the structure of the education system: the class size, the mandated testing, and so on, made it nearly impossible to implement the effective practices that had been proven by research and taught to me in my graduate program. I also think your onto something with the visionary concept. Several stories come to mind, when I think of the word visionary. People who combine their vision with action have really had some tremendous outcomes. I’m going to the get some of the details wrong, but I believe it was in city in Brazil that elected an architect for mayor, and he came up with a radical yet simple way to transform the bus system that improved the lives of many people. I think the strength of his vision came from the combination of two things – one he seemed to be thinking outside of the box, and two, I think the situation was desperate enough that people were open and willing to try anything. That is one unfortunate issue I see with visionaries, it seems like that the situation has to be really desperate before visionaries can get the support they need to make really effective change, otherwise human nature seems to like to stay safely at the status quo. Another story that comes to mind is a primary care physician outside of Seattle who noticed recently that many of his patients were not showing up for general treatments or bringing their sick kids in. He started to ask around, and many of them said they couldn’t afford their insurance and their co-pays. He decided to stop working with the insurance companies and just had his clients pay affordable amounts out of pocket. The story claimed that he was making just as much as he did when he was billing with insurance, only now he has a lot less paperwork. Hopefully some of us can work within or outside of the system and make some significant changes!
This brings a lot of ideas up about education for those working in the public sphere who may encounter individuals with addictions. First, educating social work clinicians by giving them one class on substance abuse is not enough. Many clinicians in the field of psychotherapy will be treating clients who struggle with addiction, and will not be well educated on what to do with such a client. Second, a friend of mine at OHSU said that through his four years as a medical student, he had to sit through just one four hour lecture on how best to deal with patients coming through the hospital who may have addictions. They proposed the CAGE questions, and not much more. As research has shown, this is not enough to get an individual to accept that they may be struggling with addiction, though it may encourage them to think more deeply about it, assuming that they are coherent when they receive the questions. Third, those working in the public education system, health care system, and other social services need to be given better options for assessment and diagnosis of patients with addictions. The research that has been done can greatly benefit addictions treatment today. Lastly, if this country spent half of what is spent promoting drug and alcohol use on a daily basis towards a better addictions treatment model, maybe there would be more people being helped.
Hmm, that algorithm shows some pretty serious implications for the implementation of any American systems right now, not just addiction management, namely because we’re broke! So you know cheap is going to be part of the equation. That just leaves fast or good…I have heard that much of the Federal stimulus money is yet unspent, because a lot of the “shovel ready” projects that were supposedly ready to be implemented in order to promote industry in this country actually aren’t. In a cash-strapped economy, it seems like something like implementation science would be the first to go, as to the untrained eye it might seem like something that could be sidestepped, though of course, the successful application of knowledge is dependent on the logistics of actually making it happen!
I just watched the video “Understanding Treatment”, and thank you for creating this comprehensive piece for the public. Even though you talked about it in class, I watched it over and over again because I wanted to have a fixed understanding of treatment.
Until I came to your class, I didn’t have almost any idea what treatment for addiction was like, even though I had some knowledge about addiction itself. I knew so many people around me who had suffered or was suffering from addictive behaviors, but didn’t know what to do with them, not being able to think of what to say.
I didn’t think, honestly, addiction issue lied so deep inside of the addicts, and thought it was easy to be treated once they were in treatment. Understanding addiction is so essential to be working with juveniles in my future. Last year, I was working with the teenage girls who had children or were pregnant in a residential treatment center, but I never really paid attention to their addiction problems they had. Now, I think I should have listened more about it in deeper level when the girls shared their exeriences with me. I think I should have cerebrated more, giving more warm, proud, and affirming words when one of the girls said “Azusa, it’s the first anniversary for me, clean and sober! ”
The idea of disconnectedness in system treatment is so important for me and all people related to this field, because it is the huge block to be moved in order to improve addiction treatment in general. I also appreciate the slide of interacted factors that might create the addiction issues people are suffered from. This helps me to think and see critically what the real issues are, addiction is a form of expression.
Manage, resolve and create is an overreaching model of addiction treatment; and this is a good indicator for me to see what we can start to work on in order to manage addiction as a goal.
I really appreciated the video that gave me better understanding of its complexity of the addiction problem.
Change is probably the hardest thing to ever do because it involves a fear of the unknown. I think one thing people need to recognize is that it will not just be a battle but sometimes an uphill battle. Patience is required for change. I also agree that in order for an addict to change, that ultimately it comes down to him wanting to change. He or she wants to change because they want to, not for anybody else but for themselves.