Years ago I attended a conference where I first learned of the work of Dean Fixsen and heard the phrase implementation science. What I most remember about his presentation is a PowerPoint slide he showed that to this day continues to haunt me:
The table is taken from Joyce and Showers (2002) where the authors were interested in studying the percent of teachers who actually utilized a new skill they had learned in practice. If you take a few minutes to study the table, you will see that for the new skill to be used in the classroom, it was necessary to:
- Discuss the theory behind the new skill
- Demonstrate the new skill
- Allow teachers to practice the new skill and get feedback on their performance
- Coach the teachers on the new skill in the real-world classroom
And if you take away the final component – coaching in the real-world – use in the classroom drops from 95% to 5%!
I have spent two decades of life energy in classrooms working on my own degrees, and another half-dozen years teaching in classrooms. Most of the time the learning took place in classrooms, and most of it was discussing theory in a group setting. Now can you begin to understand why this slide haunts me?
I know education is about a lot of things, but students today need knowledge and skills that they can use in the real world, and we are failing them in so many ways (while we continue to up the price of education).
Implementation Science Applied to Addiction Management
This study has implications that go far beyond the classroom. The field of implementation science is all about understanding what it takes for evidence-based practices to actually be used in practice. It’s the science that fills the gap between research and practice. While the field continues to remain unknown to most who work in the addiction treatment field (and sadly other healthcare settings), I believe the principals of implementation science can and should be used by anyone desiring to overcome addiction, trauma, or any behavioral health problem.
How do you implement the principals from implementation science into your day-to-day efforts to change difficult things?
- Learn more about implementation science. Like most things in life, knowledge is power. So take some time to read up on what we know about successful behavior change. A solid place to start is Implementation Research: A Synthesis of the Literature. You can also watch Dean Fixsen in action giving an overview of the topic on YouTube. I will add that the field has not done the best job of developing resources for the general public, so know that there is no need to become a scholar on this stuff, just gain enough insight to know that the key ingredient to successful behavior change is coaching.
- Get coaching. I know, you saw this one coming. It’s not easy teaching an old dog new tricks (or even a young one for that matter)! Those who have struggled with addiction and engaged in treatment know that behavior change is hard work. But it can be a lot easier if you find people who have successfully implemented new routines, skills, and behaviors into their life, and get them to coach you on doing the same. This idea is of course what sponsors are all about in 12 Step programs. We know that exercise, mindfulness meditation, eating right, learning to manage emotions, and successfully overcoming relapse triggers all require skills that can benefit from coaching. But know that I am not advocating you spend your precious time and money on general life coaching. This field is littered with many unlicensed helpers who often mean good, but have no business coaching others. While I know there are some solid general life coaches out there, seek out experts with a track record in the specific skills you want to acquire.
- Utilize intensive outpatient treatment instead of residential. Why would this be so you ask? Because principals of implementation science tell us that when you learn and practice new skills in real-world settings the outcomes are better. My good friend Dennis McCarty and his colleagues recently published Substance Abuse Intensive Outpatient Programs: Assessing the Evidence where they concluded that intensive outpatient is as effective as residential for most individuals, at a fraction of the cost. There are a number of reasons for this, but an important one is because they force those in treatment to practice new skills in the real world.
I know education is a life-long process and am hopeful that one day my haunting will end. I do seek out experts to help me learn things that are important to me, and am often amazed at how a little coaching can take me a lot farther than I ever imagined.
Hi Dr. Fitzgerald!
No. 2 of this article resonates with me because it is surprising that this is not more common-sense (although from an outside perspective, I suppose it’s unfair to judge). If I needed help with something, whether it be medical, spiritual, or psychological, I’d want to head over to a specialist in that area, and not necessarily one who claims to be able to assist me, but has no distinct specialization in such an area.
When you say “Get Coaching,” I think there is a prevalence of advertising by those who, as you said, “mean good,” but truly have no business coaching others. I know I have fallen victim to reading into these advertisements and realizing quickly that they are not the right individuals to contact/work with.
What would you suggest as a general guideline (if any) to helping individuals realize who the “expert” is among a sea of well-meaning coaches?
Joshua, thanks for the comment. Defining experts is hard because they don’t always have a bunch of letters after their name. First, as you say, I would seek out someone with specific expertise in what I wanted to change. For example, if I knew I had a trauma history that could benefit from therapy, I would seek out therapists who specialize in PTSD. Then I would prioritize those with education and licensure, followed by time in the trenches, phone interviews of their approach, and then face to face with at least two and preferably three before making a final commitment. Also, sometimes our best efforts still fail us, and no shame if a particular person is not working to move on to someone else (assuming we are not just running from help because we are scared). Hope this helps.
J
Reading the table made me think back to my high school and other education experiences and thinking that sadly that those statistics are true. Children and teenagers in our K through 12 education system aren’t getting well prepared for college or the real world. Your three ideas of how we can deepen our education system are very thorough and seem like they would help very much. Therefore by completing that teenagers will be more prepared for the real world and college, which will give them a better opportunity to be successful for their future. My question is how can we actually get policy’s to pass in order to for these to be implemented into our education system?
Thanks David. With common core now dominating U.S. education, it seems like an even bigger challenge helping kids learn how to apply skills in the world beyond test taking.
J
Dr. Fitzgerald,
I think that number three here is an extremely important part of learning anything. Someone can tell us information all day long and a lot of times it will not sink in until it is applied in our real lives. Although some people definitely need to have residential care for their addiction I believe that there are many more out there that would benefit more by outpatient care.
It is a lot easier to stop a bad habit when you are taken out of the environment that you previously did this habit, but as soon as you are back in that environment isn’t it more likely to relapse?
It is my belief that if you keep a person in their own environment and give them the resources that they need to quit a certain behavior it will take longer and be harder than if they were taken out, but the results are more firm and long lasting. They may still relapse into their previous behavior, but do you agree that it may be less likely that they will do so and easier to overcome if so?
Research suggests that for most people, utilizing outpatient services provides equally good outcomes as residential – so it is not necessarily true that it is easier to stop when taken out of an environment. In cases where someone simply cannot disengage from addiction long enough to benefit from treatment, residential care can be life saving.
J
Dr. Fitzgerald:
I can see the use of coaching, especially in the influence of positive changes in behavior. Although I never could get the hang of the whole 12-step & sponsor thing when I was battling addiction, I know plenty of people who swear by it. What did help, and I will advocate it to this day, is intensive outpatient treatment. Granted I participated voluntarily after relapsing with over 13 years clean. It was my choice and I got the most out of it and a grip of “tools” to put in my “toolbox”. I use them to this day, teach them to my adolescent kids, their friends, and share my tools and testimony to anyone who wants to know.
Where I really think this type of implementation science needs to have great focus is in our criminal justice system. I am a criminology & criminal justice major and the more I learn the more I support this type of rehabilitation reform. Don’t get me wrong, if you take an addict out of the “element” they can clean up quick, the same goes for jail…to an extent. If an addict wants a fix, they will get one, plain and simple. What it doesn’t focus on as much, and in some cases at all, is coping skills for when they get out. Most drug offenders are released right back to the same scenarios they left behind only to be faced with the same triggers, no job (even with the trade jail or prison may have taught them), and no public assistance for many. Quite possibly with intense “outside-in” treatment, and probation and parole officers acting more as coaches instead of wardens we can start to break the chain a little. Better yet with proper training the would be re-offenders could be coaches to other addicts and offenders on the streets. It’s a long shot but if the government could get behind something like this and give companies some kind of incentive for hiring graduates of this type of treatment, and medicaid to help pay for some of these programs, we wouldn’t have as big of a mess with recidivism of drug offenders and over crowded jails and prisons.
What do you think?
I come from a family of people with various levels of addiction. In my experience, although we have come a long way in the realization of addiction as a disease and the treating of it as such by medical professionals. Unfortunately, the attitude of said professionals isn’t always mirrored where it is most needed; in middle and high-schools. Prevention is the key. I agree wholeheartedly with your second point about coaching those who plan on becoming coaches. It is only through learning how difficult it is to change ones behavior that we become able to relate to those we mean to help. So many “coaches” don’t realize that. I am thankful to have avoided addiction in my own life, however watching others attempt to help my family members without any real tools (aside from the best of intentions), has been frustrating to say the least. Your perspective is one that needs to be adopted across the board.
Christine, thanks for the feedback! I agree we need evolve our prevention efforts, and at the same time, helped loved ones of those who struggle know about CRAFT.
J
Carolyn, first, I whole-heartedly agree that outpatient is critical for most people. I am not such a big fan of residential, although I think it has its place for some people. As to utilizing the lessons from implementation science in the criminal justice, I also agree! I believe we need to harness technology both for intervention and education. Thanks for the comment.
J
Hello there!
When you spoke about “coaching” that personally hit home. All through high school my friends and I always tried to just skate through high school without asking any questions or trying to actually understand the context. Coaching is a serious way to get help and it actually works. When you have someone next to you basically forcing you to do something and showing you the tricks of the trade that they did, it makes things so much easier and really forces you to do good. Understand the concepts is crucial to being able to take what you learned from high school on to college. (Especially if you have to take math classes in college.) This was particularly a big one for me. Everything that I learned in high school when it came to math all jumped back to me in college and I couldn’t remember how to solve equations that I could have solved in high school. It was a simple easy fix if I would have actually taken the time in high school to remember things that I thought weren’t important but actually are.
Thank for the read! What a great article!
-Alexis
Also a question to ask in regards to my comment,
Do you think if every kid in high school was presented a mentor for all 4 years of high school, that the rate at which kids actually learn would increase?
I don’t know…but perhaps we should explore coaching and mentoring more seriously in high school.
J
Dr. Fitzgerald:
After starting back to school, I originally had a different game plan of wanting to become a health coach. A few classes later has geared me towards Public Health. I had the pleasure this term in hearing you present twice and wanted to take a moment to give my thanks! I appreciate your straight forward way of presenting and several of the real stories you shared touched my heart. Now knowing how I want to help reach people differently, and after reading this article, I find it interesting how the gap inside the classroom becomes bigger between teaching skills that people can utilize over theory they don’t know how to apply. Never before being exposed to implementation science, I see how people can’t really figure out how to reach people to help them implement lasting change. When I do figure what specific skills I want to utilize, I will now now look for a coach who carries those skills. It makes sense, be the change you want to see, get help from someone who is the change. Thanks for a new perspective to help further steer me on my path.
-Stephanie
Stephanie, appreciate the kind words about my talks in your class. Yes, understanding the principles of implementation science can take you far where ever you end up in the field of public health.
J
Hey John,
The second piece of advice you gave in this article makes a lot of sense to me. I tend to be pretty unteachable (a poor quality, I know), and seldom do I seek out an expert in the field I need help in. But this is very important to my growth as a person, accepting the help from those who have strengths in the areas that I am lacking. For instance, I am not a carpenter, nor do I have the slightest clue what goes on in carpentry. If I was tasked with building a house for somebody, I wouldn’t know where to start. I wouldn’t grab a hammer and start nailing miscellaneous pieces of wood together in hopes of building a solid frame for the house, but I would instead call someone who has extensive training and knowledge in carpentry so that I may learn and see what they do. And so it goes in any and every other aspect of my life. We need a coach to guide us in areas that are unfamiliar to us, or in areas where we are simply just too weak to keep traveling on. Thank you for this post, for it should help me to do better to seek out quality “coaches” for my life.
Travis