• By Dartington SRU
  • Posted on Friday 15th May, 2009

Should the poor clinician get more blame?

Can well-trained, well-intentioned practitioners make children’s lives worse than they already are? To judge from evidence emerging from Washington on the impact of Functional Family Therapy, yes they can.Barney Barnoski at Washington State Institute for Public Policy has been examining the impact on child outcomes of proficient and less proficient clinicians implementing the evidenced based program, Functional Family Therapy (FFT).In nearly all 1,500 FFT sites, therapists have a masters degree in psychology or social work. They participate in FFT training and are supported by regular meetings with a supervisor. They also accumulate the advantage of working with adolescents and families taking part in the program, so, by most estimations, they might be expected to do a good job.Barnoski divided practitioners in one trial between four categories ranging from “not competent” to “very competent” based on how well they implemented FFT or how closely to the developers’ specifications they delivered it.Among the least competent, one did an excellent job, achieving results similar to the most able, but most not only failed to improve family functioning and children’s health and development, but were also associated with a further decline.Findings on competent practitioners were an approximate mirror image. Children and families served by very good FFT therapists generally experienced excellent outcomes, but some did not respond well.The results are part of improving understanding of the contribution clinicians, psychologists, psychiatrists, social workers and youth justice specialists make to the well-being of children and young people.What is disconcerting about the Washington State Institute findings is the suggestion that even in the context of an evidence based program poor practice and poor outcomes go together. Just as it did this week, the evidence will leave observers worrying what must happen to children and families served by ill-prepared practitioners who have no access to evidence based ideas, routines or clinical support?So far it has taken the tenacity of those at the center of evidence based program development and determined to fathom the relationship between effectiveness and fidelity of implementation to prise open this important issue. Barnoski has been a thorn in the side of opponents of evidenced based practice in Washington State. In the 1990s when they asked if certain favorite programs worked he managed the trial and concluded “no”. In the first decade of this century where he finds that evidence based programs are being poorly Implemented, he says “stop”. “I became known as Dr No-ski” Barnoski told study tourists. “But if the goal is to reduce crime, and school drop out or to help children to become productive citizens we not only need evidence based programs but we also need them to be implemented well, and we need to monitor the ability of individuals to do what is asked of them.”• In today’s video clip, Washington Senator Karen Fraser talks about the key role played by Washington State Institute for Public Policy in wise policy making.

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