“The evidence-based program approach to evidence-based practice may have substantial limitations for the implementation of evidence-based practice in agencies serving youth with multiple and complex needs”, claims Penelope Mitchell, Honorary Senior Fellow at the Centre for Health Policy, Programs and Economics at the University of Melbourne, Australia.

“A new model is needed”, she argues, “which reconciles values from clinical science and practice wisdom [and] accommodates a diverse array of interventions for a wide variety of psychosocial issues.”

If she is right – and such views will be hotly disputed – how can the content of evidence-based interventions be organized? A key starting point, she suggests, is to respect and build on existing practice rather than replacing it.

A new wave of implementation research is based on the idea that effective programs are comprised of numerous common “practice elements”. These need not be organized and delivered in fixed arrangements specified in a given program model. Examples would be “time-out” or “relaxation”, both of which are discrete techniques used as part of a larger intervention plan.

This approach, says Mitchell, can help decision-makers identify practice elements “likely to be most effective for particular clients or groups, based on how frequently those elements are found in successful treatments with populations matching the client on specified variables”.

She suggests that this offers a palatable solution to some of the barriers to implementing evidence-based programs, including the desire to adapt material for different contexts. She writes: “By breaking treatments down into small elements, practitioners and clients are better able to choose therapeutic content that addresses psychotherapeutic needs and therapeutic techniques best suited to the skills and style of the therapist and the nature of the relationship.”

She continues: “Content and techniques can be more readily selected and organized according to the developmental stage of a young person. This high level of adaptability to context may neutralize key barriers to EBP currently manifest in provider attitudes, characteristics of client populations, and the characteristics of usual practice.”

Mitchell also argues that the practice elements approach could offer cost savings. “Rather than training staff in multiple elaborate evidence-based programs that may involve content overlap on the one hand, or philosophical incompatibilities on the other, practice leaders could choose defined elements that are commonly used for the problems regularly seen in their client population”, she says.

A limitation of this “active ingredients” approach, of course, is that treatment protocols are more than the sum of their parts. Critics will be quick to point out that, as Mitchell puts it, “Deconstructing programs into elements may compromise their effectiveness by eliminating implicit, undefinable, or meta-level characteristics”. Another drawback is that the approach does not address issues such as sequencing or how to incorporate elements into a treatment plan.

For Mitchell, these concerns highlight the value of distinguishing between “therapeutic content and techniques” and “characteristics of effective programs”, and underline the importance of integrating these two aspects.

She writes: “Consensus-based characteristics of effective programs are primarily principles about ‘how’ to organize therapeutic content. For example, client-centered practice says that therapeutic content must be chosen according to the unique needs of the client and that as far as possible the client must be actively involved in choosing.”

The fact that evidence-based program models often ignore these aspects of practice infrastructure – which are highly valued in agencies serving youth with complex needs – and attempt to replace them, Mitchell suggests, may help explain why the programmatic approach to evidence-based practice has made little headway.

As this work progresses, several research teams have started analyzing the empirical literature to identify and define evidence-based program elements comprising treatments for particular mental disorders, while others have explored the idea of modular program design to support the process of combining practice elements flexibly.

One of the potential advantages of the practice elements approach is that it goes with the grain. As Mitchell says: “Many of the evidence-based program elements identified in recent implementation science will be readily recognized and understood by practitioners in children and youth services.

“Many of these elements are already being used in current practice and practice leaders are already providing training and supervision around them, although they may not yet be widely recognized and labelled as evidence-based practice. Decision-makers who venture into the emerging literature may be in for some pleasant surprises.”

Reference:
Mitchell, P. F. (2011) ‘Evidence-based practice in real-world services for young people with complex needs: new opportunities suggested by recent implementation science’, Children and Youth Services Review 33, 207-216.