Practitioner's Guide to Using Research for Evidence-Informed Practice. Allen Rubin

be out of your reach. For some of the most effective interventions, the evidence supporting them is based on evaluations involving clinicians who – as part of the research study and before they delivered the interventions to the research participants – received extremely extensive and costly training and repeated practice under supervision and monitoring. Franklin and Hopson (2007) pointed out that this training process “is too slow, cumbersome, inflexible, and time intensive for many community-based organizations” (p. 8). As an example, they cite Brief Strategic Family Therapy, which “has considerable research support for Hispanic families who need help with an adolescent with a drug abuse problem … but costs $4,000 per therapist to participate in the training” (p. 10). Moreover, agencies may hesitate to invest in costly training for their practitioners if they fear that practitioners will leave the agency and take their training with them.

BOX 2.2 Strategies for Overcoming Feasibility Obstacles

       Cut some corners. If you lack the time and access to bibliographic databases needed to conduct a thorough search for and appraisal of evidence, you might need to cut some corners. Instead of searching for and critically appraising individual studies, for example, you might choose to rely on books, reviews, and practice guidelines developed by EIP experts who have reviewed the literature, identified interventions supported by the best evidence, and described the nature of that evidence. Table 2.3 lists some Web sites that can be useful in accessing such materials. As we mentioned earlier, however, authors of some sources might have a vested interest in promoting or debunking a particular treatment modality, and you should be cautious when relying exclusively on those sources. You should rely mainly on resources known for their objectivity, some of which we identified when discussing Step 2 of the EIP process. Chapter 8 of this book discusses what to look for in appraising whether a particular review has sufficient credibility to merit guiding practice.

       Read titles and abstracts. As we mentioned earlier, when conducting your search, you don't have to read every study that you find. You can examine their titles and abstracts to ascertain which ones are worth reading. You can decide which studies to read based on the relevance of the study to your practice question as well as any mention in the abstract of attributes that might tip you off about the quality of the study.

       Work with a team. Another strategy to improve the feasibility of the EIP process is to work with a team of practitioners to move through the EIP process. Taking on each of the steps can feel daunting if you go it alone, but working with colleagues to split up the effort can be more efficient and provide you with a forum where you can discuss what you find and problem solve the challenges along the way. Your team could include colleagues at your agency or a group of independent practitioners serving similar clients.

       Use manuals or checklists. Before you can provide the interventions that have the best supportive evidence, you might have to learn more about them. You can start by obtaining readings on how to implement the intervention or consulting with colleagues who have used the intervention. Some interventions have treatment manuals that provide very specific step-by-step guidance. Increasingly, many interventions also provide fidelity checklists and other tools designed to measure whether or not you are delivering the intervention as intended.

       Obtain training or consultation. After reading about the intervention, you might realize that you need to attend a continuing education workshop or professional conference providing training in it. Perhaps you can arrange to take an elective course on it at a nearby professional school or access one of the online or virtual trainings that are becoming increasingly available. Once you feel ready to start implementing the intervention, you should try to arrange for consultation or supervision from a colleague who has greater expertise and experience in providing that intervention. For some interventions, you can receive consultations directly from the intervention developers or earn a certification to deliver the intervention, although this can be costly in some cases. You might also be able to join or organize a support group of colleagues who are using the intervention, who meet regularly to discuss their experiences with it, and who can give you feedback about how you are implementing it. You can also look for interventions that use a “train the trainer” model, so that you or your colleagues can train others in the intervention as a strategy to build training capacity and reduce training costs.

      If you implement such interventions having received less training than the clinicians in the study received, you might be less effective than they were. Not all desired interventions require such extensive training and supervision. With those that do, however, you have several options, as follows:

       One option is to find a practitioner or agency that is well prepared to provide the intervention and refer the client there.

       If that option is not feasible, an alternative would be to learn how to provide the intervention yourself as best you can, and then make sure you implement Step 5 of the EIP process carefully – in which you monitor client progress. Be prepared to alter the treatment plan if the client is not making the desired progress and you do not appear to be as effective as you had hoped to be. At that point, you might switch to an intervention that has been supported by some credible evidence and in which you are more skilled and experienced.

       Of course, a third option would be to have provided the latter intervention in the first place, particularly if you are unable to learn enough about the new intervention to reach a comfort level in providing it. Implementing Step 5 will still be important even with interventions with which you are more comfortable. Your comfort level does not guarantee effectiveness.

      One more long range option bears mentioning. You can try to educate policymakers who fund community programs about the cost savings over time for the most effective interventions that have steeper up-front costs. Franklin and Hopson point out:

       Researchers have shown, however, that adopting some costly evidence-based practices ultimately saves money because they can prevent the even more costly consequences of going without treatment. Multisystemic therapy, for example, may save money for communities by preventing incarceration and residential treatment for adolescents who use drugs (Schoenwald et al., 1996). Other researchers demonstrate that the benefits of evidence-based practices outweigh the costs in cost-benefit analyses (Chisholm et al., 2004).

      Despite the feasibility obstacles that you might encounter in the EIP process, it is hard to justify not doing the best you can to implement it, even if that involves some of the shortcuts we've discussed. After all, the alternative would be to practice in utter disregard of the evidence, which would not be ethical or compassionate. Thus, we hope this chapter has whetted your appetite for EIP and for reading the rest of this book to learn more about how to utilize research in the EIP process.

2.7 But What about the Dodo Bird Verdict?

We have noted that some studies have found that one of the most important factors influencing service effectiveness is the quality of the practitioner-client relationship. We also noted that some studies have concluded that the quality of the practitioner's clinical relationship skills has more influence on treatment outcome than the decisions made about what intervention to employ. Some have taken a more extreme position and argued that the choice of intervention is irrelevant because some studies have found that all interventions are equally effective if the practitioner providing them has good relationship skills (Wampold, 2001). Based on the latter studies, some scholars have criticized EIP and depicted it as a waste of time at best, and perhaps even harmful if practitioners just follow an intervention manual and thus ignore their relationship skills. Their argument is known as the dodo bird verdict, based on the dodo bird's declaration after a race in Alice in Wonderland that “Everyone has won, and all must have prizes” (Luborsky et al., 1975).

TABLE 2.3 Internet Sites