06 Mar Generating Support for Evidence-Based Practices When treating clients, social workers must ensure that the evidence-based prac
Discussion: Generating Support for Evidence-Based Practices
When treating clients, social workers must ensure that the evidence-based practice is appropriate for the client and the problem. Then, the social worker must get the client and other stakeholders to support the selected evidence-based practice. To earn that support, the social worker should present the client and stakeholders with a plan for implementation and evidence of the evidence-based practice efficacy and appropriateness. Social workers must demonstrate that they have carefully considered the steps necessary to implement the evidence-based practice, identified factors in the current environment that support implementation of the evidence-based practice, and addressed those factors that may hinder the successful implementation.
For this week’s Discussion, you will take on the role of the social worker in the Levy case study. You will choose an evidence-based practice and attempt to gain the support of both the client and supervisor. To do so, you will address its efficacy, appropriateness, and factors that may impact implementation of the evidence-based practice that you chose.
To prepare for this Discussion, review Levy Episode 2. Then using the registries provided in this week’s resources and the Walden Library, locate an evidence-based practice that you believe would be appropriate for Jake’s case. Then, review the Evidence-Based Practice kit for Family Psycho Education from the SAMHSA website from the resources. Note all the steps and considerations involved in implementing the evidence-based practice and which of these considerations apply to this case. Consider issues such as agency support, resources, and costs that might support or limit the application of the evidence-based intervention that you select.
By Day 3
Post an evaluation of the evidence-based practice that you selected for Jake. Describe the practice and the evidence supporting it. Explain why you think this intervention is appropriate for Jake. Then provide an explanation for the supervisor regarding issues related to implementation. Identify two factors that you believe are necessary for successful implementation of the evidence-based practice and explain why. Then, identify two factors that you believe may hinder implementation and explain how you might mitigate these factors. Be sure to include APA citations and references.
Levy Family: Episode 2 Program Transcript
SOCIAL WORKER: I want to thank you for getting me this Levy case. I think it's so interesting. Just can't wait to meet with the client.
SUPERVISOR: What do you find interesting about it?
SOCIAL WORKER: Well, he's just 31. Usually the vets I work with are older. If they have PTSD, it's from traumas a long time ago. But Jake, this is all pretty new to him. He just left Iraq a year ago. You know, I was thinking he'd be perfect for one of those newer treatment options, art therapy, meditation, yoga, something like that.
SUPERVISOR: Why?
SOCIAL WORKER: Well, I've been dying to try one of them. I've read a lot of good things. Why? What are you thinking?
SUPERVISOR: I'm thinking you should really think about it some more. Think about your priorities. It's a good idea to be open-minded about treatment options, but the needs of the client have to come first, not just some treatment that you or I might be interested in.
SOCIAL WORKER: I mean, I wasn't saying it like that. I always think of my clients first.
SUPERVISOR: OK. But you mentioned meditation, yoga, art therapy. Have you seen any research or data that measures how effective they are in treatment?
SOCIAL WORKER: No.
SUPERVISOR: Neither have I. There may be good research out there, and maybe one or two of the treatments that you mentioned might be really good ideas. I just want to point out that you should meet your client first, meet Jake before you make any decisions about how to address his issues. Make sense?
SOCIAL WORKER: Yeah.
,
The Levy Family
Jake Levy (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Jake is an Iraq War veteran and employed as a human resources assistant for the military, and Sheri is a special education teacher in a local elementary school. Overall, Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Sheri is in good physical condition and has recently found out that she is pregnant with their third child.
As teenagers, Jake and Sheri used marijuana and drank. Neither uses marijuana now but they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Neither report having criminal histories.
Jake and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due to Jake’s recent behaviors, they have slowly isolated themselves.
My first encounter with Jake was at an intake session at the Veterans Affairs Health Care Center (VA). During this meeting, Jake stated that he came to the VA for services because his wife had threatened to leave him if he did not get help. She was particularly concerned about his drinking and lack of involvement in his sons’ lives. She told him his drinking had gotten out of control and was making him mean and distant. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling.
During the assessment, Jake said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He told me that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep. Jake admitted to drinking heavily nearly every day. He reported that he was not engaged with his sons at all and he kept to himself when he was at home. He spent his evenings on the couch drinking beer and watching TV or playing video games. When we discussed Jake’s options for treatment he expressed fear of losing his job and his family if he did not get help. Jake worked in an office with civilians and military personnel and mostly got along with people in the office. Jake tended to keep to himself and said he sometimes felt pressured to be more communicative and social. He was also very worried that Sheri would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors.
Based on the information Jake provided about his diagnosis and family concerns, we agreed that the best course of action would be for him to participate in weekly individual sessions with me and a weekly support group that was offered at the VA for Iraq veterans. I then offered a referral for couples counseling at the local mental health agency. I also printed out a list of local Alcoholics Anonymous (AA) meetings in his area if he decided he wanted to attend in order to address his drinking. He would continue to follow up with Dr. Zoe on a monthly basis to monitor the effectiveness of his medications.
The following session, I spent time explaining his diagnosis and the symptoms related to PTSD. Jake said that he did not really understand what PTSD was but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expressed concern that he would never feel “normal” again and said that when he drank alcohol, his symptoms and the intensity of his emotions eased. I explained to Jake that PTSD is a severe anxiety disorder that develops after a person has experienced an event that results in psychological trauma. The event may involve the threat or perceived threat of death to oneself or to someone else. I also explained that the disorder is characterized by re-experiencing the traumatic event, including the symptoms of increased arousal, and by the desire to avoid stimuli associated with the trauma. We talked about how his behaviors fit into this cycle of hyperarousal and avoidance, including his lack of sleep and irritability and the isolation and heavy drinking. He talked about always feeling “ready to go.” He said he was exhausted from being always alert and looking for potential problems around him. He told me he always felt on edge and every sound seemed to startle him.
He shared that he often thinks about what happened “over there” but tries to push it out of his mind. It is the night that is the worst as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief. I gave him a handout on PTSD and reviewed the signs and symptoms. Jake seemed relieved to receive the information. I told him that naming the issue or concern was often helpful in the healing process. During the first few sessions my goal was to help Jake feel safe and validate his feelings. We consistently assessed his feelings of safety, including any potential suicidal ideation. He was reluctant to attend AA at that time, so we began monitoring his drinking and his behaviors after several drinks.
The Levy Family
Jake Levy: father, 31
Sheri Levy: mother, 28
Myles Levy: son, 10
Levi Levy: son, 8
Jake began his individual sessions practicing techniques I had shown him to help reduce his anxiety symptoms. We used deep breathing and guided meditation to help him remain calm and in the moment. We started to chart when he had intrusive thoughts about the war, potential triggers to his hyperarousal, and when he tried to dissociate or numb in reaction to these episodes.
Jake slowly began to share his experiences while in combat. I helped to gently guide him through the events that seemed to haunt him the most. I explained that telling one’s story in effect helped him “own it,” and in turn it would be integrated into his life on his terms. I told him that the act of telling his story can actually change the processing of the traumatic event in his brain. I was careful through this process not to push him into talking about events that seemed too traumatic for fear of re-traumatizing him. There were many sessions in which he started to share a specific event and then stopped mid-story and had to begin his relaxation exercises.
During this time he had also started participating in the veterans’ support group. Jake reported that he was uneasy during the first couple of meetings because he did not know anyone, but that the other vets were supportive. He said it was helpful to hear from others who experienced the same feelings he had since he returned home. He said he no longer felt alone nor did he feel “crazy.” Jake also shared that he had started attending AA meetings.
While I did not participate in the couples’ sessions, Jake felt it was important that I hear about how these sessions were going. He told me the social worker at the local mental health clinic helped Sheri understand what he was going through by teaching her about PTSD.
The social worker explained how PTSD affected not only the individual, but the whole family and, in turn, the home environment. Jake said Sheri admitted that she did not understand what he was going through but that he was not the same person when he returned home from Iraq, and this scared her. Jake said Sheri seemed to be empathetic toward him and appeared to be relieved when the social worker explained his diagnosis.
Jake said he and Sheri worked together to address her main concerns. She felt he drank too much, was not communicating with her, was isolating himself from the family, and appeared to be depressed. She was particularly concerned about his lack of interaction with his sons and lack of interest in the current pregnancy. She worried that he would be uninvolved in caring for this new baby just as he was uninvolved with his boys.
Jake shared that in another couples’ session, Sheri talked about wanting to be able to communicate with Jake without feeling that she was “nagging him” or fearful that she was making him withdraw. She said she avoided asking him things or talking to him for fear it would “set him off” and make him retreat to the basement on his own. As it stood, she did not think she could talk with Jake about her concerns. She told him she missed socializing with friends and having family outings and felt isolated. Jake said just keeping his intrusive thoughts at bay took all the energy he could muster, so making small talk with friends was not something he felt he could do right now. Sheri admitted that she did not know that socializing affected him that way. He said the social worker explained that for veterans with PTSD, oftentimes crowds, loud noises, and open spaces triggered intrusive memories and caused anxiety attacks. He said that he and Sheri had developed a plan that would improve their communication. He said they were going to slowly begin planning outings that he felt he could handle, and that they also agreed that if at any time he felt uncomfortable while out that they would leave.
Key to Acronyms
AA: Alcoholics Anonymous
PTSD: Post-Traumatic Stress Disorder
VA: Veterans Affairs Health Care Center
Through individual, group, and couples sessions, Jake was able to address his trauma and his PTSD symptoms abated. He realized that drinking was being used as a way to avoid his feelings and attended AA meetings regularly. He has been able to maintain his sobriety and found a sponsor who is also a veteran. Sheri gave birth to a healthy baby boy, and Jake shared pictures of his son. He continues to attend group sessions and has become involved in some mentoring with young vets here at the VA. He feels strongly in giving back and has suggested that the VA begin a program that has been piloted in another state.
,
Resources for evidence-based practices
https://www.rand.org/well-being/social-and-behavioral-policy/projects/promising-practices.html
https://www.childwelfare.gov/topics/preventing/evidence/
https://www.campbellcollaboration.org/
https://www.samhsa.gov/resource-search/ebp
,
A Road Map to Implementing Evidence-Based Programs
June 2012
Table of Contents
Course Overview ………………………………………………………………………….. 3
About this Course …………………………………………………………………….. 3
Intended Audience ……………………………………………………………………. 3
What to Expect………………………………………………………………………… 3
Course Topics …………………………………………………………………………. 4
Course Learning Objectives …………………………………………………………. 4
Implementation Language ……………………………………………………………..5
The Five Stages of Implementation ………………………………………………….7
Exploration: Getting Started……………………………………………………………8
Identifying Community Needs………………………………………………………. 8
Assessing Organizational Capacity…………………………………………………. 9
Searching Program Registries to Select the Right Program ………………….. 11
Understanding Program Fidelity and Adaptation ………………………………. 12
Installation: Launching Your Program……………………………………………. 13
Initial Implementation: Expect the Unexpected ………………………………. 15
Full Implementation: The Program is in Place …………………………………. 16
Program Sustainability: Maintaining Your Program’s Success……………. 18
Contact Us …………………………………………………………………………………. 19
Appendix A – Resources ………………………………………………………………. 20
Appendix B – References ……………………………………………………………… 24
Appendix C – Supplemental Documents …………………………………………. 25
Course Overview
About this Course
This course provides guidance to facilitate selection and implementation of one of
the many evidence-based programs related to prevention and treatment that are
publicly available today. You will learn how to (1) select the program that best
matches your organization's needs and (2) carry out the steps necessary to
implement the program you choose.
Intended Audience
Individuals who may benefit from this course include members of an organization
working collaboratively to identify and implement an evidence-based program.
Whether you're looking for a program that addresses bullying, underage drinking,
drug abuse, or treatment of a specific mental health disorder, the information here
can help you in the selection and implementation of a suitable program. Those who
may find the course useful are:
Administrators, program directors, or clinicians charged with identifying,
selecting, and implementing a program to meet the needs of their target
population, funders, community, etc.
Individuals interested in learning more about best practices and strategies for successful program selection and implementation
What to Expect
This course provides overall guidance for appropriately selecting and implementing
the program of your choice. The focus is not on individuals choosing a program, but
rather on an organization working collaboratively to select and implement a
program to fit its needs. Experience has shown that organizational commitment,
readiness, and flexibility are all critical to successful selection and implementation
of an evidence-based program or practice.
This course includes several components. A section on terminology will introduce
you to some of the language you may encounter during your program selection and
implementation tasks. A glossary is also available if you need it. Each page is
supplemented with links to other resources that may prove helpful to your learning
experience. The information presented here has been distilled from professional
publications, and full references appear at the end.
A Road Map to Implementing Evidence-Based Programs | 3 http://nrepp.samhsa.gov/AboutLearn.aspx
Course Topics
The following topics are covered in this course:
1. Course Overview
2. Implementation Language
3. Five Stages of Implementation
4. Exploration: Getting Started
5. Installation: Launching Your Program
6. Initial Implementation: Expect the Unexpected
7. Full Implementation: The Program is in Place
8. Program Sustainability: Maintaining Your Program's Success
Course Learning Objectives
This course will help you learn:
Basic terms related to program selection and implementation
How to identify your organization's needs
Where to find available programs
How to select the best program for your organization's needs, with a focus on
implementation
The five basic stages of program implementation
A Road Map to Implementing Evidence-Based Programs | 4 http://nrepp.samhsa.gov/AboutLearn.aspx
Implementation Language
This section will introduce you to some of the terms used in the field of
implementation science and research.
To begin, the general term program, as used in this course, refers to an
intervention designed to bring about specific outcomes for specific purposes or
populations. An example would be a program based on scientific principles designed
to prevent drug abuse by children.
Implementation refers to putting the program — and the scientific principles — to
work in a real setting, such as a school or community to bring benefits to a
particular target audience.
Dissemination of programs refers to the targeted distribution of information and
program materials to a specific public health or clinical practice audience. The intent
is to spread knowledge about the programs and encourage their use.
Increasingly, the approach to prevention and treatment includes the use of
evidence-based programs and practices. Evidence-based signifies that the
approach is based in theory and has undergone scientific evaluation. This contrasts
with approaches based on tradition, convention, belief, or anecdotal evidence. The
shift to evidence-based programs seeks to enhance the potential for positive
results. Today, many foundations, government agencies, and state legislatures
encourage or require the use of evidence-based programs in service delivery plans.
Evidence-based programs are designed by program developers such as researchers
at universities, practitioners in the field, and businesses engaged in promoting and
distributing social services programs.
Many evidence-based programs contain a defined set of core components, which
are the essential parts of a program. Some sample core components might be:
There are five lessons of 30 minutes each that cover five specific themes.
Sessions are conducted with a group of four to six elementary school
students.
The intervention is delivered in the home during home visits. The intervention is delivered in a specific sequence of stages.
In the above example, if you decide to change the length or frequency of the
lessons, or you use the program with a group of 12 middle school students, or you
conduct the program in a classroom instead of at home, or you change the order in
which the core components are introduced to the target population, you have
changed the core components, and you are no longer implementing the program
with fidelity. As a result, you cannot expect the same outcomes the developer
predicted.
A Road Map to Implementing Evidence-Based Programs | 5 http://nrepp.samhsa.gov/AboutLearn.aspx
So, the term fidelity refers to including all the core components of a program
during implementation to help ensure successful outcomes. The term adaptation
refers to the process of changing a program to meet specific needs. If you adapt a
program for any reason, you must maintain the core components to ensure
success. Adaptation will be discussed in more detail later.
Selecting a program for implementation in your setting involves careful planning,
community and organizational involvement, and a comprehensive assessment of
resources. Once this process is completed, you are ready to determine program fit.
Program fit can be described as the (potential) match between your community's
needs, resources, and capacity to implement a program—with the requirements of
the program.
A critical piece of implementing any program or practice is the ability to measure
the effect of the program on the population you are serving. In an outcome
evaluation, it is important to use outcome measures: How is the system
performing? What is the impact or result on what you are trying to change? In a
process evaluation, use process measures: Are the parts/steps in the system
performing as planned?
A Road Map to Implementing Evidence-Based Programs | 6 http://nrepp.samhsa.gov/AboutLearn.aspx
The Five Stages of Implementation
Successfully implementing a program that fits your organization's needs is a
process – not a single event – that occurs in multiple stages of planning, purposeful
action, and evaluating.
It is not enough to simply select a proven evidence-based program and assume
success will automatically follow. Good implementation strategies are essential.
The National Implementation Research Network (NIRN) 1
reviewed more than 2,000
articles on the
implementation of
programs and identified
five main stages of
successful
implementation (Fixsen,
Naoom, Blase, Friedman,
& Wallace, 2005), which
are all interrelated:
1 National Implementation Research Network (NIRN) – http://nirn.fpg.unc.edu
Exploration
Installation
Initial Implementation
Full Implementation Program Sustainability
Since the stages are connected, issues addressed (or not addressed) in one stage
can affect another stage. Moreover, changes in your organization or community
may require you to revisit a stage and address activities again to maintain the
program.
A Road Map to Implementing Evidence-Based Programs | 7 http://nrepp.samhsa.gov/AboutLearn.aspx
Exploration: Getting Started
The goal of the Exploration Stage is to select the right evidence-based program.
Your organization will strive to identify the best program fit, which is the match
between needs and resources and the characteristics of the program (this is
discussed in greater detail later). Four main activities are involved in this stage:
Identify your community's needs to determine the type of program that
will be most appropriate.
Assess your organizational capacity including financial resources,
organizational commitment, and community buy-in to determine your ability
to implement a program with fidelity.
Search program registries to select a program that matches your
community needs, your organization's available resources, and available
programs.
Understand program fidelity and program adaptation.
Focusing on these activities to identify a good program fit is part of ensuring
successful implementation.
Identifying Community Needs
Much has been written about the importance of the community needs assessment.
Identifying your target population and understanding its needs, challenges, and
assets is critical to your success in choosing an appropriate program. Articulating
the outcomes you want to achieve (such as reducing underage alcohol use or
improving parental bonding) will provide the framework for exploring the range of
evidence-based programs and practices and selecting the best fit for your
organization.
See Community Needs Assessment Resources and Tools 2
for more information on
community needs assessments.
2 See Appendix A
A Road Map to Implementing Evidence-Based Programs | 8 http://nrepp.samhsa.gov/AboutLearn.aspx
Assessing Organizational Capacity
Financial and Personnel Costs
Programs cost money. You will likely need program-specific materials to implement
the program (manuals, materials, etc.). However, implementing a new program
may also require additional funds to hire new staff or purchase needed equipment
or space. Contact the developer to discuss the program you are considering. The
developer can clarify basic information such as costs, time needed, what to expect,
etc. You also need to clearly identify your financial and staff and community
resources. Do you have space available? Do you have the funding you need to fully
implement the program? How much will the program itself cost? The program
developer often indicates in the program materials how much it will cost for staff
training, materials, additional equipment, technical assistance support, and all other
costs directly associated with the program. Ask the program developer about these
implementation costs and the cost of service delivery (how a program bills for the
services it provides), if appropriate.
There may also be other less obvious costs to consider related to infrastructure. For
example, if the program indicates the need for staff with specific skills (such as
someone with a master's degree in social work), you will need to consider the skills
of your current staff members and determine if you need to hire someone new or
train a current staff person. If the program requires that all staff members have
access to a computer program or an Internet connection, additional funds may be
required to make such resources available. It is also important to pay attention to
caseload standards as many evidence-based programs require a specific caseload
that may be dramatically different from usual care. The overall size and scope of
the chosen program will influence the potential associated costs of implementing it.
Questions To Ask: Financial and Personnel Resources3
See Organizational Capacity Resources and Tools4 for more information on organizational capacity.
3 See Appendix C
4 See Appendix A
A Road Map to Implementing Evidence-Based Programs | 9 http://nrepp.samhsa.gov/AboutLearn.aspx
Commitment and Buy-In
Your organization's staff at all levels will need to be committed to the
implementation process for the long term. It may take one to four years to
implement a program and achieve positive outcomes, and the process will continue
<p
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