Bringing research-based practice to fruition

The issue of research’s impact on clinicians and patient care in the helping professions is not a new one. In 1949, at the Boulder Conference on graduate education for clinical psychologists, the concept of the scientist practitioner model was introduced, with the idea that clinicians should model their therapeutic interventions after research findings, or empirical data. Although the conference was directed toward psychologists, its impact spread throughout the therapeutic world. While there has been debate over the pros and cons of this model over the years, it is certain that this topic takes on a new importance in the current healthcare climate.

The addiction treatment field is at the forefront of this movement for several key reasons. An increased emphasis from insurance providers, consumers and government agencies on outcomes of treatment as a basis for funding has led to the need for a new look at the role of research in our field. In states such as Oregon, Delaware and North Carolina, more and more funding for addiction treatment is being tied to the provider’s use of research-based practices.¹

The passage of behavioral health parity legislation, achieving the long sought goal of equity with other chronic and in many cases fatal medical conditions, only adds to the need to continue to adapt to the changing healthcare landscape. While this landmark legislation will certainly provide more access to addiction and mental health treatment for millions of Americans, there is no question that funding sources, including insurers, will increase their emphasis on working with providers that can produce clear results from their treatment protocols. Showing outcomes, and evaluating how well we as clinicians do with helping our patients achieve goals such as long-term recovery, is becoming an increasingly important task as our field enters a new era.

There are several reasons why our field hasn’t fully adopted this model; however, by changing the way we view the role of research in treatment, providers can continue to flourish by giving clients the necessary foundation to begin their recovery journey.

Prominent substance abuse researchers for years have presented the idea of “blending practice,” emphasizing a need for more clinical interventions to be based on empirical evidence, or at the least for clinicians to become better consumers of research findings.² The National Institute on Drug Abuse (NIDA) has held a series of conferences over the last several years to promote this concept. However, in the substance abuse treatment community, many still view researchers and clinicians as representing different sides of the coin, with different values and goals. Researchers often are seen as lacking insight into the true impact of the disease of addiction and the severe psychological toll it exacts on the individual battling it; practitioners frequently are seen as reluctant to adapt to new concepts regarding treatment and recovery.³

Those of us who have worked directly with clients for years know the facts—treatment works, and any methods we can employ to help our patients begin to improve their quality of life are important. Research tells us that comorbidity and other factors play a large role in predicting a client’s quality of life following treatment. It also tells us that support systems, including active 12-Step fellowship involvement, play a large role in creating an atmosphere that will help a client not only survive, but thrive.

Changing the mindset
Creating a clearer picture of what outcome research really means for clinicians, administrators and clients alike is the first step to changing our way of thinking. Research should work hand in hand with clinical processes, with good outcome measurement supporting and adding to the quality of care. For the purpose of this article, let’s focus on one specific type of research: outcomes measurement.

Outcomes measurement can be defined as simply measuring treatment outcomes over a specific time period; the measures (or instruments) can track factors such as reduction in symptoms, overall quality of life, and even a patient’s satisfaction with treatment in general.⁴ In short, it is tracking a patient’s progress, and beginning the process of collecting data that can be used, at that time or in the future, to assist in treatment planning and service delivery. In non-technical terms, that means “let’s see how well we do what we do!”

While ethical standards must be in place to ensure proper methods are followed, beginning the process is not as daunting as it may seem. Laying the foundation for a treatment culture where research-based ideas can thrive and become a vital part of an organization’s mission can begin with a few simple steps.

Despite the challenges in adopting research-based practices into treatment facilities, we have some unique advantages in the addiction field in regard to their application in our day-to-day work. For example, our primary goal as providers is helping our patients achieve long-term recovery. What could be more outcome-based than that? While the argument can be made that many other medical treatments are more easily quantified in terms of their effectiveness through testing and other methods, several studies have highlighted that in terms of adherence to aftercare protocols, success rates in addiction treatment (as measured by sustained abstinence) are no worse than those seen in the treatment of other chronic medical conditions, such as asthma and diabetes.⁵ While few insurers would place restrictions on follow-up visits to providers to treat these addictions, this unfortunately is an all too common practice in addiction medicine.

This challenge offers practitioners and researchers a golden opportunity to redefine the meaning of success in recovery, and to begin to bring together those with different views on what successful recovery entails. Those who begin to look at addiction from a global or holistic sense will see the benefits in improved patient care as well as greater financial stability. Simple practice-based outcome research, with clearly defined goals, plays a key role in this new way of thinking.

As mentioned earlier, we know treatment works when clinician and client work as a team, and we know that quality of life improves after treatment. Failure to measure this progress puts the therapist at a distinct disadvantage in treating the client, as well as placing facilities at a marketing disadvantage in being unable to quantify the positive results of interventions. In short, it is a “win-win” situation for everyone involved in the process when we begin to emphasize this way of thinking.

Importance of staff education
There are obstacles to continuing progress in this area, and in many ways a lack of understanding of the process of research, data collection and its role in changing the way we provide services is key.

The first step in laying this foundation is making education a priority for staff at treatment centers. While continuing education has long been a part of the curriculum for licensed professionals, too often this factor has gone neglected at many facilities. Beginning to stress the critical role of continuing education, not just to satisfy licensure requirements but to gain a better understanding of the nature of our clients, is of utmost importance.

Whether it is hosting a brief in-house seminar on new research on treating comorbid conditions or distributing new findings on the factors most closely associated with long-term sobriety, there are relatively simple ways to begin to reinforce the notion that practice should be based on what works. Training should not be offered to licensed clinicians alone; even staff members who have no intention to pursue licensure, including support staff, can attain a much clearer picture of the people we serve, increasing their effectiveness as helpers.

The ability to understand the patient from a holistic perspective, including spiritual, emotional and physical needs, can make everyone at a treatment center more effective. Clear, straightforward presentation of research findings can help these become practical tools for clinicians to use in their daily work.

Obviously, with financial pressures increasing in all fields right now, there is a trend toward cutting services not seen as “essential.” When this affects the areas of education and research in the field, this can come with costs. By not creating the time for clinicians and other staff to participate in continuing education, we put ourselves at a disadvantage in the changing healthcare picture.

While many centers, including some of the best-known providers, emphasize this ideal, more needs to be done. Too many times as clinicians we operate in crisis mode, with pressure from all sides to complete the daily tasks that are part of being in direct service to clients. A renewed push by the administrative bodies of treatment centers to create time for clinicians and others to continue to grow through involvement in research and education can help reduce stress by giving employees new options to pursue in helping their clients on the path to wellness. Professional and personal growth no longer can be seen as just another lofty goal, but a necessary function in today’s treatment arena.

Overcoming resistance
Of course, there are challenges. Despite the growing need to adapt to this new way of thinking about providing addiction treatment, many researchers and clinicians still harbor reservations about each other’s goals. Resistance is normal when new ideas are introduced, when research calls into question some of our field’s commonly accepted practices, or when clinicians are asked to adopt new ways of thinking based on research findings. The key here, as noted above, is an emphasis on education. The more clinicians are engaged in the process early on, the more willing they are to begin to adopt research into their daily routine.

For example, when beginning to collect data at a facility, administrators and supervisors must continue to stress that the therapeutic alliance is the key to good outcomes, and the process of tracking those outcomes is just another hallmark of good clinical practice. Making the research findings or projects that are adopted into the facility practical, directly addressing the problems clinicians see on a daily basis, can reduce resistance and pave the way for improving quality of care. Adopting a more collaborative approach, where each group learns from the other, is the way to begin to recognize similarities instead of highlighting differences.⁶

In many cases, beginning the process of research at facilities can be easier than we think. Whether in urban or rural communities, many facilities are within close proximity to academic institutions, full of motivated individuals who would jump at the opportunity to assist in conducting even basic research activities. Clinicians want to find new ways to treat the chronic relapsing patient and those who struggle with comorbid conditions such as depression.

And the vast majority of clients are willing to do their part to help us shed light on new ways to help those who fight the disease of chemical dependency. Whether filling out a survey regarding their treatment experience or participating in a clinical trial of a new intervention that helps reduce symptoms of post-traumatic stress or depression, patients feel like they are serving a cause greater than themselves. It is one of the key spiritual elements of the recovery process, and just one small example of how research and practice can work together in providing the best quality of care for those we serve.

John W. McIlveen, MEd, is Vice President of McIlveen Associates, LLC, a consulting firm focusing on education, training, research and assessment. He is a former Director of Assessment and Education at a large treatment center in South Florida, and has presented and published frequently on treatment-related issues. His e-mail address is mcilveenj@mindspring.com.

References
1. Carey B. Drug rehabilitation or revolving door? New York Times, Dec 23, 2008.
2. McLellan AT. Reconsidering addiction treatment: quality, accountability, and outcomes in a chronic care perspective. Presented at National Institute on Drug Abuse conference “Smart Practice, Practical Science: Blending Treatment and Research,” Miami Beach, Fla., June 2005.
3. Marinelli-Casey PJ, Domier C, Rawson RA. The gap between research and practice in substance abuse treatment. Psychiatric Serv 2002;53:984-7.
4. Sperry L. Treatment outcomes: an overview. Psychiatric Annals 1997;27:95-9.
5. McLellan AT, Lewis DC, O’Brien CP, et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000;284:1689-95.
6. Carise D, Cornely W, Gurel O. A successful researcher-practitioner collaboration in substance abuse treatment. J Subst Abuse Treat 2002 Sep;23:157-62.