Sharing the evidence

“We share the science, we share the practice experience as well, and then we come up with the most reasonable ways one would proceed in the absence of perfect knowledge.—Peter S. Jensen, MD

When Peter S. Jensen, MD, left the National Institute of Mental Health in 2000 after serving as the associate director of child and adolescent research, he knew that the cutting-edge research in children's mental health that he had been funding needed to more quickly find its way to practice settings.

At Columbia University, Dr. Jensen founded that same year the Center for the Advancement of Children's Mental Health, with the goal of closing the science-to-practice gap. He brought together leading scientists, researchers, and practitioners, as well as parents and school officials, to reach consensus on best practices for children. But beyond identifying and disseminating this information, Dr. Jensen knew the effort would require intensive retraining of primary care providers and behavioral health specialists. And for the training to be effective, new teaching models would have to be developed that would allow practitioners to quickly assimilate and apply evidence-based practices.

Dr. Jensen was motivated by what he observed in the real-world practice of children's mental health: lack of specific information on which treatments work, costly use of ineffective treatments, inadequate parent and family participation, limited opportunities to share knowledge, limited access to evidence-based clinical tools, and lack of models to train professionals and disseminate evidence-based information.

Dr. Jensen's efforts were jump-started when New York State and City officials asked him to assemble leading treatment developers to train New York City providers on trauma after 9/11. Dr. Jensen knew that these children's needs went beyond trauma, so he suggested training providers in depression, anxiety, and disruptive behavior disorders as well.

“It was just striking—everybody had a different way of [training],” says Dr. Jensen. “Some [treatment developers] had well-prepared slide shows, and some had old mimeographed treatment manuals that we had to copy, and some had cobbled together materials that had less rhyme or reason for how they all came together for this particular training.”

So Dr. Jensen and his center colleagues told the state officials that user-friendly manuals were needed for each of these therapeutic areas. “We thought that if we train the clinician in depression treatment, when we now start to train them in disruptive disorders, shouldn't the manuals look similar?” he asks. “It should be as seamless as possible from the learner's perspective.”

Thus, the center brought the treatment developers together and formed the Integrated Psychotherapy Consortium, with the goal of integrating the different approaches of teaching treatment modalities. “We said let's take everyone's work and recraft it so that from the clinician's end, the psychotherapy session trainings use a similar structure, whether it's for depression treatment, anxiety treatment, trauma treatment, or ADHD treatment,” he explains.

Each of the manuals was recrafted to incorporate a common graphical format, common session format, user-friendly handouts for parents and families, and a common beginning and termination session. This two- to three-year process of recrafting therapy manuals gave the center a way to train anyone in the country on the latest therapies. “People could mix and match. You could have a child with complex comorbid problems, [such as] disruptive problems and depression, and now have all the tools assembled for that child with multiple comorbidities,” Dr. Jensen says. This process was completed in 2005.

One year later, The REACH (Resource for Advancing Children's Health) Institute was launched as a separate nonprofit, with a national and even international scope in mind. The institute's mission is to accelerate the acceptance and effective use of proven interventions that foster children's emotional and behavioral health. The institute has a four-step process that represents its fundamental principles:

1. Identify and validate the latest and most effective interventions that foster children's emotional and behavioral health

2. Adapt these interventions to make them user-friendly for ready application by patients and healthcare professionals

3. Distribute, apply, and evaluate these interventions through strategic partnerships with provider groups and family organizations

4. Empower strategic partners to foster the proven methods and interventions to reach the largest number of children

Among The REACH Institute's training programs are the Child and Adolescent Training Institute for Evidence-based Psychotherapies, Mini-Fellowship in Primary Pediatric Psychopharmacology, Evidence-based Approaches for Systems Serving Youth, and the Parent Empowerment Program.

“What we're doing now is developing a whole array of new products for learners, and learners in this case means the clinicians who really need to be taught these things,” says Dr. Jensen.

The psychopharmacology mini-fellowship trains pediatricians and non-child-psychiatrists on safe and effective use of psychiatric medications. The program is based on consensus recommendations from the American Academy of Pediatrics and leading child psychiatrists. The mini-fellowship has included three six-month programs training pediatricians, psychiatrists and child psychiatrists, nurse practitioners, and physician assistants.

“A lot of the folks who have done the mini-fellowship in pediatric psychopharmacology are now asking for an advanced course,” says Dr. Jensen. He envisions a yearlong course for pediatricians to revitalize their practices and become experts in behavioral health, particularly in areas with no child psychiatrists.

The REACH Institute also offers training packages that reflect the real-world challenges faced by behavioral health clinics. The institute offers training for individual disorders as well as more common comorbid cases, such as combining depression and disruptive behavior disorders into one training. “We bring a whole package of integrated approaches into a clinic, and it ends up in quite a transformation,” notes Dr. Jensen.

Almost all of the clinician trainings start with two to three days of face-to-face training, although this training can go for as long as a week. But the peer support and learning aspects, usually conducted via conference calls, last anywhere from six months to a year.

A typical conference call encompasses eight to ten participants, with two as presenters. In 15 to 20 minutes, the two presenters discuss a case they've been struggling with, which is followed by group discussion resulting in a shared set of recommendations. The calls usually are facilitated by a pediatrician and a child psychiatrist. Attendance is carefully tracked, and CME or CEU credits, as well as a certificate issued by the REACH Institute, are awarded.

“I had not expected this to work as well as it's working—80% attendance on our last 80 to 100 calls, which is really quite amazing,” says Dr. Jensen. “One person described this experience as the highlight of their career…. I see these people talking about a life-changing experience.”

Dr. Jensen says that one key to the trainings' success was establishing the right risk-taking environment. “No one is a sharpshooting expert making other people look silly or bad,” he explains. “We set this up as, ‘We learn from each other. Here's what the research tells us, but the research isn't nearly enough, so we're going to have to mine everyone's shared experience.’ That's the spirit behind a lot of this. We share the science, we share the practice experience as well, and then we come up with the most reasonable ways one would proceed in the absence of perfect knowledge.”

Dr. Jensen recruits experts who he thinks will make the best teachers. “They have to be open and approachable and totally let their guard down,” he says. “No question is a silly question—they just have to be that kind of person instinctively.” Faculty are given training and support when they are recruited by the institute.

Overall, the training is very interactive, with role playing during face-to-face sessions, hands-on training, and workbooks—but few slides and lectures. “You can't give a lecture and have this work,” notes Dr. Jensen. And when clinicians come in for training, they are told that this training will change the way they practice. Dr. Jensen tells them, “If you don't change your practice, you've wasted our time and your money.”

Brion P. McAlarney is a freelance writer.

For more information about The REACH Institute, visit https://www.reachinstitute.net.

Behavioral Healthcare 2008 October;28(10):26-27