The slow uptake of “manualized” evidence-based programs, those that come with manuals containing detailed instructions for their implementation, offers an opportunity for social work to “blaze a new trail” through the “adoption of cutting-edge clinical practices that reflect the core values of the profession.” That is the view of a team of researchers led by Richard Barth from the University of Maryland, US.
Many manualized programs have been identified and catalogued in clearing houses like Blueprints for Violence Prevention. Such programs’ great strength, studies show, is that their outcomes are better than many of the alternatives. However, their dissemination and implementation in practice settings remains “strikingly limited,” according to Barth.
There are several reasons for this, including a poor fit with clients’ needs; difficulties in gaining access to training; a duration which is too long or short; questions over how well attuned programs are to ethnically and culturally diverse populations; and the daunting task of selecting from a huge choice of programs with little guidance. Could it be time to try other approaches?
Barth’s team advocate two approaches. The first, the “common elements framework”, is based on distilling the individual components, or practices, that comprise effective interventions. It identifies “generic components that cut across many distinct treatment protocols” or, put another way, “specific clinical procedures common to [EBPs].” One study, for example, looked at 322 randomised controlled trials of treatments for childhood depression, anxiety and disruptive behavior, coded the 615 treatment protocols represented in these studies, and then identified the 41 practice elements common to the most effective interventions.
The approach offers several advantages, not least a high level of flexibility regarding the topic of content, pace, and sequence, with the potential to “mix and match” according to the client’s needs. Further, for practitioners it may “promote mastery and confidence in delivering effective services,” while agency administrators may find it simpler and cheaper than trying to develop a workforce with expertise in multiple programs, each requiring unique contractual arrangements and processes for monitoring fidelity and collecting data.
This is not to say that “anything goes.” Advocates of this approach recognise the need for a quality assurance model involving “structured treatment sessions, ongoing progress monitoring and reporting, and evidence-informed clinical decision-making that engages clients, clinicians, and other mental health stakeholders in the processes of treatment planning and delivery.” This is “because the whole may be greater than the sum of its parts, [so] applying the common elements in the absence of a practice framework may not yield the same results as a manualized treatment.”
There are ways to help with such tasks. For example, practitioners can use a database to enter the characteristics of the client and treatment settings in order to identify suitable practice elements. Then, there are practice guides available that bring together the literature on the content of the practice element and provide step-by-step instructions on implementation. A “clinical dashboard” offers a graphic representation of clients’ progress and practice elements during treatment.
Barth and his colleagues are not arguing that the common elements framework should replace evidence-based programs. Among its limitations is the difficulty determining the effect of each individual element on its own. There is some evidence that it improves providers’ attitudes to evidence-based practice, but it is not yet known whether it achieves better outcomes than evidence-based programs.
The second approach advocated by Barth's team is the common factors framework. This is based on the premise that “the personal and interpersonal components (for example, alliance, client motivation, therapist factors) common to all therapeutic interventions are responsible for treatment outcomes to a greater extent than specific model ingredients.” Put another way, a therapist’s personal qualities, their alliance or relationship with the client, and the client’s hopes and expectations are associated with outcomes, regardless of the intervention itself. Supporters of this approach have also developed tools to help therapists monitor alliance and progress, including two four-item scales that can be asked of clients and practitioners respectively.
Although there is evidence for the common factors approach, critics contend that it is hard to disentangle the personal and interpersonal components from the specific elements of the program itself. However, there is a strong case for saying that common factors and evidence-based programs are complementary. As Barth’s team put it, “a well-trained clinician who has exceptional skills in engaging clients and creating a therapeutic alliance and in the use of an evidence-based intervention would have the best chance of a positive outcome.”
Indeed, an important message regarding both the common factors and common elements approaches is that they have a “both/and” relationship with evidence-based programs. Common elements should be viewed as an option where there is no suitable evidence-based program for the client or a particular problem. Clinicians must provide compelling evidence for deviating from such programs.
Both approaches also emphasize the involvement and contribution of clients in monitoring progress and “flexibility within fidelity.” For instance, while there should be flexibility in the selection, sequence and pacing of each common practice element, there are prescribed steps or tasks within each that require fidelity. These can be deviated from if the client shows little progress but only after first checking that they are being carried out as the program was designed to be implemented. There should also be flexibility in engaging with clients: “Fidelity here means assessing the client’s perspective of the treatment to ensure that the client’s goals are being met and, if not, changing course. In this way, fidelity does not mean staying true to a treatment manual, but staying true to the client’s goals in the treatment process.”
The most obvious challenges facing these approaches are overcoming the possible problems in ensuring that all practitioners can have access to the common elements tools, and the urgent need for more research to assess whether these approaches are as effective as evidence-based programs. Since programs alone may not be sufficient for incorporating research-based findings into practice for all clients, common elements and common factors offer an exciting new avenue. But there is also a danger that their inherent flexibility, which makes them so attractive, may lead to “forms of eclectic practice that may not significantly improve on current social work practices.”
Reference:
Barth, R. P., Lee, B. R., Lindsey, M. A., Collins, K. S., Strieder, F., Chorpita, B. F., Becker, K. D. & Sparks, J. A. (2012). Evidence-based practice at a crossroads: the timely emergence of common elements and common factors. Research on Social Work Practice 22 (1), 109-119.
