Bridging the present-to-future gap in graduate school: The importance of studying dissemination and implementation
Author: Davielle Lakind
From my first week of graduate school, I was made aware of the mandate for the use of evidence-based practices (EBPs) that has come to dominate conversations around the delivery of psychotherapy and psychiatric care. Over the course of this first year and a half of school, I have learned about the rationale for EBP dissemination, and been taught the process through which the evidence base around a particular treatment accrues. We have also discussed some of the controversies surrounding the EBP movement: for example, that the exclusion of comorbid presentations from research studies has resulted in treatments with a questionable evidence base for individuals commonly seen in usual care settings; and that EBPs have not been sufficiently studied and may not be sufficiently adapted for members of many ethnic minority groups (Chambless & Ollendick, 2001; Weisz, Jensen-Doss & Hawley, 2006).
Another critical piece of our EBP education in graduate school involves discussions of the research-to-practice gap that impelled the EBP movement initially, and that persists to this day in spite of its theoretical ascendancy (McHugh & Barlow, 2010, Garland et al., 2013). Unfortunately, the conversations too often stop there. This may not be surprising, given the disproportionate attention in the field at large to research on clinical therapies over research that examines treatment context and community-based care (Hoagwood, Olin & Cleek, 2013). But with a growing recognition that contextual factors such as intervention fit, social process factors and regulatory practices critically inform the consistency and fidelity with which EBPs are utilized in most practice settings (Aarons et al., 2011), we would be well served to incorporate this area of study into our education. Without gaining exposure to dissemination and implementation research in our formative educational years, we could be consigning ourselves not only to perpetuating the imbalance in the field’s focus, but also to minimizing our relevance as the field develops.
One thing that research on the contextual features of mental health service delivery tells us: services are no longer primarily delivered in dedicated mental health facilities. The majority of our clinical training opportunities, however, are still housed in such sites (Atkins, 2013). Certainly we can benefit from training in these incubator-like settings, but recognizing that such sites do not represent normative service delivery venues should serve as impetus to seek supplemental training experiences in “alternative” settings — schools, for example, which in reality provide more mental health care for children than any other sector (SAMHSA, 2012). We know, too, that doctoral level psychologists deliver a smaller and smaller proportion of mental health services in the U.S. (Schoenwald, Hoagwood, Atkins, Evans & Ringeisen, 2010), a trend showing no signs of reversing given fiscal realities and the changing landscape of healthcare (Garland et al., 2013); yet we train primarily to serve as clinicians.
Broadening our scope beyond the traditional bounds of the EBP conversation not only highlights the gap between research and practice, but also the gap between service provision and need. With current estimates suggesting that roughly half of children who need mental health care receive it (Kataoka, Zhang & Wells, 2002; Merikangas, Nakamura & Kessler, 2009), it is clear that we must consider the entire constellation of components that will facilitate service delivery to many more of those who require it (Atkins & Frazier, 2011). Alternative settings, providers, and services may be better positioned to overcome barriers and improve outcomes for more children and families (Stiffman et al., 2010): community members, for example, may be better positioned than outside professionals to disseminate innovations (Rogers, 2003); paraprofessional “peer family advisors” show promise in supporting families to engage and participate in services (Hoagwood et al., 2010); provision of care in alternative settings may reduce stigma, as well as improve access (Kazdin & Rabbitt, 2013); and universal prevention strategies may decrease need from the outset (Gordon, 1983).
The changing universe of mental health services and the approaches necessary to address the persistent dilemma of unmet need will require unique dissemination and implementation strategies; indeed, many EBPs themselves will require substantial modification. This information should underscore the need for our education to encompass more than preparation to deliver services ourselves, however proficiently, and more than exposure to research focused on designing and disseminating treatments for other clinical psychologists to deliver. In better understanding the whole swath of challenges the field faces, we would do well to think about how best we can facilitate dissemination and implementation of EBPs as delivered across a variety of settings by social workers, counselors, physicians, teachers, paraprofessionals and volunteers and how we can seek out research and practice opportunities now that help us toward that end (Atkins and Lakind, 2013). Whether our own careers as psychologists follow a primarily research-oriented trajectory or a practice-oriented one, we can best demonstrate our relevance by looking beyond the ivory tower and beyond our own clinical practice.
Lastly, because I work in a research group with an implementation science focus, I have seen for myself that studies that contribute to our knowledge base regarding how EBPs fare in the messy, complicated “real world” — especially those that draw on alternative settings and providers — are very different from other research ventures, not least in the degree to which they are themselves messy and complicated. Community partners may have conflicting priorities, and will most certainly have limited time and resources; macro-level shifts in policy, bureaucratic structures and funding streams may dictate changes mid-study; questions of feasibility, fidelity and contextual fit must be considered in intervention design and measured in evaluation; and data collection and analysis processes are often time-consuming, intricate and plagued by large amounts of missing data due to subject migration or inconsistent community staffing. These challenges, however, reflect realities common to community practice (Atkins, Frazier, & Cappella, 2006); we come no closer to delivering effective services by avoiding them in our work, and do ourselves no favors by avoiding them in our training.
Just as we recognize that a strong graduate education must include training toward competence in psychological assessment and quantitative statistical methods, so too should we conceptualize familiarity with an array of effectiveness-focused research strategies, theories and service delivery models as a necessary component of our education. The challenges around effectively addressing bridging the gap between research and practice and the gap between service provision and need demand it. Reinforcing today’s methods will not fully prepare us for tomorrow’s challenges, and avoiding today’s challenges because they do not conform to current research priorities will not prepare us for the challenges we cannot see but are sure to arise.
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Davielle Lakind is a doctoral student in Clinical Psychology at the University of Illinois at Chicago, and a Student Representative for APA Division 53, the Society for Clinical Child and Adolescent Psychology. She works with the Research Group on Mental Health Services for Urban Children and Families in the Institute for Juvenile Research. Her interests revolve around the integration of mental health services for children and families in low-income communities into natural settings, especially schools, with an interest in facilitating high quality, sustainable service provision by teachers, paraprofessionals and other extant community members.