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Frontline Workers’ Resistance To Evidence-Based Practice In Substance Abuse Treatment: Some Good Reasons

behavioral therapy with a patientOver the past decade, prominent federal substance abuse agencies have put a great deal of effort toward ensuring that evidence-based practice (EBP) is being utilized in the treatment of addiction.  This effort was galvanized by a 1998 report from the Institute of Medicine calling for improvements in healthcare, which included the implementation of practices proven effective through scientific research (EBPs).  However, the majority of frontline agencies that treat people suffering from addiction — community based organizations — have been slow to implement EBPs in their work. Why are frontline workers in the field of addiction treatment hesitant to implement EBPs?

A recent study from the Center for Addictions Research and Services of the Boston University School of Social Work attempted to answer this question. Dr. Maryann Amodeo and her colleagues interviewed 172 frontline addiction workers from community-based organizations that had received funding from the Center for Substance Abuse Treatment (CSAT) / Substance Abuse Mental Health Services Administration (SAMHSA) to implement EBPs.  Qualitative interviews, ones that allowed participants to express themselves in their own words, rather than a forced-choice response questionnaire, were used in this study.

Amodeo and her colleagues chose to focus on four common EBPs in the substance abuse treatment field.

Two were individually-oriented approaches:

  1. Motivational Interviewing (MI), a brief approach that targets and builds on client motivation to change.
  2. Cognitive-Behavioral Therapy (CBT), a theoretical umbrella under which a host of present-focused techniques involve identifying and modifying triggers for substance abuse, especially clients’ thought patterns, and reinforcing sobriety-related activities.

The other interventions focused on the broader environmental level:

  1. Adolescent Community Reinforcement Approach (A-CRA), a behavioral approach, that aims to supplant reinforcers for substance abuse with environmental contingencies (particularly those applied by family members) that are supportive of recovery.
  2. Assertive Community Treatment (ACT): a team treatment approach that delivers comprehensive, individually tailored case management services for clients who suffer both from severe mental illness, as well as substance-use disorders.

The authors of this study found that different barriers to implementation accompanied each type of EBP.  Barriers were categorized as having to do with the following:

  1. EBP characteristics: barriers having to do with the intervention itself. Thirty-eight percent of A-CRA participants responded in this category as A-CRA requires what is perceived as a burdensome certification process in order to practice the model.
  2. Practitioner or Organizational barriers: those having to do with philosophical or practical barriers that arise with the practitioner or the organization. More than half (54%) of MI respondents named barriers in this category.  Front-line workers complained of not receiving sufficient training in order to implement the model well. Another barrier was the conflict between the philosophy of staff and/or the organization, which tended toward an Alcoholics Anonymous perspective, and the assumptions underlying Motivational Interviewing.
  3. Client characteristics. A majority of those implementing CBT (67%) named barriers in this category. Specifically, they mentioned client resistance to CBT, clients’ lack of cognitive ability, and poor attendance. Thirty-three percent of practitioners of A-CRA complained that it was inflexible to meet individualized client needs, and they had the added challenge of engaging parents in treatment as the model demands.
  4. Resources. A lack of resources, particularly housing, in the community was named as a major barrier for ACT (82% of participants).

Since respondents in this study were all from SAMHSA-funded programs that demanded, as part of their funding, that evidence-based practice was implemented, the agencies in which they worked are likely more advanced in terms of their receptivity to and knowledge of EBP’s.  Therefore, barriers in other community-based agencies are bound to loom even larger.

This study identified specific, real-world barriers that have to do with the difficulty of implementing EBPs in community-based agencies.  Developers of these models, as well as trainers, need to be aware of barriers and find ways to dispel them.  EBPs may also require more extensive training than is currently being offered in order for practitioners to feel comfortable and competent in applying them.  Finally, treatment manuals should include instruction on possible obstacles to implementation and present ways to overcome them.

Amodeo,M.,et al.Barriers to Implementing evidence-based practices in addiction treatment programs: Comparing staff reports on Motivational Interviewing, Adolescent Community Reinforcement Approach. Assertive Community Treatment, and Cognitive-behavioral Therapy. Evaluation and Program Planning (2011), doi:10.1016/j.evalprogplan.2011.02.005

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