Adm Policy Ment Health (2013) 40:39–41 DOI 10.1007/s10488-012-0452-6

COMMENTARY

Comment to Garland: ‘‘With a Little Help from My Friends’’ William E. Reay

Published online: 2 December 2012 Ó Springer Science+Business Media New York 2012

Introduction The results presented by Garland et al. are not surprising. These problems have been widely known to both the provider and research communities for years, and have been largely ignored by policy makers and funding sources of children’s mental health services. How these problems have persisted in the face of this overwhelming evidence is perplexing. More confusing is the general lack of outrage at this multilevel failure. Clearly, our graduate school training programs have not kept pace with advancements in basic measurement, treatment, model development, and evaluation science. Graduate students are not receiving the training necessary to competently treat complex behavioral health conditions, even at the most novice level. Moreover, students are not minimally trained in identifying and avoiding services and settings that have known iatrogenic effects. Even universities with well-known evidence-based treatment programs fail to train students in adequate measurement, clinical feedback, and knowledge transfer science. Treatment oriented text books and results from randomized clinical trial research are obsolete within a few years of reaching highly motivated graduate students. It is very well known that the average time required for the results of research to reach an end-user clinician is approximately 14 years. Although most students possess computer skills required to develop an academic paper and conduct minimal research, they lack competencies necessary to conduct W. E. Reay (&) OMNI Behavioral Health, Northcentral University, 5115 F Street, Omaha, NE 68117, USA e-mail: [email protected]

web-based research aimed at finding, analyzing, and choosing the most effective evidence-based treatment programs. With very few exceptions, universities do not provide opportunities for students to learn web-based applications for accessing and critically evaluating evidence-based treatments; skills absolutely necessary for professionals to address many complicated mental health conditions. It is exceptionally rare to encounter a graduate who has been trained in the use of electronic clinical record-keeping, clinical feedback systems, or evidencebased platforms. For years, I have been disappointed at the number of terminally degreed professionals who do not read, analyze, or comment on applied research. It is impossible to adequately supervise novice and intermediate students or staff without maintaining a strong commitment and habit of systematically reading the literature and synthesizing that information to inform practice. Remarkably, associations, including the American Psychological Association (APA), cannot agree on the competencies necessary for new professionals; how academic programs should design training programs to promote competencies or how to measure competencies once identified. The need for innovative research and new models of knowledge transfer has never been more important. Over the course of three decades, community-based providers have been strongly influenced by a set of values and principles of care. The belief that promoting specific values and principles would produce superior behavioral health outcomes, has been faulty, and harmful to millions of children and families who rightfully believed their lives would improve. I have witnessed a national initiative that is best described as in a state of chronic demonstration; has virtually no scientific support; maintains a multi-million dollar industrial complex that is built upon the backs of

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hopeful parents that are desperate for anything to aid them in their daily struggle to cope with their children’s behavioral and mental health challenges. Billions of dollars continue to be spent on a mental health system in that is largely based upon local folk-lore, superstition, and professional habits passed down from year-to-year. Could we have been so naı¨ve to believe that if we just effectively coordinate unexamined services, that somehow those services would magically transform practice into something that could produce superior outcomes? For 20 years, we have had repeated opportunities to correct this path of continued failure. Funders and policy makers knowingly keep funding behavioral health services that provide little to no improvement for children and families, or cause harm; undermine the confidence in our profession; and further reduce behavioral health services to mere commodities; marginalized and minimized.

The Need for a New Agenda Although no one can argue with the results obtained, Garland and her colleagues fail to offer solutions that will substantially advance the research knowledge that will assist the provider community improve services. Although repeatedly mentioning the importance of context in the understanding and delivery of services, they fail to offer a method of conceptualizing an ‘‘ecologically valid’’ research agenda. For example, children’s mental health and family survival are influenced in particular ways, including history, social, and economic circumstances. These factors of known behavioral influence are typically treated as ‘‘demographic variables’’ and not primary proximal factors in current research efforts. Neighborhoods, schools, and groups are substantial contributors to child behavior. Individuals are members of several groups, not just the family. An ecologically valid research agenda would recognize the relevance and contribution to these groups. This agenda must provide both metrics and research methodologies to meaningfully examine hierarchically organized independent variables related to development of mental health conditions, both desirable and undesirable. The current approach to the development of EBPs perpetuates the problem and fails to offer little as way of solution. The past 30 years has seen the passage of two distinct social initiatives that shared various degrees of scientific rigor. The SOC (including the Individualized Systemof-Care) has been, and continues to be, a values-based initiative with only a very limited rigorous research branch. Evidence-Based Treatments (Including Common Factors), on the other hand, have to a large measure, followed the ‘‘black-box’’ approach to research design, analysis, and social understanding. In other words, the individual and

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family are at the focus of the intervention and analysis. Research results are discussed in terms of that very limited unit of analysis. Neither initiative produced desirable results. Both have failed to be adopted by providers, in spite of there being some evidence that principles of the SOC and approaches offered by EBPs can provide improvements on some artificial metric within some settings, and with some populations. However, these initiatives are neither helpful nor ecologically valid. Ecologically valid research approaches must include the capacity to accurately and reliably measure community variables that determine mental health status. Much of our current failed research program ignores advances in other sciences; refuses to focus on finding the underlying psychological mechanisms associated with various mental health status, and ignores the need to determine the socialization factors that reinforce and strengthen certain behavioral health conditions associated with those mechanisms. Until a research agenda address the foundational psychological processes integral to specific socialization factors associated with various mental health conditions, community providers will remain confused about evidence-based practices and how those practices can be used within their ecologies. Researchers need to expand their efforts beyond the ‘‘therapist-client’’ unit of measurement. Limiting explanations of clinical results to the relationship of the therapist and client ignores the fundamental and foundational psychological process problem. Ecologically valid treatment components exist far beyond that relationship. To be ecologically valid requires researchers to abandon their typical approach to conducting research.

The Need for New Relationships and Innovation in Research Providers must be prepared to apply and generate high quality clinical data. It must become common place for each and every provider. This can only occur if three technical capabilities with known competencies exist within each providing agency: 1. 2. 3.

Easy access to web-based EBP data; Client data entered and managed within an electronic clinical record system; Continuous Quality Improvement data are both contextually valid and ecologically relevant to the organization, supervisor, clinician, and client.

Having a provider infrastructure capable of using and producing high-quality clinical data will allow the research and provider communities to undertake the type of ecologically valid research that will guide comprehensive

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clinical behavior, and new research strategies. No longer will there be a ‘‘research-to-practice’’ gap, there will only be bi-directional feedback between provider and researcher. Researchers and providers, through the use of new and emerging technologies and relationships can generate and analyze data together. The current approach must give way to designing interventions within ecologies where they are intended to be used. Highly controlled research environments lack the very relevancy they are purportedly designed to inform. Eliminating methodological bias, something that is a central consideration within the research setting, is impractical and unavoidable in applied settings. Unavoidable bias, such as the inability of a provider to control important client co-morbid variability, may render a successful treatment developed in a controlled setting undesirable at the uncontrolled, highly variable average community agency. This variation results in misunderstandings, a waste of valuable talent and money, not to mention missed opportunities to inform the profession and improve care. The implementation of so-called EBPs that use contextually invalid designs and metrics to inform the provider community is yet another insult to our industry. Over the past 20 years there have been many opportunities to incorporate research results from more distal variables such as the what happens to children when they experience radical changes in their housing, family structure, economic conditions, as well as indifferent school policies associated with truancy and school withdrawal. This area of ‘‘intervention research’’ focuses specifically on distal variables that clearly impact the direct behavior of youth and families. Creating measures of community and social processes and mechanisms will permit a more useful analysis of the complex ecosystems of person’s lives, including clinicians, youth, parents, and the nested ecosystems within neighborhoods, schools and communities.

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Improvements in multi-level metrics and measurement must advance together. Treatments must become ecologically valid. Given this state of collective failure in efforts, perhaps it is time to be more concerned with fundamentals associated with our science so efforts can focus on identifying underlying psychological mechanisms and corresponding socialization processes associated with the disorders. Continuing the current research focus denies the complexities of relationships in an attempt to produce artificial statistical outcomes. Researchers and practitioners may agree on the importance of measuring care (treatment) and measuring the effects treatments have on some outcome, presumably associated with that care. However, that fragile agreement quickly erodes. Focusing on process and proximal goals does little to inform the distal outcomes a client actually experiences or the care they receive. Our failure to identify psychological mechanisms responsible for optimal responsiveness to treatment or what treatment processes are best described as optimal care, is more than a mere inconvenience. Our inability to identify people who are ‘‘best’’ indicated for treatment, but likely not to benefit due to specific social (distal) or physical characteristics (biological) conditions calls our fundamental research approach into serious question. Furthermore, our collective inability to define treatment-outcome targets associated with sub-optimum, yet desirable outcomes is evidence to how far our science needs to mature. Consequently, treatment processes have become adherence or fidelity mandates that somehow have received equal status to that of biochemical compounds measured in milligrams and doses. This misuse of science diverts our attention from important research questions, and relegates us to activities and constructs that are relatively easy to measure, but lack the complexity of human existence.

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