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RE: Evidence-based and "Mix and Match" Programs
Mark and Ben,
I am hesitant to get into the dialogue of two such titans in the field, but
am struck as I always am about the missing elements in our treatment
discussions. Both of you make incredibly important points and I too believe
deeply in science guiding our planning of treatment. But this discussion
leaves out two important elements in child protection work -- that I believe
we often we as researchers ignore -- WHO is actually doing the work and the
CONTEXT in which it is done. Coupled with the risk of a child death, both
may explain the desire to add and add and add.
Who - Most parent home visitors and caseworkers are not trained to do the
kind of work we want them to do. Indeed, I have seen home visitors who are
bank tellers or human resource workers or ones who did housing work. None
with prior training more than a workshop here and there. So we can develop
whatever intervention we like --we are still expecting someone to carry it
out. In many contract agency settings, supervision is minimal and
backgrounds of staff do not match the requirements of our protocols.
Where - In urban settings when I have visited homes to conduct research
interviews or in the past to do home interventions, I often have gone to
neighborhoods where a shooting has taken place just a week ago (setting off
a sense of vigilance even though I am seasoned in going to such
neighborhoods). I might have to step over a drunken neighbor who is passed
out on the stoop or the half drunk one, who insists on having a conversation
with me before I can get past them to get into the home. I then enter homes
where at times I am treated to a shouting argument between a man and a woman
that at moment feels like it will erupt into a physical fight. Other men
enter the home during the visit and stare rather belligerently at me or join
in taking the boyfriend's or husband's side. The woman may have no food and
the child appears sick. She is crying. This is the context where the work
is being done. Cognitive science tells us that cognition is disrupted under
such conditions.
Put a frightened young worker and this context together and add high risk
for a child and the worker is overwhelmed and wants all the help she can get
and probably is shaking too much to carry out anything in any standardized
way. It FEELS like more is better -- because the situation has so many
elements. She may habituate to this over time and with good supervision grow
into a decent practitioner who can carry out focused approaches. More likely
if she is good, she will leave the work for a job in a setting where she can
feel safe and carry out her work more effectively.
Yes -- in a the context of a workshop and under ideal conditions with the
right coach, caseworkers can come up with a good treatment plan that is
focused and may be enough to produce results -- but that is with a coach
like one of you and the safety of sitting in a room with nothing to lose and
no threats hanging over them.
Treatment development work in child maltreatment is unlike other treatment
development areas where most interventions are carried out by professionals
who have much education and in the context of an office setting. I want the
field to develop science based protocols, but until we deal with staffing
issues and focus our attention on methods for coping for staff -- the "add
and add and add" approach will continue to feel safer for most.
Sandra
------------
Sandra T. Azar, Ph.D.
Professor
Psychology Department, Moore 541
Pennsylvania State University
University Park, PA l6801
814-863-6019 (office)
sta10@psu.edu
-----Original Message-----
From: bounce-3424753-6833833@list.cornell.edu
[mailto:bounce-3424753-6833833@list.cornell.edu] On Behalf Of Saunders PhD,
Benjamin E
Sent: Friday, December 26, 2008 11:44 PM
To: Child Maltreatment Researchers
Subject: RE: Evidence-based and "Mix and Match" Programs
Mark,
Thank you for the excellent summary of several very important issues. Two
points are particularly critical for future research. IMHO, the current
excitement in some quarters over "components" approaches to treatment vs.
manualized "protocols" is, from a research perspective, a red herring. As
you note, both must have some sort of decision rules about what to do next
at certain points in treatment. If not, they just become virtually random
in nature. So, the results of those decisions will need to be tested
empirically whether it means following a "protocol" or decision rules about
using components. Frankly, when one scratches the surface, the two
approaches sound suspiciously similar.
Some have suggested that components approaches are more efficient because
they use only the "active ingredient" components of protocols at key points
in the treatment and skip the unnecessary stuff. Unfortunately there is
precious little dismantling research discerning exactly what those active
ingredients are, and whether or not they only get active when the other
"unnecessary" components have been used as well (what one might call
conditional component efficacy). It may turn out that the components that
have been picked to be used actually do have the most impact even when not
used in concert with other techniques. Or not. This hypothesis remains to
be tested for most approaches.
Others have suggested that "components" approaches are more palpable to
clinicians because then they can use their clinical judgment when to do what
rather than following the strict rules of a protocol. However, as you point
out, many of the components approaches then proceed to teach elaborate rules
for when and how to use the particular components chosen and end up being
more complicated than protocols (but without the outcome research to support
their efficacy). While the whole components vs. protocols debate is an
interesting pastime for some of us, from an empirical testing standpoint, it
may be a debate without a difference. The empirical question still is,
"When therapists do this, do clients get better compared to when therapists
do that?" Call it what you will, components, protocols, or whatever, you
still have to define the "this" (aka independent variable) in sufficiently
replicable manner.
You second point about "focused" vs. "comprehensive" treatment planning also
is absolutely critical. At a recent training for about 50 CPS workers, I
gave them all a case we had seen recently in our clinic and asked them to
break into groups and come up with a treatment plan. the case was a typical
train wreck, multiproblem, abusive family. We then wrote on a flip chart
all of the interventions, treatments, programs and meetings they thought the
family should receive and go to. It took 4 large flip chart sheets to write
them all down. I then asked the workers two questions. First, did they
think any family in the world, much less this family, could get their child
to even half of the appointments they were recommending. Second, did anyone
in the room believe this was an effective treatment plan that would
accomplish the goals we had set for this family. No one in the room
believed any family (even their own) could accomplish half of the treatment
plan, and not one person thought it was an effective treatment plan. Yet
they wrote it. They agreed that they have been trained and acculturated to
simply add and add and add and add to treatment plans to the point of being
ridiculous. The good news is that at the end of the day, when challenged to
come up with a feasible treatment plan composed of evidence supported
interventions and programs, they were able to do it and the plan was about
1/3 of a flip chart page.
The notions that more is better and that doing an untested something is
always better than doing nothing permeates the system and needs to be
challenged.
Again, thanks for the elegant thoughts.
Ben
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Benjamin E. Saunders, Ph.D.
National Crime Victims Research and Treatment Center
Medical University of South Carolina 843-792-2945 Phone
Charleston, SC 29425 843-792-7146 Fax
Visit our web sites: www.musc.edu/ncvc www.musc.edu/tfcbt
www.musc.edu/ctg www.musc.edu/saprevention
________________________________________
From: bounce-3422423-6832002@list.cornell.edu
[bounce-3422423-6832002@list.cornell.edu] On Behalf Of Chaffin, Mark J.
(HSC) [Mark-Chaffin@ouhsc.edu]
Sent: Wednesday, December 24, 2008 8:31 PM
To: Child Maltreatment Researchers
Subject: RE: Evidence-based and "Mix and Match" Programs
Tom,
Yaiiii....where to start. There is considerable interest in the idea of
extracting common elements from across evidence based models, then applying
these depending on assessed case characteristics and some systematic
algorithm. Probably the most detailed system of how this process might be
undertaken has been described by Chorpita and colleagues. Note, however,
that the processes for identifying both the elements themselves and the
matching algorithm as described by Chorpita are NOT just a matter of
logic-model 'mix and match' eyeballing based on the clinician's gut or
personal preferences. It is a quite structured and quantitative process.
It is still a protocol (and a complicated one at that), and not at all the
same thing as free-styling, fly-by-the-seat-of-the-pants services often
advocated by the anti-EBT crowd. If anything, it is a system probably
requiring more expertise and training than most simple EBT's. How well
these algorithm-driven, elements-based systems work in practice is a subject
of ongoing study. The jury is not in. Some EBT's such as MST, have done
essentially this same thing for years and its worked out well. MST, for
example, is not a single protocol, but is assessment driven and tailored,
yet focuses the intervention on what we know matters, using basic elements
that are known to work In this sense, there are fairly complex EBT's, such
as MST, which target broad populations, and more specific EBT's, such as
TF-CBT for example, which are specific for particular types of well-defined
problems (i.e. PTSD).
The elements-based idea does have a clear appeal--EBT's are probably not
monolithic entities incapable of being subdivided. Most share common
elements within a given domain (e.g. most evidence-based parenting programs
share many common elements such as use of labeled praise, application of
structured time-out protocols, etc.). However, I would be very skeptical of
efforts to use this rationale to neuter EBT's, or to simply say "oh, we're
already doing all that" or "this is the same thing" when it really isn't the
case. One need look no further than the Blueprints implementations to find
evidence of this, where well-intended shooting from the hip led to blending
in ad hoc crap with EBT's and spoiled the results. The point is that the
elements-based approach is not an excuse to allow anything and everything to
come into the intervention or to mix-and-match without some fairly tight
limits, such as those described by Chorpita and colleagues.
The area of most concern in your question lies in the idea of whether more
is better. There is excellent evidence at this point that this is not only
false but that more can become harmful. For example, where parenting
interventions are concerned, it appears that adding additional services to a
parenting program actually poisons the benefits (Kaminsky, et al.
meta-analysis). CPS and courts are notorious for this misconception--often
prescribing so many services that whatever benefits any of the services
might have offered may be quickly lost in the confusion. The analogy to
"polypharmacy" in psychiatry is not a bad one. Focus (i.e. directly
behaviorally targeting the top priority that needs to change) rather than
comprehensiveness (trying to fix everything), is the new watchword in many
service systems. Exactly how much is too much, and what demands the
highest priority is an unanswered empirical question. But the emerging
science in this area does, IMO, suggest a couple of general principles.
First, tailoring might work...IF the elements are selected carefully based
on scientific evidence and are clear essential common components across
EBT's. Second, there are clearly both practical and therapeutic limits to
how many things can be done well at once, and this point is reached rapidly
and past that point quickly begins to ruin the overall service benefit. So,
"focus" not "comprehensive" should be the watchword. We need to emphasize
this watchword because practitioners have been so imbued with the idea that
"comprehensive" is necessary that it takes considerable effort to disabuse
them of this unfortunate misconception. This is another reason why any
novel algorithm-driven, elements-based protocols need to be structured. And
why it needs to be rigorously evaluated. Keep in mind that implementations
of novel blended or elements-based programs cannot properly be called
evidence-based just because the sources for the elements were
evidence-based. For that matter, it cannot even be presumed to be effective,
altough we might predict that it would be.
Mark
________________________________________
From: Tom Hanna [tph3@cornell.edu]
Sent: Thursday, December 18, 2008 8:25 AM
Subject: Evidence-based and "Mix and Match" Programs
On another list, there is active discussion underway on starting an
"ancillary" parenting education program to an existing "core" home
visitation program. The conversation quickly turned to the topic of
"evidence-based", and then to funders and their requirements.
The picture quickly got cloudy for me:
1. Some folks who already have an ancillary parenting education
program reported that "blending" aspects of two evidence-based
programs allowed them to tailor the trainings to the specific needs
of their "home visited" parents. Others quickly pointed out that
this is "wrong" and should not be done -- neither evidence based
program is being followed precisely, and therefore both are
"contaminated." Funders frown.
2. No one has said what additive effect, if any, is expected from
providing a parenting program on top of a home visitation program.
The underlying assumption is that families will be better off with
two distinct interventions instead of one. (In fact, many centers in
this home visiting network have many ancillary programs that serve
some if not many of their home visited families.)
3. I know that lots of funders are demanding that agencies use
"evidence-based" programs. But I now learn that funders are pushing
implementation of a "matrix" of "evidence-based" programs. The
underlying assumption is that "if one evidence-based program is good
for families, then many are better."
My question: Is there any research that helps multi-service agencies
make their way through this minefield when working with a cohort of
families?
-- Any study of the "deterioration of effects" of the blending of two
evidence based models for the same intervention?
-- Any classical studies of "additive effects" of multiple targeted
interventions?
-- Any evidence that a "matrix" of evidence based programs has a
stronger effect than a "pure" one-program approach?
-- Any analysis that shows that evidence based programs in different
interventions (home visitation vs parenting ed vs therapy groups) are
(or are not) internally consistent? (ie, my doctor gave me one
instruction about diet, my nutritionist gave me a contradictory
instruction, and my home visitor's instruction differed from the
other two.)
TIA
Tom
--
--
Tom Hanna, Director
Child Abuse Prevention Network
www.child-abuse.com
tom@child-abuse.com
tph3@cornell.edu
off 607.275.9360
cel 607.227.4524
fax: 415.962.0510
--