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Message ID: 7978
Date: 2009-01-05

Author:Ben Saunders

Subject:Re: Evidence-based and "Mix and Match" Programs

Sandra,

Absolutely agree with your comments (other than the "titan"

characterization). Without question, neighborhood and other contextual

factors have an enormous impact not only on the functioning of people

living in them, but also on the range of options available to helping

professionals trying to do their job. Our challenge is, how can we best

do good child welfare work in very bad contexts with families with

multiple problems. Do we have to cure poverty, crime, unemployment,

poor education, housing shortages, and discrimination in order to do

quality child welfare work? I hope not. But do these social ills make

it tough work? Absolutely. I think this is the focus part Mark is

speaking about and I am agreeing with. (Mark, I am sure you will feel

free to correct me.) It may be that in trying to mitigate all problems

with multiple, specific interventions/programs we actually decrease the

potential for the positive impact of any of them. Giving direction for

the most effective mix of interventions with which families is one of

the jobs of research. The good news is that we seem to be learning more

about this. It may be that by actually doing one or two things that

effectively attack a limited set of problems, we will have a more

positive impact not only on the targeted problems but also on many other

problems compared to trying to do a lot of things all at once. The

burden of multiple interventions imposed on families (and workers) may

reduce their individual effectiveness, perhaps because they are never

properly delivered. There also may be negative interactions between

interventions that inherently reduce their impact even when families

participate in everything assigned. These are all hypotheses to be

tested. However, the evidence does seem to be mounting that there is

not simply a linear, additive effect to interventions so that more is

better. A primary challenge for researchers right now probably is not

to develop and test yet more interventions and programs. Rather, we

might want to examine the "reach" or generalization effects to

nontargeted problems of some of our more effective existing

interventions and the interactions positive or negative, between them.

Mark's work with PCIT is a great example of that sort of work. Without

this sort of research to base their work on, I think you are right,

frontline workers will continue to see awful situations and think trying

to give the family everything is the way to go. Without reliable

information to the contrary, why would they not? As you say, it feels

right to do so and the stakes often are very high.



I also agree that any system that does not provide effective training,

ongoing supervision, and ready access to useful information and practice

tools for its front-line workforce is unlikely to produce good work, and

the child welfare and mental health systems are no different. Our

challenge as researchers is to figure out better ways of doing that

effectively and efficiently. The emerging dissemination and

implementation research literature can be of help here, as well as the

substantial dissemination work going on around the country. I am

optimistic. In our statewide EBT dissemination and implementation

project (Project BEST) we find that the practice wisdom of frontline

caseworkers is not contrary to the existing research, as my training

example in the previous post illustrated. Caseworkers have a pretty

good idea which programs work and which do not. They lament that

ineffective programs are often part of the "standard" treatment plan

institutionalized on the agency computer system and that effective,

evidence-based programs often are not available in their community.

They know treatment plans with multiple interventions often fail even

with highly motivated families because they are unrealistic for the

context. After relatively brief training, they are excited about the

notion of evidence-based treatment planning, and for the most part have

a good feel for titrating interventions and capitalizing on the

strengths of families in treatment plans. With ongoing consultation,

practice tools, and administrative support, they are able to put it in

practice. Our state is rethinking its traditional approach to new

worker training as a result. However, more research is needed to better

understand optimal approaches to training, implementation and

sustainability. How best to get what is known incorporated into the day

to day work of the frontline worker is yet another challenge for

researchers. And this is a tough one.



Ben



Sandra Azar wrote:

> 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

> --

>

>

>

>

>



--

Benjamin E. Saunders, Ph.D.

National Crime Victims Research and Treatment Center

Medical University of South Carolina

165 Cannon Street, MSC852 843-792-2945 Phone

Charleston, SC 29425 843-792-7146 Fax



Visit our web site: www.musc.edu/ncvc

Take our web-based courses: www.musc.edu/tfcbt www.musc.edu/ctg











Sandra,

Absolutely agree with your comments (other than the "titan"

characterization). Without question, neighborhood and other contextual

factors have an enormous impact not only on the functioning of people

living in them, but also on the range of options available to helping

professionals trying to do their job. Our challenge is, how can we best

do good child welfare work in very bad contexts with families with

multiple problems. Do we have to cure poverty, crime, unemployment,

poor education, housing shortages, and discrimination in order to do

quality child welfare work? I hope not. But do these social ills make

it tough work? Absolutely. I think this is the focus part Mark is

speaking about and I am agreeing with. (Mark, I am sure you will feel

free to correct me.) It may be that in trying to mitigate all problems

with multiple, specific interventions/programs we actually decrease the

potential for the positive impact of any of them. Giving direction for

the most effective mix of interventions with which families is one of

the jobs of research. The good news is that we seem to be learning more

about this. It may be that by actually doing one or two things that

effectively attack a limited set of problems, we will have a more

positive impact not only on the targeted problems but also on many other

problems compared to trying to do a lot of things all at once. The

burden of multiple interventions imposed on families (and workers) may

reduce their individual effectiveness, perhaps because they are never

properly delivered. There also may be negative interactions between

interventions that inherently reduce their impact even when families

participate in everything assigned. These are all hypotheses to be

tested. However, the evidence does seem to be mounting that there is

not simply a linear, additive effect to interventions so that more is

better. A primary challenge for researchers right now probably is not

to develop and test yet more interventions and programs. Rather, we

might want to examine the "reach" or generalization effects to

nontargeted problems of some of our more effective existing

interventions and the interactions positive or negative, between them.

Mark's work with PCIT is a great example of that sort of work. Without

this sort of research to base their work on, I think you are right,

frontline workers will continue to see awful situations and think trying

to give the family everything is the way to go. Without reliable

information to the contrary, why would they not? As you say, it feels

right to do so and the stakes often are very high.



I also agree that any system that does not provide effective training,

ongoing supervision, and ready access to useful information and practice

tools for its front-line workforce is unlikely to produce good work, and

the child welfare and mental health systems are no different. Our

challenge as researchers is to figure out better ways of doing that

effectively and efficiently. The emerging dissemination and

implementation research literature can be of help here, as well as the

substantial dissemination work going on around the country. I am

optimistic. In our statewide EBT dissemination and implementation

project (Project BEST) we find that the practice wisdom of frontline

caseworkers is not contrary to the existing research, as my training

example in the previous post illustrated. Caseworkers have a pretty

good idea which programs work and which do not. They lament that

ineffective programs are often part of the "standard" treatment plan

institutionalized on the agency computer system and that effective,

evidence-based programs often are not available in their community.

They know treatment plans with multiple interventions often fail even

with highly motivated families because they are unrealistic for the

context. After relatively brief training, they are excited about the

notion of evidence-based treatment planning, and for the most part have

a good feel for titrating interventions and capitalizing on the

strengths of families in treatment plans. With ongoing consultation,

practice tools, and administrative support, they are able to put it in

practice. Our state is rethinking its traditional approach to new

worker training as a result. However, more research is needed to better

understand optimal approaches to training, implementation and

sustainability. How best to get what is known incorporated into the day

to day work of the frontline worker is yet another challenge for

researchers. And this is a tough one.



Ben



Sandra Azar wrote:

> 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)

> sta10psu.edu

>

> -----Original Message-----

> From: bounce-3424753-6833833list.cornell.edu

> [mailto:bounce-3424753-6833833list.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-3422423-6832002list.cornell.edu

> [bounce-3422423-6832002list.cornell.edu] On Behalf Of Chaffin, Mark J.

> (HSC) [Mark-Chaffinouhsc.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 [tph3cornell.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

> tomchild-abuse.com

> tph3cornell.edu

> off 607.275.9360

> cel 607.227.4524

> fax: 415.962.0510

> --

>

>

>

>

>



--

Benjamin E. Saunders, Ph.D.

National Crime Victims Research and Treatment Center

Medical University of South Carolina

165 Cannon Street, MSC852 843-792-2945 Phone

Charleston, SC 29425 843-792-7146 Fax



Visit our web site: www.musc.edu/ncvc

Take our web-based courses: www.musc.edu/tfcbt www.musc.edu/ctg