Evidence-Based Practice at the
Crossroads: The Role of Common
Elements and Common Factors
Richard P. Barth, Bethany R. Lee, Michael Lindsay
Presented at the NASW 6th Annual Fall Clinical Conference
Baltimore, MD
September 22, 2011
What is EBP?
The Alphabet of EBP
What is needed, it seems to me, is some
course of study where an intelligent young
person can ... be taught the alphabet of
charitable science.
Anna Dawes (1883)
From a paper given at the International Congress of Charities and
Correction at the Chicago World's Fair.
Source: Lehninger, L. (2000). Creating a new profession: The beginnings of
social work education in the United states. Washington, DC: Council on
Social Work Education.
ING Importance of
The GROW
Evidenced Based Practice
GPRA* Requirements
• OMB and GRPA require an annual report
from the Office of Child Abuse and Neglect
(and other federal agencies) the
percentage of total funding going to
support evidence-based and evidenceinformed programs and practices
*Government Performance Results Act of 1993
Emerging State Legislation
• Many states and localities have now
enacted legislation requiring the use of
ESIs for:
– Mental health
– Juvenile services
More are beginning to use this framework for
CWS, although very loosely (e.g., Family
Team Decision Making and Wrap Around
Services)
Emerging Federal Actions
• Peter Orszag, Former Director of OMB
– Comparative effectiveness research can
“promote higher value care”
Carolyn Clancy, Director, Agency for Health
Care Research and Quality (AHRQ)
– Our mission is fulfilled when health care decision
makers – including patients, clinicians, purchasers,
and policymakers – use up-to-date, evidence-based
information about their treatment options to make
informed health care decisions.
Question
• Other reasons for embracing
evidence-based practices from
your perspectives?
To Achieve SW’s Promise and Yours
• Fairness
– Giving families meaningful opportunities to improve
the quality of their care
• Compassion
– Reducing the suffering of families and children who
cannot succeed without powerful assistance
• Honor
– To honor the call to service with the very best
possible service
• Enjoyment
– Many practitioners find the supportive framework of
EBP models to be a great relief and the improved
outcomes to be a joy
EBP and MESTs and Practice Guidelines
• Evidence Based Practice
– Procedures and processes that result in the
integration of the best research evidence with clinical
expertise and client values
• Manualized Evidence Supported Treatments
– Interventions that have been manualized and tested
in a rigorous manner –typically in a RCT– and shown
to be more effective than Treatment as Usual (TAU)
• Practice Guidelines
– A set of strategies, techniques, and treatment
approaches that support or lead to a specific standard
of care that guides systems, care, and professions in
their relationships to consumers
Effective & Efficacious Interventions
• Effective (or well-established) treatments are those
which have beneficial effects when delivered to
heterogeneous samples of clinically referred
individuals treated in clinical settings by clinicians
other than researchers
• Efficacious (or clinical utility or efficacy) studies are
directed at establishing how well a particular
intervention works in the environment and under the
conditions in which treatment is typically offered.
Source: Lonigan, C.J., Elbert, J.C., & Johnson, S.B. (1998). Empirically
Supported Psychosocial Interventions for Children. Journal of Clinical Child
Psychology, 27:2. 138-14
QUESTIONS
• What manualized evidence supported
treatments are you familiar with?
• Which have you learned?
– How did it go?
• Which have you wanted to learn?
• Has anyone learned more than one?
– How did they compare?
Fidelity in Social Work: What are the
Boundaries?
• Manualized: Manuals provide the objectives for each
activity/session and the structure, organization, sequence,
and duration of each session/program. Strategies to optimize
the intervention are provided
• Fidelity: The degree to which the treatment that was
described in training or manuals was the treatment that was
delivered
– Flexibility within Fidelity: “client-driven individualizations” of
the manualized treatment (e.g., exposure tasks would vary by
phobia type)
• The treatment strategy: guides the choices of acceptable flexibility
Source: Kendall, P. C. (2006). Flexibility within fidelity: Advocating for and
implementing empirically based practices with children and adolescents. Child
and Family Policy and Practice Review, 2 (2), 17-21.
Implementing MESTs
• Transportability: The extent to which an
intervention can be moved from the
setting in which it was tested to other
settings and maintain it’s effectiveness.
• Uptake: The extent to which an
organization can implement a MEST
– What strategies have you used to
improve uptake in your agency?
Conclusion re Terms
• An evidence based practice framework can
be used to generate a manualized evidence
supported treatment delivered by a social
worker who understands the treatment
strategy--and employs flexible fidelity. This
MEST is likely to be most beneficial when
transported to agencies with good
implementation science and when the
agencies have a strategy for uptake.
Evidence Based Practice is a Process
Evidence Based Practice PROCESSES
Clinical State &
Circumstances
Clinical Expertise
Client
Preferences
and Actions
Source: Shlonsky and Wagner, 2005
Research
Evidence
EBP, Not All About Manuals: It’s About Processes
Contextual
Assessment
Client
Preference
or Willing to
Try?
Cultural
Barriers?
Clinical State &
Circumstances
Appropriate for
this client?
Clinical Expertise
Client
Preferences
and Actions
Source: Shlonsky and Wagner, 2005
Valid
Assessment?
Research
Evidence
Effective
Services
EB Education — The Reality
Whitehurst, G.J. (2002). Evidence-based education (EBE). United States Department of Education.
Retrieved April 26, 2005 from http://www.ed.gov/nclb/methods/whatworks/eb/edliteslide021.html.
The Necessity for Evidence & Wisdom
• Professional wisdom is needed for
-- adapting to specific situations
-- operating where research evidence is
missing or incomplete
• Empirical evidence is needed for
-- reconciling competing approaches
-- “generating cumulative knowledge”
-- avoiding popular wisdom and
individual bias
Whitehurst, G.J. (2002). Evidence-based education (EBE). United States Department of Education.
Retrieved April 26, 2005 from http://www.ed.gov/nclb/methods/whatworks/eb/edliteslide007.html.
Implementation and Fidelity Matters
Cultural Keys to Implementation Success
1. The status and skills of the change agent who
introduces and advocates for a particular ESI (or
for evidence-based practice in general)
2. The extent to which a specific ESI or evidencebased practice in general supports or threatens
the existing cultural system
3. The extent to which that existing cultural system
is sustained and supported by the external
environment (i.e., funding and administration)
4. The cultural fit with practitioner values
Source: Palinkas et al., 2009
MESTs and Culture: Do MESTs Help
“Minority” Children & Families
• Standard evidence-based MH interventions appear
to have as much success, or more, with minority
youth and adults
– Miranda et al (2005) ethnic minorities and depression
– Huey and Polo (2008) ethnic minority youth & MH
– Weisz, Jensen-Doss, & Hawley (2006) evidence-based
youth psychotherapy vs. usual care
– Wilson, Lipsey, & Soydan (2003) on delinquency
• At the same time if cultural adaptations increase
engagement or fidelity by clinicians, then these
should be developed in the spirit of “flexible fidelity”
Implementation with Fidelity
• Fidelity is more difficult to achieve when
the work is more complex—like yours
– But it can be done (take MST and ACT)
• Regular, quality, prolonged supervision is
critical to success— training is not enough
– Attention to methods
– Attention to interim (mediating) outcomes
– Attention to longer term outcomes
Implementing HFA in 6 Sites
89
84
88
82
67
64
% Screened
H1
H2
H3
H4
H5
H6
Hospitals in Which Families Were Screened
Source: Anne Duggan, JHU, SOM
Substantial Variation Across Sites in
Keeping Families Active
Percent of Families Active
120
Percent
100
Hi Fidelity to Assertive Outreach
Approach
80
60
Agency B
Agency A
Agency C
40
20
0
0
4
8 12 16 20 24 28 32 36 40 44 48 52
Weeks of Age
Effective Program Outreach Mattered to Outcomes
Percent Active in Program
100
80
60
40
20
Assertive Outreach
Relaxed Outreach
0
16
32
48
64
80
Maternal Anxiety Score
96
An assertive
outreach
policy
promoted
retention of
mothers
(with high
relationship
anxiety).
Next Steps for Social Work
“Better late than never is poor
consolation for losing an opportunity
of a lifetime”
Henri Matisse
Next Steps for Social Work
• Embrace MESTs with strong
implementation plans and histories (e.g.,
PCIT, ACT, CBT for Depression, MST)
– Learning a single MEST may have a
generalizable benefit (Barth, speculation, 2011)
• Consider alternative approaches that
have emerged from the MEST
dominated early years—
–Common Elements
–Common Factors
Next Steps for Social Work
• Adapt and test interventions having
strong evidentiary support and that are
already in place, to fit some of the
populations that we work with that have
not had interventions developed for
them
• Support continuous evaluation and
research to fill evidence gaps that are
most keen for social workers
Thank you.
OR
S
WHAT IS THE COMMON
ELEMENTS APPROACH?
Bethany Lee, PhD, MSW
Richard P. Barth, PhD, MSW
Michael Lindsey, PhD, MSW, MPH
Fred Strieder, PhD, MSW,
Nicole Evangelista, PhD
School of Medicine, University of Maryland, Baltimore
Kim Becker, PhD
School of Public Health, Johns Hopkins University
The Common Elements approach…
• AKA Distillation and matching method
– Distillation: separating mixtures into distinct
components;
• Breaking down a treatment manual into specific
techniques, tools, and procedures;
– Matching: pairing the solution to the problem;
• Finding the most appropriate technique for the
client need
Origins of the Common Elements approach
Step 1:
Emphasis on
evidence-based
treatments
•Evidence-based practice: a process
of using scientific evidence/ knowledge
from research, clinical wisdom, and
Step 3:
consumer preference to guide treatment
Information
decision-making;
overload: too
Step 2:
many treatment
Development
of
•Evidence-based treatments
(aka
manuals to
learn
treatment
evidence supported interventions):
and manuals
manuals
as new
Treatments that have changes
been shown
to be
knowledge
is
effective through the use
of randomized
gained
clinical trials or other strong
research
designs;
Origins of the Common Elements
approach
Treatment
manuals:
Step 1:
Emphasis on
evidencedbased
treatments
Step 2:
Development
of treatment
manuals
Step 3:
• Guide
practice
Information
overload: too
• Describe
the
many treatment
intervention’s
manuals to learn
and manuals
activities
as new
• changes
Standardize
knowledge is
implementation
gained
• Promote
fidelity
Origins of the Common Elements
approach
Step 1:
Emphasis on
evidencedbased
treatments
Step 2:
Development of
treatment
manuals
Step 3:
Information
overload: too
many treatment
manuals to learn
and manuals
changes as new
knowledge is
gained
How will I ever
master all these
treatment
manuals ???
What are the difficulties with
relying only on manualized
treatments…
From a clinical perspective?
From an administrator
perspective?
38
IS THERE AN ALTERNATIVE WAY
TO LEARN EFFECTIVE
PRACTICE?
What is the Common Elements approach?
• “Clinicians ‘borrow’ strategies and techniques
from known treatments, using their judgment
and clinical theory to adapt the strategies to fit
new contexts and problems” (Chorpita, Becker & Daleiden,
2007, 648-649)
• Using elements that are found across several
evidence-supported, effective interventions
• Practice elements are selected to match
particular client characteristics
A Tale of Two Perspectives:
Treatment Manual
Approach
 Clinicians select a
treatment manual to guide
practice
 Clinicians use the same
techniques at the same
level of intensity with each
client
 Clinician must maintain
fidelity to the treatment
manual
Common Elements
Approach
 Clinicians select practice
elements known to be
effective from manualized
treatments
 Practice elements vary
based on client needs,
response, current
presenting issues
 Clinician must maintain
fidelity to the steps of the
practice element
How were the practice elements identified?
(Chorpita & Daleiden, 2009)
 Trained coders reviewed 322 randomized
controlled trials for major mental health disorders
for children and teens;
 Over $500 million invested in these research
studies
 Studies conducted over a span of 40 years
 More than 30,000 youth cumulatively in the study
samples
 Approach: What features characterize successful
treatments? What strategies are common across
effective interventions?
Coding Process for 322 RCTs:
 Two coders read each study and identified:
 Age range of sample
 Gender of sample (boy only, girl only, mixed)
 Any ethnicities included
 Problem area experienced by sample
 “Winning” treatment group: which group in 2-group
study did better on outcomes
 Practice elements of winning treatment group
 Frequencies of practice elements from winning treatment
groups were then tallied to see what practice elements
were most commonly found in effective interventions
 41 practice elements identified that were found in at least
3 of the 232 winning treatment groups
Illustration of Chorpita’s Common
Elements terminology
Treatment Family
Treatment Protocols
Practice Elements
From Chorpita & Marder, 2009. UCLA Common Elements Summer Social Work Workshop
Common
Elements for
Depression
From Chorpita & Marder, 2009. UCLA Common Elements Summer Social Work Workshop
Common Practice
Elements for
Disruptive
Behavior:
Differences by
Age group
From Chorpita & Marder, 2009. UCLA Common Elements Summer Social Work Workshop
PRACTICEWISE TOOLS
www.practicewise.com
•Practitioner Guides
•Modular Approach to Therapy for Children
•Clinical Dashboard (MATCH
•Practice Wise Evidence Based Services Data base
(PWEBS)
47
Practitioner Guides
• Summarize the common elements of evidence-based
treatments for youth;
• Handouts guide clinician in performing the main steps of the
technique
• Currently 29 Practice elements, including:
– Response cost
– Modeling
– Social Skills
– Time out
– Engagement with caregiver
• Guide is searchable by: practice, audience (child, caregiver,
family), purpose, objectives
Example of
printable
PDF
describing
practice
element:
Audience
Goals of this
practice element
Steps for
using
this
practice
element
Practice Element Demonstration
• Child Psycho-education: Depression
• http://www.xtranormal.com/watch/6140791
/child-psychoeducationdepression?listtype=ALL
51
PUTTING THE PRACTICE
ELEMENTS TOGETHER:
MATCH
Modular Approach to Therapy- Children
52
Conduct Flow Chart Example:
MATCH Example
HOW DO YOU TRACK CLIENT
PROGRESS?
55
Clinical Dashboards
• Microsoft Excel based monitoring tool
– Tracks achievement of treatment goals or
other progress measures on a weekly/session
basis
– Documents which practice elements were
used when
• Potential uses:
– Documenting session activities
– Tracking client progress
– Clinical supervision
Docume
nt which
practice
element
was
used
when
3 Steps to Using a Dashboard
1. Identify relevant outcomes
2. Document what practice elements were
used
3. Implement and Evaluate
58
PWEBS: Practice Wise Evidence
Based Services database
• Decision support tool
• What youth characteristics are associated with what
effective treatments?
–
–
–
–
What papers describe those treatment protocols?
What practice elements make up the treatment protocols?
What are the settings of the treatment protocols?
What are the formats of the treatment protocols?
• Each paper and protocol was coded and reviewed by at
least two trained, professional coders.
• The data in this database represent interpretations of the
studies, structured by an extensive set of definitions.
Research
Study
Waiting List/
Control
A protocol
likely has
several
practice
elements
Protocol A
Practice
Element
Practice
Element
Protocol B
Practice
Element
Practice
Element
Practice
Element
Practice
Element
PracticeWise Evidence-Based Services
Database (PWEBS)
Example Case Study
• Let’s say I have a client who is a 12 year old
girl with depression.
• What are the treatment protocols and
practice elements of treatments with the most
support?
Step 1. Enter youth characteristics into PWEBS
search by Youth Treatments
Step 2: Summary of studies and
protocols that meet criteria
Scrolling down on the summary…
What do we know so far about what works
with a 12 year old girl with depression?
A look at the Treatment Protocols
What can we learn from this list of treatment
protocols?
Selecting one protocol to find more
detail…
This protocol uses cognitive behavioral therapy in a group
format in a clinic setting. The practice elements that are
part of this intervention are cognitive and parent
psychoeducation.
Summary of paper related to this
protocol:
Extension of paper summary
Summary of Study Findings: Evidence
to support use of this protocol
• Organized by outcome measure
• Compares treatment group to usual care
WHAT IS THE VALUE OF
COMMON ELEMENTS?
Cautions about the Common Elements:
• Sequence, pace, and style that are specified
in treatment manuals are not irrelevant
• Practice elements are not in themselves
evidence-based. They may not be the (only)
active ingredients.
• What works for whom is still just a “best
guess”- may not work for all youth with
specific characteristics or even work best for
this slice of a study sample.
Current Efforts on Common
Elements in Maryland
• SSW: Training classroom and field instructors:
• SSW: Building the common elements for social
work practice with families and children
– Engagement
– Placement Prevention
• Identify the common elements of trauma
treatment (NCTSN.org)
• Training and Implementing Common Elements
in School Mental Health Services
Questions? Comments?
blee@ssw.umaryland.edu
74
The Common Elements of Treatment
Engagement
Michael Lindsey, PhD, MSW, MPH, Bethany Lee, PhD, MSW,
Fred Strieder, PhD, MSW, and Richard P. Barth, PhD, MSW
School of Social Work
University of Maryland, Baltimore
Nicole Evangelista, PhD
School of Medicine
University of Maryland, Baltimore
Kim Becker, PhD
School of Public Health
Johns Hopkins University
75
Common Elements of Treatment
Engagement: History at UM, Baltimore
• Funding: Center for Medicaid and Medicaid Services
1915(c)
• Project goals:
– Identify practice elements associated with treatment engagement
and placement prevention
– Train practitioners in the treatment engagement common elements
• Social Work Educators and Field Faculty
• School-based Mental Health Providers
• In-home Mental Health Service Providers
– Compare implementation (and eventually treatment) outcomes
among CE-trained practitioners versus others
76
Treatment Engagement: Huge Threat to
Treatment Access and Therapy Gains
• Majority of youth in need of treatment do not
receive it; early termination is likely (USDHHS, 2001; 2003)
• Ethnic minority children and those most in need
tend to be underserved (Snell-Johns, Mendez, & Smith, 2004):
– Identifiable disorder, but no receipt of any service
– In receipt of services, but services lack scientific
support
• Significant public health implications
77
Importance of Engagement in CWS
• CWS workers regularly refer children to mental health
services
• Parent training is an important area in CW practice and
research
– Highly resistant parents are 40% more likely to terminate
services early, than their supportive counterparts (Chamberlain, et
al., 1984, as cited by Nock & Ferriter, 2005)
– Minimizing parental barriers to social services (e.g. low
motivation or perceived irrelevance) increases the child’s
involvement and decrease chances of premature termination
(Kazdin, Holland, & Crowley, 1997; Kazdin, Holland, Crowley, & Breton, 1997)
• Engaging families remains a challenge in CSW
78
Staudt (2007) Conceptualization of
Engagement Process
Treatment relevance; daily stressors; therapeutic alliance;
external treatment barriers; cognitions and beliefs about treatment
“Engaged” Attitudinal
Component
“Engaged” Behavioral
Component
Outcomes
Reviews of Treatment Engagement
Literature
• Six treatment engagement reviews between 20042010
• Engagement outcomes and methods vary widely
• Engagement strategies:
– Tend to have theoretical support, but not empirical
support
– Delivered with interventions of known entity (e.g.
MST), but their unique contributions are not
80
supported.
A Need to Identify Common
Elements of Treatment Engagement
• What treatment engagement strategies have
been employed?
• What strategies address behavioral vs. attitudinal
dimensions of engagement?
• How are engagement strategies related to
outcomes?
• Service participation
• Child mental health and functioning
81
Process to Identify Engagement
Practice Elements
• Step 1: Developed an initial list of treatment
engagement practice elements
• Sources for development initial elements :
– Review articles on treatment engagement
– UM team developed definitions
– Shared list with “engagement” experts
• Missing treatment engagement practice elements?
• Revision of definitions
82
Examples of engagement practice
element candidates
Element name
Definition
Source
Expectations
Clarification about steps to obtaining services, roles
(of therapist, youth, caregiver), content of sessions,
frequency of sessions, out-of-session practice of
skills, agency policies regarding attendance, etc.
Donohue et al. 1998
McKay et al., 1996b
McKay et al., 1998
Practical Concerns
Eliciting concrete, practical concerns for the
youth/family (e.g., lack of electricity, difficulties with
school system) and developing a plan for the clinician
to assist in addressing concerns. These concerns are
separate from “barriers to treatment” and are only
coded as the latter if the therapist elicits or the client
presents them as potentially interfering with
treatment.
McKay et al., 1996b
McKay et al., 1998
Prinz & Miller, 1994
Barriers to
Treatment
Discussion to elicit pragmatic (e.g., transportation)
and/or psychological (e.g., stigma surrounding
services, perceived relevance of services) barriers to
participation in treatment. May include developing a
plan to address barriers.
Donohue et al., 1998
McKay et al., 1996a
McKay et al., 1996b
McKay et al., 1998
Prinz & Miller, 1994
Swartz et al. 200783
Aspects of Engagement Techniques
• In addition to the “building blocks” of engagement
practices, we also wanted to capture:
– Engagement protocols: comprehensive, multicomponent procedures established to promote
engagement
• Brief Strategic Family Therapy
• Mary McKay’s Engagement Protocol
• Motivational Interviewing
– Style codes: the interpersonal approach of clinician
or methods employed to facilitate intervention goals
• Empathic vs. evaluative
• Directive vs. client-directed
• Collaborative vs. expert
84
Step 2: Identify Potential Articles
Conduct a database
search
Scan relevant
articles for key
words
Search backward
from eligible articles
Search forwards
from eligible articles
PsycINFO
Pubmed
Social Sciences Citation Index
Any other relevant databases
Within articles relevant to the topic (although they may not be
eligible for coding), identify key words for subsequent
database searches. For example, a search based on the term
“engagement” may benefit from the inclusion of additional
terms such as “attendance” or “barriers to treatment.”
Review the reference lists of articles eligible for coding to
identify previous research that may also be eligible for coding.
Using a database, identify the articles that have cited an article
that has already been identified for coding.
Scan other resources Review papers, meta-analyses, book chapters, and special
issues may be a useful source for identifying potential articles
that may cite
for coding.
potential articles
Contact experts in
the field
Ask experts about relevant publications that have not yet been
identified. Also inquire whether the expert knows of work by
85
other researchers that might be relevant.
Net: 35 Engagement RCTs
• Inclusion/exclusion criteria
– RCT
– Identified engagement technique and outcome;
– Sample with child mental health need
• Range in years of publication: 1975—2010
• Externalizing problems typified child’s behavior
• Primarily clinic settings
86
Step 3: Coding of articles
• Coders were members of the research team
• Each article was coded by 2 team members
• “Super-”coder
– Team member trained in the Common
Elements framework
– Reviewed each article and reconciled any
discrepancies
– Developed final codes
87
Preliminary Results from 27 of the 35 RCTs
88
What Engagement Protocols were
observed?
• Mary McKay’s Protocol (5/27)
• Brief Strategic Family Therapy (3/27)
• Motivational Interviewing (2/27)
89
What Style Codes were observed?
• Task-Oriented/Neutral
• Empathic
• Person Oriented/Warm
• Least coded were: Collaborative; expert
90
What Practice Elements were Most
Frequently Employed in RCTs?
• Psychoeducation of services
• Appointment Reminders (e.g. letter,
telephone call)
• Discussion/resolution of barriers to treatment
• Goal setting
91
Engagement Outcomes Measured?
Attendance measured as an outcome in 96% of RCTs (26/27)
92
Discussion
• Sophisticated conceptual models of engagement (e.g.
Staudt, 2007) not tested in actual RCTs
• Interventions typically targeted initial stages of treatment
• Limited attention paid to:
– Attitudinal dimensions of engagement
– Impact of on-going engagement on treatment outcomes
• What we know most about treatment engagement concerns
how best to engage caregivers in service participation for
their children.
93
Next Directions for Engagement Research
• Next steps in Common Elements of treatment
engagement project:
– Identify practice elements found in RCTs that either tie
or win against the comparison group.
– Link winning practice elements to service participation
and child mental health outcomes
• Clarify manualization: Theory of change;
fidelity/implementation assessment
• Measurement: Target multiple dimensions of
engagement (e.g. targeting perceived relevance,
treatment attitudes as potential mediators)
94
Next Directions in CWS
• Training, implementation, and evaluation agenda
in child mental health, but can this work also
inform CWS, e.g. parent training?
• What are the key engagement challenges in
CWS?
– Different presenting circumstances require different
engagement strategies?
– Build upon current engagement strategies in CWS with
empirical support.
95
Acknowledgments
• Funding:
Support for this work was provided by a sub-award to the School of Social Work from
a grant from the Center for Medicare and Medicaid Services 1915(c) Community
Alternatives to Psychiatric Residential Treatment Facilities National Demonstration
Grant Waiver to the Innovations Institute of the School of Medicine, University of
Maryland (#10-10226G/M00B040011).
• Drs. Bruce Chorpita and Eric Daleiden of
PracticeWise
• Engagement research colleagues at Columbia
University, Mt. Sinai SOM, Duke University, and the
CASRC (Rady Children's Hospital-San Diego)
96
The Timely Emergence of Common
Elements and Common Factors
Based on Barth, R. P., Lee, B. R., Lindsey, M. A., Collins, K. S., Strieder,
F., Chorpita, B. F., . . . Sparks, J. A. (2011). Evidence-Based Practice at a
Crossroads: The Emergence of Common Elements and Factors.
Research on Social Work Practice. doi: 10.1177/1049731511408440
rbarth@ssw.umaryland.edu
Summary
• Evidence based practices need to be based,
primarily, on practice principles and common
practice elements, not on manualized
interventions
• Increasing the uptake of evidence based
methods will best be achieved by increasing
knowledge of common practice elements and
common factors
• Adapting evidence based practices to new
settings, populations, and cultural groups will
require emphasis on common factors
Specific
Knowledge of
Problem & Solutions
Not Drawn to Scale
Regarding the Number
in Each Set
Manualized Evidence
Supported Treatments
(Manualized Programs)
Common (Practice) Elements
Common Factors
Practice Principles
“Practice” (Policy) Framework
99
A Language for Evidence Supported
Interventions for Children and Families
• Specific Competence
– Needed to increase the acceptability of services and, possibly, to
improve interventions
• Manualized Evidence Supported Treatments
– Multi-systemic Therapy (MST);
– “Wrap Around”
– Multi-Dimensional Treatment Foster Care for Adolescents (MTFC-A)
• Evidence Supported Manualized Interventions
– e.g., Cohen and Mannarino’s Trauma Focused-CBT
• Common (Practice) Elements Approach
– Chorpita and colleagues
• Common Factors Approach and Measurment Feedback Systems (MFS)
– Duncan, Lambert and Sparks (CDOI)
• Practice Principles
– Hurlburt & Barth Parent Training Programs
• Practice (Policy) Framework
– Commitment to “Place Matters” or “Family Focused Services” or “Safety
First”, or Safety, Permanency & Well-Being”
Specific Knowledge of Problems &
Solutions
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•
•
•
•
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Adoption Triad Issues
Sexual Abuse
Trauma
Phobia
Running Away
Chronic health and mental health problems
What Makes a Manualized Evidence
Supported Intervention Work?
• Trauma Focused CBT is more tightly
manualized with a somewhat SMALLER
Collection of Practice Elements
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Psycho-education
Stress-management
Narrative therapy
Exposure therapy
Cognitive restructuring
Parental treatment
What Makes an Evidence Based
Program Work?
• Multi-Dimensional Treatment Foster Care is
a LARGE Collection of Practice Elements
– Parent Daily Report
– Parent Management Training for Foster and
Biological Family
– Behavioral Group Work
– More Positive Parenting
– Mentoring (Skill Training) of Youth
• We Really Do Not Know
– There has been very little deconstruction
Common Factors (Client Directed
Outcome Informed)
• Effective therapy arises from allegiance to a
treatment model, monitoring of change, and
creating a strong therapeutic alliance
– Feedback from clients on their level of functioning
– Feedback to therapists on the therapeutic alliance
– A coherent treatment approach that encourages
action to change
Duncan et al., (2010) Heart and Soul of Change: Delivering What
Works in Therapy (2nd Edition). Washington, DC: APA
104
Practice Based Evidence
“A continuous feedback or practice-based
evidence approach individualizes psychotherapy
based on treatment response and client
preference;
systematic feedback addresses the dropout
problem, as well as treatment and therapist
variability…” (p. 702).
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes:
A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704.
Client-Directed, Outcome-Informed
(CDOI) Treatment & Wrap Around
• Adapt to specific individual and family needs based on
client feedback
• Move from punitive and restrictive to optimistic and
responsive interventions
• Utilize brief and systemic client-report measures
throughout therapy
• Strengths-based and culturally responsive
“At its core, wraparound is flexible,
comprehensive, and team-based.” (p. 65)
Sparks, J. A., & Muro, M. L. (2009). Client-directed wraparound: The client as connector in community
collaboration. Journal of Systemic Therapies, 28, (3), 63-76.
Tools for Feedback: ORS and SRS
• Reliable and valid four-item, self-report
instruments used at each meeting
• Scored and interpreted in a collaborative
effort between client and therapist
• Rather than the therapist assigning meaning
to a client’s feedback, the client explains the
meaning behind the mark on the scale
• Help identify alliance strengths and
weaknesses in therapy
Sparks, J. A., & Muro, M. L. (2009). Client-directed wraparound: The client as connector in community
collaboration. Journal of Systemic Therapies, 28, (3), 63-76.
Outcome Rating Scale (ORS): Adults
Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have
been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high
levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing.
Individually
(Personal well-being)
I ---------------------------------------------------------------------------------------------------- I
Interpersonally
(Family, close relationships)
I --------------------------------------------------------------------------------------------------- I
Socially
(Work, school, friendships)
I --------------------------------------------------------------------------------------------------- I
Overall
(General sense of well-being)
I --------------------------------------------------------------------------------------------------- I
Institute for the Study of Therapeutic Change
www.talkingcure.com
© 2000, Scott D. Miller & Barry L. Duncan
Session Rating Scale (SRS V.3.0): Adults
Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience.
Relationship
I did not feel heard,
understood, and
I -------------------------------------------------------------------------------- I
I felt heard,
understood, and respected.
Goals and Topics
We did not work on
We worked on and
or talk about what I
wanted to work on
and talk about.
I ----------------------------------------------------------------------------------------- I
talked about what I
wanted to work on or talk about
Approach or Method
The therapist’s
approach is not a
good fit for me.
I ------------------------------------------------------------------------------------------- I
The therapist’s
approach is a good fit for me
Overall
Overall, today’s
session was right for I ------------------------------------------------------------------------------------------ I
me.
© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson
There was something
missing in the session today.
Child Outcome Rating Scale (CORS)
How are you doing? How are things going in your life? Please make a mark on the scale to let us know. The closer to the smiley
face, the better things are. The closer to the frowny face, things are not so good. If you are a caretaker filling out this form, please
fill out according to how you think the child is doing.
Me
(How am I doing?)
I ---------------------------------------------------------------------------------------------------- I
Family
(How are things in my family?)
I --------------------------------------------------------------------------------------------------- I
School
(How am I doing at school?)
I --------------------------------------------------------------------------------------------------- I
Everything
(How is everything going?)
I --------------------------------------------------------------------------------------------------- I
GIVES YOUTH A VOICE IN THEIR OWN TREATMENT
© 2003, Barry L. Duncan, Scott D. Miller & Jacqueline A. Sparks
Child Session Rating Scale (SRS V.3.0)
How was our time together today? Please put a mark on the lines below to let us know if how you feel.
Listening
Did not always
listen to me
I ---------------------------------------------------------------------------- I
Listened to me.
How Important
What we did and talked
What we did and
about was not
really that
important to me.
I --------------------------------------------------------------------------- I
talked about
were important
to me.
What We Did
I did not like
What we did
today.
I --------------------------------------------------------------------------- I
I liked what we
did today.
Overall
I wish we could
do something
different.
I --------------------------------------------------------------------------- I
•
I hope we do the
same kind of
things next time.
© 2003, Barry L. Duncan, Scott D. Miller, Jacqueline A. Sparks, and Lynn D. Johnson
Key to Common Elements & Factors:
Measurement Feedback Systems
• A MFS is a battery of comprehensive measures administered frequently
concurrent with treatment, providing timely feedback to clinicians and
supervisors to report on clinical processes and treatment adherence
(Bickman, 2008). A good MFS should have measures that are:
– short,
– Psychometrically sound, and
– useful in everyday practice by clinicians
• MFSs should assess several domains by multiple reporters that include
treatment progress (e.g. youth and family outcomes) and treatment
processes (e.g. therapeutic alliance and treatment activities).
• A MFS provides systematic feedback that can be used to enhance
clinical decision-making, improve accountability, drive program planning,
and inform treatment effectiveness (Chorpita et al. 2008; Kelley & Bickman 2009).
Common Factors RCT: Client
Feedback with Couples
• This study provides reliable support for alliance
building and monitoring treatment progress for
clients and therapists in couple therapy.
• Feedback tools (e.g., ORS and SRS) that are not
linked with a certain therapy or method can be
used in community settings more easily than
specific treatment packages.
• The feedback condition showed a moderate to large effect
size (0.50)
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes:
A randomized clinical trial in naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704.
Other Common Elements/MFS: The
Parent Daily Report
Practice Frameworks
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SAFETY, first
Family Focused
Youth Empowerment
Systems of Care
Culturally Responsive
Practice Policy Framework
• Clarity about the purposes of societal
efforts to protect children, promote
permanence, and support children and
family is an essential element of a child
welfare services practice framework.
THANK YOU
• rbarth@ssw.umaryland.edu
• blee@ssw.umaryland.edu
• mlindsey@ssw.umaryland.edu
SSW Celebrates 50 YEARS!!