"But then I kept seeing kids come to our clinic having already seen lots of different community providers, without getting any better"—most likely, she says, because they weren't receiving evidence-based interventions. What the community had in its toolbox just wasn't working.
But her hope was renewed when children at the clinic participated in an evidence-based treatment for anxiety called Coping Cat, and nearly all of them were able to improve the quality of their lives. That's when Beidas became convinced about the effectiveness of evidence-based practices and the need for them to be more widely available.
"Evidence-based practices need to be available in the community so that kids have access to them and can benefit from them, as a matter of social justice," says Beidas, now an assistant professor of psychiatry at the University of Pennsylvania.
Today, she is one of many psychologists working at the state, county and city levels to make sure evidence-based treatment is available beyond academic medical centers, which aren't accessible to most people. As part of that effort, she sought to find out why more evidence-based practices aren't in wider use. In a study she conducted with clinical psychologist Arthur C. Evans Jr., PhD, commissioner of the city of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services, she found some answers: When it comes to treating children and adolescents with psychiatric disorders, organizational factors—such as the support therapists get from others on the health-care team—are better predictors of the use of evidence-based practices than an individual therapist's knowledge and attitude about therapy techniques (JAMA Pediatrics, 2015).
"Implementation happens at multiple levels," says Beidas, who also directs implementation research at Penn's Center for Mental Health Policy and Services Research. "Even though a provider might be the one in the room with a patient, it's not just about that provider deciding to do an evidence-based practice. It's also about their organization and their supervisor supporting them, and the larger system supporting that process."
Focus on accountability
Serene Olin, PhD, a professor of child and adolescent psychiatry at New York University, is fostering the use of evidence-based treatments in another way: She is exploring how the use of evidence-based practices can help health-care systems establish greater accountability for patient care.
"Care in the real world is so much driven by who pays for what and what you're being held accountable for," she says.
In line with this shift toward more accountability, New York's state mental health department is focusing on what works—and how to train providers in these evidence-based treatments as efficiently and effectively as possible, says Olin, deputy director of New York University's Center for Implementation-Dissemination of Evidence-Based Practices Among States, known as the IDEAS Center. In 2011, the center began training clinical staff to implement evidence-based practices such as the "4 Rs and 2 Ss for Strengthening Families Program," at nearly 350 child-serving outpatient clinics in the state. The trainings vary in intensity, from one-hour webinars to yearlong collaborative learning experiences. The goal is to help clinics develop strong business and financial models, informed by empirical evidence, to ensure sustainability.
The IDEAS research team is using state administrative data to predict who will adopt these business-improvement and evidence-based clinical practices to help the state target its funding. They found that state clinical trainings were more likely to be adopted by clinics with more staff, likely because they're more easily able to release health-care providers for training compared with agencies with smaller staffs. In addition, clinics affiliated with smaller health-care systems were more likely to attend and implement business-practice trainings compared with clinics associated with larger, more efficiently run agencies (Psychiatric Services, 2015). These findings suggest that policymakers should understand the factors that influence the type and amount of training clinics are willing or able to adopt.
Sustaining evidence-based practice
In another effort to understand the use of evidence-based practices in community settings, Anna Lau, PhD, a psychology professor at the University of California, Los Angeles, and Laura Brookman-Frazee, PhD, a University of California, San Diego, psychiatry professor, are working to understand what happens when community therapists are required to deliver these interventions.
According to the American Medical Informatics Association, it can take 17 years for evidence-based practices to trickle down to practice in community-based settings. In a system-driven reform that cuts short that lag time, the Los Angeles County Department of Mental Health is reimbursing contracted agencies for delivering evidence-based practices through a countywide prevention and early intervention initiative. Lau and Brookman-Frazee are investigating how those practices are sustained. The Knowledge Exchange on Evidence-based Practices Study (4KEEPS) examines how community therapists work with evidence-based practices for youth and identifies barriers and facilitators to their implementation with ethnically diverse and disadvantaged communities.
Through the study, Lau and Brookman-Frazee are collecting data from agency leaders and frontline therapists about their experiences implementing six evidence-based interventions for child mental health problems. The pair is studying whether and how these treatments are still being used up to eight years following their adoption.
"We hear a lot about people's concerns that these evidence-based practices aren't equally applicable or equally accessible across different cultural or socioeconomic groups, so we're trying to see if there's evidence of that," she says.
As of September, more than 800 therapists and nearly 200 program managers from 68 agencies have participated in the study with an additional two years of data still to be gathered, says Brookman-Frazee.
"There are huge benefits in learning from what therapists are doing that might inform the intervention development process and allow for a more bi-directional communication process between research and practice," she says.
By Amy Novotney
This article was originally published in the January 2017 Monitor on Psychology