The importance of utilizing evidence-based practices (EBPs) has taken over health care in the medical, psychiatric and substance use treatment arenas (Institute of Medicine, 2001). Patients, insurance companies and other payors want to ensure that only treatments that have been shown to be effective through carefully designed research are being used. In some spheres, utilizing EBPs is becoming a requirement to continue to receive funding for the services that are provided. As a result of this wellspring, community treatment programs are being forced to implement such interventions.

For a number of reasons, implementing EBPs, while well intended, may not be the best way to ensure quality of care. In fact, a case can be made that to ensure quality care, a focus needs to be maintained on other aspects of care that may be as, if not more, important, than utilizing EBPs. Unfortunately, due the limited resources of most treatment programs, if the focus on adopting EBPs is the priority, these other important aspects of care will not receive the attention they need, which will diminish the overall quality of care. 

In this article, we examine research regarding the importance of using EBPs to ensure quality care, and the problems treatment programs may experience when attempting to implement EBPs will be reviewed. We further assert that in order to improve treatment quality, the resources it takes to implement EBPs may be better or at least as well placed on a variety of other initiatives.

How effective are EBPs?

An enormous body of research has examined the utility of using EBPs when delivering psychotherapeutic interventions (Lambert & Bergin, 1994; Miller, Duncan & Hubble, 1997; Task Force on Promotion and Dissemination of Psychological Procedures, Division of Clinical Psychology of the American Psy- chological Association, 1995; Wampold, et al., 1997). While a review of all of this research is beyond the scope of this article, it is clear that some research supports the use of EBPs, whereas other research has found that EBPs fare no better than structurally equivalent therapies that are not designated as evidence-based (Norcross, Beutler & Levant, 2006). Furthermore, there is no conclusive evidence that treatment manuals improve treatment outcomes (Norcross, Beutler, & Levant, 2006). Others have suggested that the quality of the therapeutic alliance between the therapist and patient may be a more robust ingredient in positive treatment outcome than the technique (Hubble, Duncan & Miller, 2002; Martin, Garske & Davis, 2000; Norcross, 2002).

Perhaps a way to make sense of such disparate findings is to evaluate the importance of EBPs within the context of other factors that are also relevant to positive treatment outcome. In a meta-analytic study, Lambert (1992) has looked at factors responsible for positive treatment outcome. He found that technique or the practices used accounts for 15 percent of the variance in treatment outcome. Other notable variables that are relevant to treatment outcome were hope and expectancy (15 percent), client variables (40 percent) and the therapeutic relationship (30 percent). So, in this meta-analytic study, technique or the EBP used had a modest impact, but clearly, 85 percent of the variance was due to other variables. One can argue that delivering EBPs should not be an end-all endeavor to ensure quality treatment outcomes.

Implementation concerns

The resources necessary to train staff to successfully deliver some EBPs are enormous, and include: the cost of the training itself, which can amount to thousands of dollars; the loss of income that will be incurred during times staff are being trained and unable to see clients; and the ongoing cost of supervision and fidelity monitoring to ensure that staff retain their new skills. A one-time lecture or workshop, or reading a treatment manual, unless followed by ongoing supervision and continued training will not enable staff to adopt the new approach. 

In addition, researchers have noted the high turnover rates in substance abuse treatment programs (McLellan, Caris & Kebler, 2003). From counseling staff to program directors, about half had not been in their jobs for even one year. Given the large number of trained staff members leaving organizations, there is an ongoing need to constantly retrain new staff, which keeps the cost of implementing EBPs very high. While these costs should not stop a program from implementing an EBP, programs should consider whether such money could be better spent in other ways, especially given the research that suggests only 15 percent of the variance in treatment outcomes is a function of the EBP (Lambert, 1992). 

The limitation of EBPs

In reviewing the practices that are currently evidence-based that are listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Practices and Programs (NREPP), most of them are designed to be delivered within schools or outpatient treatment programs. None could be found that have been conducted within residential treatment or detoxification programs. The obvious question is what should a residential or detoxification program implement if an EBP doesn’t yet exist? While features of some EBPs can be used, modifying the EBP for use with a different treatment population will affect its overall usefulness. To complicate this further, residential programs typically run groups with 15 or 20 individuals, whereas group designed EBPs typically have been researched with group sizes of 6 to 10. Again, how this will affect the overall effectiveness of EBPs in real world settings? 

Furthermore, many are focused on clients with particular addictions rather than on those who are poly-addicted, which is more the norm. Even others are only appropriate for trauma survivors and those with post-traumatic stress disorders who also struggle with addiction. While such clients do enter outpatient programs, the majority may not fit these diagnoses and thus, most clients may not be able to benefit from many of these practices.  Finally, to date, EBPs do not adequately address issues of race, ethnicity, sexual orientation, disability status and diversity, in general (Sue and Zane, 2006). To assume that an EBP will work as well among patient populations for which it has never been used is presumptuous, if not bordering on unethical.

Clients require different treatment

The National Institute on Drug Abuse (NIDA) published a guidebook that reviewed effective principles of drug addiction treatment (NIDA, 1999). In this, 13 principles are offered that should be included in any treatment program in order to achieve maximum effectiveness. Relevant to this discussion is principle one, which states, “No single treatment is appropriate for all individuals.” This certainly is solid advice as clients are different, and as a result, they may desire and require different kinds of treatment.

For example, some clients may resonate with the disease concept of addiction and gain benefit from 12-step facilitation therapy and attending 12-step programs, whereas others may find the disease concept and 12-step philosophy to be less satisfying and will not gain benefit from this approach. Given the importance of taking into account client preferences, is it possible for a program to have clinicians trained in the variety of EBPs that will be needed in order to meet the varied need of its clients? While it may be possible to have some staff trained in some EBPs, it is highly unlikely that all interventions with all clients can be delivered using EBPs. It is clear that for many clients, supervisors will need to work with staff on delivering principles of quality care as opposed to supervising fidelity adherence to a therapy manual. 

In summary, apart from question of how much benefit clients will obtain by receiving treatment with an EBP, there are other issues that must be considered when a program plans to implement an EBP. Whether a program has the resources to successfully implement an identified EBP and ensure that when staff leaves, new staff can be trained, needs careful consideration. There are levels of care where, as well as clients for whom, no EBP exists. Additionally, in order to meet the diversity of our clients, an appropriate question is how many different EBPs can staff be adequately trained to deliver? 

Given this, a key question is with the limited resources programs have, where should these resources be placed to have the largest impact? Should these resources be placed on implementing an appropriate EBP, or could resources be better spent on other aspects of care that may have a greater impact on treatment outcome? In what follows, other aspects of service delivery that need to be addressed to ensure quality care will be suggested. 

Other aspects of service delivery  

Incorporating NIDA’s Principles of Drug Addiction Treatment. NIDA’s previously mentioned Principles of Drug Addiction Treatment (NIDA, 2000) list 13 principles of effective drug treatment, the majority of which have nothing to do with EBPs. Rather, they outline overarching principles of effective drug treatment, such as making treatment readily available; attending to the multiple and varied needs of clients, including their other non-substance related problems; and ensuring that medications are available to clients. Client retention is also an important principle. Consequently, it is obvious that in order to have a quality program, there are many other elements of service delivery that must be incorporated into the agency. 

For example, programs need to ensure that treatment is individualized and that treatment plans attend to needs of the client. Furthermore, medications need to be suggested and offered when appropriate, either onsite or through referral linkages. In addition, basic counselor skills should include being able to assess clients for co-occurring psychiatric disorders and to treat such clients in an integrated way. Programs also must establish linkages to other providers in the community for services that are not available onsite. Apart from training staff in EBPs, effort must be placed on these other elements of care in order to ensure quality.

Client satisfaction. Regardless of what interventions are used, the importance of clients being satisfied with treatment is critically important. If clients are dissatisfied and unhappy with the treatment experience, it is likely that they will prematurely drop out of treatment, which will impact the quality of care. For example, in a residential program, if clinicians are employing an EBP, but other staff within the program treat clients unprofessionally or disrespectfully, clients will leave treatment prematurely and they will not get the care that they need. Even in outpatient settings, if phone calls are not responded to or administrative staff treat clients in a less than dignified manner, clients will be dissatisfied with treatment and may drop out prematurely. As a result, clients’ overall satisfaction with their treatment experience must be consistently monitored and when needed, changes to the program must occur. 

Treatment Access. Clients who struggle with substance use are often ambivalent both about changing and entering treatment. When a call is made to a treatment program, offering treatment in a timely way is important, if the time between the call and the scheduled appointment is too long, clients may fail to come to their first appointment. In addition, a timely follow up appointment must be offered as well. 

Focusing on treatment access and a program’s timeliness in responding to calls is in line with NIDA’s Principles of Drug Addiction Treatment, as Principle Two states that “Treatment needs to be readily available.” The importance of treatment access is also consistent with one of the goals of the Network for the Improvement of Addiction Treatment (NIATx — see www.NIATx.net). Using quality improvement processes, within the outpatient service where this author works, it was found that 45 percent of clients never even showed for their initial intake appointment! Also, of the 55 percent of clients who did show for their intake, another 40 percent of them never came for a second appointment! So, of 100 potential new clients, about 32 came for a second appointment.     

When this was reviewed, it became clear that if an appointment was made a week or more away from the initial call, the chance of the client coming for the appointment was small. In addition, for a variety of reasons, clients often left their intake appointment without a follow up appointment scheduled. By instituting a centralized scheduler system so that all clinician appointment times were managed centrally, the initial intake appointment no-show rate was decreased by 15 to 20 percent, and only 25 percent of clients failed to come for a second appointment. Thus, after these changes were made, of 100 potential new clients, about 60 now successfully come for a second appointment. In another program that used process improvement to enhance its access to treatment, the percentage of clients who come for an initial assessment increased from 25 percent to 65 percent. In addition, 52 percent (as opposed to 19 percent) actually made it into treatment (Capoccia, et al., 2007). This demonstrates the point that a focus on treatment access, which has nothing to do with the implementation of a specific EBP, is an important way to improve the quality of treatment that is rendered. 

Continuous Performance Improvement. Consistent with the goals of NIATx and quality care in general, ongoing continuous performance improvement activities need to be a part of any program. Much has been written about continuous performance improvement and having a system of always monitoring the services rendered with the aim of consistently working to enhance and improve service delivery (Maurer, 2004). 

Performance improvement activities can address any aspect of treatment that needs improvement, including: improving satisfaction with food services; increasing treatment completion rates; enhancing satisfaction with transportation services; improving how phones are answered; increasing staff’s ability to address clients who may be violating program rules; enhancing the variety and quality of recreational opportunities that may be offered; or modifying the times a service is open to better meet client need.

Initiating and sustaining ongoing performance activities takes staff time and resources.  While these efforts may not focus on the implementation of a specific EBP, addressing these other elements of care are important to ensure that the treatment offered is of the utmost quality. 

Offering quality care to individuals who struggle with substance use disorders is a complicated task and requires constant vigilance on a multitude of fronts. The position offered in this paper is that the present primary focus on implementing EBPs as a way to ensure quality care is short-sided and does not take into account the numerous factors that play a role in delivering quality treatment services. Despite the organizational, financial and logistical problems in implementing EBPs, and the fact that for many levels of care, as well as for particular clients, EBPs simply do not exist, there is merit to implementing EBPs. However, there is much more to quality care than whether a program has staff fully educated in delivering manual-based EBPs.  

Unfortunately, in the current climate of evaluating the quality of a treatment program by using the standard of whether the program offers EBPs, it can be easy for a program, as well as outside funders, accreditors and licensers, to lose sight of these other critical elements of care. Perhaps if the demand on community treatment programs to offer EBPs as the primary means of determining whether a program is a quality agency could be relaxed, programs could be freer to place greater emphasis on these other aspects of care, which it could have the same, if not greater benefit, on improving the system of care, treatment delivery and client outcome. Client outcome, which can be accomplished using a variety of interventions and activities, could be the yardstick to determine quality care, rather than whether or not a program simply offers an EBP.

Michael Levy, PhD is a licensed psychologist and is the Director of Clinical Treatment Services at CAB Health & Recovery Services. He is also on the faculty at Harvard Medical School, and has been the principle investigator of a number of federal grants funded through CSAT and the CDC. He has written numerous articles, book chapters, and given many workshops, and recently published his first book through Johns Hopkins University press, Take Control of Your Drinking … And You May Not Need to Quit.

References

Capoccia, V.A., Cotter, F., Gustafson, D.H., Cassidy, E.F., Ford, J.F., Madden, L., Owens, B.H., Farnum, S.O., McCarty, D., & Molfenter, T. (2007). Making “Stone Soup”: Improvements in clinic access and retention in addiction treatment. 33: 95-103.
Hubble, M.A., Duncan, B.L., & Miller, S.D. 2002. The Heart and Soul of Change. Washington DC: American Psychological Association. 
Institute of Medicine (IOM) (2001). Crossing the Quality Chasm; a New Health System for the 21st Century.  Washington DC: National Academy Press.
Lambert, M.J., & Bergin, A.E. 1994. The effectiveness of psychotherapy. In A.E. Bergin & S.L. Garfield (Eds). Handbook of Psychotherapy and Behavior Change. (4th Edition, pp. 143-189). New York: Wiley
Lambert, M.J. 1992. Implications of outcome research for psychotherapy integration. In J.C. Norcross and M.R. Goldstein (Eds.), Handbook of Psychotherapy Integra-tion (pp. 94-129). New York: Basic Books.
Martin, D.J., Garske, J.P., & Davis, M.K. 2000. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology 68: 438-450.
Maurer, Robert. One Small Step Can Change Your Life: The Kaizen Way. New York, NY: Workman, 2004.
McLellan, A.T., Caris, D., & Kebler, H.D. 2003. Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment 25: 117-121.
Miller, S.D., Duncan, B.L., & Hubble, M.A. 1997. Escape from babel: Toward a unifying language for psychotherapy practice. New York: W.W. Norton.
National Institute on Drug Abuse, 1999. Principles of Drug Addiction Treatment. National Institutes of Health. NIH Publication No. 00-4180. 
Norcross, J.C. 2002. Psychotherapy Relationships That Work (pp. 37-69). New York: Oxford University Press.
Norcross, J.C., Beutler, L.E., & Levant, R.F. 2006.  Evidence-Based Practices in Mental Health. Washington, DC: American Psychological Association.
Sue, S, & Zane, N. 2006. Ethnic minority populations have been neglected by evidence-based practices. In J.C. Norcorss, L.E. Beutler, & R.F. Levant (Eds.), Evidenced-Based Practices in Mental Health (pp. 329-337).  Washington, DC: American Psychological Association.
Task Force on Promotion and Dissemination of Psychological Procedures. 1995. Training in and dissemination of empirically-validated therapies. The Clinical Psychologist 49: 3-23.
Wampold, B.E., Mondin, G.W., Moody, M., Stich, F., Benson, K., & Ahn, H. 1997. A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “All must have prizes”. Psychological Bulletin 122: 203-215.

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