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July 2016

Best Practices; Alterations; Jim Gaffigan


Jennifer Harrison, PhD., LMSW., CAADC is a social worker and chemical addictions counselor.  She is on the faculty at the School of Social Work, Western Michigan University in Kalamazoo and is a member of the Michigan Fidelity Assessment and Support Team (MiFAST).  Her clinical practice is in behavioral and physical medicine.  In 2010, Jennifer helped me pull together some of my best  Tips and  Topics over the years all in one place in a book: “ Tips and Topics: Opening the Toolbox for Transforming Services and Systems“. You can see more on the  Tips &  Topics book at:
Recently Jennifer sent me “some materials that I think are a starting point for a future  Tipsand  Topics edition, highlighting some research on best practice implementation, sustainability, and alteration. Please take this as only ideas, and of course feel free to edit as you choose.” So I am sharing with you her selection of research.
In 2007, I wrote about evidence-based practices (EBP) and how the research finds that the therapeutic alliance predicts treatment outcomes even more potently than the EBP used.
It got some readers thinking and I included their comments and my responses in the October 2007 edition of  Tips and  Topics.
Here’s what Jennifer Harrison wrote and referenced:
In behavioral health, it’s important to hear the clinical wisdom that exists in the field, and develop research questions based upon those insights. This leads to:
  • Research
  • Translation of what we know works in research settings into
  • What can actually be used in clinical practice. (1)
Best practices for people with co-occurring mental illness and substance use, or co-occurring disorders, are important in part:
  • Because co-occurring disorders are so prevalent. For example, people with schizophrenia or bipolar disorder have an over 50% risk of also having a substance use disorder, as compared to only 16% of the general population (2)
  • Because when people have co-occurring disorders, the outcomes in many areas, including hospitalization, arrest and incarceration, homelessness, unemployment, and even HIV infection, are much worse compared to people with either a mental illness or substance use disorder alone. (3,4)
Integrated Dual Disorder Treatment (IDDT) is one evidence-based practice for individuals with severe co-occurring disorders with a toolkit developed by SAMHSA, the Substance Abuse and Mental Health Services Administration. IDDT uses a full multi-disciplinary team of professionals (doctors, nurses, case managers, addiction, housing, and employment specialists). Services are offered based upon key modalities:
  • Addressing stage of readiness of the client
  • Employing motivational interviewing
  • Family education and
  • Active outreach. (5, 6)
How we implement, sustain, and alter IDDT and other best practices for people with co-occurring disorders can have a big impact on their recovery and wellness.
Think about implementation of best practices. Are you committed to implementing this practice to the gold standard of care?
In one study of IDDT implementation across an entire state, IDDT was implemented at high fidelity by over 50% of teams by a third review, so could achieve that gold standard with work. But there was also significant variation in individual areas of the best practice, with some teams doing better on having a full multidisciplinary team and time-unlimited services, but struggling with family services and self-help liaising. (7)
Think about sustainability of best practices. How can you sustain this practice over time, and not let the practice erode to something very different from when it started?
In a study about IDDT sustainability over 7 years of implementation across a state, IDDT fidelity improved over time. We got better the longer we practiced, and generally did not lose steam with sustainability. Interestingly, those IDDT teams that adopted IDDT later had higher baseline fidelity scores. This brings up the issue of organizational or statewide system of care support for implementation and sustainability of best practices. (8)


Dr. Jennifer Harrison continues:
Often, best practices can feel like they are created in an ivory tower of academia, and as such not well related to the real demands of practice. In the real world we cannot, as in a research methodology, neatly exclude people from treatment to manage our variables in practice. Or there may be additional priorities beyond what the best practice specifies. As a result, when best practices are translated into real practices, they are often changed or altered to meet local or clinical needs.
When you are changing a best practice to meet your local needs, be intentional about those changes, and measure the outcomes.
Altering best practices is often necessary, but should be done intentionally. Your organization or team should make the decision “even though the best practice says this is the way we should implement; we are deciding to add/subtract/change this component for this reason.” And then, you have the opportunity to create practice-based research, to study the effects of your alteration, and perhaps improve the best practice over time.
Here is an example of altering a best practice:
IDDT was not explicitly designed with the inclusion of peers, but like many evidence-based practices, the practice has been altered in its implementation in some areas to include peers. In the state of Michigan, IDDT was systematically altered since 2007 to add peer specialists, people with lived experience with mental illness and/or substance use disorders.
The result of this alteration?
In a study of the relationship between teams having peers and IDDT fidelity, teams with peers had higher fidelity than teams without peers, and there was a significant difference between teams with part-time peers and full-time peers on their teams. Only teams with full-time peers had mean fidelity at the high fidelity range. This is also clinically significant, remembering that high fidelity is associated with improvements in clinical outcomes. (9)
1. Fixsen, D.L., Naoom, S.F., Blasé, K.A., Friedman, R.M., & Wallace, F. (2005).  Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).
2. Hunt, G.E., Siegfried, N., Morley, K., Sitharthan, T., & Cleary, M. (2013).  Psychosocial
interventions for people with both severe mental illness and substance misuse. Cochrane Database of Systematic Reviews, 10, 1-258.
3.  Lai, H.M., Sitharthan, T., & Huang, Q.R. (2012).  Exploration of the comorbidity of alcohol use disorders and mental health disorders among inpatients presenting to all hospitals in New South Wales, Australia. Substance Abuse, 33(2), 138-45.
4. Drake, R.E., O’Neal, E.L., & Wallach, M.A. (2008).  A systematic review of psychosocial research on psychosocial interventions for people with co-occurring mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123- 138.
5. McHugo, G. J., Drake, R. E., Whitley, R., Bond, G. R., Campbell, K., Rapp, C. A., & Finnerty, M. T. (2007).  Fidelity outcomes in the national implementing evidence-based practices project. Psychiatric Services, 58(10), 1279-1284.
6 .Substance Abuse and Mental Health Services Administration (2010).  Integrated treatment for co-occurring disorders evidence-based practice (EBT) kit. Rockville, MD: Author.
7. Harrison, J., Curtis, A., Cousins, L., & Spybrook, J. (2016). Integrated Dual Disorder Treatment implementation in a large state sample. Community Mental Health Journal. In Press. DOI: 10.1007/s10597-016-0019-1.
8. Harrison, J., Spybrook, J, Curtis, A., and Cousins, L. (2016).  Integrated Dual Disorder Treatment: Fidelity and implementation over time. Social Work Research. In Press.
9. Harrison, J. (2015).  “I’ve been there too”: Peers in co-occurring services and relationship with fidelity. Proceedings from the International Symposium on Evidence in Global Mental Health, held January 7-9, Kerala, India, 170-177.


I’m excited. I’m going to a comedy show August 5 and I thought I had missed out on tickets. However the email advertisement popped into my Inbox the other day. I thought I would just check if any seats had opened up since last I saw that the show was sold-out. There they were. Two seats together, front row, section 6. Marcia and I were in!!
If you don’t know Jim Gaffigan, it’s time for a laugh (if you share my kind of humor). Actually, I’ve run into a bump before when I’ve been all enthusiastic about a comedian and showed the video to friends, only to see stone faces and not a peep of a chuckle. So here’s a link to Jim Gaffigan’s piece on visiting McDonald’s. I enjoy it every time and maybe you will too.
I’ve been to my fair share of comedy shows over the years. My favorites are the ones who can make you think while they make you laugh. There’s a real art to changing attitudes and opening minds and hearts by sneaking in through the back door of humor.  For me, Jim Gaffigan does that.  So does Jerry Seinfeld and I’m sure you have your favorites too.
Some comedians get laughs (not from me) by being loud, crude, bombastic, insulting and egotistical – and no, I’m not talking about Donald Trump….although I don’t like politicians either who act like that.
In behavioral health training, Scott D Miller, Ph.D. is my favorite “edutainer” (educator and entertainer). Scott will educate you about Feedback Informed Treatment and change your whole attitude about how to track outcomes and the balance between the therapeutic alliance and EBPs. But you’ll be entertained in the process as he dismantles some of your fixed ideas and attitudes.


I’ve even received some complimentary evaluations in my 20 years of full-time training that my sense of humor makes the training day go down a little easier. But I better be careful, because I don’t like egotistical trainers either, although I am proud of my humility.

Anyway, enjoy Jim Gaffigan. I know we will next week at his show.


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