Implementing best practice care for persons struggling with mental illness and substance use in real world settings can be challenging. At the Institute for Community Living (ICL), where we provide behavioral and physical health care for a widely diverse population and place strong emphasis on innovation, best-practice, and evidence-based care implemented through a trauma informed, integrated health, and recovery oriented perspective, we recognize that clinicians working with persons with dual diagnoses must continuously navigate an ever-evolving web of theory, research, and technique while negotiating the demands of organizational policies, managed care, and multi-systemic factors.
As a group committed to implementation of best practice care in real world settings, we set out to develop ways to facilitate uptake and implementation of empirically validated treatment across an urban environment where clients are involved with multiple systems and who may experience extreme poverty, serious medical and mental illness, substance abuse, and histories of trauma. Additionally, we sought to identify common elements and themes across evidence-based models. For example, an individual with Type II diabetes and Bi-polar disorder who feels estranged from their family supports, distrustful of doctors and the mental health system, and is battling the stigmas often associated with chronic physical and behavioral health problems would benefit from a clinician who understands the importance of providing psycho-education, meeting the individual at her stage(s) of change, supporting the individual with understanding the relationship between thoughts, feelings, and behaviors, and inspiring hope and optimism within a recovery-oriented perspective. Emphasizing core elements of treatment that have been empirically validated allows for the flexibility inherent in combining research-informed practices and the complex demands of real-world clinical settings.
In the first iteration of the evidence-based movement, there was the direct handoff of a sacred volume of EBPs, with step-wise instruction and expected word for word delivery of the evidence-based model. This, however, would often prove unsuccessful as people would report that manualized treatment felt cumbersome and non-inclusive of clinician training and the myriad of presenting issues encountered. Over time, a more collaborative approach emerged, facilitated by both research and a partnership among researchers, practitioners, advocates, and clients. In this spirit, we set out to identify evidence-based models that resonated with staff and clients, and common elements across practices that could be used as a foundation of care. Our goal was to develop a concise framework from which therapists can navigate systemic issues as well as the flood of new therapies and developing trends. Clinicians are expected to be facile in individual, group, and family therapy with diverse clients from many cultural backgrounds and to adjust their care in accordance with the systems requirements of clinics, agencies, hospitals, schools, communities, and private practice settings. However, we believe that seven core processes (Wofsy & Mundy, 2012) are consistent across settings and interventions and can be utilized to promote client-driven care that is research-informed:
- Joining and Establishing the Therapeutic Relationship
- Psychoeducation and Recovery Principles
- Stage of Change Orientation
- Motivational Interviewing
- Cognitive Behavior Therapy
- Mindfulness and Acceptance-Based Principles and Practices
- An emphasis on Relapse Prevention, Trigger Management, and the Completion of Treatment
These 7 processes provide a flexible, research-informed framework to complex care. More specifically, no successful practice delivery can occur independent of a well-established, non-judgmental therapist-client relationship. This relationship sets the stage for therapists and clients to develop a mutual understanding of presenting issues and related, reputable scientific information that exists to help contextualize symptoms and treatment. Meanwhile, clinicians must honor each individual’s stage of readiness, and identify, and help resolve ambivalence about change. Once a person is ready to make a change, incorporating a perspective that works to strengthen the relationship between thoughts, feelings, and behaviors is necessary to off-set symptoms and promote ongoing skill acquisition. Additionally, fostering the capacity for mindfulness and acceptance can assist individuals with increasing their flexibility in response to difficult thoughts and feelings. Ultimately, the client is empowered to lead a rich, meaningful life with the understanding that triggers will arise and that sustained recovery is an ongoing, dynamic process.
Clinical science is an ever-evolving process reflective of the spirit of ongoing improvement that these core processes embody. Practices that have been researched and validated are imperative, and providing clinicians with a framework of core elements that provide a foundation for care further help to facilitate effective treatment. We look forward to dialogue and ongoing collaboration with the client, provider, colleague, and research communities as we continue to develop these processes.
Brian Mundy, LCSW, is Clinical & Implementation Specialist at the Institute for Community Living; Matt Wofsy, LCSW-R, is Director, Best Practice and Evidence-Based Initiatives at the Institute for Community Living; Elizabeth Cleek, PsyD, is Vice President, Program Design, Evaluation & Systems Implementation at the Institute for Community Living; and Nancy Boyd-Franklin, PhD, is Distinguished Professor in the Graduate School of Applied and Professional Psychology at Rutgers University.
The authors have recently published this framework, several years in the making, in a book published by Guilford, entitled Therapy in the Real World.
Boyd-Franklin, Nancy; Cleek, Elizabeth N., Wofsy, Matt, & Mundy, Brian. (2013) Therapy in the Real World: Effective Treatments for Challenging Problems. New York: Guilford Press.
Wofsy, M., & Mundy, B. (2012, April 18). Core Best Practice Strategies. PowerPoint interactive training presented at the Institute for Community Living, Brooklyn, NY.