The Need and Opportunity for Leadership in Clinical Psychology to Bridge the Enduring Great Divide: “It’s the How, Stupid!”
By Bradley E. Karlin, Ph.D., ABPP
Last week, after the last box was unloaded from the moving truck into our new home in beautiful Raleigh-Durham, North Carolina, my wife and I took a stroll around our subdivision to take in the new experience, reflect on a new chapter of our lives, and meet some neighbors. Upon rounding the corner, we were greeted by a pleasant, middle-aged couple who live down the street. After about 5 minutes in (and some nostalgic reflection on our very different home and lifestyle in Times Square, NY!), the conversation shifted to discussion of careers. My wife described her work as a foundation professional, and I noted that I am a clinical psychologist. “Tom” and “Jill” responded with several questions about what my work involves, whether I see patients in a private practice, and what “therapy” really consists of. I informed Tom and Jill that my work primarily involves working to promote the dissemination and delivery of evidence-based psychological treatments in public and private systems and to improve mental health and dementia care at systems levels. To this, Tom replied, “I didn’t know that psychologists do that type of work! And, what are evidence-based psychological treatments?” This now rather familiar exchange reflects important needs and opportunities for professional psychology (and clinical psychology, in particular) to be (and be seen as) leaders in dissemination and implementation and systems change and, relatedly, in advancing public awareness and understanding of psychological treatments.
In my March 2016 President’s column in The Clinical Psychologist, I wrote about the important, but largely exclusive, focus within clinical psychology on developing evidence-based psychological treatments (the “what”) and argued for greater focus on examining and promoting processes for how to effectively implement evidence-based treatments in routine practice settings (the “how”). For decades, social scientists (including many psychologists) have written about the considerable but unrealized promise of evidence-based psychological and psychosocial treatments for addressing a wide range of psychological, behavioral, and social problems. Despite their established efficacy in controlled research contexts, many psychological and psychosocial treatments fail to be implemented in real-world clinical settings due to barriers at multiple levels. Awareness of the now well-known research-to-practice gap among professionals and the public was intensified by the Institute of Medicine’s (IOM) seminal 2001 report, “Crossing the Quality Chasm,” in which the IOM Committee concluded that it takes an average of 17 years for new scientific discoveries in randomized controlled trials to be implemented in routine practice settings. This lag time, however, has shown to be considerably greater in mental health than in medical care contexts due to a number of unique factors. For example, unlike many biomedical treatments, such as medications, psychological and psychosocial treatments are considerably more complex and, consequently, require a much more complex distribution and dissemination mechanism(s). In addition, unlike medical treatments, psychosocial treatments often lack industry sponsors that have a vested interest in promoting broad dissemination and delivery of treatments. Furthermore, there is no FDA or regulatory or other process for identifying, communicating, and distilling psychosocial treatments. This has contributed to limited awareness of and difficulty distinguishing between specific therapies among insurance companies, other payors, and consumers.
A new dawn of promoting attention to and leveraging how to effectively distribute and disseminate evidence-based treatments has emerged with the developing field of dissemination and implementation science and practice – a field that has moved beyond severed factions into an established, multidisciplinary discipline with a unique identity and contribution to science and practice. In our own work, we have leveraged the knowledge and discoveries of implementation science to inform and guide broad and strategic dissemination and implementation of evidence-based psychotherapies (EBPs) and dementia care interventions. This includes the application of models and specific strategies for addressing barriers and leveraging facilitators at multiple levels, including policy, provider, systems, and patient levels and for incorporating implementation activities that span a spectrum from pre-implementation readiness assessment and enhancement through sustainability (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Karlin & Cross, 2014; Moullin, Sabater-Hernández, Fernandez-Llimos, & Benrimoj, 2015; Tabak et al., 2012).
Furthermore, the critical paradigm shift toward recognizing, understanding, and addressing implementation and contextual factors has significantly permeated and become increasingly emphasized in specific research contexts. As a grant reviewer, I have witnessed a sea change beginning to emerge over the past 5-7 years where increasing emphasis is being placed on implementation and effectiveness. Deliberations about internal validity and controlled environments have increasingly been joined or even superseded by conversations about external validity and implementation factors. Moreover, journal reviewers have increasingly come to value and comment on the importance of effectiveness and real-world implementation and generalizability.
The growing interest in and prominence of dissemination and implementation in research is reflected in the maturation of the field of implementation research. Evolving from a scattered science of individual, one-dimensional (and often highly context-specific) factors that may impact adoption and delivery of interventions or approaches, implementation science has developed into an increasingly sophisticated field of research from which has emerged a spate of theoretically-driven, multi-level dissemination models and the identification of pre- and post-implementation processes for guiding and promoting implementation in different settings. The growing prominence and reputation of the field’s flagship journal, Implementation Science, is a further reflection of how the field of implementation science has come in a sort time. In just five years, the impact factor of Implementation Science has risen to above 4. (If implementation science were a stock, now would be a buy opportunity!) In the years to come, the findings of implementation science and the incredibly impressive work of an increasing number of implementation science researchers (including many psychologists) are likely to yield important new discoveries and identify even more sophisticated approaches for bridging the great divide between psychological science and practice.
There is a significant opportunity for clinical psychologists to contribute to and help shape the field of dissemination and implementation for promoting the delivery of evidence-based psychological treatments. It is essential that clinical psychology be recognized thought leaders and actors in bridging the research-to-practice gap and helping to identify and adapt policies, systems, and other requirements for promoting the delivery of evidence-based treatments in real-world settings within community agencies and health care systems. Clinical psychologists are well poised to be agents of change at macro and systems levels, as well as individual levels. Organizationally, SCP is well poised to be a leader in dissemination and implementation within professional psychology, an opportunity embraced enthusiastically by the SCP Board of Directors.
As a first step in supporting and empowering SCP members interested in learning more about, and becoming more involved in, dissemination and implementation, we are developing a Dissemination and Implementation section of the SCP website that will include introductory information on dissemination information and resources related to specific implementation barriers and facilitators, implementation frameworks, and examples and case studies of evidence-based psychotherapy and related dissemination and implementation efforts. Shannon Wiltsey Stirman and Torrey Creed, two clinical psychologists who have been very active in the field of D&I, are helping to lead the efforts related to the development of the new section of the website. Working SCP Website Administrator, Damion Grasso, we will soon have a virtual D&I home within SC. I am hopeful this new information and resources will be helpful to many members, including those who are new to the field of D&I as well as those interested in learning more.
Finally, a critically important, but under-recognized, need and opportunity for promoting the dissemination and implementation of evidence-based psychotherapies involves addressing patient factors that are essential to EBP delivery (Karlin & Cross, 2014). Strategic dissemination and implementation must leverage the importance and power of patient awareness, engagement, and informed choice – beginning even prior to the initiation of treatment. If the “Toms” and Judys” of the world are knowledgeable about EBPs, their benefits, and the treatment process, and they are engaged in an early process of shared decision making, they are more likely to initially seek out and be engaged in care. The pharmaceutical industry has well-recognized and leveraged “pull” factors for drawing interest and demand through the use of direct-to-consumer education and marketing. Promoting public awareness of and patient engagement in EBPs is an area of significant interest and focus in my current work and one I hope professional psychology (including clinical psychology, in particular) will focus greater attention to as other health care disciplines have done in recent years. I look forward to pontificating more about this in the future and to hearing your thoughts about opportunities for how clinical psychology – working at multiple levels – can contribute to and help lead efforts to close the enduring research-to-practice gap and improve mental health care delivery!
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As the APA Convention approaches, I hope to see many SCP’ers who plan to be in attendance in Denver! If you will be at the Convention, I hope you will come to the new SCP Social Networking Event and Awards Ceremony on Friday August 5, 2016, in the Hyatt Regency Denver Hotel, Centennial Ballroom F – and please bring colleagues and students! The event should be lively and engaging. In addition to fun, food, and drinks with colleagues, we will be holding a Speed Mentoring Event to kickoff the SCP Mentorship Program. The SCP Mentorship Program will soon be a new member benefit available to all members and will cover a wide rage of professional interest areas! I would like to thank Michele Karel and Natalia Potapova for helping to coordinate the Speed Mentoring Program and the development of the Society-wide Mentorship Program, along with a committee of dedicated SCP members and Board Members.
Please be on the lookout for the SCP Needs Assessment that we will be sending electronically to all SCP members in June. The Needs Assessment is designed to help us to identify members’ needs, what they value about SCP and SCP membership, and what more we might do to promote the value proposition of SCP membership. Thank you to Elizabeth Davis and Claire Collie (Co-Chairs of the SCP Membership Committee) and the Membership Committee for their help with developing the Needs Assessment.
Warm wishes to all for a pleasant, safe, and fun Summer!