Experiences in Evidence-Based Addiction Interventions: Change Laboratory Insights

1. The Change Laboratory: Social Workers, Addiction Counsellors and Community Based Project Workers experiences of training, implementation and accreditation in evidence-based interventions for problem substance misuse  Robert O’Driscoll Thursday 13 June 2019

2. Evidence Based Practice National Policy and Strategic Direction Documents National Drugs Rehabilitation Framework Document July 2010

3. Evidence Based Substance Misuse Treatment Adolescent Community Reinforcement Approach (A/CRA) The Community Reinforcement Approach and Family Training (CRAFT)

4. Training in Evidence-Based Addiction Treatment • 40 Practitioners trained • Addiction Counsellors • Social Workers • Young Person’s Probation Officers • Community Drugs Project Workers • Managers • 20 of those trained reported that they had no funding for accreditation • 18 practitioners participated in the research- • 2 managers • 4 social workers • 4 community drugs project workers • 7 addiction counsellors • 2 declined the invitation to participate

5. Cultural Historical Activity Theory (CHAT)

6. Cycle of Expansive Learning • NEED STATE • DOUBLE BIND • BREAKTHROUGH • STABILISATION • ADJUSTMENT, ENRICHMENT • RESISTANCE

7. Semi-Structured Interviews (n=17) Change Laboratory Workshops (n=4)

8. 17 Semi-Structured Interviews Analysis of the interview data: • identified 59 practice contradictions, tensions and dilemmas as a result of the introduction of EBT as a new tool into the HSE-CKCH addiction services health and social care activity system “I suppose there was a huge emphasis on evidence-based, evidence-based, evidence-based, and we were missing the client in that, or we were missing some process in that, that were kind of key in terms of relationship and things like that, do you know what I mean?”

9. The Change Laboratory . MODEL, VISION ACTIVITY SYSTEM CYCLE OF EXAPNSIVE LEARNING . PAST PRESENT I FUTURE . MIRRORR • Videotaped work situations. • Problematic cases. • Customer feedback • Statistic. • Etc.. Board scribe Video Recorder Researcher-interventionist Minutes keeper Practitioners

10. Thematic Map of the Findings OVERARCHING THEME: COMMUNITY OF PRACTICE v v v v • Main theme 4: • Pros and cons of training: • Training negative • Training positive • Main theme 1: • Implementation stage: • Pre-implementation • Early implementation • Advanced implementation Main theme 2: Leadership • Main theme 3: • Characteristics of • A/CRA and CRAFT: • Compatibility • Complexity • Observability • Relative advantage • Reinvention • Trialability Sub-Theme 1.1: Recording Practice Sub-Theme 1.2: Suitable clients Sub-Theme 1.3: Staff attitude Sub-Theme 1.4: Time Sub-Theme 2.1: Working on different things Sub-Theme 2.2: Case management Sub-Theme 2.3: The role of supervision Sub-Theme 2.4: CRA v Psychotherapy Sub-Theme 3.1: We’re doing it already Sub-Theme 3.2: Overlooking professional expertise Sub-Theme 3.3: Cultural relevance Sub-Theme 3.4: Why get accredited? Sub-Theme 4.1: Refresher training Sub-Theme 4.2: Communication about training Sub-Theme 4.3: Wasting Money

11. Community of Practice

12. Main Theme 1: Implementation Stage

13. Main Theme 1: Implementation Stage

14. Themes Four Themes Data extracts Sub-Theme 1.1: Recording Practice Sub-Theme 1.2: Suitable clients Sub-Theme 1.3: Staff attitude Sub-Theme 1.4: Time “I don’t enjoy mandatory trainings. And maybe that’s one of the reasons that people haven’t invested in going forward. It’s probably one of the reasons I haven’t invested in going forward, in that I wasn’t given a choice, and I really feel that is important.” (AC1) “Time, and I suppose time went on then and you’re kind of, it goes further and further behind, and I just didn’t catch up on it.” (SW3)

15. Main Theme 2: Leadership • be proactive around implementation needs, • be a support to staff while they are applying the new practice, • be knowledgeable about and able to guide the implementation process, • be perseverant in addressing emergent barriers and obstacles, as having critical implications for successful EBT implementation, and • to have, and communicate a vision for practice. “No managers. Of the service that we work in, so there’s no managers, there’s no people that make the real kind of decision-making, yeah, they’re not here. OK, so I’d see that as a problem. [M1] was here, but yeah, but even I’m talking even a level above [M1]…You know, or people that are, you know, that have probably a real say, that are funding it, …That have the main power, I suppose, because they have the resources”

16. Sub-Themes Four Themes Data extracts Sub-Theme 2.1: Working on different things Sub-Theme 2.2: Case management Sub-Theme 2.3: The role of supervision Sub-Theme 2.4: CRA v Psychotherapy “We help the client to get to where they want to go. Well, that’s our aim.” (AC4) “Now the thing, you see even the thing there with the case management, I don’t know where that has after been kind of formulated from, you know?” (AC5) “Do you know the significant difference with case management lads is that you don’t have a choice.” (M1)

17. Main Theme 3: Characteristics of A/CRA and CRAFT: • “So it kind of, it blended in with harm reduction, with abstinence, with do you know what I mean, with whatever kind of even, no changes in terms of use, and the different factors in people’s lives and stuff. The other thing was the adolescent piece because again we were designing it because our work involved primarily adolescents and we were working with [social work department] and the child protection teams and you know, probation teams, etc. and such.” (M1) • Compatibility • Complexity • Observability • Relative advantage • Reinvention • Trialability

18. Sub-Themes Four Themes Sub-Theme 3.1: We’re doing it already Sub-Theme 3.2: Overlooking professional expertise Sub-Theme 3.3: Cultural relevance Sub-Theme 3.4: Why get accredited? “It’s stuff we have been doing for years, but we just didn’t formalise it.” (M2) “If I’m honest, we were kind of doing it already.” (AC2) “Sure, well, I have been using it where possible. I have found, I found feedback from clients in relation to some of the language that’s in it, some of it is Americanised.” (AC1)

19. Main Theme 4: Pros and Cons of Training Training negative Training positive “I think again, yeah, I think that’s one of the things that stood out for me on the training, like, you know, I didn’t like the training anyway. I thought it was the worst, one of the worst trainings I ever did because I just found it so boring really. There wasn’t, there was very little kind of experiential input in it really. I think it went into groups once or twice, but it was Bob up there and doing his stuff, yeah, so I didn’t like that” (AC5) “I felt that the training was very engaging. You spent, what was it, four days, is it, that, like, you really wanted to go the next day and listen to him again, like, you know. And you would go to this thing and he was presenting it very well and he obviously knows what he’s talking about. So it was very interesting and made, everyone kind of wanted to do it” (SW1)

20. Sub-Themes Three Themes Data extracts Sub-Theme 4.1: Refresher training Sub-Theme 4.2: Communication about training Sub-Theme 4.3: Wasting Money “I think maybe, like I said, a refresher to get enthusiasm going and interest going again”. “I never got whose idea it actually was, you know, to bring this in?” ““You know, money has been paid and I mean, my senior doesn’t come back and say, “There is three grand sitting there, like, why has it never happened?” So there’s never been any pressure really following me, like, to do it.”

21. Embedded Contradiction System demand for uninterrupted service provision, contemporaneous care plans, updated client records and case management. Policy Demand for EBT Implementation COMMUNITY OF PRACTICE

22. Zone of Proximal Development (Vygotsky, 1928)

23. THANK YOU questions?