Although other researchers have evaluated different blends of technology, training and supervision in promoting the adoption of CBT for treating SUDs (LoCastro et al., 2008
; Scholomskas et al., 2005
) to our knowledge, this is the first study to test the feasibility of implementing this innovative blend of instructional technology in a geographically diverse sample of practicing community substance use counselors. This study has several limitations. First, we did not include a no-training control condition. Both groups of participants received some training in CBT making it difficult to parse out the effect of the protocol from the influence of other potential influencing factors (e.g., regression to the mean). A no training control condition would have helped more clearly elucidate the impact of our training on important provider outcomes such as job-related burnout. Second, we did not directly examine whether the supervision/consultation sessions consistently differed from one another. For example, the LF supervision/consultation sessions were designed to be more flexible than the HF conditions, but no manipulation check (e.g., coding of audio tapes) was used to ensure that these sessions remained consistent. Thus, it is difficult to determine the whether any differential outcomes between the two conditions were due to the experimental manipulation. Third, no direct measure of clinician behavior was used in the study. This would have had the obvious advantage of shedding some light on how much of an impact our training protocols had on the adoption of CBT-based therapy skills in actual clinical practice. Fourth, patient outcomes were not measured in this study. An important next step in this line of research will be to examine whether the level of structure provided in different blended learning interventions have differential impacts on clinician practices and patient outcomes.
Despite these limitations, the present study provides us with a valuable demonstration of the feasibility of a blended training intervention that takes place entirely on the Internet. It is critically important to establish the feasibility of this approach because community-based substance abuse counselors typically practice in organizations that lack computer and information resources (e.g., email) (McLellan et al., 2003
), and report a high degree of workplace burnout (Knudsen et al., 2006
). These factors conspire to make community SUD treatment providers a particularly challenging audience for a training intervention that relies entirely on Internet technology. The present study provides compelling evidence that given a single 30-minute orientation session, and ongoing technical support, a diverse audience of practicing SUD counselors can successfully engage with both synchronous and asynchronous online training resources, and demonstrate significant improvement on measures of knowledge and self-efficacy as a result.
The results of this feasibility study have important implications for dissemination and implementation of evidence-based treatment practices, because the technology-based training program that was evaluated is entirely scalable. A training intervention is said to be scalable if one can rapidly increase the number of trainees while only marginally increasing the resources required to train those additional individuals. Once the WBT modules have been developed and deployed, the cost of delivering the course content to an additional 10, 20, or even 1,000 counselors is fairly trivial. Furthermore, using web conferencing technology to facilitate group supervision sessions is far more scalable than holding face-to-face supervision groups as it allows a single centrally located clinician to conduct multiple supervision sessions per day with groups composed of trainees from around the country or around the world.
In addition to testing the feasibility of this innovative blended learning intervention, the present study compared learner outcomes across two conditions that varied in the degree to which they explicitly promoted adherence to the manual-based CBT treatment protocol. Participants in both experimental conditions demonstrated equivalent improvements in scores on a test of knowledge about CBT, and similar improvements in their ratings of their self-efficacy in their ability to use CBT in their clinical practice. The present results suggest that counselors who participate in relatively more structured training designed to promote adherence to a manual-based treatment may not result in better training outcomes than counselors who are afforded a greater degree of control over their individual training experience.
This finding has important implications for those who are interested in implementing evidence-based treatments for individuals with SUDs. In the “Stage Model of Psychotherapy Development” (Onken, Blaine, & Battjes, 1997) alternately been referred to as the “Psychotherapy Technology Model” (Morgenstern & McKay, 2007
) or “Systematic Replication Model” (Hayes, 2002
), dissemination research tests the external validity of scientifically proven technologies, identifying subpopulations of responders and non-responders, and the necessary and sufficient conditions for replication of the results obtained in efficacy trials. Clinical training is thus conceptualized as occurring at the end of a long, unidirectional translation pipeline. Its primary purpose is to promote adherence, fidelity and compliance with the treatment protocol among counselors practicing in the field. Adherence is typically measured by listening to audiotapes of clinicians working with clients, and having an independent rater code those interactions according to a standardized system (e.g. Yale Adherence & Competence Scale, YACS; Carroll et al., 2000
; Motivational Interviewing Treatment Integrity scale for Motivational Interviewing, MITI; Moyers, Martin, Manuel & Miller, 2002). The success of a training intervention is then judged primarily by the degree to which trainees can adhere to the manual-based treatment protocol.
Although this model has tremendous intuitive appeal, Morgenstern & McKay (2007)
have recently invited us to question some of its most fundamental assumptions. These authors point out that literally hundreds of methodologically rigorous randomized control trials have yet to yield convincing evidence that theory-based active ingredients of so-called ESTs are curative agents, or that the specific factors captured in the manual based treatment protocols are more important than non-specific ones. Barring such clear evidence, it has become increasingly difficult to justify adherence to these specific factors as the primary goal of clinical training in SUD.
An alternative perspective on the objectives of clinical training reflects the broader, more comprehensive view of evidence based practices that have been proposed in recent years. The APA Presidential Task Force on Evidence Based Practice (2006)
defines Evidence-based Practice in Psychology (EBPP) as “the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture and preferences”. This model is consistent with the principle of evidence-based medicine endorsed by the Institute of Medicine (2001)
, which conceptualizes evidence based practice as a stool resting upon a three “legs”; (a) research evidence, (b), clinical expertise of the health professional and (c) the unique preferences and expectations of the client (APA, 2006
; Spring, 2007
If we expand our view of implementing effective practices beyond the unidirectional transmission of theory-based active ingredients of manual based treatment protocols (Weingardt & Gifford, 2007
), training in evidence-based practices can similarly move beyond a narrow focus on promoting adherence to treatment protocols and embrace the clinical expertise of the counseling professional and the individual challenges faced by the clients that he or she is working with. Such a view is consistent with that expressed by Hayes (2002)
, who outlined a “practical application model”, wherein dissemination research examines how to improve outcomes in the real world of health care delivery. In Hayes' model, the focus is not on strict adherence to a manual-based treatment protocol, but rather on the identification of “…technologies that clinicians are willing to accept and adopt. If they are to hard to learn, too confusing, too complex, or too boring, then that limits their practical applicability… (p. 411).“
Rather than being trained to closely follow a prescribed sequence of interventions, an alternative training model would explicitly encourage trainees to use their best clinical judgment to pick and choose among the clinical strategies and techniques, with an eye towards the unique challenges experienced by their individual clients. Building upon the popular metaphor that clinicians learning new strategies and techniques are like craftsmen obtaining new tools, this practical application model has been termed “Toolbox Adoption” (Guydish, Manser, Jessup, & Tajima, 2007
). In this model, training provides counselors with new clinical tools which they are then free to select and apply in eclectic fashion. Such a self-directed approach to clinical training is reflective of contemporary evidence-based models of training and performance improvement which uniformly advocate for maximizing “learner control” over training experiences (see Committee on Developments in the Science of Learning, 1999
; pp. 192).
Of course the ultimate test of a clinical training program is whether it results in improved outcomes among the patients of clinicians who are trained. More research is clearly needed to determine whether the flexible, blended training model described in the present paper will result such improved patient outcomes. However, the present study does suggest that such a flexible model can result in equivalent improvements in therapist knowledge and self-efficacy as a more traditional training approach. Furthermore, our results suggest that a more flexible training model may also increase feelings of personal accomplishment among counselors relative to clinicians who participate in a more traditional, structured training program. Given the extraordinarily high rates of voluntary turnover among clinicians who treat substance use disorder, this finding alone is encouraging and worthy of further exploration.