As Morgenstern and McKay (2007) point out, a cornerstone premise of the technology approach is the specificity hypothesis: EBTs produce impacts largely due to the curative effects of model-specific, theory-based techniques that differ from common elements or placebo effects of psychotherapy. The specificity hypothesis is the underlying premise of both mediational research and client-treatment matching studies. In the substance use field, tests of mediation have yielded positive and negative results in equal abundance (Morgenstern & McKay, 2007), and matching studies have failed across the board to confirm hypotheses about which treatments are best suited for which clients (Carroll & Rounsaville, 2007; Morgenstern & McKay, 2007). Even surefire hypotheses regarding the benefits of strong fidelity to core EBT ingredients are frequently upended. Recent studies of both adolescent (Hogue et al., 2008) and adult substance users (Barber et al., 2006) have reported a curvilinear relation between treatment adherence and some client outcomes: Too much adherence (as well as too little) can be a bad thing. And therapist competence in delivering EBTs is often weakly related or unrelated to outcome—when competence can be reliably assessed and differentiated from adherence, a difficult trick to master (Barber, Sharpless, Klostermann, & McCarthy, 2007).

The task of transporting EBTs to everyday settings—known as technology transfer—has proven formidable. A host of factors influences the amenability of community agencies to adopting EBTs, including strength of partnership between EBT developers and providers, belief by clinical personnel in the value of integrating EBTs into existing services, and suitability of agency resources (including personnel) and organizational context for implementing EBTs with fidelity (Simpson, 2002). It appears that technology transfer can work under conditions of extensive support from model developers utilizing quality assurance (QA) “superstructures” to cultivate training, implementation, and monitoring activities on-site. QA superstructures invariably contain four components (see Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005): (a) guidelines for selecting adoption-ready sites and identifying qualified staff for training; (b) standardized training toolkits that include a treatment manual, protocol for training workshops, demonstration videos and clinician workbooks, on-site supervision procedures, and fidelity checklists; (c) procedures for ongoing training and consultation from model experts that include observational coaching of clinic cases; and (d) continuous quality improvement procedures to evaluate implementation data, feed selected data back to therapists, and buttress organizational support. However, commitment to QA superstructures demands substantial and costly changes in agency infrastructure, administrative and clinical supervision, material resources, and ongoing technical support. And as yet there is no evidence that EBTs can be sustained in usual care after external support ends, or what level of partnership is needed to maintain a “good enough” QA structure indefinitely.

Concerns about the feasibility of EBT technology transfer have led researchers in both mental health and substance use to advocate a “core elements” approach to increasing use of EBPs in agency settings. The core elements approach emphasizes dissemination of reduced sets of essential treatment techniques common across EBT models for similar populations. The benefits of shifting away from wholesale name-brand EBTs toward distilled core techniques could be profound (Chorpita, Daleiden, & Weisz, 2005): unify and simplify the task of transporting curative ingredients of EBTs into routine care with fidelity; forego the herculean demand to master a different treatment manual for each clinical disorder; retain the importance of provider judgment about duration, intensity, and sequencing of EBPs; and provide evidence-based options for client groups with diagnostic complexity and/or for whom no manualized EBT exists. Disseminating EBT core elements could also enhance dissemination of full-scale EBTs by augmenting the basic technical competencies of community practitioners and galvanizing the process of adapting discrete manuals to fit usual care (Chorpita & Daleiden, 2009). Core techniques might also be deployed as a first-line option in primary behavioral care, with nonresponders referred to more comprehensive, EBT-based specialty care (Carroll & Rounsaville, 2006). Note that the core elements approach subscribes (at least in principle) to the specificity hypothesis, and progress in generating an evidence base for core techniques in various client populations appears linked to progress in mechanisms of change research.

As mentioned above, QA superstructures that accompany complex EBTs may ultimately prove unsustainable in many clinical settings. It seems likely that model-specific algorithms for reducing, modifying, and reinventing EBTs will become de rigueur to supplement existing QA protocols (Garner, 2009). Also, interactive computer-based training and distance learning methods hold great promise for increasing the accessibility and perhaps precision of technology transfer (Weingardt, 2004). On the other hand, QA superstructures may thrive in large government-operated sectors of care where substance use is prevalent: criminal justice, juvenile justice, welfare, child welfare, even schools. Each sector presents a unique service context—and dissemination opportunity—with regard to resource availability, organizational capacities, and barriers to effective treatment implementation (Institute of Medicine, 2006). Because government is often the sole funder of services and a primary stakeholder in the accountability and quality of those services, strong research-government partnership increases the likelihood that EBTs will take root and be sustained at a systems level (Morgenstern, Hogue, Dauber, Dasaro, & McKay, 2009).