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Implementing EBPs
in Mental Health Systems
David Lynde, MSW
Co-Director Dartmouth EBP Center
Dartmouth Psychiatric Research Center
Presentation Overview
EBP Perspective
 Some Lessons We Are Learning:
Statewide Implementation
 Stages of Dissemination of EBPs in
Systems

EBPs in Perspective
Six currently identified SAMHSA EBPs
for adults with SMI that have
implementation resource kits
 Do not cover all service needs
 Continuing process of evolution
 Identify well researched practices

Core Values in EBPs
Recovery
 Comprehensive Assessments
 Individualized Services
 Recovery-oriented practitioner skills
 Informed, shared decision making

Lessons from
the Field
“What You
Learn When
You Step in It”
State/Public
Mental Health Authority
Evidence Based Practices
Dissemination
Stages of Change
System Stages of Change:
Precontemplation Questions
What are EBPs?
 What is the difference between EBPs
and what we are doing right now?
 Why is this a good time for us to tackle
this?

System Stages of Change:
Precontemplation Questions
Why should this be one of our system
priorities?
 What are the benefits of changing the
status quo?

System Stages of Change:
Precontemplation Actions
Provide information and forums for
meaningful discussions for all
stakeholders
 Engage providers in discussions at all
levels

System Stages of Change:
Contemplation Questions
How committed is our leadership to
disseminating EBPs in our system?
 What are the unmet needs in our
system for EBPs?
 What EBPs are priorities for our
system?

System Stages of Change:
Contemplation Questions
What other EBPs already exist in our
system?
 What lessons can be learned from our
previous experiences with systems
change?

System Stages of Change:
Contemplation Actions
System leadership honest discussions
 Assessing priority needs areas for the
system from multiple stakeholder
perspectives
 Assessing current outcomes for priority
needs areas
 Assessing current EBPs in system
 Reviewing system change history

Lessons Learned: Stakeholders

Consumers, family members and
providers play a crucial role
– Engage in discussions and discourse with
stakeholders not just information sharing
– Stress philosophy, values and goals of EBPs
– There is no one single consumer, family or
provider perspective
– Honor ambivalence
Lessons Learned: Stakeholders
Involvement
= Support
Lessons Learned: Stakeholders

Building “consensus” is nearly
impossible
– Building “Informed Support” is an
alternative view
– The Status Quo is powerful
– Finances often “drive” resistance
– Define significant and meaningful roles
for stakeholder involvement
System Stages of Change:
Preparation Questions
Who will lead the EBP dissemination
when the resistance to this change
surfaces?
 Who are the stakeholders that need to
be involved?
 Are we willing to set up a Statewide
EBP Team?

System Stages of Change:
Preparation Questions
How do EBPs fit with our mission
statement?
 What is our system willing to change to
support EBPs?
 What is our system not willing to
change?

System Stages of Change:
Preparation Actions
Designation of EBP leadership
structures
 Commitment to EBP leadership
 Engagement of broad spectrum of
stakeholders
 Statewide EBP leadership team
 Understanding EBPs in relationship to
system mission

Lessons Learned: Leadership
“Why do we want to change
the status quo? After all,
that is what got us where
we are today?”
Lessons Learned: Leadership
 State
Mental Health Authority (SMHA)
Leaders have used
– Public Forums
– Websites
– Written Statements
– State System Plans and Priorities
Lessons Learned: Leadership
 SMHA Leaders
have used
– Commitment of Resources
– System Mission Statements
– Internal and External Forces
– Grant Funding
– Commitment of Personnel
Lessons Learned: Leadership

Statewide EBP Teams
– Multiple stakeholders
– System feedback regarding
• Implementing
• Sustaining
• Improving
– Coordinated by State EBP Leader
Lessons Learned: Leadership Teams
System Stages of Change:
Action Questions
What can we do to keep the sources of
support for EBPS active and public?
 How will we constantly communicate
where we are and where we are going
with EBPs?
 How will our system support the time for
staff to be trained in EBPs?

System Stages of Change:
Action Questions
How will we utilize and develop training
and consultation resources for EBPs?
 Will we set up a technical assistance
center in our system for EBPs?
 How will early sites be selected and
what will be the expectations?
 What will our system do with fidelity and
outcome assessments?

System Stages of Change:
Action Actions
Plans for constant communication and
feedback
 Plans for training and consultation
processes
 Development of early site selection
protocol
 Description of how fidelity and outcome
assessments will be used

Lessons Learned: State EBP Plan
 Fit
with mission statement
Methods for describing State
responses to EBPs
 EBP implementation process
 Outreach and involvement for
stakeholders

Lessons Learned: State EBP Plan
Funding delivery of EBPs
 Training resources
 Involvement of other State
agencies

Lessons Learned: State EBP Plan
“Policies and Funding
are the fuel of
Evidence Based Practices”
Lessons Learned:
Policies & Regulations

Current State System Policies
– Often cited as barrier
– Rarely support EBPs as they exist
– Sometimes punish providers for doing
the practice
Lessons Learned:
Policies & Regulations

System Policies are Crucial
– Rarely designed for “structured practices”
that include
• Preparation Time
• Supervision Time
• Team Meetings
• Outreach Services
Lessons Learned:
Policies & Regulations
“Every system is perfectly
designed to achieve the results
it is achieving”
--Paul Batalden
Lessons Learned:
Policies & Regulations

Non-SMHA are often important “Players
in this Process”
– Vocational Rehabilitation in SE
– Substance Abuse, Law Enforcement, Judicial
and Corrections in IDDT
– Peer Support Agencies in IMR
– Medicaid Authorities in all EBPs
Lessons Learned: Training

The goal of most mental health training
as usual is not “implementation”

Implement
– to give practical effect to and ensure of
actual fulfillment by concrete measures
– to put a plan or system into operation
Lessons Learned: Training
“We now have thousands of
experiments across the country
which have proven that in
mental health, training by itself,
is not enough to create change.”
--Bob Drake
Lessons Learned: Training

Effective implementation requires much
more than just didactic “training”
– Many agencies and systems benefit from
university collaborations
– Agencies benefit from consultation
– “Skills training” is a later stage in the
organizational change process, not an
earlier stage
Lessons Learned: Change Takes Time
Lessons Learned: Training

Agencies benefit from high quality
training & consultation
– Trainers assist agency leadership in the
organizational change process
– Trainers engage with agencies over a
sustained period of time
– Trainers have access to their own peer
supervision & collaboration
Lessons Learned: Fidelity & Outcomes
Clear expectations for fidelity and
outcomes monitoring and use
 Quality improvement/assurance process
 Self-assessment is not a reliable
science
 Clear, consistent outcomes definitions
and reporting

System Stages of Change:
Maintenance Questions





What are the current fidelity assessments &
outcomes?
What are the high fidelity sites are doing that
they can share with other sites?
What other EBPs are we going to
disseminate?
How do we extend EBPs to other
populations?
What are the benefits to our system to
combine EBPs?
Lessons Learned

The State Mental Health Authority plays
a crucial role in the implementation of
EBPs

There are many actions at the State
Mental Health Authority level that may
facilitate the dissemination and
implementation of EBPs
Summary
State system and Mission Achievements
 Education re: EBPs
 Stakeholder Involvement
 Costs/Benefits of Doing or Not Doing EBPs
 Leadership
 Policies
 Training and Consultation

Recovery & Hope
“If people are treated as capable,
they often surprise everyone and
live up to expectations.”
• Ken Steele “The Day the Voices Stopped.”