In my two preceding posts, I began to explore and explain the truly complex nature of behavioral health, and the implications of a complex systems perspective on the applicability of Evidence-Based Practices. In this post, I want to take a look at the predominant approach to substance abuse prevention, again through the lens of complexity.
SAMHSA advocates the use of a Strategic Prevention Framework (SPF), as a way for groups to plan, implement, and assess the results of specific prevention strategies and tactics. As with other funded behavioral health programs, there is the expectation of reliance on evidence-based practices, and fidelity to those practice standards upon local implementation. First, a look at the SPF. This comes from SAMHSA publication Identifying and Selecting Evidence-Based Interventions, HHS Pub. No. (SMA)09-4205:
The Strategic Prevention Framework (SPF):
Step 1. Assess population needs (nature of the substance abuse problem, where it occurs, whom it affects, how it is manifested), the resources required to address the problem, and the readiness to act;
Step 2. Build capacity at State and community levels to address needs and problems identified in Step 1;
Step 3. Develop a comprehensive strategic plan. At the community level, the comprehensive plan articulates a vision for organizing specific prevention programs, policies, and practices to address substance abuse problems locally;
Step 4. Implement the evidence-based programs, practices, and policies identified in Step 3; and
Step 5. Monitor implementation, evaluate effectiveness, sustain effective activities, and improve or replace those that fail.
You don’t have to be an expert in complex systems, to raise some questions from your own experience with prevention:
…there are many systems whose interdependence drives patterns in behavioral health. How can we know what to do on just one part of the whole system, let alone know the effect on other parts of the system? Complexity teaches us that we can not predict the behavior of the whole, from an analysis of the parts in any complex system. Neither can we predict the full range of consequences that will follow from changing one part of the whole system.
…There is an old saying in the world of business organizations that “culture eats strategy for lunch.” In other words, how can we fully know the organizational culture where an evidence-based practice originated from, let alone know the differences between that originating culture and the culture where you intend to implement the strategy/tactic? Some say that there are no “best practices,” only “practices that worked well for those people in that place and under their circumstances. How can you understand the context where the practice originated, and compare it to your own context and culture?
…When we work with a community or any group of stakeholders, we are always dealing with the diversity of individual beliefs, knowledge, values, and meaning-making. How can we know the full range of these differences among the people at our table, let alone help them engage in respectful and collaborative dialogue? How can we learn to suspend our judgments and engage in collaborative dialogue, so that we may think, learn, and act together?
…How can we act if we are dealing with truly complex problems, filled with both known and unknown unknowns? Complexity teaches us that in the face of truly complex problems, we are not likely to know, or be able to use, a single “best practice.” In a complex domain, we are best served by trying multiple “safe to fail probes” – experiments using various approaches to the problem. We assess the results, and we keep/amplify what works, and discard/dampen what does not work.
In these ways we can begin to overcome what I call “AS IF…” change leadership – the unproductive practice of treating truly complex problems AS IF they were technical and merely complicated. If that were true, we would have solved these problems by now.
Coalitions at any level, and to address any issue, must be built on the foundations of engagement and trust. Seek the powerful “attractors of meaning” – ideas that inspire and motivate people – and use dialogue methods to think and act together. Rather than “fidelity to an evidence based practice,” work together to define your core values and operating principles. You can – and I think must – assess your fidelity to your own espoused values and principles. Your practices will yield results, and that result will be the evidence of your success.
All contents of this post and the preceding two posts are (c)copyright Bruce Waltuck, 2012. Permission is granted under a Creative Commons license for non-commercial use of the contents of these posts, so long as proper attribution and citation to this source is given.