Barriers to Evidence-Based Counseling Practices: A Counselor Educator Training Model

This paper highlights existing barriers to the training and implementation of evidence-based practice (EBP) within the counseling profession. In response to the current need for counselor accountability and adherence to best practices, counselor educators are called to support this agenda. An evidence-based counseling practice (EBCP) training model is presented here to guide this critical process. Ideas and Research You Can Use: VISTAS 2013 2 Important progress has been made in the merger of science and practice within all branches of the helping professions, thereby serving to bridge the “science-to-service gap” (Fixsen, Blasé, Duda, Naoom, & Van Dyke, 2010, p. 435). Most recently, schools and community agencies have begun to mandate the use of evidence-based interventions supported by school movements such as No Child Left Behind and Response to Intervention. At the same time, the mental health initiative was launched by the President’s New Freedom Commission Report (2003) and further supported by the National Institute for Mental Health (NIMH). These actions have begun to bring greater accountability to the counseling profession. The adherence to evidenced-based practice not only supports these initiatives, but also reinforces best practices within the counseling profession, bringing efficiency, transparency, and excellence in counseling outcomes. Yet there are a number of barriers that prevent the universal adoption of evidence-based practice (EBP) and interventions (EBIs) across all areas of the helping professions. Counselor educators need to become aware of these barriers and their impact on counseling student knowledge, attitudes, and subsequent future application of evidencebased practices within the counseling profession. In this paper we briefly discuss evidence-based practice and why we believe it is here to stay. Next, we discuss the importance of embracing evidence-based practice for the viability of the counseling profession, especially since so many counseling-related disciplines have already begun to lay basic foundation in this area. Building on these points, we discuss barriers to Evidence-Based Counseling Practice (EBCP). In particular, if EBIs have been with us for some time, why are we as counselor educators not universally teaching these methods to both school and clinical mental health counselors? Finally, we introduce a model to guide counselor educators in successfully incorporating EBCP into counselor preparation, including implementation of these concepts into the curriculum and promoting EBCPs within the wider counseling community. Evidence-Based Treatment and Practice There is a need for clarification of the terms related to evidence-based research in the literature. The professional research is flooded with terminology to reflect portions of this practice. Many studies reference specific programs, techniques, therapies, theories, and treatments (Jameson, Chambliss, & Blank, 2009; Powers, Bowen, & Bowen, 2010; Southam-Gerow, Hourigan, & Allin, 2009). Other studies examine the adaption of specific techniques or interventions deemed evidence-based or scientifically researched. Yet specific applicability to field-based practice is often left to reader interpretation. In regard to counselor education, a clear definition of practices and clinical effectiveness needs to be established within the literature (Powers et al., 2010). Evidence-based practice is defined by Thomason (2010) as “the integration of research with clinical expertise in the context of the client’s characteristics, culture and preferences” p.30. Furthermore, evidence-based practice specifically includes “practices that are informed by research, in which the characteristics and consequences of environmental variables are empirically established and the relationship directly informs what a practitioner can do to produce a desired outcome” (Dunst, Trivette, & Cutspec, 2002, p. 3). Inherent in both of these definitions is the development of competence in the decision making process related to evidence-based practice implementation. Ideas and Research You Can Use: VISTAS 2013 3 Training students in evidence-based practice as a model for clinical decision making (Addis, 2002; Thomason, 2010) includes a process to help practitioners address issues of treatment selection, ethical practice and application issues with a scientific influence (Gambrill, 2010). Additionally, training future practitioners in EBP includes the consideration of serving the individual counseling needs of those students and clients we work with, as well as multicultural considerations and goal setting as an integral part of treatment selection (Roysircar, 2009). There is a distinct need to bridge the researchpractice gap between university research and direct service providers (Abdul-Adil et al., 2010). This would entail the instruction of evidence-based practice as a decision making process of treatment selection and application of EBI within applied settings. Not only would this implementation result in better care for the clients and students that we serve, but it would also help to support the legitimacy of the counseling profession. It is imperative that counselor educators consider the impact of EBP, barriers to our graduate students’ future ability to adopt EBP, and subsequently the impact on the gap between research and practice within our profession. Barriers to Implementation Utilizing evidence-based practices is not as straightforward as one would imagine. There are many barriers that exist for practitioners including anti-EBP bias and cost of implementation. Counselor educators must be aware of these barriers in order to facilitate the effective utilization of EBP. “Conducting evidence-based practice requires both the existence of feasible, relevant, and effective intervention choices and the availability of detailed information about those choices” (Powers et al., 2010, p. 314). Barriers for Practitioners Practitioner barriers to Evidence-Based Practice in the community are many and include lack of training, limited access to treatment manuals, inadequate research evaluation skills, and limited professional supervision (Aarons, Wells, Zagursky, Fettes, & Palinkas, 2009; Chambless, 1999; Chan et al., 2010; Karekla, Lundgren, & Forsyth, 2004). One of the primary factors associated with lack of utilization among current practitioners is insufficient graduate training in basic concepts of research, evidencebased methods, knowledge, and utilization (Chan et al., 2010). Practitioners, especially those in supervisory or administrative positions, need to be armed with basic concepts related to evidence-based practice, such as those described by the Council for Training in Evidence-Based Behavioral Practice (2008). The Council describes five steps for carrying out the Evidence-Based Practice process: 1) asking, 2) acquire, 3) appraise, 4) apply, and 5) analyze. Once established in the profession, practitioners report insufficient time for training in the utilization of evidence-based interventions in the field and difficulty in receiving training through continuing education (Chambless, 1999; Chan et al., 2010). Even if practitioners feel adequately trained, a sample of seasoned professionals report barriers and exhibit resistance to adherence. Explanations might include the fact that treatments are reported as not easily adapted to the multifaceted needs of the applied setting (Southam-Gerow et al., 2009) and treatment manuals are not easily accessible or are costly. When they are accessible, many practitioners report that treatments are not Ideas and Research You Can Use: VISTAS 2013 4 always described in sufficient detail to implement the treatment (Rathvon, 2008). Oftentimes, true implementation of an EBP requires resources beyond an agency or institution’s ability to provide. For example, EBPs may require consulting teams, extended training, live supervision, or other fidelity-ensuring mechanisms that may be seen as interfering with the agency’s fiscal productivity. In addition, the appropriateness of the treatment within a particular setting comes into question. Within a clinical mental health setting, length and frequency of treatments may not coincide with third party payment issues (Addis, 2002). For example, evidencebased intensive in-home family counseling approaches that divert children from inpatient or residential treatment are frequently not reimbursed by managed care companies. Even though they may be far more effective in the long-term, the short-term investment is viewed as cost-prohibitive. Within schools, many evidence-based treatments are viewed as impractical (Rathvon, 2008) and not easily adaptable to an education setting. When an EBI is deemed acceptable, the school personnel may lack the necessary supports to guide and sustain proper application (Becker & Domitrovich, 2011). Moreover, theory based agencies may reject particular treatments perceived as conflicting with the orientation of choice. Those strongly committed to behavioral interventions will be reticent to incorporate modern psychodynamic methods within an existing practice, despite scientific evidence of success. In both school and agency settings, practitioners may be resistant, feeling that manuals detract from the authenticity of the therapeutic interaction (Addis, 2002, Karekla et al., 2004) or that they fail to appreciate unique aspects of the individual (i.e., cultural diversity, client treatment preferences; Bernal & Scharron-DelRio, 2001). Organizational issues such as level of supervision and adequate funding often limit the viability of adherence to EBP. Poor leadership and lack of supervision contribute as barriers to EBP (Chambless, 1999; Rapp et al., 2010; Swain, Whitley, McHugo, & Drake, 2010). Supervisors may be less likely to make EBP a priority due to increased attention, costly training, and the need for extra personnel (Powers et al., 2010; Swain et al., 2010). Without these aforementioned supports, practitioners would need to independently research interventions, a practice for which they often don’t have time (Rathvon, 2008). Barriers for Counselor Educators Further, the literature suggests that practitioners are aware of the importance of treatment effectiveness but feel they lack the training and resources to effectively perform these interventions (Karekla et al., 2004). The barriers to utilization of EBPs across the professional counseling field threatens to further impede future practice and derail accountability. Unfortunately, barriers also exist at the training level for many helping professions. Therefore, it is imperative that counselor educator programs adequately provide students with the knowledge and skills needed to deliver counseling services within an EBP framework. Current research suggests that this is not consistently happening (Karekla et al., 2004; McHugh & Barlow, 2010). Various mental health disciplines, including social work and psychology, have called for increased attention on the pedagogy of EBP (American Psychological Association Presidential Task Force on Ideas and Research You Can Use: VISTAS 2013 5 Evidence-Based Practice, 2006; Forman, Fagley, Stenier, & Schneider, 2009; Rubin, 2007). In light of university academic requirements, accreditation and licensure guidelines, not surprisingly, counselor educators experience a lack of time in the curriculum to dedicate to empirically validated methods (Council for Accreditation of Counseling and Related Educational Programs [CACREP]). There is also evidence of resistance among training professionals who hold a bias towards authority-based decision making, based on consensus, anecdotal experience, or tradition (Gambrill, 2006). Counselor educators may feel pressure to choose one school of thought in regards to student training needs. In turn, some prefer training students in theoretical orientation and view the emphasis on scientific evidence as inconsistent with this view. Regardless, educators may be required to incorporate content in response to best practices, state and local mandates, and patterns of need within the profession. Clinical mental health counseling programs that fail to adequately prepare students to understand, value, and choose EBPs may inadvertently be setting students up for professional failure by limiting future job skills and marketability. For licensed professional counselors and helping professionals who depend on third party payment, the literature suggests a trend toward insurance reimbursement for EBI, mandatory adherence of EBP in order to qualify for liability insurance, and mandatory use of brief interventions to treat clients (Thomason, 2010). Herein is an ethical responsibility for all counselor educators. Ethical Issues and Obligations for Counselor Educators Counselor educators are ethically obligated to train future practitioners to appropriately evaluate and utilize EBP (Gambrill, 2006) and recognize barriers to this practice (Addis, 2002) in both school and community settings. School and community settings require counselor accountability, including the use of evidence-based techniques, impact on student/client growth, and data to support this impact. Furthermore, providing best practices in the counseling profession is an ethical obligation to our graduate students, their students/clients, and the profession at large. In fact, it is a social justice imperative. Counselors, including students in field work, could easily be overwhelmed by the limited resources and daunting responsibilities inherent in community mental health practice (Paris & Hoge, 2009). Students who work in areas of poverty, diversity, or high need require training in best practices to enable them to even the playing field for those who do not have as much in terms of resources. Counselor educators have an ethical responsibility to provide the necessary mindset, skills, and training to prepare future counselors to implement effective interventions. As well, counselor educators can impact the culture of responsible, ethical treatment planning by emphasizing the importance of supporting EBP through on-site provision of resources, time for training and on-going supervision. Literature suggests that lack of adherence is in part due to lack of agency organizational support (Rapp et al., 2010; Swain et al., 2010), poor leadership, and guidance that ensures practitioners follow guidelines (Rapp et al., 2010; Swain et al., 2010). Resource Availability Implementation of evidence-based counseling in community agencies or schools requires an intense investment in training, money, and other resources. Practitioners must Ideas and Research You Can Use: VISTAS 2013 6 be provided with workshop training, manual(s), and clinical consultation/supervision (Sholomskas et al., 2005). This is similarly true for supporting EBC in counselor education. Even if counselor educators and students are highly motivated, good pedagogical practices in EBC require exposure to a variety of evidence-based models and their materials, including treatment manuals. Students should then have opportunity to apply this clinical knowledge at a minimum in role-play or most ideally with actual client populations in lab or fieldwork settings. There are some significant problems with these training needs. First, treatment manuals and other program-fidelity supportive materials are expensive. Frontline practitioners have been found to harbor concerns about program costs (Rapp et al., 2010) and to skeptically view new evidence-based approaches as propaganda, pseudoscience, or fads (Gambrill, 2006). Given the costs, it may be difficult to convince university colleagues to view evidence-based materials as necessary. Evidence-based approaches may not be appreciated by counselors who have been working longer who are perhaps more entrenched in a particular theoretical orientation, or who feel that manuals detract from authenticity of therapeutic interaction (Addis, 2002; Karekla et al., 2004) or the art of psychotherapy (Thomason, 2010). In addition, university administrators may fail to understand how critical it is to support the purchase of comprehensive treatment materials, including manuals and other supportive literature. Counselor educators must be adequately trained in the general evidence-based philosophy as well as at least one to two evidence-based approaches. This kind of training is by nature, extensive. Indeed, brief workshops and the like appear to be ineffective in helping clinicians implement EBCs in practice (Beidas, Edmunds, Marcus, & Kendall, 2012). We could thus draw similar conclusions about counselor educators attempting to teach these approaches and concepts; a workshop or didactic training program is no replacement for supervised clinical practice. However, in spite of the need for counselor educators to have some real-world experience with an evidence-based approach, the academy including counselor education may not recognize or reward clinical training as it does publications and other scholarly artifacts (Orr, 2005). Further, the rigors of committee work and other university and community service coupled with an increasing teaching burden may make it impossible for tenure-track faculty to engage in applied practice in either schools or community settings. To help support counselor educators in their efforts at teaching evidence-based approaches, consultants or external speakers should be invited to share practical expertise in the classroom. Coordinating such visits takes time and energy on both the part of the counselor educator and the community practitioner. Moreover, the state of our mental health system requires that practitioners increasingly limit their duties to revenuegenerating activities. Perhaps the most arduous challenge is that a model-adherent evidence-based approach that actively monitors program fidelity often requires full-time practice alongside intensive supervisory/consultant oversight. As in many situations, the best learning is by doing. Therefore, a small amount of training such as a one-day workshop becomes significant if it is accompanied by subsequent supervisory or consultation support. Indeed, active monitoring of program fidelity by way of expert consultation is found to correlate significantly with higher clinical skill levels and is viewed as a critical Ideas and Research You Can Use: VISTAS 2013 7 component of any evidence-based treatment (Beidas et al., 2012). This is true of counselor educator training as well as student counselor training.