Issues in Implementing Community-based Intervention Research John S. Brekke, Ph.D., Professor School of Social Work University of Southern California NIMH Intervention Research Workshop July 11, 2012

There is a relatively new field of Dissemination and Implementation Research. NIMH review committee on it. Good literature to know. I will talk about issues in implementing intervention research on the ground, what I have learned from successes, failures, and lots of trial and error. The lived toolkit.

4 topics, plenty of time for discussion 1.Overview of some types of community- based MH research 2. Agency recruitment 3. Agency groundwork 4.Project logistics

1. Overview of some types of community-based MH research The helicopter approach: The agency as a good recruitment host There is little attempt to create a partnership We do our research thing, you keep doing what you do and we try to stay out of each others way. Agency can feel like a victim: you dont call, you dont write, what happened here?

If you are in the community, and you are involving an agency site, you have a partner whether you like it or not. (JV example). If you are doing interventions research you have a partnership that must be cultivated and nurtured. So, lets focus on the partnership.

Partnered Research –University led (R01 examples) –Agency led (samhsa examples) –Shared (risp example) Where the partnerships vary in terms of: Leadership Decision making Tasks Accountability

Here is the dilemma. Even in a university-led partnership where the leadership, decision making, tasks and accountability for the project rest fully with the academic side, the agencys leadership, decision making, tasks and accountabilities can have a dramatic influence on the success or failure of a project.

Examples: Recruitment demands on agency staff lead to loss of commitment Relationships sour when commitments are broken Agency demands take precedence for staff, so agency leadership is critical for maintaining staff commitment

These partnerships are hard to build well, and easy to lose. I am the gatekeeper and train all my staff and students in the ways of these partnerships. I monitor interactions carefully. Hiring the right personnel is critical (taxi driver analogy) Providing proper and ongoing oversight is critical (MM example)

2. Agency recruitment Cold calls are very difficult. You need an introduction of some kind, but know who is introducing you, know the halo. Have a project pitch (or multiple project pitches) that are based on understanding the payoffs for the agency. Be open to reciprocities. Know your agency patron and that takes time. Make use of serendipity. Be political.

3. Once you are in, there is agency groundwork to do As part of developing and implementing any project you need to understand that agencies are socio-political fields, and you cannot successfully act within that field unless you understand them in that way.

Get familiar with: Agency mission Agency structure Clinical models Funding streams Regulatory context Billing and fiscal demands Significant stakeholders Board of Directors Formal governance structure

Power structures (formal and informal) Significant dilemmas and challenges to the agency: internal and external e.g., local and national political/policy contexts Past experiences with research Attitudes towards evidence and research Role of research or evaluation in the agency

How to do this? Read agency material and talk to administrators and staff Ask permission to hang out and watch Ask questions, and most importantly: listen Work around their schedules and understand that they are not there to serve you or your agenda You need to build the partnership by building relationships and trust. Be a good suitor.

Find an organizational translator! Someone you are building trust with, someone who can translate the organization to you, and who can mediate and understand your concerns and issues. Best if it is someone respected, and who can eventually play a formal role like this. Can take real time to find the right translator. At times I have become a confidant.

You are going to have to navigate and use top- down and bottom-up influence and leverage structures. You cannot use only one, it must be both. Leverage external to the agency can be short lived and shallow. So you need to build relationships at as many levels in the organization as you can, and it takes TIME!

Things can change quickly in terms of agency investment in any project, both positively and negatively Try to build in payoffs for the agency from your data so you can withstand these shifts.

4. Now, on to the Project Is it on mission with the agency? What is the payoff for them? Will its demands be reasonable? What internal leverage can you build? Be exact about resources required of the agency Work our resource agreements What are your reciprocities? Be very clear on the NIMH (or funder) timeline

Project logistics Recruitment (usually slower, things change, have plan B and C) Retention (who, what, how, when) Assignment (need to work with them) Data gathering (be clear about protocol: what, who, how) Intervention logistics: Whose staff, how trained, fidelity, time, space, support, supervision, billing,

Interventions Evidence-based practice Practice-based evidence Any good intervention should have had a phase of intensive stakeholder input and advice

Once the project begins Have the communication channels and agreements clearly worked out (who, weekly, or need to know) What are your leverage points for emerging problems? IRB agreements Presentation and publication agreements Think through negative findings, and try to build in positive for the agency

Honor you reciprocities during and after the project Do not promise what you cannot deliver, and it will be tempting to do that to get over some humps Problems are opportunities, and you will have lots of opportunities.

Stages for successfully launching and sustaining a peer-led intervention at a mental health agency: Stage 1: Priming the Agency with Administration Stage 2: Training the Peer Health Navigators Stage 3: Integrating the Intervention into the Agencys Practices with Line Staff 23