ORIGINAL PAPER

Organizational Adaptation: Bridging the Research to PracticeGap

William E. Reay

Published online: 9 February 2010

� Springer Science+Business Media, LLC 2010

Abstract Currently, the children’s mental health system

appears dysfunctional and in need of serious attention. A

possible remedy for this disarray would be for researchers

and providers to establish integrated management systems

which include mutual, cross organizational learning, and

reciprocal feedback mechanisms. This type of adaptive co-

management to organizational governance would fully

integrate research and practice at the community level.

Using a public health service model, this organizational

management approach to research and practice would

harvest diverse scientific knowledge and disseminate that

knowledge through the natural occurring culture and

practice of each community. Organizational and clinical

knowledge acquisition, as well as practice improvements

would necessarily occur over time and across institutions.

Keywords Organizational adaptation � Research

to practice

Context is Everything

Thirty years ago, children’s mental health services were

powerfully influenced by stories told about children and

adolescents being needlessly housed in restrictive settings

and inadequately treated by outpatient programs. At that

time, the number of children and youth placed in residen-

tial treatment centers (RTCs) was alarming. Knitzer (1982)

estimated the number of children in these residential

facilities or treatment centers (RTCs) to be more than

50,000. Government agencies were known to quickly place

children in RTCs because community-based alternatives

were not available in sufficient quantities. Even more

troubling were findings that children and adolescent mental

health functioning did not improve during their stay at

RTCs (Burns et al. 1998). At about the same time, reports

regarding the over-use of private hospitals for adolescents

with substance-abuse and mental health needs surfaced as

well (Jackson et al. 1987).

Jane Knitzer’s (1982) monograph Unclaimed Children

ushered in a new movement in the United States to develop

quality community-based services as an alternative to the

restrictive, costly, and uncoordinated services that domi-

nated the service system at that time. In 1984, the Child

and Adolescent Service System Program (CASSP), a

Federal initiative, was created to provide technical support

to states. This CASSP initiative provided the foundation for

the System of Care for Children’s Mental Health (Stroul

and Friedman 1986). The System-of-Care (SOC) provided

a conceptual basis to design ‘‘mental health and other

necessary services which are organized into a coordinated

network to meet the multiple and changing needs of chil-

dren and adolescents with severe emotional disturbances

and their families’’ (Stroul and Friedman 1986, p. 3). There

was a basic assumption that the mental health ‘‘treatment’’

was effective and the real problems in children’s mental

health services were due to poor coordination of all ser-

vices, a general lack of collaboration between services, and

lack of parental involvement.

Over the next three decades, and as a direct result of

these initiatives, we witnessed tremendous efforts to

change mental health public policy; how organizations

structured and managed services; and how to conceptual-

ize, implemented, and evaluate services. The promise of

the SOC initiative, with over 20 years of expansive

W. E. Reay (&)

OMNI Behavioral Health and Northcentral University,

5115 F Street, Omaha, NE 68117-2807, USA

e-mail: breay@omnibehavioralhealth.com

123

Adm Policy Ment Health (2010) 37:95–99

DOI 10.1007/s10488-010-0275-2

funding, program evaluation, and expenditures in excess of

1 billion dollars, has not eliminated the fragmentation or

resulted in sustainable large-scale reform (Hogan 2003).

Despite efforts of government, universities, providers,

and child and family mental health advocates, current

delivery systems continue to cost too much, services are

purchased in ways that defy common sense and are

inconsistent with sound business practice (Frank and Gar-

field 2007; Rhuel 2005; Stone 2004). Some mental health

services continue to be provided and coordinated in the

absence of informed reason, or basic science (Norcross

et al. 2006). This state of dysfunction is incontestable and

is seen in financing methodologies, poor service design,

inadequate and outdated training of professionals at all

levels (Baker et al. 2009; Lambert et al. 2005). There is

general agreement that the children’s mental health system

is in need of repair.

Twenty Hours at Vanderbilt

This paper expresses my perspective on the meeting upon

which this special issue is based. It is also a reflection of a

research-practitioner who began their career at the begin-

ning of the CASSP initiative and became intensely

involved in the SOC movement from the start. As one of

the original founding members of the National Federation

of Families for Children’s Mental Health, and a current

clinician and administrator, my perspective is shaped by

the stories and experiences of both children and parents.

With that caveat, I suggest that modest changes in research

efforts, training programs, and professional practice may

drastically improve the lives of children and families.

Approximately 20 h of work produced a discrete set of

recommendations that are described in the four action

agendas in this volume. For the most part, professional

differences were set aside in an atmosphere designed to

promote open discussion around the most important and

critical areas in children’s mental health services today.

Obviously, challenges and opportunities were discussed as

well as what the ultimate promise of providing higher

quality mental health care for children and families could

accomplish. However, it became equally clear that ‘‘best

evidence’’ varies by stakeholder group and those differ-

ences may be formidable.

The Problem with Evidence

Evidence includes not only research results but the context

in which they were achieved and the scientific values of the

researcher. The effort to acquire evidence is not precise.

The differential importance researchers and practitioners

place on two types of validity and how evidence is dis-

seminated are two related areas that need attention.

Researchers place a relatively high emphasis on the need to

maintain fidelity to program elements believed to be

responsible for targeted clinical outcomes. Practitioners, on

the other hand place a high emphasis on the need to

innovate and adapt program elements in their attempts to

serve diverse populations (external validity). Similarly,

there is a general lack of agreement on how scientific

knowledge should be disseminated to end users. Taken

together, these two important areas of production and

transfer of scientific knowledge represent serious ongoing

challenges for both researchers and practitioners. Clearly, a

new working model is in order.

Mental Health within a Public Health Framework

One of the four recommendations that resulted from the

meeting is to use a public health approach to children’s

mental health service (Stelk et al. this issue). Public Health is

defined as ‘‘what we, as a society, do collectively to assure

the conditions for people to be healthy’’ (Institute of Medi-

cine 1988, p. 6). A public health approach to mental health

must involve defining, measuring mental health problems,

identifying causes and risk factors for the specific mental

health problem, determining how to prevent and treat the

problem, and using effective strategies to evaluate the impact

(Centers for Disease Control and Prevention 2007). All of

this must take place at the community level.

In public health, the gap between research and practice

has not been reduced. However, it does appear that public

health researchers and practitioners have a better under-

standing of the reasons for the gap between research evi-

dence and practice. In public health models, dissemination is

not seen as an outcome, but as a process of reinventing the

scientific knowledge and adapting that knowledge in context

with the natural occurring influences of culture, practice,

organizational and community constraints (Green 2006).

As with public health, community-based mental health

treatments rarely consist of discrete interventions (Brownson

et al. 2009). The typical community-based program uses

multiple interdisciplinary interventions under the general

framework of mental health. In fact, many community

mental health organizations are required by accreditation

organizations and licensing or regulatory bodies to provide

services in such a manner. Like public health, community

mental health organizations rely on a variety of disciplines to

provide direct services (psychiatry, psychology, social work,

counselors, and human service therapists). This workforce

diversity, although considered by many to be a considerable

strength, guarantees substantial variation in clinical perspec-

tives, case conceptualization, epidemiological understanding

96 Adm Policy Ment Health (2010) 37:95–99

123

and clinical decision making. Variation in professional train-

ing and socialization also produces a richness of conceptual

diversity and understanding of ‘‘what is evidence’’ and who

provides it. For example, ‘‘to have evidence is to have some

conceptual warrant for belief or action’’ (Goodman 2003,

p. 2). For science to advance in the practitioner’s world,

researchers must do a far better job at understanding the

subjective experiences of the practitioner, where science is

seen as assisting the practitioner at the clinical and admin-

istrative level.

The Need for Balance in Applied Research

In an effort to bridge the gap between science and practice,

public health approaches may have promise for children’s

mental health services. Several changes in professional

practices and training programs could lead to substantial

improvement in care:

1. Participatory approaches that actively involve academ-

ics, practitioners, and community members define

community and neighborhood problems, develop and

test strategies and interventions, and evaluate processes,

have shown tremendous promise (Kohatsu et al. 2004).

2. Dissemination and implementation of evidence-based

practices requires organizational leaders to place high

value on research-informed practices, time efficient

approaches to training and monitoring, and the practice

of clinical supervision (Dobbins et al. 2001).

3. Practitioners need assistance from researchers in

determining the most powerful components of each

evidence-based practice associated with the substantial

clinical improvement, iatrogenic effects, and no effect

(Kelley et al. 2001).

4. Organizational executives must become outspoken

advocates for science and the use of evidence.

Furthermore, they must be willing to abandon tradi-

tional organizational structures and promote bottom-up

governance approaches (Brownson et al. 2009).

The United States expends just short of $30 billion each

year on health science research (Office of Management and

Budget 2008). We must find a more efficient way of getting

health science research to end users. To move this agenda

forward, a possible vehicle would be to establish new

organizational governance structures.

Adapting Integrated Management Structures

One of the most promising models of research-practice

interaction is based upon mutual, cross organizational

learning (Van Kerkhoff and Lebel 2006). Based on the work

of Nonaka (1994), Nonaka and Toyama (2002) and Nonaka

et al. (2000), the model integrates the idea of organizational

reform with knowledge sharing, knowledge management,

cross organizational learning and co-management. A key

element of this approach is to promote action with knowl-

edge. Innovation and change occur through specific actions

of persons within social systems (Leeuwis and Pyburn

2002). Within this model, management is about harvesting

knowledge from diverse sources and applying that knowl-

edge to practice in a bidirectional manner, i.e., research-to-

practice-to-research (Gunderson et al. 1995). System and

management processes that cause bidirectional learning,

knowledge and contextualized understandings become part

of the adaptive capacity of the system to change based upon

the demands and pressures of the environment.

‘‘Adaptive Governance’’ is often used to describe rules

and coordinated action associated with decision-making

and sharing of power (Boyle et al. 2001). Governance

occurs through co-management mechanisms that inti-

mately involve nested networks and levels of leadership.

Management becomes an ongoing process of bringing

together existing knowledge from a variety of disciplines in

an effort to create novel perspectives and hypotheses

(Gunderson et al. 1995). In such systems, knowledge

acquisition and practice dissemination occur over time.

Therefore, adaptive co-management approaches are flexi-

ble ‘‘community-based’’ systems of management that are

specifically responsive to the diversity of individuals, sit-

uations and organization itself. Such management systems

help address the common problem that practitioners face

when deciding if the findings of an evidence-based treat-

ment apply to their specific context.

Organizational cultures and climates that support change

are unquestionably required for any organizational inno-

vation or rapid change (Simpson 2002). Part of that inno-

vative approach includes acquiring multi-trained generalist

and specialist practitioners, and multi-functioning para-

professionals. Adaptive organizations reject rigid policies

and procedures that maintain any organizational ‘‘status

quo.’’ Management strategies include incentives to improve

and/or reinvent the scientific bases of interventions and

management practices. Forging and maintaining continuous

relationships with e-based technicians assist the practitio-

ners in identifying new research that may be applicable to

general and specific social, clinical, and political problems.

For example, it is not uncommon for a community-

based provider to be called upon to treat a youth that has

juvenile diabetes; addicted to nicotine; considered to have a

conduct disorder; a verifiable learning disability and has

developmental delays. This clinical presentation, although

common, offers substantial challenges for even the best

trained, highly motivated and monitored practitioner,

regardless of guild (psychology, psychiatry, social work).

Adm Policy Ment Health (2010) 37:95–99 97

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The expertise required to adequately screen, evaluate,

manage, and directly treat these physical, emotional,

behavioral, and cognitive challenges is substantial and

beyond the abilities of most direct line practitioners.

In adaptive co-governance organizations that are co-

managed by practitioners and researchers from diverse

professions, the organization would harvest the available

treatment evidence in an effort to develop the best treatment

and social interventions for this youth. Viewed as opportu-

nities for cross organizational leaning, this single case pro-

motes changes in organizational function and structure, i.e.,

it adapts to the pressures and demand of the clinical pre-

sentation and the context of the community. The knowledge

acquired, managed and shared is aimed at immediate service

production, and practice and policy changes both within the

organization, as well as the research community. Consis-

tently redesigning the system based upon actual care may

help organizational co-managers understand why treatments

work for whom, for how long, and under what circum-

stances. Improving outcomes can only occur with improved

clinical decision-making, including evidence-based assess-

ments, treatments, client monitoring systems, and practi-

tioner supervision (Wagner et al. 1996).

Conclusions

Our best effort to improve the children’s mental health

service system is to promote an adaptive co-management

system that is community-based, scientifically integrated

with the diverse values of each and every family. Practi-

tioners and researchers unified through the process of

assuring a balanced research agenda could address the

ongoing failures to translate usable scientific information to

the practice level, and take the results of that action back to

the research table in an attempt to continuously adapt and

provide useful information. Clearly, it is the responsibility

of both researchers and practitioners to find mechanisms to

translate research knowledge into daily mental health

practice. This paper underscores the need for a new

approach to management that actively involves community

members, practitioners, and researchers in a co-manage-

ment adaptive organizational structure. Diversity in both

professional practice and research training are viewed as

specific strengths to be managed by the adaptive organi-

zation, and not a factor that needs to be controlled.

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