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: [email protected]
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
123
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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