Meeting the Evidence-Based Standard

1. Meeting the Evidence-Based Standard One Sky Center R. Dale Walker, MD, Director Michelle Singer, Communications Coordinator, ICMI Project Director Doug Bigelow, PhD, Deputy Director

2. �The Learning HealthCare System� Our view is that �EBI� is a somewhat misleading term. Government and courts and insurance companies have found it convenient. But it is now falling into disrepute. Like the IOM, We are conceptualizing a more useful concept: The Learning Healthcare System. By the end of this presentation, we hope to make the LHS and how it is usefulOur view is that �EBI� is a somewhat misleading term. Government and courts and insurance companies have found it convenient. But it is now falling into disrepute. Like the IOM, We are conceptualizing a more useful concept: The Learning Healthcare System. By the end of this presentation, we hope to make the LHS and how it is useful

3. Outline Evidence-Based vs Culture-Based Dilemma What is �Evidence�? Multiple Streams of Evidence The Learning Healthcare System Description: A Scientific Framework Some Culture-Based Interventions This is not the �silver bullet� What is the EBI-CBI dilemma about? Based on? Controlling epistemology, way of life, and practice by the purse strings Bridging from CBI to EBI is necessary and do-able.This is not the �silver bullet� What is the EBI-CBI dilemma about? Based on? Controlling epistemology, way of life, and practice by the purse strings Bridging from CBI to EBI is necessary and do-able.

4. EBI � CBI Dilemma Epistemological gulf Western Traditional AI/AN Epistemological debate Validity of traditional world view Freedom to live by a traditional world view Practical debate Controlling by purse strings Cultures have epistemologies�ways of knowing; rules for establishing what is true. Conflicts are often driven by the underlying epistemological differences. If you believe a deity decides your fate, then an immunization program may be contested (some N. African countries) If you don�t believe in a spiritual realm, you may insist upon �heroic medical interventions� rather than palliative care Western epistemology now bases knowing and certainty on scienific approaches. Theory, deductive reasoning, mechanistic models, verifiable prediction, experimental testing, objective observation, and mathematical analysis of quantitative information. Traditional AI/AN epistemology bases knowing and certainty on Tradition, authority, spirituality, the supernatural, and anecdotal information. Western view does not altogether trust the traditional epistemology Challenges to self-determination�opportunity to live by a world view While participating in the larger social enterprise Practically: exert control thru purse-strings. Cultures have epistemologies�ways of knowing; rules for establishing what is true. Conflicts are often driven by the underlying epistemological differences. If you believe a deity decides your fate, then an immunization program may be contested (some N. African countries) If you don�t believe in a spiritual realm, you may insist upon �heroic medical interventions� rather than palliative care Western epistemology now bases knowing and certainty on scienific approaches. Theory, deductive reasoning, mechanistic models, verifiable prediction, experimental testing, objective observation, and mathematical analysis of quantitative information. Traditional AI/AN epistemology bases knowing and certainty on Tradition, authority, spirituality, the supernatural, and anecdotal information. Western view does not altogether trust the traditional epistemology Challenges to self-determination�opportunity to live by a world view While participating in the larger social enterprise Practically: exert control thru purse-strings.

5. Bridging EBI � CBI Bridging Evidence is? Status of evidence for EBI How to meet reasonable standards of evidence Practice Improvement Multiple Streams of Evidence Learning Healthcare System Western view does not altogether trust the traditional epistemology. AI/AN projects and programs, therefore, need to convince Western authorities by some bridging techniques. This requires understanding what �evidence� really is what actual evidence Western interventions rest upon; and what the reasonable standards of evidence should be pursued in research on CBI Reaching a new and better understanding of the means of achieving what EBI are intended to achieve: practice improvement Center for Substance Abuse Treatment. Understanding Evidence-Based Practices for Co-Occurring Disorders. COCE Overview Paper 5. DHHS Publication No. (SMA) 07-4278. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007. LeighAnne Olsen, Dara Aisner, and J. Michael McGinnis, editors, (2007). The Learning Healthcare System: Workshop Summary (IOM Roundtable on Evidence-Based Medicine). Washington, DC: National Academies Press. Western view does not altogether trust the traditional epistemology. AI/AN projects and programs, therefore, need to convince Western authorities by some bridging techniques. This requires understanding what �evidence� really is what actual evidence Western interventions rest upon; and what the reasonable standards of evidence should be pursued in research on CBI Reaching a new and better understanding of the means of achieving what EBI are intended to achieve: practice improvement Center for Substance Abuse Treatment. Understanding Evidence-Based Practices for Co-Occurring Disorders. COCE Overview Paper 5. DHHS Publication No. (SMA) 07-4278. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007. LeighAnne Olsen, Dara Aisner, and J. Michael McGinnis, editors, (2007). The Learning Healthcare System: Workshop Summary (IOM Roundtable on Evidence-Based Medicine). Washington, DC: National Academies Press.

6. Sources of Evidence Intervention/program research Randomized Controlled Trials (RCT) Nonrandomized, uncontrolled Evaluation Adaptation of Proven Intervention Like a Proven Intervention Basis in Proven Theory, Principles, Facts Here are four ways to obtain evidence supporting an intervention. We�ll talk about three of them later on. As we go thru this discussion, we�ll begin to define �scientific evidence� The first way of obtaining evidence is what most people immediately think of �collecting evidence on a practice, project, or program thru direct study of the intervention. We also think of that research as being like research that generates evidence for the efficacy of drugs and devices�that is, RCT. Also known as: the scientific experiment But the vast majority of EBIs actually rest mainly on �evaluation� which is neither randomized nor controlled.Here are four ways to obtain evidence supporting an intervention. We�ll talk about three of them later on. As we go thru this discussion, we�ll begin to define �scientific evidence� The first way of obtaining evidence is what most people immediately think of �collecting evidence on a practice, project, or program thru direct study of the intervention. We also think of that research as being like research that generates evidence for the efficacy of drugs and devices�that is, RCT. Also known as: the scientific experiment But the vast majority of EBIs actually rest mainly on �evaluation� which is neither randomized nor controlled.

7. Evidence-based InterventionsProcess and Criteria Criteria: Fidelity Internal Validity (vs confounding variables) External validity Reliability�repeatability. Process: Scientific experts Independent judging and rating Compilation and Summary Many criteria are used to establish that an intervention really works E.g., intervention fidelity; reliability; internal validity; missing data and attrition; potential confounding variables; appropriateness of analysis; external validity (sampling) T he overall criterion is �repeatability�. Can you do the intervention a second time, and does it still work? The evidence is not taken to a Council of Elders for review against tradition, continuation of the people, prophesy, But, rather, to a number of scientific experts Each of whom independently reviews the evidence, then rates the evidence on scales The ratings and descriptions are compiled and summarized. This could lead into a discussion of how to do RCTs or Evaluations�but we are going to skip ahead: We turn next to the constraints and limitations of knowing what behavioral health interventions work.Many criteria are used to establish that an intervention really works E.g., intervention fidelity; reliability; internal validity; missing data and attrition; potential confounding variables; appropriateness of analysis; external validity (sampling) T he overall criterion is �repeatability�. Can you do the intervention a second time, and does it still work? The evidence is not taken to a Council of Elders for review against tradition, continuation of the people, prophesy, But, rather, to a number of scientific experts Each of whom independently reviews the evidence, then rates the evidence on scales The ratings and descriptions are compiled and summarized. This could lead into a discussion of how to do RCTs or Evaluations�but we are going to skip ahead: We turn next to the constraints and limitations of knowing what behavioral health interventions work.

8. Nature of Behavioral Intervention Therapeutic power of Choice Self-healing guided by expert healers Uniqueness of interpersonal relationships Complexity of factors We are now beginning to build toward our conclusion about the actual status of �scientific evidence� in EBI. Behavioral health interventions are different from drugs and devices. Drug trials treat human factors as �error� (i.e., placebo effect). Behavioral interventions must, necessarily, treat human factors as the �active ingredients� Choice is a powerful factor in healing�it even overwhelms the efficacy of the particular intervention. This is partly a matter of �belief� �belief on the part of the healer and the patient are efficacious in behavioral interventions and, indeed, in all interventions. �Choice� and �belief� can be controlled a little bit, but not enough to yield useful research results. Self-healing is not a treatment over which you can establish any kind of research control, and the guidance must be responsive to the patient, the healer, and context�which are not readily controlled. The nature and quality of interpersonal relationships are central to many interventions, but are not controllable. And all of this takes place in a complex of etiological, mediating, and moderating factors well beyond realistic research control. We are now beginning to build toward our conclusion about the actual status of �scientific evidence� in EBI. Behavioral health interventions are different from drugs and devices. Drug trials treat human factors as �error� (i.e., placebo effect). Behavioral interventions must, necessarily, treat human factors as the �active ingredients� Choice is a powerful factor in healing�it even overwhelms the efficacy of the particular intervention. This is partly a matter of �belief� �belief on the part of the healer and the patient are efficacious in behavioral interventions and, indeed, in all interventions. �Choice� and �belief� can be controlled a little bit, but not enough to yield useful research results. Self-healing is not a treatment over which you can establish any kind of research control, and the guidance must be responsive to the patient, the healer, and context�which are not readily controlled. The nature and quality of interpersonal relationships are central to many interventions, but are not controllable. And all of this takes place in a complex of etiological, mediating, and moderating factors well beyond realistic research control.

9. Status of �Evidence� in EBI Individual studies Reviewed collections Lists of model, best, promising, alternative Survivors of meta-analyses So, what is the status of evidence behind �evidence-based interventions� that are referred to all the time, as though we know for sure that they are efficacious and effective? There are practices, projects, and programs with a couple or more research studies in which they were able to find some measure of improvement. The intervention goals are reduced suicide, homicide, substance abuse, etc., But the measure is frequently a desired �attitude change� or a �interim� behavior change. There are review papers which put together a number of such studies, often to support one or another belief system Do you believe that �scared straight�� or that �strengthening families��is more likely to be effective? There are lists of practices, projects, and programs which meet some kind of criteria for acceptance by some kind of judging process. The judging process is rarely exhaustive Understanding of the intervention vague�(The �active ingredients� or �methods of action�.) Often the intervention is a �black box� on a long list of �black boxes.� More often, the intervention is a �salad� or �stew� of many ingredients, most shared with other interventions. �Multi-systemic family therapy� is praised as an outstanding, evidence-based program, for example. But then, there is a process called meta-analysis used by expert and independent bodies in an exhaustive review of research on a single type of intervention. Bodies like the Cochrane Commission, Campbell Collaboration (C2), the National Research Council of the National Science Academies. The results of such reviews are frequently: �inconclusive,� �contradictory evidence,� �study design flaws,� �insignificant �effect size� across replications.� Multi-systemic family treatment did not survive the Cochrane Commission review. Restriction of access to firearms�the much praised suicide and violence prevention-- did not survive the NRC review. And Scared Straight approaches was actually found to be harmful. In fact, CBT is among the few behavioral health intervention to have survived a CC review. (and is a core ingredient of many intervention programs)So, what is the status of evidence behind �evidence-based interventions� that are referred to all the time, as though we know for sure that they are efficacious and effective? There are practices, projects, and programs with a couple or more research studies in which they were able to find some measure of improvement. The intervention goals are reduced suicide, homicide, substance abuse, etc., But the measure is frequently a desired �attitude change� or a �interim� behavior change. There are review papers which put together a number of such studies, often to support one or another belief system Do you believe that �scared straight�� or that �strengthening families��is more likely to be effective? There are lists of practices, projects, and programs which meet some kind of criteria for acceptance by some kind of judging process. The judging process is rarely exhaustive Understanding of the intervention vague�(The �active ingredients� or �methods of action�.) Often the intervention is a �black box� on a long list of �black boxes.� More often, the intervention is a �salad� or �stew� of many ingredients, most shared with other interventions. �Multi-systemic family therapy� is praised as an outstanding, evidence-based program, for example. But then, there is a process called meta-analysis used by expert and independent bodies in an exhaustive review of research on a single type of intervention. Bodies like the Cochrane Commission, Campbell Collaboration (C2), the National Research Council of the National Science Academies. The results of such reviews are frequently: �inconclusive,� �contradictory evidence,� �study design flaws,� �insignificant �effect size� across replications.� Multi-systemic family treatment did not survive the Cochrane Commission review. Restriction of access to firearms�the much praised suicide and violence prevention-- did not survive the NRC review. And Scared Straight approaches was actually found to be harmful. In fact, CBT is among the few behavioral health intervention to have survived a CC review. (and is a core ingredient of many intervention programs)

10. The Buffalo jump for Ebi Meta-analysis �Best Practice� Review Research Description Practice Culture To review what we�ve just said: Interventions are usually invented by a culture�prayer, contingency management, reconciliation, purification, etc. (CBI) That intervention becomes commonly practiced, if the community and practitioners like it. (PBI) Then, the intervention gets a rigorous description�the first step toward becoming an EBI. The rigorous description is needed to people can understand, copy, and evaluate it. Then a few research studies are carried out to find out if it works, and how. Then there is an integration of research reports into some kind of research review document, usually ending with endorsement and recommendations for implementation. The intervention may be inducted into the various government, professional, or advocacy organization�s �best practice� lists (e.g., SAMHSA; OJJP; NIDA/NIAAA/NIH, NREPP; SPAN/SPRC And then comes the buffalo jump. The meta-analytic review by NRC or CC is the pinnacle of certainty�the application of all the rules, criteria, and review processes. So much of what proponents of EBI don�t realize is that very few interventions actually survive the jump through meta-analysis! To review what we�ve just said: Interventions are usually invented by a culture�prayer, contingency management, reconciliation, purification, etc. (CBI) That intervention becomes commonly practiced, if the community and practitioners like it. (PBI) Then, the intervention gets a rigorous description�the first step toward becoming an EBI. The rigorous description is needed to people can understand, copy, and evaluate it. Then a few research studies are carried out to find out if it works, and how. Then there is an integration of research reports into some kind of research review document, usually ending with endorsement and recommendations for implementation. The intervention may be inducted into the various government, professional, or advocacy organization�s �best practice� lists (e.g., SAMHSA; OJJP; NIDA/NIAAA/NIH, NREPP; SPAN/SPRC And then comes the buffalo jump. The meta-analytic review by NRC or CC is the pinnacle of certainty�the application of all the rules, criteria, and review processes. So much of what proponents of EBI don�t realize is that very few interventions actually survive the jump through meta-analysis!

11. Reasonable standards of evidencefor improved practices �Best Practices� = highest scientific standards Balance point Reasonable standards are: Repeatability Achievable within resources and constraints Allow conclusions without intolerable doubt Low risk of harm, if conclusions are wrong The point of the Buffalo Jump is: There are few, if any, impeccable EBIs. Science provides more knowledge with more certainty�not all knowledge, nor absolute certainty�about any intervention Somewhere along the spectrum-- from origins in Culture to RCTs with meta-analysis� there is a balance among scientific rigor, practicality, and adaptation to local context and culture In that area of balance are reasonable standards. Definition: Yields replication because dissemination of improved practice is our purpose Are practically achievable�given funds, interference with normal practice conditions, comparison group feasibility, measurement, etc. Allow conclusions that stand up to reasonable criticism and debate, even if not absolutely provable And are unlikely to put people at high risk, if the conclusions are wrong. The point of the Buffalo Jump is: There are few, if any, impeccable EBIs. Science provides more knowledge with more certainty�not all knowledge, nor absolute certainty�about any intervention Somewhere along the spectrum-- from origins in Culture to RCTs with meta-analysis� there is a balance among scientific rigor, practicality, and adaptation to local context and culture In that area of balance are reasonable standards. Definition: Yields replication because dissemination of improved practice is our purpose Are practically achievable�given funds, interference with normal practice conditions, comparison group feasibility, measurement, etc. Allow conclusions that stand up to reasonable criticism and debate, even if not absolutely provable And are unlikely to put people at high risk, if the conclusions are wrong.

12. Adaptation-Adoption Adoption requires buy-in Acceptance Implementation Beyond the logic of scientific study is another major consideration in dissemination of practice improvement: Even if you are replicating a protocol in a hospital just down the street, the medical and other staff will require an adaption process, if the replication is to be adopted (accepted and implemented). The local players will accept and implement a replication only if it is tailored to their culture and context. This well-known phenomenon among disseminators of best practices is the �adaptation-adoption� process. Under any regime, the people who will implement a practice, must �buy-in� � must chose to accept it And they will change the practice in its implementation. They actually have to change it, because every implementation site is unique. Beyond the logic of scientific study is another major consideration in dissemination of practice improvement: Even if you are replicating a protocol in a hospital just down the street, the medical and other staff will require an adaption process, if the replication is to be adopted (accepted and implemented). The local players will accept and implement a replication only if it is tailored to their culture and context. This well-known phenomenon among disseminators of best practices is the �adaptation-adoption� process. Under any regime, the people who will implement a practice, must �buy-in� � must chose to accept it And they will change the practice in its implementation. They actually have to change it, because every implementation site is unique.

13. Adaptation-Adoption Adaptation to unique local culture and context Players Rules, expectations, traditions Resources/collaborations Opportunity to contribute to strategic plan EBIs are not ever replicated with 100% fidelity. They cannot be, because every implementation site is unique. In fact, replication with �fidelity� is something of a myth, as we found out back in the �Community Support Program� days. Although some people do fantasize! EBIs are not ever replicated with 100% fidelity. They cannot be, because every implementation site is unique. In fact, replication with �fidelity� is something of a myth, as we found out back in the �Community Support Program� days. Although some people do fantasize!

14. Adaptation-Adoption MI, CBT, SFP, Project Venture, Canoe Journey implementations are unique in every setting Every replication is an Adaptation Therefore, EVERY replication of a �best practice� is ACTUALLY an ADAPTATION�to some extent, an original CBI! There is a great deal to say about Adaptation-Adoption, and the technology of Implementing Best Practices, But we will skip to other positive ways of obtaining evidence for CBI �the �multiple streams of evidence� idea. Therefore, EVERY replication of a �best practice� is ACTUALLY an ADAPTATION�to some extent, an original CBI! There is a great deal to say about Adaptation-Adoption, and the technology of Implementing Best Practices, But we will skip to other positive ways of obtaining evidence for CBI �the �multiple streams of evidence� idea.

15. EBI out of the box The EBI idea is changing SAMHSA: �multiple streams of evidence� IOM: �Learning Healthcare System� The rigorous-research-only fad in EBI is fading�too many buffalos have gone over the jump! Increasingly, agencies are beginning to realize and acknowledge that gaining knowledge and certainty�the purpose of science �is a very complex undertaking. And practice improvement requires a less restrictive and more appropriate standard of evidence. SAMHSA and others have begun to talk about �multiple streams of evidence� Including culture and practice as well as various research strategies AND including existing knowledge The IOM concluded a study of EBI by adopting a new name: the Learning Healthcare System. This term more adequately reflects the fact that practice improvement is a matter of increasing our knowledge and certainty and putting that growing knowledge into practice. This leads us to considering the other streams of evidence�other ways to obtain evidence for CBI.The rigorous-research-only fad in EBI is fading�too many buffalos have gone over the jump! Increasingly, agencies are beginning to realize and acknowledge that gaining knowledge and certainty�the purpose of science �is a very complex undertaking. And practice improvement requires a less restrictive and more appropriate standard of evidence. SAMHSA and others have begun to talk about �multiple streams of evidence� Including culture and practice as well as various research strategies AND including existing knowledge The IOM concluded a study of EBI by adopting a new name: the Learning Healthcare System. This term more adequately reflects the fact that practice improvement is a matter of increasing our knowledge and certainty and putting that growing knowledge into practice. This leads us to considering the other streams of evidence�other ways to obtain evidence for CBI.

16. Other Sources of Evidence Intervention/program RTC; Evaluation Adaptation of Proven Intervention Analogous to a Proven Intervention Basis in Proven Theory, Principles, Facts So, we�ve canvassed the first and most esteemed source of evidence for EBIs. But, there are other very powerful ways of obtaining evidence to support CBIs than original research. That�s a good thing because original research can be very expensive and protracted. Evidence for Psycho-social therapeutic interventions have been underway for more than half a century. A number of best practices in AI/AN country are adaptations of proven interventions. Project Venture is an adaptation of �Service Learning�. A number are analogous to Proven Interventions: Don Coyhis of White Bison describes interventions which were part of AI/AN culture before the Europeans, but can show that they are analogous to Western practices like 12-step. Most important is basing or even just describing a CBI using proven theories�e.g., learning theories. We believe, the place to start bringing evidence to bear on CBIs, is to describe them within a western scientific framework.So, we�ve canvassed the first and most esteemed source of evidence for EBIs. But, there are other very powerful ways of obtaining evidence to support CBIs than original research. That�s a good thing because original research can be very expensive and protracted. Evidence for Psycho-social therapeutic interventions have been underway for more than half a century. A number of best practices in AI/AN country are adaptations of proven interventions. Project Venture is an adaptation of �Service Learning�. A number are analogous to Proven Interventions: Don Coyhis of White Bison describes interventions which were part of AI/AN culture before the Europeans, but can show that they are analogous to Western practices like 12-step. Most important is basing or even just describing a CBI using proven theories�e.g., learning theories.

17. Description The strategies for obtaining evidence (which we just mentioned) rely heavily upon �description� This logic model is used in Western thinking about interventions. If you can describe a CBI in these terms, you can persuade Western thinkers of its validity. This is partly a matter of translation into western terms, concepts and paradigms (cf., Don Coyhis). It is also a matter of adopting a different (Western) perspective on the same things that may thought of differently in a CBI. There is value in thinking systematically about some aspects of a CBI that may not have been important in its original cultural context.The strategies for obtaining evidence (which we just mentioned) rely heavily upon �description� This logic model is used in Western thinking about interventions. If you can describe a CBI in these terms, you can persuade Western thinkers of its validity. This is partly a matter of translation into western terms, concepts and paradigms (cf., Don Coyhis). It is also a matter of adopting a different (Western) perspective on the same things that may thought of differently in a CBI. There is value in thinking systematically about some aspects of a CBI that may not have been important in its original cultural context.

18. Importance of Program Manuals �Operationalization� a way of knowing/believing From black box to detail Consistency with body of knowledge Who, what, when, where, how, decisions Repeatability A practice becomes much more credible to the Western mind when it is �operationalized� Which usually means a manual of specific steps. Operational manuals are a Western way of knowing and believing. When the steps in the manual are recognizably consistent with a Western body of knowledge, its credibility becomes very strong. (as when an elder judges a �hoop journey� as consistent with traditional wisdom) Do you believe that �scared straight�� or that �strengthening families��is more likely to be effective? The details consist of specific actions taken by specified individuals, at specified times, in specified places, making decisions according to specified rules (e.g., a dirty urine) Program manuals are also a critical part of repeating the intervention elsewhere, which is part of �proving� its efficacy and effectiveness.A practice becomes much more credible to the Western mind when it is �operationalized� Which usually means a manual of specific steps. Operational manuals are a Western way of knowing and believing. When the steps in the manual are recognizably consistent with a Western body of knowledge, its credibility becomes very strong. (as when an elder judges a �hoop journey� as consistent with traditional wisdom) Do you believe that �scared straight�� or that �strengthening families��is more likely to be effective? The details consist of specific actions taken by specified individuals, at specified times, in specified places, making decisions according to specified rules (e.g., a dirty urine) Program manuals are also a critical part of repeating the intervention elsewhere, which is part of �proving� its efficacy and effectiveness.

19. Proven Theory, Principles & Facts Social ecology (influences) Prevention Universal/ selected/ indicated Risk and Resilience Readiness to Change Risk taking/seeking Stress vulnerability Modeling (observational learning) Instrumental learning Group dynamics Conformity, altruism Listening and support Catharsis Psychopharmacology There are many proven theories which can be called on as evidence for a CBI. Here are some. Others include: Problem-behavior (Jessor); suicide (Joiner) and other specific theory re behavioral health problems and treatment strategy.There are many proven theories which can be called on as evidence for a CBI. Here are some. Others include: Problem-behavior (Jessor); suicide (Joiner) and other specific theory re behavioral health problems and treatment strategy.

20. Kinds of Intervention Strategy Screening Gatekeeping Diagnosis Treatment Traditional healing Traditional ritual/ceremony Postvention Parent/family training Group work School/institution-based Education/skills Experiential Socialization/acculturation Public Health (risk/resilience) Services develop/coord L E/justice/corrections Community competency Community change Culture There are lots of intervention strategies that can be called on to describe a CBI. Each has some evidence and some credibility already behind it.There are lots of intervention strategies that can be called on to describe a CBI. Each has some evidence and some credibility already behind it.

21. AI/AN Prevention, Tx, Rehab Interventions Story telling Talking circles Sweat Lodge Ceremonies and Ritual Purification Passages Naming Grieving Drumming, singing, dancing Vision Quest Flute playing/meditation Reconciliation Mentoring Service learning GONA There is an emerging catalog of CBI specific approaches.There is an emerging catalog of CBI specific approaches.

22. �Best Practices� Cultural Enhancement Through Story Telling (Tohono O�odham Res) AI Strengthening Families Program (U UT) Across Ages (Mentoring) (Temple U) Creating Lasting Family Connections Dare to Be You (Ute Res) With Eagles Wings (N. Arapaho Nat) Families That Care�Guiding Good Choices And some more.And some more.

23. �Best Practices� Families and Schools Together (Rural Wisconsin Res) Parenting Wisely Preparing for Drug Free Years Project Alert Project Venture (NIYLP) Promoting Alternative Thinking Strategies Zuni Life Skills (Zuni Pueblo) And some more. These examples are taken from Strode AD. (Ed.) Best Mental Health Practices for Vulnerable Populations, the Washington Institute for Mental Health Research & Training : http://www.spokane.wsu.edu/ResearchOutreach/wimhrt/research2.asp And some more. These examples are taken from Strode AD. (Ed.) Best Mental Health Practices for Vulnerable Populations, the Washington Institute for Mental Health Research & Training : http://www.spokane.wsu.edu/ResearchOutreach/wimhrt/research2.asp

24. Bottom Line Deal with Epistemological Gulf Know limitations of Evidence in EBI Agree upon �Practice Improvement� Goal Make credibility gains with �Scientific Framework� for Description Use existing practices and knowledge as evidence for similar CBI

25. Feel Free To Contact Us At: One Sky Center (o) 503-494-3703 onesky@ohsu.edu www.oneskycenter.org