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Evidencebased Practices EBPs in Community Treatment Programs: EBPs are just one piece of the pie Ame

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Title: Evidencebased Practices EBPs in Community Treatment Programs: EBPs are just one piece of the pie Ame


1
Evidence-based Practices (EBPs) in Community
Treatment Programs EBPs are just one piece of
the pieAmerican Psychological Association
ConferenceSan Francisco 2007
  • Michael S. Levy, Ph.D.
  • CAB Health Recovery Services, Inc.
  • Peabody, MA

2
Key Factors Relevant to Client Change Processes

Lambert, M.J. (1992). Implications of Outcome
Research for Psychotherapy Integration. In J.C.
Norcross M. R. Goldstein (Eds.), Handbook of
Psychotherapy Integration (pp. 94-129). New
York Basic Books.
3
  • Psychotherapy manuals are helpful for training
    and research. In particular, they enhance the
    internal validity of comparative outcome studies,
    facilitate treatment integrity, ensure the
    possibility of replication, and provide a
    systematic way of training and supervising
    therapists. At the same time, manuals are also
    associated with some untold negative effects.
    There is no conclusive evidence that manuals
    improve treatment outcomes or that they should be
    required in practice. (Norcross, Beutler,
    Levant, Evidence-based Practice in Mental Health,
    2006)

4
  • Manualizing psychological interventions as if
    they were independent of those administering and
    receiving them does not reflect what is known
    about psychotherapy outcome. (Duncan Miller,
    2006).

5
  • In looking at individual drug counseling (IDC) in
    NIDAs Collaborative Cocaine Treatment Study, it
    was found that in cases when the alliance was
    strong, counselor adherence did not much matter
    those patients typically improved. However, for
    cases in which the alliance was weak, adherence
    did matter. Those patients improved more when
    their counselors adhered moderately to IDC
    principles than when the counselors were either
    minimally or highly adherent (Barber, et al.,
    Psychotherapy Research, 16, 229-240, 2006).

6
  • It makes good sense to give priority to EBTs,
    particularly within this era of fiscal austerity.
    We owe it to our clients to provide the best
    possible treatment within available resources.
    (Miller, Zweben, and Johnson, JSAT, 29, 267-276,
    2005).

7
  • in community-based settings there is often not
    enough money to recruit and maintain a workforce
    qualified to provide evidence-based treatments
    (Expert Panel on Juvenile Justice and Adolescent
    Substance Abuse Treatment, April 2007).

8
  • NIDAs Principles of Drug Addiction Treatment
  • No single treatment is appropriate for all
    individuals.
  • Treatment needs to be readily available.
  • Effective treatment attends to multiple needs of
    the individual, not just his or her drug use.
  • An individuals treatment and services plan must
    be assessed continually and modified as necessary
    to ensure that the plan meets the persons
    changing needs.
  • Remaining in treatment for an adequate period of
    time is critical for treatment effectiveness.

9
  • Counseling (individual and/or group) and other
    behavioral therapies are critical components of
    effective treatment for addiction.
  • Medications are an important element of treatment
    for many patients, especially when combined with
    counseling and other behavioral therapies.
  • Addicted or drug-abusing individuals with
    coexisting mental disorders should have both
    disorders treated in an integrated way.
  • Medical detoxification is only the first stage of
    addiction treatment and by itself does little to
    change long-term drug use.

10
  • Treatment does not need to be voluntary to be
    effective.
  • Possible drug use during treatment must be
    monitored continuously.
  • Treatment programs should provide assessment for
    HIV/AIDS, Hepatitis B and C, tuberculosis and
    other infectious diseases, and counseling to help
    patients modify or change behaviors that place
    themselves or others at risk of infection.
  • Recovery from drug addiction can be a long-term
    process and frequently requires multiple episodes
    of treatment.

11
Network for the Improvement of Addiction
Treatment (NIATx )
  • Focuses on
  • Decreasing time to obtain treatment.
  • Increasing admissions.
  • Decreasing no show rates.
  • Increasing treatment retention.
  • Uses rapid cycle plan-do-study-act projects, as
    opposed to evidence-based practices.

12
  • Most all EBPs focus on the outpatient realm, so
    what about residential treatment which can offer
    90 -250 different groups during a treatment
    experience, not to mention that group size can
    vary from 15 to 30 to 40 and even more.
  • And what about a detoxification program with a
    length of stay of 4-6 days?

13
List of OMHAS Approved Evidence-Based Practices
  • CYT Family Support Network (FSN) for Adolescent
    Cannibis Users
  • CYT Multidimensional Family Therapy for
    Adolescent Cannabis Users (MDFT)
  • Dialectical Behavioral Therapy (DBT) Approaches
  • DBT adapted for adolescents
  • DBT for Substance Abuse (DBT-S)
  • Supported Employment
  • Co-occurring Disorders Integrated Dual
    Diagnosis Treatment (IDDT)
  • Illness Management and Recovery
  • Family Psychoeducation
  • Assertive Community Treatment (ACT)
  • Medication Management Approaches in Psychiatry
    (MedMAP)
  • Stimulant Treatment of ADHD (methylphenidate,
    dextroamphetamine, mixed salts emphetamine,
    pemoline)

14
List of OMHAS Approved Evidence-Based Practices
  • Multisystemic Therapy MST)
  • Cognitive Behavior Treatment for Childhood
    Anxiety Disorders
  • Trauma Focused Cognitive Behavioral Therapy
  • Parent Management Training
  • Multi-Dimension Treatment Foster Care (MTFC)
  • Brief Strategic Family Therapy
  • Wraparound (a treatment planning process model,
    not a treatment model
  • Functional Family Therapy
  • Seeking Safety a present-focused therapy to
    help people attain safety from trauma/PTSD and
    substance abuse
  • Communities that Care
  • LifeSkills Training
  • Incredible Years

15
List of OMHAS Approved Evidence-Based Practices
  • ASAM Patient Placement Criteria 2nd
    Edition-Revised
  • The Matrix Model Outpatient Stimulant Treatment
  • Methadone Maintenance
  • Motivational Enhancement Therapy
  • Twelve-Step Facilitation Therapy
  • Cognitive Behavioral Therapy
  • Motivational Interviewing
  • Motivational Enhancement Therapy/Cognitive
    Behavioral Therapy (MET/CBT) for Adolescent
    Cannibis Users 5 Sessions
  • CYT Motivational Enhancement Therapy and
    Cognitive Behavioral Therapy Supplement 7
    Sessions of Cognitive Behavioral Therapy for
    Adolescent Users
  • CYT The Adolescent Community Reinforcement
    Approach for Adolescent Cannibis Users (ACRA)

16
List of OMHAS Approved Evidence-Based Practices
  • Motivational Interviewing
  • Seeking Safety

17
NREPPs Evidence-based Practices
  • Behavioral Couples Therapy for Alcoholism and
    Drug Abuse
  • Border Binge-Drinking Reduction Program
  • Brief Marijuana Dependence Counseling
  • Challenging College Alcohol Abuse
  • Clinician-Based Cognitive Psychoeducational
    Intervention for Families
  • Cognitive Behavioral Social Skills Training
  • Cognitive Behavioral Therapy for Adolescent
    Depression
  • Cognitive Behavioral Therapy for Late-Life
    Depression
  • Coping Cat
  • Critical Time Intervention
  • DARE to be You
  • Dialectical Behavior Therapy
  • Family Matters
  • Functional Adaptation Skills Training (FAST)
  • Lions Quest Skills for Adolescents

18
NREPPs Evidence-based Practices
  • Matrix Model
  • Multisystemic Therapy (MST) for Juvenile
    Offenders
  • Network Therapy
  • New Beginnings Program
  • Parenting Through Change
  • Prevention and Relationship Enhancement Program
    (PREP)
  • Primary Project
  • Program to Encourage Active, Rewarding Lives for
    Seniors (PEARLS)
  • Project ALERT
  • Project EX
  • Project Northland
  • Project Towards No Drug Abuse
  • Responding in Peaceful and Positive Ways (RiPP)
  • Safe Date

19
NREPPs Evidence-based Practices
  • Second Step
  • Seeking Safety
  • SMARTteam
  • SOS Signs of Suicide
  • Success in Stages Build Respect, Stop Bullying
  • Trauma Recovery and Empowerment Model (TREM)
  • United States air Force Suicide Prevention Program

20
NREPPs Evidence-based Practices
  • Motivational Interviewing
  • Seeking Safety

21
A sample of specific treatments and
evidence-based practices for the treatment of
addiction.
  • Acceptance and Commitment Therapy, Acupuncture,
    Affective Contra-Attribution Therapy, Assertive
    Community Treatment, Aversive Counter-conditioning
    , BAC Discrimination Training, Behavior
    Contracting, Behavioral Marital Therapy,
    Behavioral Self-Control Training, Bibliotherapy,
    Brief Intervention, Brief Strategic Family
    Therapy, Biofeedback, Client-Centered Therapy,
    Cognitive Therapy, Community Reinforcement
    Approach, Contingency Management, Covert
    Sensitization, Cue Exposure, Dialectical Behavior
    Therapy, Existential Therapy, Functional
    Analysis, Functional Family Therapy, Group
    Psychotherapy, Guided Self-Change, Hypnosis,
    Matrix Model, Medical Management, Mindfulness,
    Minnesota Model, Moderation Management,
    Motivational Enhancement Therapy, Motivational
    Interviewing, Multidimensional Family Therapy,
    Multisystemic Therapy, Problem Solving,
    Psychodynamic Psychotherapy, Psychoeducation,
    Rational Emotive Therapy, Rational Recovery,
    Recreational Therapy, Relapse Prevention
    Relaxation Training, Secular Organization for
    Sobriety, Self-Monitoring, Social Skills
    Training, Stress Management, Solution-Focused
    Therapy, Supportive-Expressive Psychotherapy,
    Systematic Desensitization, Therapeutic
    Community, Transcendental Meditation, Twelve-Step
    Facilitation Therapy, Women for Sobriety.
  • (From Miller, W., 2006, Presentation at 2006
    Blending Conference, Seattle, WA)

22
  • There must be some commonalities among EBPs that
    attempt to treat clients who suffer from
    addictive disorders.
  • If this is true, how much energy should be placed
    on training regarding specific EBPs or instead,
    could energy be better spent on other things?

23
EBPs that are Implemented
  • Motivational interviewing
  • Methadone
  • Buprenorphine
  • Naltrexone, Acamprosate, Vivitrol (Soon)
  • Contingency Management
  • Matrix Model
  • Adolescent Community Reinforcement Approach
    Assertive Continuing Care (ACRA/ACC)
  • Harm Reduction
  • Seeking Safety

24
Train ALL staff in overriding principles of
quality treatment of addiction.
  • Address motivation and reinforcing factors of
    using drugs, and help clients to develop non-drug
    reinforcing activities.
  • Dont be confrontational and meet clients where
    they are at.
  • Teach specific coping skills and ways to avoid a
    return to drug use.
  • Attend to the clients social environment.
  • Think about psychopharmacological intervention.
  • Your relationship to the client is critical and
    extremely important.
  • You must attend to the multiple treatment needs
    that clients have.

25
Client Satisfaction
  • An extreme focus on the importance of client
    satisfaction and at all times, treating clients
    with dignity and respect. This includes nursing
    staff, clinical staff, and milieu staff, as well
    as non-clinical staff.
  • Power and powerlessness trainings.
  • Client satisfaction surveys are given in all
    programs, which are reviewed with all staff.

26
  • All satisfaction surveys are reviewed by our
    senior management team and the CEO writes a note
    to every staff member who was mentioned in a
    positive way.
  • In residential programs, there are less negative
    comments about staff attitude or disrespect
    from staff and more positive comments about the
    professionalism of staff and staffs
    helpfulness.
  • As client satisfaction goes up, more clients
    complete treatment, go on to aftercare, and less
    are administratively discharged.

27
Treatment engagement and decreasing no show
rates.
  • If clients do not receive treatment, they will
    not get better
  • In our outpatient office, half of clients did not
    show for their intake appointment and another
    half did not come back for a second appointment.
  • By beginning treatment engagement over the
    telephone, instituting centralized scheduling so
    all clinician schedules are overseen by intake
    staff, ensuring that all clients leave with a
    scheduled appointment, and conducting appt.
    reminder calls, we decreased intake no-show rates
    to 19 and increased the percentage of people who
    return for a second appointment to 95.

28
Administrative Discharges
  • A huge issue in residential treatment.
  • Often for ongoing drug use, but other factors are
    treatment non-compliance and getting into
    disagreements with staff, which can often be
    staff initiated.
  • Have made this an important issue with program
    managers.
  • Administrative discharges must be approved by
    program manager.
  • Review data monthly.
  • In many cases, a return to drug use does not
    result in a discharge.

29
Individualized Care
  • Attending to the multiple needs of clients.
  • Instituted a modified ASI in all programs.
  • Chart audits review the ASI Severity Index and
    ensure that identified problems are noted in the
    treatment plan and progress notes address
    identified problems.
  • Results are given to the clinicians, in an effort
    to ensure that care is individualized.

30
A focus on practice-based evidence
  • Obtaining feedback from clients on the treatment
    that is received may be a powerful way to enhance
    care.
  • A formalized process of asking clients
  • Are they getting their needs met?
  • How is the quality of the therapeutic
    alliance?

31
  • Have begun an initiative on training clinicians
    to ask clients if the treatment is useful and if
    not, what would make it more useful.
  • In one program, clients reported that in many
    groups, there was too much cross-talk and that
    more structure/information would be useful.
  • Feedback was given to the clinicians and they are
    working to modify their approach.

32
  • Developed a survey that asked clients why they
    relapsed.
  • Survey results were aggregated and discovered the
    most relevant reasons why our clients relapsed.
  • Developed groups that addressed these specific
    reasons and trained staff.

33
  • Are these groups evidence-based?
  • No....or not yet.....

34
  • Are these groups relevant and have they enhanced
    the quality of care?
  • We think so........

35
A Culture of Continuous Performance Improvement
  • All programs are involved in ongoing performance
    improvement activities using rapid cycle
    plan-do-study-act (PDSA) projects.
  • Can focus on anything!

36
  • Decreasing no show rates.
  • Increasing treatment retention rates.
  • Increasing the number of clients who get involved
    in an educational or vocational program.
  • Decreasing episodes of aggressive acting-out.
  • Increasing referrals to the program.
  • Increasing overall treatment compliance.
  • Increasing satisfaction with group therapy.

37
  • In a short term residential treatment program
    (LOS about 15-30 days), it was found that 75 of
    people who left treatment early did so in the
    first five days of treatment.
  • Developed a new client fact sheet that reviewed
    what would occur in treatment and what to expect.
  • Worked with Case Managers to try to meet with
    their clients more quickly.
  • Reduced the of clients who left treatment early
    within the first five days to 37.

38
  • In a working halfway house, we found that only
    38 of clients were able to obtain work within
    the first 30 days of treatment.
  • Trained staff in a Job Seekers Workshop.
  • Extended the time clients needed to return to the
    program.
  • Over four months, 81 of clients were able to
    obtain work within the first 30 days of treatment.

39
Summary
  • The goal of evidence-based practices is to
    enhance the effectiveness of care and to provide
    clients the best possible treatment.
  • However, the delivery of evidence-based practices
    is just one piece of the pie.
  • Let us not forget the many other ways to enhance
    the quality of care that is delivered for clients
    with SUDs.
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