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

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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

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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.
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• 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)

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• 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).

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• 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).

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• 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).

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• 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).

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• 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.

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• 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.

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• 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.

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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.

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• 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?

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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)

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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

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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)

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List of OMHAS Approved Evidence-Based Practices

• Motivational Interviewing
• Seeking Safety

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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

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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

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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

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NREPPs Evidence-based Practices

• Motivational Interviewing
• Seeking Safety

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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)

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• 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?

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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

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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.

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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.

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• 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.

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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.

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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.

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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.

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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?

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• 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.

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• 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.

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

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

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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!

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• 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.

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• 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.

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• 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.

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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.