An EvidenceBased Treatment System for Improving Practice

1
An Evidence-Based Treatment System for Improving
Practice
Science to Services Institute State Systems
Development Program Conference (November 20-22,
2002 Wash DC)
D. Dwayne Simpson Texas Christian University
2
IBR
Institute of Behavioral Researchat Texas
Christian University
The IBR specializes in the study of drug abuse
treatment including new interventions,
therapeutic process, and outcomes.
IBR HOME PAGE
WHATS NEW ABOUT IBR STAFF PROJECTS NEWSLETTERS P
UBLICATIONS PRESENTATIONS MANUALS FORMS OTHER
LINKS Search Contents Site map
TCU Resource Collections National
Treatment Evaluations Correctional Treatment
Evaluations Treatment Process Counseling
Manuals Cognitive Interventions Technology
Transfer Client/Treatment Assessments

• Spotlight_______________
• New studies on transferring research to
  practice were recently published in a special
  issue of Journal of Substance Abuse Treatment
• The latest Research Roundup Newsletter is out,
  focusing on IBR technology transfer research
• Handouts from presentations available
• Core Forms Research Summaries available
• Publication Abstracts available

SITE GUIDES

• New Activities___________
• The IBR Website is redesigned to streamline
  access and highlight integrated sets of materials
  manuals, forms, findings in specialized
  Resource Collections

Summary PowerPoint Presentations
www.ibr.tcu.edu
3
Drug Abuse Treatment Core Components and
Comprehensive Services
Medical
Mental Health
Financial
Vocational
Housing Transportation
Educational
Child Care
Legal
Family
AIDS / HIV Risks
Etheridge, Hubbard, Anderson, Craddock, Flynn,
1997 (PAB)
4
Improving Treatment(Panel III Page 65-85 of NTP)
OrganizationalCulture Info Mgmt
Changes?
Business Mgmt
Financing
Services
Costs, Efficiency, Performance
Stages of Treatment
5
No Wrong Doors
Attic for Special Populations
Basement for CJ Populations
6
CJ Drug Abuse Treatment Studies NIDA Cooperative
Agreement (2002-07)
CJ-DATS
Surveys
Assessments
Interventions
Evaluations
7
Program Change Model
Institutional Personal Readiness
Stages of Transfer
Program Change
Staff

• 1-Exposure
• (Training)
• Lecture
• Self Study
• Workshop
• Consultant

Organizational Dynamics
Simpson, 2002 (J Substance Abuse Treatment)
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Foundations

• Is treatment effective?
• How does it work?
• Can we improve it?
• How do programs change?

Science to Services
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Psychosocial Changes in Outpatient Methadone
Treatment (OMT)
Self-Esteem Problems
Depression Problems
Anxiety Problems
Risk Taking Problems
Social Conformity Problems
plt.01
of DATAR Sample (N279)
10
Drug Use Crime Changes in Outpatient Methadone
Treatment (OMT)
Alcohol Use Heavy (3 drinks/hr)
Injection Freq Daily
Opiate Use UA
Cocaine Use UA
Crime or Jail 15 Days (last 30 days)
plt.01
of DATAR Sample (N298)
11
Outcomes by Time in Treatment in Outpatient
Methadone Treatment (OMT)
Alcohol Use Heavy (3 drinks/hr)
Injection Freq Daily
Opiate Use UA
Cocaine Use UA
Crime or Jail 15 Days (last 30 days)
plt.01
12
Performance Records (OMT Program)
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Drug Abuse Treatment Outcome Studies
DATOS
NIDAs Third National Evaluation of Treatment
Effectiveness
70 Studies Published (Special Issues)
Psychology of Addictive Behaviors (Dec 97) Drug
and Alcohol Dependence (Dec 99) Journal of
Adolescent Research (Dec 01 for DATOS-A) Archives
of General Psychiatry (99, 01, 02)
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Drug Abuse Treatment Outcome Studies
Collaborating Centers_____
NDRI
NIDA
UCLA
TCU

• HOME PABE
• ABAOUT DATOS
• BACKGROUND
• (DARP/TOPS)
• ADULTS
• Introduction
• Services
• 1-Yr Outcomes
• Retention
• Engagement
• History Effects
• Cocaine Treatment
• Cost benefits
• 5-Yr Outcomes
• ADOLESCENTS
• Introduction
• Services

• Spotlight____________
• Archives of General Psychiatry publishes new
  5-year outcome study based on adults treated for
  cocaine dependence
• Adolescent treatment follow-up outcome studies
  based on 1167 youth treated in 23 programs from 4
  cities are released in --
• Archives of General Psychiatry
• Journal of Adolescent Research

• Summary PowerPoint Presentations
• 1-Year Outcomes
• Treatment Retention
• Engagement
• Cocaine Treatment

• New Activities________
• The DATOS Website is redesigned to streamline
  access and highlight studies focused on
  Adolescents versus Adults
• Funding for the DATOS project is ending, but a
  concluding set of 5-year outcome studies are
  being prepared, expected to bring the total
  publications from this project to 75 by mid-2002

www.datos.org 
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5-Year Outcomes for Cocaine Treatment Changes
from Before to After Treatment
plt.001
of DATOS Sample (N708)
Simpson, Joe, Broome, 2001 (Arch Gen Psychiatry)
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Types of Problems at Admission

With Problems in Year Before Admission
Simpson, Joe, Fletcher, Hubbard, Anglin, 1999
(Arch Gen Psychiatry)
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Weekly Cocaine Use(in Year After Treatment)
Problem Severity at Intake (plt.001)
Simpson, Joe, Fletcher, Hubbard, Anglin, 1999
(Arch Gen Psychiatry)
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Weekly Cocaine Use (in Year After Treatment)
HIGH Problem Patients (plt.001)
Simpson, Joe, Fletcher, Hubbard, Anglin, 1999
(Arch Gen Psychiatry)
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Retention Predicts Outcomes

• National Studies Funded by NIDA
• 1970s DARP (n44,000 admissions)
• 1980s TOPS (n11,000 admissions)
• 1990s DATOS (n10,000 admissions)
• Other National Evaluations (1990s)
• England NTORS (n1,150 admissions)

The Black Box of Treatment?
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Elements of a Modelfor Treatment Process?


Detox
Patient Factors
?
OP-DF
Sufficient Retention
Drug Use
PsychologicalFunctioning, Motivation,
ProblemSeverity
Crime
TC/Res
Social Relations
OP-MM
Posttreatment
Cognitive Behavioralcomponents with
therapeutic impact
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TCU Treatment Process Model
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Posttreatment
Engagement
Simpson, 2001 (Addiction)
22
Relapse TX Compliancefor Medical Problems
OBrien McLellan, 1996 (Lancet) McLellan et
al., 2000 (JAMA)
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Treatment for Sequence of Recovery Stages
Patient Readiness for Trt
Program Participation
Behavioral Change
AdequateStay in Trt
Therapeutic Relationship
Cognitive Change
Targeted Interventions
Get Focused!!
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Interventions should focus on maintaining this
process
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Posttreatment
Simpson, 2001 (Addiction)
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Induction to Treatment(Readiness Training)
ProblemRecognition
Desirefor Help
Readinessfor Treatment
Simpson Joe, 1993 (Pt) Blankenship et al.,1999
(PJ) Sia, Dansereau, Czuchry, 2000 (JSAT)
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Counseling Enhancements (Cognitive Mapping)
Dansereau et al., 1993 (JCP), 1995 (PAB) Joe et
al., 1997 (JNMD) Pitre et al., 1998 (JSAT)
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Contingency Management(Token Rewards)
Rowan-Szal et al., 1994 (JSAT) 1997 (JMA)
Griffith, Rowan-Szal et al., 2000 (DAD)
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Specialized Interventions (Skills-Based
Counseling Manuals)
Supportive Networks
Bartholomew et al., 1994 (JPD) 2000 (JSAT)
Hiller et al., 1996 (SUM)
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TCU Counseling Manuals

• Treatment Readiness/Induction
• Cognitive Mapping
• Social Relationships (women men)
• HIV/AIDS Education
• Parenting Skills
• Cocaine Use
• Transition Skills (to Aftercare)

Download from Web
30
IBR
Institute of Behavioral Researchat Texas
Christian University
The IBR specializes in the study of drug abuse
treatment including new interventions,
therapeutic process, and outcomes.
IBR HOME PAGE
WHATS NEW ABOUT IBR STAFF PROJECTS NEWSLETTERS P
UBLICATIONS PRESENTATIONS MANUALS FORMS OTHER
LINKS Search Contents Site map
TCU Resource Collections National
Treatment Evaluations Correctional Treatment
Evaluations Treatment Process Counseling
Manuals Cognitive Interventions Technology
Transfer Client/Treatment Assessments

• Spotlight_______________
• New studies on transferring research to
  practice were recently published in a special
  issue of Journal of Substance Abuse Treatment
• The latest Research Roundup Newsletter is out,
  focusing on IBR technology transfer research
• Handouts from presentations available
• Core Forms Research Summaries available
• Publication Abstracts available

SITE GUIDES

• New Activities___________
• The IBR Website is redesigned to streamline
  access and highlight integrated sets of materials
  manuals, forms, findings in specialized
  Resource Collections

Summary PowerPoint Presentations
www.ibr.tcu.edu
31
NIDA List of Scientifically Based Approaches
?
Principles of Drug Addiction Treatment A
Research Based Guide (NIDA, 2000)
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Motivational Enhancement (ME)
Principles of Drug Addiction Treatment A
Research Based Guide (NIDA, 2000)
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Behavioral Therapy (Adoles/MM/Nicotine)Voucher
Based Reinforcement TherapyCommunity
Reinforcement Therapy
Principles of Drug Addiction Treatment A
Research Based Guide (NIDA, 2000)
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Relapse Prevention Multidimensional Family
Therapy
Family Friends
Social Skills Training
Principles of Drug Addiction Treatment A
Research Based Guide (NIDA, 2000)
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Matrix Model Individualized Drug Counseling
Behavioral Strategies
Family Friends
Enhanced Counseling
Social Skills Training
Principles of Drug Addiction Treatment A
Research Based Guide (NIDA, 2000)
36
Conclusions

• Long-term outcome studies --
• Indicate that treatment is effective
• Lead to questions about HOW
• Treatment process studies --
• Identify important therapeutic dynamics
• Define interim performance measures
• Clarify the role of interventions
• Lead to management strategies

Full Model?
37
Evidence-Based Treatment Model
Behavioral Strategies
Family Friends
Induction
Personal Health Services
Supportive Networks
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Posttreatment
Enhanced Counseling
Social Skills Training
Social Support Services
Simpson, 2001 (Addiction)
38
Threat from Growing Economic Pressures

• Restricts needs criteria
• Minimizes treatment duration
• Shifts aftercare to community
• Reduces outcome accountability
• Limits wrap-around services

39
Evidence-Based Treatment Model
Behavioral Strategies
Family Friends
Readiness Training
Personal Health Services
Supportive Networks
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Posttreatment
Enhanced Counseling
Social Skills Training
Social Support Services
Simpson, 2001 (Addiction)
40
Impact of Economic Pressures
Behavioral Strategies
Family Friends
Readiness Training
Personal Health Services
FormalDiagnosis of addiction (dependence) for In
surance Coverage
Supportive Networks
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Posttreatment
Enhanced Counseling
Social Skills Training
Social Support Services
41
Impact of Economic Pressures
Behavioral Strategies
Family Friends
Readiness Training
Personal Health Services
FormalDiagnosis of addiction (dependence) for In
surance Coverage
Supportive Networks
Early Engagement
Early Recovery
AA/NA/CA
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Aftercare
Posttreatment
Enhanced Counseling
Social Skills Training
Social Support Services
42
Impact of Economic Pressures
Behavioral Strategies
Family Friends
Readiness Training
Personal Health Services
FormalDiagnosis of addiction (dependence) for In
surance Coverage
Supportive Networks
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Therapeutic Relationship
Psycho-Social Change
Posttreatment
Enhanced Counseling
Social Skills Training
Social Support Services
43
Impact of Economic Pressures
Behavioral Strategies
Family Friends
Readiness Training
Personal Health Services
FormalDiagnosis of addiction (dependence) for In
surance Coverage
Supportive Networks
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Therapeutic Relationship
Psycho-Social Change
Posttreatment
Enhanced Counseling
Social Skills Training
Social Support Services
44
Impact of Economic Pressures
FormalDiagnosis of addiction (dependence) for In
surance Coverage
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Therapeutic Relationship
Psycho-Social Change
Posttreatment
3-7 Day Slice(Detoxification)
45

• Changing the System
• Program characteristics?
• Assessment strategies?
• Barriers to change?

46
Patient Retention Rates for Programs(beyond
minimum thresholds)
BestProgram
PoorestProgram
Simpson, Joe, Broome, Hiller, Knight,
Rowan-Szal, 1997 (PAB)
47
Programs with Lower Retention had more troubled
caseloads!

• Admissions to these programs had --
• More cocaine alcohol problems
• More time in previous treatments
• More psychological problems

But these patient problems did not explain all
program differences in retention rates!
Simpson, Joe, Broome, Hiller, Knight,
Rowan-Szal, 1997 (PAB)
48
Counseling Rapport( with HIGH Scores in 12
Programs)
Lowest
Highest
TCU/NF-ATTC Survey (April 2001 High scores
gt40)
49
Engagement ( High) by Motivation (Treatment
Readiness)
TCU/NF-ATTC Survey (April 2001)
50
Findings Using the CEST (Aggregated client-level
data)

• Outpatient programs had
• Lower trt readiness peer support
• Lower depression hostility
• Adolescent programs had
• Lower trt readiness peer support
• Lower rapport Higher hostility
• Womens programs had
• Higher trt readiness peer support

Joe, Broome, Rowan-Szal, Simpson, 2002 (J
Substance Abuse Treatment)
51
Evidence-Based Treatment Model
Behavioral Strategies
Family Friends
Readiness Training
Personal Health Services
Supportive Networks
Early Engagement
Early Recovery
Program Participation
Behavioral Change
Sufficient Retention
Drug Use
Crime
Therapeutic Relationship
Psycho-Social Change
Social Relations
Posttreatment
Enhanced Counseling
Social Skills Training
Social Support Services
Program Interventions
Simpson, 2001 (Addiction)
52
Organizational Assessments
OrganizationalDynamics

• Motivation
• Program Needs
• Training Needs
• Pressures

• Staff
• Growth
• Efficacy
• Influence
• Adaptability
• Orientation

• Climate
• Mission
• Cohesion
• Autonomy
• Communication
• Stress
• Change

• Resources
• Offices/Staffing
• Training
• Equipment

Program variations ?
Lehman, Greener, Simpson, 2002 (J Substance
Abuse Treatment)
53
Org. Climate Cohesion (Average scores range
10-50)
Lowest
Mid-point on Scale
Highest
12 programs in TCU Workshop
TCU/NF-ATTC Survey (April 2001)
54
Findings Using the ORC/CEST (Aggregated
staff/client-level data)

• Higher Client Satisfaction
• in programs with staff higher on
• Autonomy, Communication, Chg Orient.
• Higher Client Rapport
• in programs with staff higher on
• Mission, Cohesion, Autonomy,
• Communication, Chg Orient.
• Higher Client Engagement if
• Staffing levels perceived influence higher

Lehman, Greener, Simpson, 2002 (J Substance
Abuse Treatment)
55
Program Change Model

• Satisfaction
• Ease of use
• Values fit

Institutional Personal Readiness
Reception Utility
Resources
Motivation
Stages of Transfer
Program Change
Staff

• 1-Exposure
• (Training)
• Lecture
• Self Study
• Workshop
• Consultant

2-Adoption (Leadership decision)

• Services
• Process
• Mgmt

3-Implementation (Exploratory use)
Time Place
Program Improve- ment
4-Practice (Routine use)
Institutional Supports
Organizational Dynamics
Climatefor Change
Staff Attributes

• Monitoring
• Feedback
• Rewards

Simpson, 2002 (J Substance Abuse Treatment)
56
Planning Evaluating Training
Workshop Plans
WEVAL
Program Changes?
57
Planning Evaluating Training
A
B
C
D
WEVAL
And how to improve it?
Who wants it?
Who uses it?
Are there changes?
58
IBR
Institute of Behavioral Researchat Texas
Christian University
The IBR specializes in the study of drug abuse
treatment including new interventions,
therapeutic process, and outcomes.
IBR HOME PAGE
WHATS NEW ABOUT IBR STAFF PROJECTS NEWSLETTERS P
UBLICATIONS PRESENTATIONS MANUALS FORMS OTHER
LINKS Search Contents Site map
TCU Resource Collections National
Treatment Evaluations Correctional Treatment
Evaluations Treatment Process Counseling
Manuals Cognitive Interventions Technology
Transfer Client/Treatment Assessments

• Spotlight_______________
• New studies on transferring research to
  practice were recently published in a special
  issue of Journal of Substance Abuse Treatment
• The latest Research Roundup Newsletter is out,
  focusing on IBR technology transfer research
• Handouts from presentations available
• Core Forms Research Summaries available
• Publication Abstracts available

SITE GUIDES

• New Activities___________
• The IBR Website is redesigned to streamline
  access and highlight integrated sets of materials
  manuals, forms, findings in specialized
  Resource Collections

Summary PowerPoint Presentations
www.ibr.tcu.edu