Transcript American Psychological Association Conference San

Evidence-based Practices (EBPs) in Community
Treatment Programs:
EBPs are just one piece of the pie
American Psychological Association Conference
San Francisco 2007
Michael S. Levy, Ph.D.
CAB Health & Recovery Services, Inc.
Peabody, MA
Key Factors Relevant to Client Change Processes
Therapeutic
Relationship, 30%
Extratherapeutic
Change, 40%
Expectancy
(placebo effects),
15%
Techniques, 15%
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.
• “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)
• “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).
• In looking at individual drug counseling (IDC) in
NIDA’s 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).
• “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).
• “…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).
• NIDA’s 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 individual’s treatment and services plan must be
assessed continually and modified as necessary to
ensure that the plan meets the person’s changing
needs.
• Remaining in treatment for an adequate period of
time is critical for treatment effectiveness.
• 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.
• 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 longterm process and frequently requires multiple
episodes of treatment.
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.
• 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?
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)
List of OMHAS Approved Evidence-Based Practices
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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
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
NREPP’s Evidence-based Practices
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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
NREPP’s Evidence-based Practices
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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
NREPP’s Evidence-based Practices
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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
NREPP’s Evidence-based Practices
• Motivational Interviewing
• Seeking Safety
A sample of specific treatments and evidence-based
practices for the treatment of addiction.
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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)
• 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?
EBPs that are Implemented
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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
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.
• Don’t 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 client’s 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.
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.
• 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 “staff’s helpfulness”.
• As client satisfaction goes up, more clients complete
treatment, go on to aftercare, and less are
administratively discharged.
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%.
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.
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.
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?
• 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.
• 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.
• Are these groups evidence-based?
• No....or not yet.....
• Are these groups relevant and have they enhanced
the quality of care?
• We think so........
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!
• 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.
• 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%.
• 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.
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.