Transcript Contingency Management Enhanced Assertive Continuing Care

Community
Reinforcement
Approach
Susan Harrington Godley
Chestnut Health Systems
Bloomington, IL
Funded by:
Center for Substance Abuse Treatment (TI11894 TI13356)
National Institute on Drug Abuse (R01 DA 018183)
Based on slides by
Robert J. Meyers, Ph.D. and Jane Ellen Smith, Ph.D.
University of New Mexico
Goals of Presentation
Supporting Research
What is CRA?
Hunt & Azrin 1973
Inpatient Alcoholics
job finding counseling
 behavioral/marital therapy
 social/leisure counseling
 reinforcer access counseling
 social club
 home visits
 [total 50 hrs per client]

Results: 6 month follow-up
80
60
40
20
0
Drink Days
Jobless Days
Days away
from family
Traditional
Institution
CRA
Separated/Div
Azrin 1976: New &
Improved CRA
inpatient
alcoholics
disulfiram
w/compliance
protocol
problem
prevention
buddy system
early warning
mood monitoring
~70% as aftercare
home visits
[Average 30
contact hrs]
CRA new & improved:
Results
70
60
50
40
30
20
10
0
Drink Days
Jobless Days
Days away from
family
Traditional
CRA
Institution
CRA Outpatient Study (1982)
Azrin, Sisson, Meyers, & Godley
43 outpatient alcoholics
3 groups:
(1) traditional tx
(2) traditional tx + disulfiram
compliance
(3) CRA + disulfiram
compliance
increased use of
positive reinforcement
sobriety sampling
drink refusal training
+/- functional analysis
job club
phone contacts
[Average: 5 sessions]
6 Month Follow-up (1982)
CRA + disulfiram compliance
% days abs = 97%
Traditional +
disulfiram compliance
% days abs = 74%
Traditional
% day abs = 45%
CRA with Homeless AlcoholDependent Individuals
CRA
Group Sessions
Problem-Solving
Communication Skills
Drink-Refusal
Independent Living Skills
Goal Setting Meeting
Social Club
Disulfiram Compliance
(for a sub-group)
Individual Sessions
Job Finding
Case Management
STANDARD TREATMENT
Day Treatment
12-Step Counselor
Job Service Program
VA Benefits Advisor
Drinks Per Week By
Condition
20
18
--- Standard
16
Median
SECs
--- CRA
14
12
10
8
6
4
2
0
2 Month
4 Mont
6 Month
9 Month
Follow-Up Period
12 Month
Percent Homeless By
Condition
35
30
CRA
25
Percent
Standard
20
15
10
5
0
2 Month
4 Month
6 Month
9 Month
Follow-up Periods
12 Month
Evidence of Effectiveness:
Meta-analyses & Reviews
Holder et al. (1991)
Miller et al. (1995)
Social skills training
Self-control training
Brief motivational tx
Behavioral Marital tx
CRA
Stress management
Brief intervention
Social skills training
MET
CRA
Behavioral contract
Aversion tx
Evidence of Effectiveness
(cont’d)
Finney et al., 96
CRA
Social skills training
Behavioral Marital tx
Disulfiram Implants
Other marital tx
Stress Management
Miller et al., 03
Brief Intervention
MET
Acamprosate
CRA
Self-Change
Naltrexone
Miller et al., 05
Cognitive-Behavioral
CRA
MI
Relapse Prevention
Social Skills Training
Behavioral Marital Ther.
CRA Clinical Trials
Hunt & Azrin, ‘73 (inpatient alcohol dependent)
Azrin, ’76 (inpatient alcohol dependent)
Azrin et al., ‘82 (outpatient alcoholic)
Higgins et al., ’91 (cocaine)
Budney et al., ‘91 (cocaine)
Higgins et al., ’93 (cocaine)
Smith et al., ’98 (homeless alcoholics)
Abbott et al., ’98 (methadone/heroin addicts)
Roozen et al., ’00 (opioid dependent individuals)
Schottenfeld et al., ’00 (opioid & cocaine dependent individuals)
Meyers & Miller., ’01 (outpatient alcoholics)
Godley, et al., ’02 (Adolescent aftercare mj & alc)
Azrin, ’04 (outpatient adolescent patients)
Roozen et al., ’06 (nicotine dependent individuals)
Slesnick, et al., ’07 (homeless, street living youth)
De Jong et al., ’07 (opioid dependent individuals)
DeFuentes-Merillas, & De Jong ’08 (opioid & cocaine dependent
individuals)
What does not work!
Educational films and lectures
General alcoholism counseling
Process psychotherapy (individual
or group)
Confrontational counseling
Antipsychotic medication
Insight therapy
If punishment worked,
there would be few, if
any, alcoholics or drug
addicts…
What is the goal of CRA?
“…to rearrange the vocational, family,
and social reinforcers of the alcoholic
such that time-out from these reinforcers
would occur if he began to drink.” (Hunt
& Azrin, 1973)
CRA Session Structure
Been tested in clinical trials for 3-month
period, but designed to be open-ended based on
individual needs
Can be combination of individual/group
sessions
Frequency of sessions based on client’s
motivation and progress
Assessment and treatment planning used for
all; skills training as needed
CRA Induction: First
Session
Build rapport, build rapport, build rapport
Stay client-focused
Use positive reinforcement
Provide an overview of the basic CRA
objectives
Begin to establish “reinforcers”
(motivators)
Positive Reinforcer
What is a reinforcer?
How do I find one?
Does everyone have reinforcers?
How can I use them to help?
Functional Analysis
(F.A.)
An interview that examines the antecedents
and consequences of a behavior
“Roadmap”
F.A.s can be used for 2 kinds of behaviors:
 A problem behavior
 A healthy, fun behavior
Sobriety Sampling
Provide the rationale (Step 1)
The negotiation (Step 2)
Plan for Time-Limited Sobriety (Step 3)
Happiness Scale
Goals of Counseling:
Setting Goals
Goals of Counseling contains the categories
on the Happiness Scale
Guide the client’s selection of a category
In general, set short-term goals
Develop a step-by-step weekly strategy for
reaching each goal.
The strategy = the “homework” for the
week
Skills Training
Communications Skills
Problem Solving
Drink/Drug Refusal
Job-Finding Skills
Assigning Homework
Refer to as “practice exercises”? An experiment?
Offer rationale
Get client’s input
Describe agreed-upon specific assignment
Ask about potential obstacles; problem-solve
Identify time for completing assignment
Review homework at next session
Social/Recreational
Counseling
Discuss importance of healthy social life
Identify areas of interest:
 Ongoing? Pro-Social F.A.
 New? 2 x 2 table; Problem-solving; Leisure
Questionnaire; goal-setting
Encourage “reinforcer sampling”
Systematic Encouragement
Social Club
Drink/Drug Refusal
Training
Review high-risk situations
Enlist social support
Refuse drinks/drugs assertively
Additional Relapse
Techniques
CRA Functional Analysis for Relapse
Behavioral “chain” of events
Early warning monitoring system
Relationship Counseling
Self-Reminder to Be Nice
Common Mistakes Made
When Implementing CRA
Losing sight of client’s reinforcers
Failing to involve concerned others in treatment
Neglecting to emphasize the importance of
having a satisfying social and recreational life
Not stressing the necessity of having a
meaningful job
Common Mistakes Made
When Implementing CRA
Inadequately monitoring the client’s contact
with triggers
Not checking for generalization of skills
Being reluctant to suggest the use of
appropriate medications
More Information
http://www.robertjmeyersphd.com/
The Community Reinforcement Approach. (Available from
the Behavioral Health Recovery Management Project c/o
Fayette Companies, P.O. Box 1346, Peoria, IL 616541346; or at http://www.bhrm.org).
Meyers, R.J., & Miller W.R. (Eds.). (2001). A Community
Reinforcement Approach to Addiction Treatment.
Cambridge, UK: University Press.
Meyers, R. J., & Smith, J. E. (1995). Clinical guide to
alcohol treatment: The Community Reinforcement
Approach. New York: Guildford Press.
CSAT’s Assertive
Adolescent Family
Treatment
Susan Harrington Godley
Chestnut Health Systems
Bloomington, IL
Funded by:
Center for Substance Abuse Treatment (TI11894 TI13356)
National Institute on Drug Abuse (R01 DA 018183)
Goals
A-CRA vs. CRA
Assertive Continuing Care (ACC)
Technical assistance provided to
grantees to learn the EBTs
Target population
Outcomes
A-CRA vs. CRA
Added caregiver sessions
Changed Happiness Scale so that it
was relevant for adolescents
Samples in treatment manual were
based on how one might talk with an
adolescent and the issues they would
talk about
Critical Parenting
Practices
Good modeling
Increase positive
communication
Monitor the adolescent’s
whereabouts
Involvement in
adolescent's life
outside the home.
Based on the work of R. Catalano, H. Hops, & B.Bry
Similarity of Clinical
Outcomes by Conditions
.
Total days abstinent
over 12 months
300
50%
280
40%
260
30%
240
20%
220
10%
200
MET/ CBT5
MET/
CBT12
Total Days Abstinent*
269
256
Percent in Recovery**
0.28
0.17
*
FSN
MET/ CBT5
A-CRA
MDFT
260
251
265
257
0.22
0.23
0.34
0.19
n.s.d. effect size f=0.06
** n.s.d., effect size f=0.12
Source: Dennis et al., 2004
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
0%
.
Percent in Recovery
at Month 12
Trial 2
Trial 1
A-CRA did better than
Trial 2
MET/CBT5, and both did
better than MDFT
Cost per day of abstinence
over 12 months
Trial 1
$20
$20,000
$16
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
$0
MET/ CBT5
MET/
CBT12
FSN
MET/ CBT5
ACRA
MDFT
CPDA*
$4.91
$6.15
$15.13
$9.00
$6.62
$10.38
CPPR**
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* p<.05 effect size f=0.48
** p<.05, effect size f=0.72
Source: Dennis et al., 2004
*
p<.05 effect size f=0.22
** p<.05, effect size f=0.78
Cost per person in recovery
at month 12
Moderate to large differences
in Cost-Effectiveness by
Condition
What is Assertive
Continuing Care (ACC)
A continuing care intervention that was
specifically designed for adolescents
following residential treatment
Increasingly, it is also being used following
outpatient or other primary treatment
ACC clinicians use A-CRA procedures, but
typically provide services in the home and
increase case management activities
Assertive Continuing
Care Motto:
We can’t help them if we
don’t see them!
Continuing Care Linkage and Retention
During the 90 day CC Phase
100%
12
94%
90%
10
10
80%
70%
8
60%
54%
50%
6
40%
4
30%
20%
2
2
10%
0%
0
Percent Linked
ACC
Median Number of Sessions
UCC
57% Higher Rate of Continuous Abstinence
for ACC (Cannabis)
100%
Two months after
residential, 58% in ACC
vs. 40% in UCC still
clean
Percent Remaining Abstinent
90%
80%
At 9 months 4 out of
10 in ACC are still
abstinent vs. less than
3 of 10 in UCC
70%
60%
50%
ACC (n=96)
40%
30%
UCC (n=78)
20%
10%
0%
0
30
60
90
120
150
180
210
Follow-up Phase
Continuing Care Phase
Days from Discharge
240
270
Unique Components of
AAFT initiative
GAIN clinical certification
ABS software
Clinical supervisor certification process
Web-based tool for clinical and
supervisory certification based on digital
technology
Implementation calls paired with monthly
implementation progress reports
Cultural responsiveness committee
Training & Certification
Process for A-CRA
Treatment Manual
and
Upload session
recordings &
data to the
web;
Get expert
ratings and
narrative
feedback
Record clinical
and
supervision
sessions
Knowledge Test
3.5-day
centralized
training session
A-CRA/ACC Technical
Assistance
A-CRA/ACC Certification
Requirements are clearly
delineated & monitored
Bi-Weekly
Coaching calls
A-CRA Clinician Certification
Requirements
Take a knowledge test
Attend the 3.5 day training
Attend coaching calls
Participate in local supervision sessions
Enter session data
Demonstrate competency on 9 core
A-CRA procedures through DSR reviews
Supervisor Certification
Requirements
Take a knowledge test
Attend the 3.5 day training
Attend coaching calls
Provide local supervision sessions
Demonstrate supervision skills during
supervision sessions
Demonstrate ability to rate clinician
DSRs
Upload
Digital Session
Recordings
Read
Reviews
Sample Procedure
Rating
1
|
poor
2
3
|
|
needs
satisfactory
improvement
4
|
very
good
5
|
excellent
Caregiver Overview, Rapport Building, and Motivation:
48. ____
49. ____
50. ____
51. ____
52. ____
____ Provided an overview of A-CRA
____ Set positive expectations
____ Reviewed research regarding parenting practices
____ Identified CG reinforcers for continued work
____ Kept discussion (about adolescent) positive
Narrative Comments
Are Also Provided
Assigned Homework: The assignment for next week is….
Happiness Scale
Good: You gave a nice rationale for the happiness scale! You explained that he would rate his
happiness in different areas of his life and that his ratings would be used to make short-term
goals. It was great that you mentioned that he would do several scales and they would be used
to assess progress.
Good: You gave good directions for the scale. You explained that he should rate his current
happiness for today on a scale from 1-10 (1-low, 10-high)…It’s also good to mention that he
should rate the categories independently from one another. It was good that you reviewed
some of the ratings! For legal issues and emotional life, you asked him why he rated it the way
he did. For emotional life, you asked him what could improve his ratings. It’s important to do
this with a number of categories (a few that are rated very high, some that are rated
moderately, and some that are rated very low). For each category, it’s important to ask why he
rated it the way he did and what could improve his rating. Also, this procedure should only take
15 minutes or so. It seemed like you got stuck while going over the emotional life category and
spent the rest of the session discussing this.
Overall – Stayed Within ACRA Protocol: You were behavioral, supportive, and positive…
Overall – Introduced ACRA Procedures at Appropriate Times: You assigned homework…
General Clinical Skills: You were warm, nonjudgmental, and supportive…
AAFT Performance Data
2,137 Adolescents have been open to the project
25,463 Sessions have been posted to EBTx
2,726 Of DSRs have been rated with feedback to clinicians
88 Clinicians have been certified
31 Supervisors have been certified
Average # of DSRs to certification is 21; range 9 - 49
Average # of months to certification is 9; range 2.2 - 19
261 of fidelity checks conducted: 51% pass on first check,
and 72% pass on the second check
Demographic Profile
Female
28%
16%
African American
31%
Caucasian
21%
Mixed/Other
32%
Hispanic*
16%
12 to 14 years old
78%
15 to 17 years old
18 to 25 years old
6%
81%
Outpatient
Intensive Outpatient
Long Term Residential
Outpatient Continuing Care
0%
5%
5%
10%
20%
40%
*Any Hispanic ethnicity separate from race group.
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
60%
80%
100%
55%
Anything
14%
Alcohol
43%
Cannabis
Cocaine
Opioid
Other Drugs
Needle Use
2%
4%
6%
1%
52%
Tobacco
Controlled Environment
22%
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Pattern of Weekly Use (13+/90 days)
51%
Conduct Disorder
49%
Attention Deficit/Hyperactivity Disorder
39%
Major Depressive Disorder
26%
Traumatic Stress Disorder
12%
64%
Ever Physical, Sexual or Emotional Victimization
46%
High severity victimization (GVS>3)
38%
Ever Homeless or Runaway
20%
Any homicidal/suicidal thoughts past year
Any Self Mutilation
8%
Prior Mental Health Treatment
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
42%
100%
90%
80%
70%
Any Co-occurring Psychiatric
General Anxiety Disorder
70%
60%
50%
40%
30%
20%
10%
0%
Co-Occurring Psychiatric Problems
83%
Any violence or illegal activity
72%
Physical Violence
63%
Any Illegal Activity
47%
Any Property Crimes
Any Interpersonal/ Violent Crime
45%
Other Drug Related Crimes \a
44%
86%
Lifetime Juvenile Justice Involvement
68%
Current Juvenile Justice involvement
36%
1+/90 days In Controlled Environment
Probation/Parole with Urine Testing\b
30%
Notes: \a Dealing, manufacturing, prostitution, gambling (does not include simple possession or use);
\b 14 or more days on probation/parole with urine monitoring
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Past Year Violence & Crime
Count of Major Clinical Problems
at Intake\a
100%
90%
80%
70%
60%
50%
None, 6%
One, 9%
Two, 12%
Three,
14%
Four, 13%
Median =
4 Problems
40%
30%
20%
10%
Five to
Twelve,
46%
0%
Note: \a Based on count of self reporting criteria to suggest Alcohol, cannabis, or other drug disorder, depression,
anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
No. of Problems\a by Severity of
Victimization
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
None
One
Two
Three
Four
Five+
71%
45%
14%
Low
(OR 1.0)
Mod.
(OR=5.0)
High
(OR=15.0)
Severity of Victimization
Note: \a Based on count of self reporting criteria to suggest Alcohol, cannabis, or other drug disorder,
depression, anxiety, trauma, suicide, ADHD, CD, victimization, violence/ illegal activity. OR=Odds
Ratio relative to Low
Source: CSAT February 2009 AAFT GAIN Data Set (n=2,415)
Performance (goal):
Recruitment and Monitoring
0%
10%
20%
30%
40%
50%
60%
70%
80%
Sites with 2+ Staff GAIN Certified or In process
Within Window (100% of Sites)
90%
100%
100%
Recruitment Rate (80%+)
88%
Session 2 Alliance (80%+)\q
87%
89%
3 Month follow-up (80%+)\a
6 Month follow-up (80%+)\a
12 Month follow-up (80%+)\a
Site Data Submission Ok to Good (80%+)
80%
73%
100%
Notes: \a based on done divided by due minus expected, plus same percent expected of those still pending in window
Source: CSAT February 2009 AAFT Management Report (n=2,415)
A-CRA/ACC Certification
Progress
Staff
0
20
40
31
A-CRA Supervisor
ACC Supervisor
80
88
A-CRA Clinician
ACC Clinician
60
19
12
100
120
33
7
53
14
Certified
In Progress
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Performance (goal): Treatment
Received
Sites with 2+ Staff A-CRA Certified or
Pending (100% of Sites)
100%
Evidenced Based Treatment (80%+)
[ACRA 86%, ACC 10%, other 1%]
97%
Treatment Initiation within 2 weeks (80%+)
87%
Treatment Engagement of 4+ weeks (80%+)
88%
86%
Continuing Care for 90+ days (50%+)
ACC Linkage within 14 days (50%+)
Targeted Improvement over general practice
Source: CSAT February 2009 AAFT Management Report (n=2,415)
57%
Performance: Change Over Time in
Selected Outcomes
100%
Abstinence
90%
80%
70%
No Mental
Health Problems
60%
50%
40%
30%
No Illegal
Activity
20%
10%
0%
0
3
6
9
12
Months from Intake
Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)
No Family
Problems
73%
Abuse/Dependence Sx
38%
Physical Health
43%
Mental Health
99%
Nights of Psychiatric Inpatient
47%
Illegal Activity
90%
Arrests
68%
Family/Home Problems
Quarterly Cost to Society
100%
63%
Abstinent
Recovery Environment Risk
90%
80%
70%
60%
50%
40%
30%
20%
10%
Reduced 50% or
No Problem
No Problem
0%
Outcome Status at Last Wave
14%
35%
Source: CSAT February 2009 AAFT GAIN Data set with 1+ Follow-up (n=1,732)
Comments from
Therapists
thanks... the team has been awesome!! Brandi was always responsive
and the web-based system was user friendly. I gave some feedback on
our last conference call re: possibly having separate calls for
supervisors... other than this...TOP NOTCH! Will be in touch if any
issues should arise moving forward. Be well and thanks again...
Thank you so much; you all have helped me greatly with this process. I
really appreciate the time and care you provide for all of us undergoing
ACRA/ACC certification. I want you all to know that I felt fully
supported from the beginning and I still feel that way today. There was
always someone available to answer all of my questions and I never
felt like I was alone in this process. I am very proud of this
accomplishment and it is a wonderful feeling to be a part of the
ACRA/ACC program. I am seeing first hand the opportunities and client
empowerment this program provides for our youth, their families, and
our community and it's amazing.
Summary
The CSAT Adolescent Treatment program
has demonstrated the ability to replicate ACRA and ACC approaches in community
based settings
Both the GAIN and the A-CRA/ACC training
and certification processes appear to be
working well in AAFT based on numbers of
staff achieving certification
Adolescents appear to like the intervention
Outcomes to date compare favorably to
previous CSAT replication efforts and other
CSAT funded initiatives
Monograph of CRA Research
Community Reinforcement and
Family Training: CRAFT