Transcript Milieu Enrichment (aka Management)

Choosing & Using
Evidence-Based
Programming
20 February 2013
Fred Zackon M.Ed.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
What’s at Issue Here?
Evidence-Based Programs (or Practices or Curricula)
Treatment methodologies and interventions of demonstrated
effectiveness with specifically defined staff practices or
protocols, typically manualized.
nrepp.samhsa.gov
Comparison of Selected Interventions
Search criteria: Substance abuse treatment
Date of Search: 02/15/2013
Intervention Title
Outcomes
Ages
Races/Ethnicities
Settings
ALSO: nrepp.samhsa.gov/Courses/Implementations/resources/registries.html
Cocaine-Specific Coping
Skills Training
Review Date: March 2008
18-25
American Indian or Alaska
1: Number of cocaine use days
(Young
Native
2: Maximum number of cocaine use days
adult)
Asian
in a row
26-55
Black or African American
©to2013
Fred
granted
for or
useLatino
by BJA funded
3: Relapse
cocaine
useZackon Permission
(Adult)
Hispanic
4: Alcohol use
White
Residential
Outpatient
RSAT programs
2
This presentation has two parts
What’s important to consider that’s often neglected
when selecting an EBP.
What matters most in implementing an EBP, since
it is almost impossible to get it exactly right.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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This presentation assumes:
All Personnel Want an Effective Program
Program Administrators
• Determine EBP budget and resource parameters
• Expect competent implementation to take a year or more
Treatment Staff
• Do not want additional work
• Will not all readily adopt the EBP
• Will all inevitably adapt the EBP to their own styles
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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A Common Way To Choose An EBP
First, review approved lists of EBPs and find one you like,
or have heard or read good things about.
Then, consider the feasibility of implementing it given your
treatment population and culture, capacities and resources,
institutional administration, political climate, finances, etc.
See for example:
Implementation: Making an Evidence Based Program Work for You
A Guide to Selecting and Implementing a Program to Meet Your Needs
nrepp.samhsa.gov/pdfs/implementation_course.pdf
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Date of Search: 02/15/2013
Sample EBP comparison table from SAMHSA’s NREPP data base
Intervention Title
Outcomes
Ages
Races/Ethnicities
Settings
Cocaine-Specific Coping
Skills Training
Review Date: March 2008
1: Number of cocaine use days
2: Maximum number of cocaine use days
in a row
3: Relapse to cocaine use
4: Alcohol use
18-25
(Young
adult)
26-55
(Adult)
American Indian or Alaska
Native
Asian
Black or African American
Hispanic or Latino
White
Residential
Outpatient
55+
(Older
adult)
Matrix Model
Review Date: December 2006
1: Treatment retention
2: Treatment completion
3: Drug use during treatment
18-25
(Young
adult)
26-55
(Adult)
Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Outpatient
Motivational
Interviewing
Review Date: December 2007
1: Alcohol use
2: Negative consequences/problems
associated with alcohol use
3: Drinking and driving
4: Alcohol-related injuries
5: Drug use (cocaine and opiates)
6: Retention in treatment
18-25
(Young
adult)
26-55
(Adult)
Asian
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Outpatient
Review Date: April 2008
1: Relapse
2: Extent of relapse
3: Employment rates
4: Criminality
18-25
(Young
adult)
26-55
(Adult)
White
Race/ethnicity unspecified
Non-U.S. population
Inpatient
Outpatient
Recovery Training and
Self-Help
School
Other
community
settings
55+
(Older
adult)
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3 Other Ways to Assess EBP Needs
Identify a current program component or staff
practice that needs improvement.
Identify an area of need by reviewing the
principles of effective correctional treatment
programs, or similar.
Identify a core recovery goal your program needs
to better address. (Bonus points for this one.)
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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From the Ohio Department of Rehabilitation and Correction
Principles and Characteristics of Effective Programs
1. Programs should adhere to the “risk principle.”
2. Programs should target the criminogenic needs of offenders who are assessed as
having a need in a particular area.
3. Take steps to ensure that the program is implemented well and that program
integrity is preserved.
4. Treatment programming should use cognitive-behavioral and social learning
strategies.
5. Address offender responsivity (i.e., the skills needed for program success).
6. Program structure and activities should reach out into the offenders’ real-world
social network, when possible.
7. Aftercare services, continuity of care in the community, and relapse prevention
are very important for offenders reentering the community after imprisonment.
Also see: nic.gov/ThePrinciplesofEffectiveInterventions
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To Identify A Core Recovery Goal …
Consider a developmental recovery model
Resolves old shame & guilt
Embraces a re-defined & honorable self-concept
Pursues new self-determined horizons
Disciplines attention & energy as needed
Fully enjoys regular drug-free recreation
Achieves extinction of most triggers
Maintains productive daily routines
Adopts regular spiritual or moral practices
Makes recovery practices central to lifestyle
Makes recovery top personal priority
Bonds with new friends & community
Experiences recovery
self-efficacy
Achieves substantial abstinence
Acquires fundamental skill-set for abstinence
Identifies with redemptive or uplifting spiritual or moral creed
Fully acknowledges addiction and its costs
Connects with a recovery-supportive group or community
Embraces the vision of a good life, drug-free
Identifies with a recovering role model
Connects with a helpful person
Endures withdrawal
Bottoms out
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Proposed Milestones of Foundational Recovery
Achieves substantial abstinence
Acquires fundamental skill-set for abstinence
Identifies with redemptive or uplifting spiritual or moral creed
Fully acknowledges addiction and its costs
Connects with a recovery-supportive group or community
Embraces the vision of a good life, drug-free
Identifies with a recovering role model
Connects with a helpful person
Endures withdrawal
Bottoms out
These achievements
represent core
recovery issues for
RSAT programming
© 2013 Fred
Zackon
granted for
use by for
BJAuse
funded
RSAT
programs
© 2010
FredPermission
Zackon Permission
granted
by BJA
funded
RSAT programs
10
Proposed Milestones of Mature Recovery
• Resolves old shame & guilt
• Embraces a re-defined & honorable self-concept
• Pursues new self-determined horizons
• Disciplines attention & energy as needed
• Fully enjoys regular drug-free recreation
• Achieves extinction of most triggers
• Maintains productive daily routines
• Adopts regular spiritual or moral practices
• Makes recovery practices central to lifestyle
• Makes recovery top personal priority
• Solidifies friendships & community
These usually require
years of life in the free
world.
Most can barely begin
before the person returns
to the community.
But RSAT programs can
make those achievements
much more likely.
• Experiences recovery self-efficacy
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Other EBP Criteria and Categories
Therapeutic Objectives Insight? Skills? Self-efficacy? Relapse
Prevention? Etc.
Theoretical Orientation Cog-beh? Social Learning? Contingency
Management? Twelve Step? Etc.
Delivery Mode
Group? Individual? Journal? MultiMedia? Etc.
Relevance & Realism
Supportability Throughout The Program
Acceptability By Staff
Requisite Professional Skills & Training
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Will You Get Research-Level Results?
Very likely!
IF you implement the EBP “by the book.”
And how likely is that? Not very. But don’t worry.
You can have an excellent implementation
and get authentically good results if you
know where to put your attention.
Consider …
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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What Made the EPB Effective?
No one mechanism, ingredient, or feature of any EBP is
proven to make the difference. But effective treatment
programs seem to have some common features.
Such as:
• Support, structure, and goal direction
• Rewards for abstinence and sober activities
• Abstinence-oriented norms and models
• Enhancement of self-efficacy and coping skills
Adapted from Theory-based active ingredients of effective
treatments for substance use disorders. Moos RH. Drug Alcohol
Depend. 2007 May 11; 88(2-3):109-21.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Other Things Most EBPs Have In Common
Content
• Sufficient to fill time and minds
• Sensitive to client realities
• Theoretically mainstream and non-exclusionary
• Explicitly pro-social, pro-sober in values &
orientation
• Progressive and developmental
• Explainable with clear simple principles
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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More Things Most EBPs Have In Common
Delivery
• Standardized with specific recommended procedures
• Organized and systematic
• Strongly and steadily focused on the content
• Sustained over a regular schedule
• Tolerant of minor disruption and resistance
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Common EBP Qualities In A
Nutshell
Sensible content,
delivered systematically,
with a steady focus.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Something Else EVERY EBP Had …
A research-sensitive implementation,
that was carefully observed,
to ensure all procedures were done as prescribed,
from and about which much data was collected,
so that outcomes could be measured.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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… But Your Programming WON’T
Because, quite naturally, nobody will have the extra
time or energy or resources to make that happen in
your program. Instead, the work of implementing
the EBP will be extra work enough.
What to do?
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Establish an Implementation Team
Keep it small and active, but representative of
and sensitive to all personnel who will be
delivering, overseeing, or helping to manage
the EBP. A strong voice for counselors is vital.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Identify the EBP’s Core Elements
Read the developer’s program
description and manual or protocols.
Contact the developer and ask lots of
questions.
Discuss among colleagues and reach
out or study as needed.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Get a “Champion”
A respected staff person
who learns the EBP well,
especially its Core Elements,
to lead the implementation
and ensure sustained coaching –
lots and lots of coaching.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Doing It Right Isn’t Easy
Effective staff training in new styles or
procedures—and sometimes new ways of
thinking—requires
Explanation
Demonstration
Observation
Coaching—again, lots and lots.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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How Important Is Staff Buy-in?
It’s all important.
It’s the ballgame.
Staff who do not see the
value of the new methods or
content will not deliver it
effectively. Period.
Not only that …
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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The Challenge of Fidelity
Even for true believers, styles, habits,
reactions, anecdotes are all stubborn things.
Over time specific EBP content can turn into
advice, maxims, or comfort zone counseling.
This is due to the almost universal and sometimes insidious
“Regression to Me”
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Some Common Infidelities
Sessions are rushed or not completed
Discussion turns into debate or confrontation
Acting out is indulged
Personal stories substitute for content
Practice is short-changed or skipped
Maxims substitute for clear explanation
Specific ideas/skills become generalizations
And each of us could commit new ones.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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If You Can’t Be Pure … Be Open.
Observe yourself. Let others observe you.
Discuss with colleagues how to make your stuff EBP
compatible. Ask, compare, share. Sharpen your
stories, find new ways to see them, construct new
ones. Try out new grooves. Let yourself feel
awkward. Joke at your own non-EBP habits.
Above all know the EBP’s core elements and do
your best to maintain a good learning environment
for everyone.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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You’re A Role Model For Learning, Right?
Once you get inside a new way to
think—you’ll think new things.
You can get good at it. And make
new sense of what you thought
before.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Your Real-World EBP Can Still Rock!
Boost its power by ensuring
• Frequent, regular sessions
• Skills or practices that are readily usable in daily life
• Content that is naturalistic (i.e., not strange-seeming)
• Knowledgeable and respectful delivery
• Clearly and continually reinforcing the content in
social learning opportunities throughout the program.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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This is what makes real learning happen
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Something REALLY IMPORTANT
… ABOUT LEARNING THAT WE SHOULD NOT FORGET:
Without lots of practice and reinforcement we return to
our pre- or un-learned condition. This is especially true
of new behaviors intended to replace strong habits.
True for offenders, true for counselors, true for you and me.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Got EBP? So How Ya Doin?
If you currently have an EBP,
here are a few questions
that might be worth
answering every so often.
Do all RSAT staff understand
the program’s basic EBP
approach and key terms?
Are EBP sessions monitored
to assure that proper
techniques are used?
Do staff reinforce EBP principles or skills outside of sessions?
Are your other treatment tools and program rules consistent with
your EBP’s principles?
Are inmates accountable for EBP homework and for applying the
skills or principles to their ongoing program activities?
Are staff behaviors on-site consistent with the EBP principles?
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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A Simple Tool To
Assess Your EBP
Your Evidence-Based Program’s Fitness
Here’s a way to assess how robustly you are implementing your chosen EBP. Score your
program on the 1 to 7 scales for each of the following questions. Better yet, have more than
one person perform the ratings and average out the scores. If no question is rated lower than
4 and the total score is 35 or better, we would say you’re doing well! If the program’s total is
less than 30, look for where and how it might be strengthened. We suggest assessing your
program a few times a year.
Note: The phrases under the numbers indicate relative values along the scale.
Do all RSAT staff understand the EBP’s basic approach and key terms?
1
very few
2
3
4
most counselors
5
6
all treatment staff
7
all staff
Are EBP sessions/groups monitored to assure that appropriate techniques are used?
Try this:
This simple and brief assessment
instrument uses the questions on
the prior slide. You can download it
from the RSAT-TTA website.
1
almost never
2
3
seldom-casually
4
5
6
occasionally-carefully
7
regularly-carefully
Do staff reinforce the EBP’s principles or skills outside of sessions?
1
almost never
2
3
sometimes
4
5
often
6
7
almost always
Are your other program tools and rules consistent with the EBP’s principles?
1
not really
2
3
somewhat
4
5
pretty much
6
7
very much so
Are offenders accountable for any EBP homework and for applying its skills or principles to
their ongoing program activities?
1
not really
2
3
somewhat
4
5
pretty much
6
7
very much so
Are staff behaviors on-site consistent with the EBP’s skills and principles?
1
not really
2
3
somewhat
4
5
pretty much
6
7
very much so
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Broad EBP Treatment Objectives
A well-managed Therapeutic Community is a sturdy,
multi-functional, and goal-conducive vehicle for most
of foundational recovery. Clearly it can facilitate
abstinence and compliance with communal rules. A
TC’s social-learning capacities are uniquely suited to
fostering role modeling and early pro-sober, pro-social
attitudes and behaviors that are at the heart of
foundational recovery.
Engaging and interactive psycho-education that
focuses strongly on select principles of addiction and
recovery can ensure vital understanding that allows
for informed self-awareness.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Broad EBP Treatment Objectives
Cognitive-behavioral skills training can provide
offenders with a foundational skill-set. Skill
acquisition and use will be greatly enhanced if the
program clearly identifies particular skills or
competencies for goal achievement. Reinforcing use
of select skills on a daily program-wide basis makes
the skills more natural and robust.
Within the TC environment especially, a counselor’s
deft use of Motivational Interviewing and
Motivational Enhancement methods can sensiively
and effectively align an inmate with the recovery
journey itself, as well as particular treatment goals.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Broad EBP Treatment Objectives
There is no substitute for close attention to one’s
own personal and particular situation. Relapse
Prevention training (which itself usually relies heavily
on cognitive-behavioral skills) needs to be fine-tuned
to individual circumstance and style. Most of all, an
inmate needs rehearsal and practice for specific risks
most likely to arise following discharge.
Not least, every inmate should be fully acquainted
with and if at all possible experience well-run Twelve
Step groups wherein solid role models can be found.
Even if the Steps and Fellowships are not to one’s
liking, hearing from others about how they came to
accept a truth and power greater than themselves can
lead to one’s own community of support. Even if not
of the Twelve Steps.
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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nrepp.samhsa.gov/pdfs/CSAP_checklist_on_program_fit.pdf
37
From SAMHSA: Questions to ask the program developer as you
explore the possible use of an intervention
Implementations
• Where has this intervention been implemented? In what settings? With what populations?
• What are the particular challenges to effective implementation? How might these
challenges be overcome?
• What common mistakes have been made, and how can we avoid them?
• Can you provide contact information for two or three directors of implementation sites
that are currently in the process of implementing the intervention?
Adaptations
• Has your intervention been adapted in any ways that might be relevant to its
implementation in a setting like mine (describe your setting) or with a population like mine
(describe your population)?
• Have you been able to identify whether there are any “core components” of the
intervention— parts of the intervention that must be implemented and/or should not be
adapted?
Staffing
• What are the staffing requirements (number and type)?
• What are the minimum staff qualifications (degree, experience)?
• What methods are used to select the best candidates (philosophy, skills)?
• Is there a recommended practitioner-to-client ratio?
• Is there a recommended supervisor-to-practitioner ratio?
nrepp.samhsa.gov/pdfsquestions_to_ask_developers.pdf
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From SAMHSA, Questions continued
Quality Assurance Mechanisms
•What are the core components that define the essence of the intervention?
• How are supervisors prepared to provide effective support for practitioners?
• What is the supervision protocol for providing effective support for practitioners?
•What practical instruments are available to assess adherence and competence of the
practitioner’s use of the intervention’s core components?
• What tests have been done to ensure the validity and reliability of the fidelity instruments?
Training and Technical Assistance
•Is training required before a site can implement this intervention?
• Who conducts the training, and where is it conducted?
• Can staff at implementation sites be certified to conduct the training?
• Who is typically trained (practitioners, staff selection interviewers, staff trainers, staff
supervisors/coaches, agency administrators)?
•What is the duration of the training (hours, days)?
• Is retraining required/available?
• What on-site assistance is provided by the developer, if any?
• How long does it usually take for a new implementation site to become a high-fidelity user of
the intervention?
Costs
• How much does it cost to secure the services of the developer? What is included in that cost?
•If the intervention costs more than my budget allows, is there a way to implement only part of
the intervention?
• Do costs include salaried positions? In-kind costs? Special equipment?
nrepp.samhsa.gov/pdfsquestions_to_ask_developers.pdf
39
Training Staff in Treatment Strategies
vs. Techniques
“Rather than focusing so heavily on understanding specific
types or orientations of treatment, such as CBT or TSF,
training should emphasize common treatment processes,
such as promoting support, goal direction, and structure in
treatment and patients’ life contexts, enhancing patients’
involvement in new rewarding activities, and building their
self-efficacy and coping skills.”
Theory-based active ingredients of effective treatments for substance use disorders.
Moos RH. Drug Alcohol Depend. 2007 May 11; 88(2-3):109-21.
40
Supervising Staff Implementation Of An EBP
“The core elements of high-quality competency-based supervision
are the same activities that have been used to train counselors in
the clinical trials that established treatments as evidence-based:
direct observation of counselors’ sessions and the use of
performance feedback and individualized coaching … Supervisors
listen to audiotapes of counselors’ client sessions and rate the
frequency with which the counselors use specific treatment
strategies, their skill when implementing the strategies, and any
intrusion of counseling strategies that are incompatible with the
EBT ... The supervisors review their observations with counselors,
give advice for improvement, and sometimes suggest practice
scenarios or exercises (e.g., role-play during supervision) or model
or demonstrate skills. A typical clinical supervision schedule calls
for biweekly discussions, some with individual counselors and
some with groups of counselors, extending over several months.”
Strategies for Training Counselors in Evidence-Based Treatments. Steve
Martino, Ph.D. Addiction Science & Clinical Practice. 2010. December; 5(2): 30–39.
41
Words of humility on behalf of EBPs
from a leader in the field
Perhaps the proper attitude toward EBTs [i.e., EBPs] is one of
respect but not reverence. Evaluating scientific evidence is a
complex and evolving process. There is danger that funders
and regulators will take action prematurely, with out good
understanding of the state of the evidence and the practical
constraints inherent in implementing worthy goals.”
Evidence-based treatment: Why, what, where, when, and how? William
R. Miller, (Ph.D.) Joan Zweben, (Ph.D.) Wendy R. Johnson, (M.S.) Journal of Substance Abuse
Treatment 29 (2005) 267–276
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Thanks for Joining Me Today
Please feel free to get in touch to follow-up.
Fred Zackon
[email protected]
978-766-0098
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs
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Next Presentation
Ethical Issues in Offender Treatment: Professional Boundaries
March 20, 2013, 2:00 PM EDT
Ethical issues related to professional boundaries are among the most problematic and
challenging. Although some issues may seem cut-and-dried in a correctional setting,
others may fall into the “gray area” depending on one’s role / job description. This
training will provide an awareness and understanding of professional boundaries –
what they are and why they are important. It will introduce participants to the
concept of the Power Differential and how it impacts the relationships between all
RSAT Program staff and community members. It will review various slippery slope
scenarios that highlight compromised boundaries and will provide participants with
responses that they can call upon if they are in danger of crossing a professional
boundary within their program.
After completing this webinar, participants will be able to:
• Define the concept of “power differential”.
• Identify three types of professional boundaries and their relevance to offender
treatment.
• List at least three warning signs that boundaries may be at risk of being crossed /
compromised.
• Develop a plan of action if boundaries are in danger of becoming unprofessional /
boundaries have been crossed.
Presenter: Roberta Churchill
© 2013 Fred Zackon Permission granted for use by BJA funded RSAT programs