Transcript Evidence-Based Treatment Practices

Expanding
Evidence-Based Treatment
Doreen A. Cavanaugh, Ph.D.
Georgetown University
Health Policy Institute
November 12, 2009
Overview
Call to Action
 Scan of the Horizon
 Population Description
 Context
 National Level Support
 Evidence-based Treatments
 Moving forward in NC

© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
URGENT
THIS IS NOT A DRILL!!
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
The Horizon: For The Times They
Are A-Changin’*
Parity
 Integration
 Medical Home/Advanced Primary Care
 Health Reform

Doreen A. Cavanaugh, Ph.D.
November 12, 2009
*Bob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
The Horizon: For The Times They
Are A-Changin’*

Parity
 “In
the case of a group health plan that provides both
medical and surgical benefits and mental health or
substance use disorder benefits, such plan shall
ensure that-
‘…(ii) the treatment limitations applicable to such mental
health or substance use disorder benefits are no more
restrictive than the predominant treatment limitations applied
to substantially all medical and surgical benefits covered by
the plan and there are no separate treatment limitations that
are applicable only with respect to mental health or
substance use disorder benefits.” **
*Bob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
**Section 512
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
The Horizon: For The Times They
Are A-Changin’*

Parity
 Public and private insurance
 SU and MH disorder treatment benchmarked to
medical/surgical
 Emphasis on medical necessity and evidence
 More treatment purchased through insurance model
 Parity in all of the health reform bills
 Treatment is on the market – what will insurers/health
plans want to buy?
*Bob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
The Horizon: For The Times They
Are A-Changin’*

Integration
 Increased
focus on the integration of
treatment for substance use and mental
health disorders
 Challenges and Opportunities
*Bob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
The Horizon: For the Times They
Are A-Changin’*

Medical Home/Advanced Primary Care
 Coordination
of substance use/mental health
disorder treatment and primary care
Several models
 All emphasize team concept

Networks of care
 Coordination
 Technology


More interaction with medical sector
*Bob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
The Horizon: For The Times They
Are A-Changin’*

Health Reform
 Parity
included in all health reform bills
 Reliance

on insurance-based system
What will the market buy?
*Bob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
The Horizon: For The Times They
Are A-Changin’*

All changes on the horizon are
emphasizing:
 standards
 accountability
 evidence
BBob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Adolescent AOD Dependence/Abuse
Up 27%
from 7%
in 1995
Prevalence
6.0 to 8.4%
8.5 to 9.0%
9.1 to 9.9%
10.0 to 14.6%
U.S.Avg.=8.9%
Source: Wright, D., & Sathe, N. (2005). State Estimates of Substance Use from the 2002–2003 National Surveys on Drug Use and Health
(DHHS Publication No. SMA 05-3989, NSDUH Series H-26). Rockville, MD: Substance Abuse and Mental Health Services Administration,
Office of Applied Studies (retrieved from http://oas.samhsa.gov/2k3State/2k3SAE.pdf ) and Kilpatrick et al, 2000.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Substance Dependence or Abuse
and Treatment

Substance Use or Dependence
 In
2007 among adolescents aged 12-17, 7.7% of
adolescents were classified1 as substance dependent
or abusive.
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

Substance Use Treatment

1 Note:
4.3% of adolescents were classified as substance dependent
or abusive for illicit drugs in 2007.
5.4% of adolescents were classified as substance dependent
or abusive for alcohol in 2007.
In 2007, 7.6% of adolescents aged 12 to 17 who were in need of
treatment received substance abuse treatment services.
Dependence or abuse is based on definitions found in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
Source: National Survey on Drug Use and Health (2007)
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Past Year Substance Dependence or Abuse
for Specific Substances among Adolescents
Aged 12-171
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1 Source:
Marijuana and hashish: 3.1%
Nonmedical use of psychotherapeutics2: 1.3%
Pain relievers: 0.9%
Hallucinogens: 0.5%
Cocaine: 0.4%
Inhalants: 0.4%
Stimulants: 0.3%
Tranquilizers: 0.2%
Sedatives: 0.1%
Heroin: 0.0%
National Survey on Drug Use and Health 2007
2
Nonmedical use of prescription-type psychotherapeutics includes the nonmedical use of pain relievers, tranquilizers,
stimulants, or sedatives and does not include over-the-counter drugs
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Substance Use Disorders Among Adolescents
Involved with the Juvenile Justice System

Adolescents involved with the juvenile justice system
experience higher rates of substance use disorders.
 In a multi State study analyzing over 1,400 youth across
three juvenile justice settings (community-based, detention
centers and secure residential facilities), Shufelt and
Cocozza found that 46.2% of sampled youth met criteria
for a substance use disorder.*
 In an analysis 1,066 individuals participating in 14 CSAT
Young Offender Reentry Program (YORP) sites from
2004-2006, 90% self-reported criteria for substance
disorders and 40% were classified with past year
dependence.**
* Shufelt, J.L. and Cocozza, J.J. (2006). Youth with Mental Health Disorders in the Juvenile Justice System: Results from a Multi-State Prevalence Study. National Center for
Mental Health and Juvenile Justice.
** Dennis, M.L. (2006). Part 2: Institution-Based Treatment for Adolescents with Substance Use/Co-Occurring Disorders. A Presentation
made to the SAMHSA/OJJDP Expert Panel on Juvenile Justice and Substance Abuse Treatment, December 6, 2006.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Distribution of Substance Abuse
Treatment Services

The majority of individuals under age 18 receive
community-based treatment:
 Data from SAMHSA’s National Survey of Substance Abuse
Treatment Services (N-SSATS) show that in 2007 among clients
under age 18 in substance abuse treatment:
 87.1% received outpatient* substance abuse treatment
services;
 11.9% received residential (non-hospital)** substance abuse
treatment services;
 1.0% received hospital inpatient*** substance abuse
treatment services.
* N-SSATS defines outpatient treatment as regular outpatient treatment, intensive outpatient treatment, day treatment or partial hospitalization, detoxification,
methadone / buprenorphine maintenance)
** N-SSATS defines residential (non-hospital) treatment services as long-term (more than 30 days) , short-term (30 days or fewer), detoxification.
*** N-SSATS defines hospital treatment services as inpatient treatment, inpatient detoxification.
Source: SOURCE: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, National
Survey of Substance Abuse Treatment Services (N-SSATS), 2007.
http://www.oas.samhsa.gov/nssats2k7/NSSATS2k7Tbl5.6.htm
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Context

The field is increasingly facing demands from payers,
parents, policymakers, and the public at large for “evidencebased practices (EBP)” which can reliably produce practical
and cost-effective interventions, therapies and medications
that will:
 reduce substance use and its negative consequences
among those who are abusing or dependent,
 reduce the likelihood of relapse for those who are
recovering, and
 reduce risks for initiating drug use among those not yet
using.
Source: Dennis, Michael, 2005 NIDA Blue Ribbon Panel on Health Services Research
(see www.nida.nih.gov )
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
So what does it mean to move the field
towards Evidence-Based Practice (EBP)?

Introducing reliable and valid assessment that can be used:
 At the individual level to immediately guide clinical judgments about
diagnosis/severity, placement, treatment planning, and the response to
treatment
 At the program level to drive program evaluation, needs assessment, and
long term program planning

Introducing explicit intervention protocols that are:
 Targeted at specific problems/subgroups and outcomes
 Having explicit quality assurance procedures to cause adherence at the
individual level and implementation at the program level

Having the ability to evaluate performance and outcomes
 For the same program over time,
 Relative to other interventions
Source: Dennis, Michael, 2005.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Growing Infrastructure

Increasing availability and use of standardized assessment to
help focus and improve clinical practice

Growing number of manualized protocols designed for replication
and use in practice

CSAT increasingly encouraging and/or requiring the use of
standardized assessment, manuals, training, and quality
assurance practices to ensure adherence

ATTCs collaborating with CSAT, NIDA, and NIAAA to train
individual staff

Growing literature
Source: Dennis, Michael, 2005.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Ways of Viewing EBP

EBP is a process. EBP is a way of doing
practice that integrates the best evidence with
clinical expertise and consumer values. (EBP
as a verb.) (Sackett et al., 2000)
Practitioner
Expertise
Best
Evidence
EBP
Client Values
& Preferences
Source: Godley, Susan H. and McCracken, Stanley, 2007.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Source: Godley, Susan H. and McCracken, Stanley, 2007.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Definition of Fidelity


Strategies used to monitor the faithful delivery of
a manual-guided behavioral intervention
Important dimensions include:
 adherence
(i.e., extent to which intervention
procedures were delivered as prescribed in the
treatment manual)
 competence (i.e., qualitative measure of the
skillfulness in which intervention procedures are
delivered)
Source: Godley, Susan H. and McCracken, Stanley, 2007.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
What has CSAT done?

For the past decade SAMHSA’s Center for Substance Abuse
Treatment (CSAT) has funded a series of initiatives to replicate
evidence-based practices and collect information on their
effectiveness in the community

Targeted Capacity Expansion Grants
 Cannabis Youth Treatment studies
 Implementation of promising practices with a research component
 Yield: information on practices that have a basis in science
Muck, Randy, 2009.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
What has CSAT done?
Dissemination of evidence-based
treatments essential
 Implementation requires infrastructure
 National symposium - 2002

© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
History of the Adolescent Substance Abuse
Treatment Coordination (SAC) Initiative

CSAT/RWJF Adolescent Substance Abuse Treatment
Systems and Support Summit (2002)

Purpose:
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To reach consensus on the most critical levers for promoting integrated
systems of care that incorporate multiple services and pro-social
opportunities for youth.
To understand how to better utilize existing funding streams.
To understand what is working to develop and maintain a competent
workforce.
To understand how to adapt proven program interventions given the
constraints of existing community treatment programs and systems.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
History of SAC Initiative

CSAT/RWJF Adolescent Substance Abuse Treatment Systems and
Support Summit (2002)

Selected Recommendations:



Coordination: States should establish a comprehensive approach to
adolescent substance abuse treatment and the coordination of all
adolescent health and social services.
Organization: States should work with participating agencies to
develop an integrated intake and delivery system.
Finance:



States should coordinate financial resources and develop a State plan.
States should promote screening and assessment of substance use
disorders through EPSDT and other financing mechanisms.
Workforce Development:

States should train clinicians and other staff in adolescent development and
other adolescent-serving systems

States should raise the standards for licensure and certification of adolescent
substance abuse treatment professionals.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
History of SAC Initiative

CSAT/RWJF Adolescent Substance Abuse
Treatment Systems and Support Summit (2002)

Selected Recommendations:

Dissemination of Evidence-Based Practices
 Fund initiatives to study “best practices” in the real world.
 Develop technical assistance and training infrastructure/capacity.
 Build in training incentives.
 Address all levels of the workforce (e.g., administrators, managers,
counselors).
 Address all venues
 Develop appropriate tools to help build organizational capacity for
change.
 Develop a guidebook that describes the research on interventions,
provides contact information for obtaining more information, and
indicates the funds and other resources that are needed to implement
them.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Summit Response: SAC NOFA
1.
2.
3.
4.
Small infrastructure grant ($400,000/3 yrs)
Coaching
Technical assistance
Required States to create change in five
overarching areas:





Interagency collaboration
Finance/Organization
Workforce development
Dissemination of evidence-based practices
Family involvement
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Summit Response: SAC NOFA
48 States applied
 16 SAC grants were awarded 8/05 (AZ,
CT, DC, FL, GA, IL, KY, MA, NC, OH,
SC,TN, VA, VT, WA, WI)

© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
SAC Grant Management

Manage to Success
 SAC
Grant Management Structure
 Direction
- CSAT Project Officers
 Management - Georgetown Health Policy Institute
 National Expert Consultation Team
 Expectations
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
SAC NOFA:
Evidence-Based Practice

Identify barriers (fiscal, regulatory, and policy) that impede the adoption and
provision of accessible evidence-based treatment across the full continuum
of care recommended by the American Society of Addiction Medicine
(ASAM).

Devise and implement strategies, in concert with all other State-agencies
that may fund and/or regulate these services, to improve the access to
treatment, increase capacity and quality, and expand the available
continuum in communities and throughout the State implementing treatment
interventions with a scientific evidence base for the population to be served.

Identify and provide linkages across the universe of discretionary federal
and foundation-funded adolescent substance abuse treatment grant
programs for the purpose of supporting and disseminating learning across
the State-wide treatment system and to provide assistance to ensure
sustainability and adoption of best/evidence-based practices identified in
these programs.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
State addressed a common substance
abuse screening instrument with the
following agencies:
3
States
1
1
1
1
2
3
3
1
2
5
6
6
7
4
7
Substance Department of Department of Department of Department of
abuse agency Mental Health
Juvenile
Child Welfare
Education
Justice
Influenced change
Already in existence
No influence
3 Categories are not mutually exclusive; N = 16
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Specific screening tools endorsed by
SAC States
3
1
1
1 St at e - 3 or more
screening t ools
4 States - 2 or
more screening
tools
3
GAIN-SS
CRAFFT
MAYSI
POSIT
CAFAS
10
8 States - 1or
more screening
tools
5
3 State endorsed screening tools are not mutually exclusive; n = 16
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
State addressed a common substance
abuse assessment tool with the
following child-serving agencies:
3
5
States
5
3
4
8
4
2
6
5
4
Substance
Department of Department of Department of Department of
Abuse Agency Mental Health
Juvenile
Child Welfare
Education
Justice
Influenced change
Already in existence
3 Categories are not mutually exclusive; N = 16
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Specific assessment tools
endorsed by SAC States
1
1
GAIN
CANS
1
CASI
CAFAS
7
N = 16
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Dissemination
Knowledge Exposure
 EBP training
 Supervision
 Coaching
 Fidelity

© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Evidence-Based Practices
Within 24 months:
 16 States increased knowledge exposure to evidence-based
practices.

11 States supported specific evidence-based practices; 8 States
supported through revised policies.

9 States developed and implemented sequenced evidence-based
practice implementation plans.

4 States required evidence-based practices through contracts.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
State Examples:
Evidence-Based Practices

CT: implemented MDFT and MST statewide.

GA: Implemented Seven Challenges statewide.
 Signed a MOU with DJJ to blend funds to provide Seven Challenges training
to DJJ staff.
2
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VT: Developed six Centers of Excellence across the State.

TN: Catalyst for legislation requiring DCS to contract solely with agencies/providers
that can implement EBPs for youth in JJ; created director of Evidence-Based
Practices
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AZ: Worked with State best practices committee to adopt three evidence-based
practices statewide.

SC: Created Systems Integration/Best Practices Coordinator position at State level.
Housed at DMH, position will focus on improving practice in adolescent SA/MH and
co-occurring disorders
2 Data from SAC grant Year 3
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
SAC EBP Dissemination Strategies
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Virginia: RFA to Counties
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Arizona: Protocols
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Kentucky: Implementation drivers

North Carolina: Primer/training/website
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Why Weren’t Gains Made without
the SAC Grant?
No political will
 Competing priorities
 No required focus on adolescent treatment
 No adolescent treatment experts in some
States

© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Sustaining and Expanding
SAC Gains in North Carolina
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Know Your EBPs
Include in higher education curricula
 Incorporate knowledge exposure and
training into in-service training
 Incentivize adoption of EBPs

© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
MET/CBT
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Description:
 Involves the integration of sessions of Motivational Enhancement
Therapy (MET) and Cognitive-Behavioral Therapy (CBT)
 Adaptation of adult treatment for adolescents
 Available in two versions: 5 sessions or 12 sessions: first two are 60minute individual, MET sessions; the rest are 75-minute group, CBT
sessions
Study Populations:
 Adolescents (12-18)
 Cannabis Users
Outcomes:
1. Abstinence
2. Days of use
3. Severity of problems
4. Dependence symptoms
Source: http://www.azdhs.gov/bhs/guidance/catsu_attach_c.pdf
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Chestnut Health Systems – Bloomington
Adolescent Outpatient (OP) and Intensive
Outpatient (IOP) Treatment Model
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Description:
 Designed for youth who meet the American Society of Addiction Medicine's
criteria for Level I or Level II treatment placement.
 Incorporates outpatient and intensive outpatient programs based on a blended
therapeutic approach, drawing on four theoretical frameworks (Rogerian,
behavioral, cognitive, and reality) for behavioral and emotional change
 Emphasizes an individualized treatment plan that includes the family unit as well
as the adolescent
Study Populations:
 13-17 (Adolescent)
 Black or African American, White, Race/ethnicity unspecified
Adaptations: None
Outcomes:
1. Substance use
2. Substance-related problems
3. Recovery environment
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Brief Strategic Family Therapy
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Description:
 Aims to:
(1) prevent or treat adolescent behavior problems such as drug use, conduct
problems, delinquency, sexually risky behavior, aggressive/violent behavior,
and association with antisocial peers
(2) improve prosocial behaviors: school attendance/performance
(3) improve family functioning, including effective parental leadership and
management, positive parenting, and parental involvement with the child/
peers/school
 Typically delivered in 12-16 family sessions but may be delivered in as few as 8 or
as many as 24 sessions.
Study Populations:
 6-12 (Childhood), 13-17 (Adolescent)
 Black or African American, Hispanic or Latino
Adaptations: African American, German, Swedish, and White families
Outcomes:
1. Engagement in therapy
2. Conduct problems
3. Socialized aggression (delinquency in the company of peers)
4. Substance use
5. Family functioning
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Adolescent Community
Reinforcement Approach (A-CRA)
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Description:
 Replaces environmental contingencies that have supported alcohol or drug use
with prosocial activities and behaviors that support recovery
Study Populations:
 13-17 (Adolescent), 18-25 (Young adult)
 American Indian or Alaska Native, Asian, Black or African American, Hispanic or
Latino, White
 DSM-IV cannabis, alcohol, and/or other substance use disorders
Adaptations: adapted for use with Assertive Continuing Care, which provides home
visits to youth following residential treatment for alcohol and/or substance
dependence, and for use in a drop-in center for street-living, homeless youth
Outcomes:
1. Abstinence from substance use
2. Recovery from substance use
3. Cost effectiveness
4. Linkage to and participation in continuing care services
5. Substance use
6. Social stability
7. Depression symptoms
8. Internalized behavior problems
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Family Behavior Therapy
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Description:
 Outpatient treatment aimed at reducing drug/alcohol use in adults/youth along
with common co-occurring problem behaviors
 Owes its theoretical underpinnings to the Community Reinforcement Approach
 Includes a validated method of improving enlistment and attendance
 Participants attend therapy sessions with at least one significant other, typically a
parent or a cohabitating partner
 Typically consists of 15 sessions over 6 months; sessions initially are 90 minutes
weekly and decrease to 60 minutes monthly as participants progress in therapy
Study Populations:
 13-17 (Adolescent), 18-25 (Young adult), 26-55 (Adult)
 Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified
Adaptations: adapted for use with youth diagnosed with conduct disorder. It has also
been used to treat mothers in the child welfare system who abuse substances.
Outcomes:
1. Drug use
2. Alcohol use
3. Family relationships
4. Depression
5. Employment/school attendance
6. Conduct disorder symptoms
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Family Support Network (FSN)




Description:
 Outpatient substance abuse treatment program
 Includes a family component along with a 12-session, adolescent-focused
cognitive behavioral therapy--called Motivational Enhancement Therapy/Cognitive
Behavioral Therapy (MET/CBT12)--and case management.
 Establishes a support system, encourages family communication, and teaches
parents behavioral management skills with the ultimate goal of improving the
quality of family interrelationships.
Study Populations:
 13-17 (Adolescent)
 Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified
Adaptations: adapted for an outpatient program that treats recently victimized youth
who have co-occurring mental and substance use disorders
Outcomes:
1. Abstinence from substance use
2. Recovery from substance use
3. Cost effectiveness
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Integrated Co-Occurring Treatment
Program (ICT)




Description:
 Integrated treatment approach that uses an intensive home-based model of
service
 Both a reintegration program (for youth returning home from placement) as well as
a diversion program for youth referred from the court as a condition of probation
 Includes comprehensive screening and assessment
 Program clinicians are available to youth (and their families) 24 hours a day, 7
days a week
 Treatment stage approach, geared toward meeting the youth and family's primary
presenting needs prior to proceeding to more complex needs
 Includes individual and family therapy, individual treatment focusing on skill and
asset building, and focus on risk reduction
 Family interventions include building parenting skills and rebuilding family
relationships
Study Populations:
 Justice-involved youth (ages 13-18)
 Co-occurring mental health and substance use disorders
Adaptations: None
Outcomes:
1. Mental health
2. Substance abuse
3. Juvenile justice outcomes
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
4. Functioning in relevant life domains.
Multidimensional Family Therapy (MDFT)




Description:
 Family-based outpatient/day treatment program for substance-abusing adolescents,
adolescents with co-occurring substance use/mental disorders, and those at high risk for
continued substance abuse and other problem behaviors
 Helps the youth develop more effective coping/problem-solving skills for better decisionmaking
 Helps the family improve interpersonal functioning as a protective factor against
substance abuse and related problems
 Delivered across a flexible series of 12 to 16 weekly or twice weekly 60- to 90-minute
sessions
Study Populations:
 6-12 (Childhood), 13-17 (Adolescent)
 Asian, Black or African American, Hispanic or Latino, White, Race/ethnicity unspecified
Adaptations: Some program materials have been translated into Spanish. Training
materials have been translated into Dutch, with additional translations underway into
French, German, and Russian.
Outcomes:
1. Substance use
2. Substance use-related problem severity
3. Abstinence from substance use
4. Treatment retention
5. Recovery from substance use
6. Risk factors for continued substance use and other problem behaviors
7. School performance
8. Delinquency
© Doreen A. Cavanaugh, Ph.D.
9. Cost effectiveness
November 12, 2009
Multisystemic Therapy (MST) for
Juvenile Offenders
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Description:
 Treatment focuses on factors in youth's social network that are contributing to his/her antisocial
behavior
 Primary goals: to decrease rates of antisocial behavior and other clinical problems, improve
functioning (e.g., family relations, school performance), and achieve these outcomes at a cost
savings by reducing the use of out-of-home placements such as incarceration, residential
treatment, and hospitalization
 Ultimate goal: to empower families to build a healthier environment through the mobilization of
existing child, family, and community resources
 Delivered in the home, school, or community
 Typical duration of home-based MST services is approximately 4 months, with multiple
therapist-family contacts occurring weekly
Study Populations:
 6-12 (Childhood), 13-17 (Adolescent)
 American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, White,
Race/ethnicity unspecified
Adaptations: training materials have been translated into Danish, Dutch, Norwegian, Spanish,
and Swedish
Outcomes:
1. Post-treatment arrest rates
2. Long-term arrest rates
3. Long-term incarceration rates
4. Self-reported criminal activity
5. Alcohol and drug use
6. Perceived family functioning-cohesion
© Doreen A. Cavanaugh, Ph.D.
7. Peer aggression
November 12, 2009
Seeking Safety
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Description:
 Treatment for clients with a history of trauma and substance abuse
 Designed for flexible use: group or individual format, male and female clients, and a
variety of settings (e.g., outpatient, inpatient, residential)
 Focuses on coping skills and psychoeducation
 Emphasizes: (1) safety as the overarching goal; (2) integrated treatment; (3) a
focus on ideals to counteract the loss of ideals in both PTSD and substance abuse;
(4) four content areas: cognitive, behavioral, interpersonal, and case management;
and (5) attention to clinician processes
Study Populations:
 13-17 (Adolescent), 18-25 (Young adult), 26-55 (Adult)
 American Indian or Alaska Native, Asian, Black or African American, Hispanic or
Latino, White, Race/ethnicity unspecified
Adaptations: has been tested with dually diagnosed women, men, and adolescent
girls. Samples have included clients in outpatient and residential settings, low-income
urban women, incarcerated women, and veterans (both men and women). The
treatment manual is available in both English and Spanish
Outcomes:
1. Substance use
2. Trauma-related symptoms
3. Psychopathology
4. Treatment retention
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Seven Challenges
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Description:
 Designed to treat adolescents with drug/other behavioral problems
 Counselors and clients identify the most important issues and discuss issues while
the counselor seamlessly integrates a set of concepts called the seven challenges
into the conversation
 Skills training, problem solving, and family participation are integrated into sessions
that address drug problems, co-occurring problems, and life skills deficits
 The Seven Challenges reader, a book of experiences told from the perspective of
adolescents who have been successful in overcoming problems, is used by clients
to generate ideas and inspiration related to their own lives
 Youth write in a set of nine Seven Challenges Journals, and counselors and youth
engage in a written process called cooperative journaling
 Can be implemented in an array of settings, including inpatient, outpatient, homebased, juvenile justice, day treatment, and school.
 Number, length, and frequency of sessions depend on the setting
Study Populations:
 13-17 (Adolescent)
 Hispanic or Latino, White, Race/ethnicity unspecified
Adaptations: program materials available in Spanish
Outcomes:
1. Substance use and related problems
2. Symptoms of mental health problems
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Phoenix Academy
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Description:
 Therapeutic community (TC) model enhanced to meet the developmental
needs of adolescents ages 13-17 with substance abuse and other cooccurring mental health and behavioral disorders
 Integrates residential treatment with an on-site public junior high and high
school.
Study Populations:
 13-17 (Adolescent)
 Black or African American, Hispanic or Latino, White, Race/ethnicity
unspecified
Adaptations: None
Outcomes:
1. Substance use
2. Psychological functioning
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Challenges – Evidence-based
Treatment
Workforce
 Retention
 Policies and procedures
 Leadership
 Cost/reimbursement (supervision)
 Not tested on all populations

© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Practice Based Evidence

Field-based research
 For
untested populations
 For adaptations
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
Verifying Effectiveness
Practice-based
Evidence-based
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Large randomized, multi-site trials
Key components of treatment
clearly defined a priori for specific
populations and disorders
Manualized
Target population is clearly
defined
Adherence to treatment manual is
carefully monitored (fidelity)
Outcomes are typically measured
at the end of treatment
Ann Doucette, Ph.D.

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Systematic monitoring of
outcomes concurrent with
treatment
Components of treatment are
sensitive to need of individuals
and may deviate from manual
Target population is assumed to
vary in terms of co-morbid
conditions
Careful monitoring of concurrent
outcomes
(improvement/deterioration)
Evidence is cumulatively collected
across consumers throughout the
course of treatment
Ensuring The Quality of Treatment
Evidence-based
Practice-based
 Training is essential
 Booster training is needed
from time to time to avoid
drift
 Grand
 Varying
ability to
incorporate train-thetrainer models
 Continuous cost of
training
 Staff turnover
 Evaluation of
outcomes is a
separate activity
rounds approach is
taken where cases are
presented by staff

Staff look for consistency in terms
of consumer characteristics in
cases demonstrating
improvement
 Evaluation
of outcomes is
integrated with treatment

Staff form learning communities
to learn and share information
based on concurrent (with
treatment) monitoring of
consumer improvement
Ann Doucette, Ph.D.
Challenges - Recovery

Need for research on and implementation
of recovery-oriented services and supports
for youth.
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009
URGENT
THIS IS NOT A DRILL!!
For The Times They Are AChangin’*
*Bob Dylan: Copyright ©1963; renewed 1991 Special Rider Music
© Doreen A. Cavanaugh, Ph.D.
November 12, 2009